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Pharmacy education
Clinicians do not want pharmacists to be walking BNFs
From Professor A. T. Florence, FRPharmS
Duncan McRobbie fails to answer the question I posed in my letter to
which he purportedly replies (PJ, 26 June, p802). The question was: “If
science does not underpin clinical practice, what does?” One could
ask a supplementary question: “What distinguishes a pharmacist’s
clinical opinion or knowledge from that of a physician or nurse?” He
chooses instead to invoke a reductio ad absurdum in selecting a fragment
of science that we teach, namely the synthesis of drugs. Pharmacists,
he says, are never asked about how to synthesise drugs, therefore this
topic is irrelevant. At least that is the interpretation he wishes readers
to place on his piece of fun. Pharmacists may never be asked about the
structure of DNA, either, but we believe that if they are to understand
much about modern medicines or future medicines, they must.
The education of professionals requires a certain knowledge base, which
is constantly being refined and extended. The criterion for inclusion
of a subject in the MPharm programme cannot be what Mr McRobbie’s
pharmacist colleagues are asked on the wards today. There is an element
of chicken and egg: if pharmacists are found wanting in extending the
canon of knowledge through their own specialist understanding of matters
outside the realm of their colleagues, then they will not be asked, at
least not more than once.
If the object is to draw me into a debate about the particular topic
he raised, then I would respond that we wish to impart something of the
properties of drugs and to explain their reactivity and possible variability.
So pharmacists might be asked about enantiomers and their behaviour,
cross-reactivity in adverse reactions between different classes of drugs,
hapten formation and metabolism, or if not asked might add something
to the discussion about possibilities.1 Could it be potential contaminants
that cause this adverse reaction and not the drug? Why is it that biologics
vary? And does it matter?
Senior medical clinicians that I have talked to do not want pharmacists
to be walking BNFs but want them to have knowledge and understanding
that they, themselves, do not have, namely pharmaceutical knowledge.
They do not wish to see physicians manqué, but true pharmacists
whose clinical understanding is underpinned by a different (but overlapping)
subset of science from theirs.
We, here, certainly do not believe we have all the answers but through
our academic pharmacy units and departments in hospitals, including the
Centre for Paediatric Pharmacy Research at Great Ormond Street Hospital
and the Institute of Child Health, we are gaining first-hand experience
of what is uniquely required of pharmacists. We hope soon to appoint
a Professor of Clinical Pharmaceutical Science jointly with University
College London Hospitals, to pursue this vision of the future and to
reinvigorate a research culture into practice, which might revive an
interest in the fundamentals. Perhaps Mr McRobbie, who has published
widely and is extremely knowledgeable on pharmaceutical competencies,
can sit down with us to map out what the tree of pharmaceutical knowledge
should look like, roots, warts and all.
A.T. Florence
Dean, The School of Pharmacy,
University of London
Reference
1. Florence AT, Salole EG. Formulation factors in adverse reactions.
London: Wright; 1990.
Practice — the appliance of science?
From Dr M. J. Norris, MRPharmS
I am distressed to read Duncan
McRobbie’s letter about the perceived
inadequacies of the Master of Pharmacy degree courses offered by UK universities
(PJ, 26 June, p802). I believe that it is important to reassure the profession
that pharmacy academics do not just sit in ivory towers, completely divorced
from the rest of the profession. I am just about to start a five-hour
shift on a Sunday afternoon in a community pharmacy — the only
one open within a radius of 40 miles!
Our courses are carefully constructed in consultation with all branches
of the profession via employers’ liaison groups. We also have both
community and hospital teacher practitioners on the staff. The Master
of Pharmacy degree courses are designed to give students a good understanding
of the science underpinning pharmacy and to prepare them for continuing
professional development upon graduation. To give but a single example,
within pharmaceutics at Portsmouth, we try to teach the subject so that
the students will have a good understanding about how formulation can
be used to support clinical practice. For example, we would expect a
student to understand the constraints on a formulation that should be
administered by nasogastric tube rather than by simple oral administration.
Mr McRobbie mentions the inadequacies of recent graduates in undertaking
simple patient counselling, providing routine health promotion or basic
therapeutic drug monitoring. I share his concerns but I believe the best
way of tackling this problem is not by diluting the science on the degree
course but by giving the students more experience and hence the confidence
in applying it. How can you tackle basic therapeutic drug monitoring
without an in-depth knowledge of the drug? For example, to undertake
monitoring of gentamicin, the pharmacist must be aware of the spectrum
of activity of the drug and the desirable plasma levels associated with
inhibition or death of the causative organism. Knowledge of the drug’s
pharmacokinetics and the factors that influence it are equally essential.
Finally the chemistry of the drug must be understood to prevent possible
interactions if the drug is co-administered with other drugs, eg, beta-lactams
used for a synergistic effect. I do not accept that our students should
tackle therapeutic drug monitoring without such an in-depth knowledge.
I recognise that the vast majority of our graduates leave university
absolutely delighted that they will never see a spectrophotometer or
gut bath again. However, the scientific knowledge that they have learned
and applied with us will set them in good stead for their future in the
profession.
Michael J. Norris
Head of Division of Pharmaceutics
School of Pharmacy and Biomedical Sciences,
University of Portsmouth
Reasonable level of patient contact needed
From Professor L. I. Goodyer, MRPharmS
In many respects I would agree with Duncan
McRobbie’s sentiments
concerning the focus of the MPharm courses towards pharmacy practice
(PJ, 26 June, p802). However, I do believe that sufficient scientific
content must be included in the curriculum to provide a firm basis for
future practice. For instance, the programme should aim to develop an
understanding of the physico-chemical properties of drugs, dosage form
and design, chemistry and pharmacology but contextualised as far as possible
to application in pharmacy practice, ie, to the patient. In other words
I am arguing for applied scientific content within the MPharm degree
that is of most relevance to drug therapeutics, which may result in certain
subjects being taught in less depth than has been the tradition in many
schools of pharmacy. We should therefore be aiming to produce pharmacists
who have a good grasp of the science supporting the subject area rather
than a “scientist” in the true sense of the word.
In my opinion, the only way to produce graduates more oriented towards
the health professions is to ensure a reasonable level of patient contact
throughout the undergraduate period, as alluded to by Mr McRobbie. In
so doing the curriculum can provide relevant learning opportunities and
also practical interprofessional education within the working environment.
The placement system is, after all, how all other health professionals
are trained.
I recognise that this direction presents huge challenges and changes
to the current system of pharmacy education, but if government policy
is to make use of the pharmacist as a health professional to deliver
the NHS agenda it is a situation that cannot be ignored.
Larry Goodyer
Head, Leicester School of Pharmacy,
De Montfort University
Has extra year not provided more practice experience?
From Mr P. I. Wilson, MRPharmS
In response to the letter by Duncan
McRobbie (PJ, 26 June, p802) I would
support his view that the undergraduate pharmacy degree has not prepared
students for their future pharmacy practice. Having graduated as one
of the last cohort of BPharm students I spent the first six months of
my preregistration year in an industrial setting. When I started the
second six-month placement in a hospital I quickly realised how little
I knew about clinical practice. Only excellent clinical training in an
understanding environment both in my preregistration year and then as
a junior pharmacist, including that provided by Mr McRobbie himself,
has led to my current competence. I know I am not alone in having felt
little confidence in my abilities on starting out in clinical practice.
However, I would have expected that since my qualification the standard
of clinical knowledge and confidence of graduates entering preregistration
positions and therefore newly qualified pharmacists should have improved.
Surely the extra year of undergraduate study now undertaken should have
provided an ideal opportunity to increase the exposure of undergraduate
pharmacy students both to clinical knowledge and experience and to the
way in which they will be learning postqualification. Since the extra
teaching time the MPharm degree gives has occurred as pharmacists are
endeavouring to undertake increasingly clinically focused roles, I would
expect this to be reflected in the knowledge gained by undergraduates.
I am ignoring differences between undergraduate pharmacy courses exemplified
by the split preregistration year used in Bradford, which may provide
a greater clinical impact for the students who experience it.
Patrick Wilson
Nottingham
What is the fourth year being used for?
From Dr I. H. Stockley, FRPharmS
Duncan Robbie says: “... UK pharmacy undergraduate programmes
fail to prepare future pharmacists for practice” (PJ, 26 June,
p802). If this is so, what is the additional fourth year of the degree
course being used for?
Ivan Stockley
Willoughby-on-the-Wolds,
Leicestershire
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