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Nick Barber, professor of the practice of pharmacy,
School of Pharmacy,
University of London
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Pharmacy is unusual compared with other medical disciplines, such as
optometry, dentistry, chiropractic, in that it is not based on parts
of the body. Nor is it based on manipulating, cutting or caring for the
body (eg, physiotherapy, surgery, nursing). Instead, pharmacists focus
on things: stuff, chemicals, medicines. Call them what you will, pharmacists
focus on physical objects with the potential to help or harm patients.
While the ultimate aim is to help patients, pharmacy’s history,
education and daily practice is rooted in providing medicines that have
some chance of being effective and reducing the chance that they will
cause harm or inconvenience. The risk of harm is key. We deal with potentially
dangerous things and dangerous things need skilled keepers — pharmacists
for medicines, medical physicists for radiation, and so on. The first
volume of The Pharmaceutical Journal in 1841 (p115) contains an article
taken from a pharmacy journal in the US, which argued that the pharmacist’s
special knowledge meant that the public was much safer getting something
from pharmacists than from apothecaries (one of whom had previously used
the wrong chemical and killed a patient) — pharmacists were skilled
in identifying the right ingredients and in combining them.
As risks changed, pharmacists expanded their knowledge so they could
control them. As chemical analysis grew they extended their assessment
of the quality of medicines from identifying the correct species of plant
to testing for heavy metals and other contaminants. Pharmacists’ use
of microbiology came from the same need to stop contamination.
In the 1960s and 70s a combination of the industrialisation and regulation
of the development and production of medicines led to something of a
loss of way for pharmacy, as many of the traditional risks (eg, poor
manufacturing practices) had become controlled, and the skilled part
of production was removed. However, there was also growth in the number
and effectiveness of medicines and the risks changed again. First, drugs
were more potent and needed to be prescribed more precisely to get the
best risk:benefit ratio. Second, more drugs led to more errors. In the
1960s, new systems (eg, ward pharmacy) were developed in UK and US hospitals
that involved pharmacy in reducing these risks. Finally, the health purchasers
and managers considered medicines an economic risk — drugs were
seen as expensive and the rate of growth of expenditure exceeded inflation.
Hospital pharmacists were central to controlling risks and the number
of pharmacists and services influencing the choice and use of medicines
proliferated.
How did hospital pharmacists control risks? Through their knowledge of
pharmacokinetics (pivotal in the development of clinical pharmacy, moving
from giving information passively to recommending optimal prescribing),
and being able to assess the strength of the evidence for therapeutic
effects. Risk reduction continued with the development of safe systems
of monitoring prescribing and of distributing and administering medicines.
Today, pharmacy policy continues to reduce the risk from prescribed medicines,
and to increase the likelihood of their effectiveness. However, the focus
is now moving from advising doctors to engaging additionally with the
patient as an autonomous person.
This policy is enacted through services,
such as prescribing and medicines review, in which pharmacists use their
knowledge of drugs and the actions patients could take, to improve the
chances of a medicine benefiting a patient.
Pharmacy did not arrive where it is now out of the blue. As I have already
discussed, the profession is at this point because of its history. It
is worth asking whether or not there is some core aspect of pharmacy
that helps explain what pharmacists do. This is necessary so that pharmacists
can have a common language among themselves, differentiate themselves
from nurses and other professions involved with medicines, and decide
on the balance of their education.
In reviewing the history of pharmacy, the one theme that comes through
consistently is that pharmacists have a detailed knowledge of medicines
and use this to do what patients, society and their employers want. Pharmacists
know what is a medicine and what is not, how it is made, how it works,
how the body deals with it and, increasingly, what people do with medicines,
be they health care professionals (in terms of prescribing or administration
errors) or patients (in term if non-adherence). I call this ability to
see into the properties of medicines, and predict their effects, “the
pharmaceutical gaze”. This term was stimulated by “the medical
gaze” described in Michel Foucault’s ‘The birth of
the clinic’. In this book, Foucault studies the power of the profession
of medicine.
The pharmaceutical gaze is something that no other profession has. It
helps define and differentiate pharmacy. It is a source of our power.
When pharmacists look at a medicine they see much more than others. They
see formulations, clinical trials, manufacturing standards, pharmacologically
active compounds and specific physiochemical properties. This ability
to see the properties of medicines, and hence to predict the
likely consequence of their use, is a unique
and valuable property of the pharmacy
profession.
However, the pharmaceutical gaze is not a complete description of being
a pharmacist. It ignores many other factors, some of which should be
held by any high level professional, such as ethical judgement, integrity,
management skills and political acuity. Indeed, the more pharmacists’ pharmaceutical
gaze is defined by objects (medicines), the more important it becomes
that pharmacists have a well defined set of values, particularly as their
involvement with patients (as persons rather than bodies) grows.
The pharmaceutical gaze, like the medical gaze, is not fixed — its
scope changes over time. As knowledge and social institutions progress
some areas are dropped, others acquired. These shifts may be large, as
happened to medicine in the 18th century when it “acquired” mental
illness, which had previously been defined in religious terms. We may
be going through such a shift in pharmacy, in which our new areas of
knowledge become how organisations deal with the risks from medicines
and how patients decide what they want to do with medicines and what
their subsequent behaviour is.
The power of theory is that it can give us relatively simple ways to
explain these complex issues. One of my great pleasures as an academic
is the exploration of theoretical frameworks that allow pharmacists to
predict the likely effects of medicines in humans and social systems,
rather than simply in the physical body. Examples are the psychology
of human error, models of cognition, technology diffusion, information
systems, and complexity theory. Perhaps some of these will become part
of the body of knowledge that will be the pharmaceutical gaze of the
future, defining pharmacists, and the source of their power. |
The
Pharmaceutical Journal