Health Care and Pharmacy

Pharmacy Practice in the United States From its very beginnings, pharmacy was considered the art of making medicines. Like most arts that originated in earlier times, it came eventually to be regarded as a science in the modern age (Wutoh 2). Throughout history, various cultures have practiced pharmacy by creating drugs "to treat illness, relieve pain, create euphoria and promote health" (Wutoh 3). All of the medicinal creations around the globe over the past millennium show that the making of medicines has been a universal process that is natural to humankind.

Yet, in the United States, the science of pharmacy has taken a new trajectory -- with the pharmaceutical industry representing a significant portion of gross domestic product. Pharmacy practice in the United States is not just an art or science -- it is also a big business.

Nonetheless, while the usage and significance of medicines has differed from culture to culture, place to place, and time to time, one constant that has remained throughout the history of pharmacy is the special focus from every culture that medicinal substances have received throughout the world.

Today, in the United States, the science of pharmacy has risen to incredible heights with a broad range of implications for those who develop drugs, those who administer them, those who use them, and those who oversee legal aspects related to the manufacturing of drugs. This paper will examine the practice of pharmacy in the United States and discuss its many several aspects. A Highly Specialized Science As Rosemary Onuegbu points out, pharmacy practice in the United States is a highly specialized science with a wide variety of practice areas.

One of the most common areas of pharmacy practice today in the U.S. -- and most likely to be the first place one goes in order to purchase self-care pharmaceuticals -- is the community pharmacy, or better known as the chain pharmacy. Chain pharmacies like CVS, Walgreens and Kroger are commonplace examples of community pharmacies: what sets them apart from other types of community pharmacies is the fact that they are corporately owned and typically have brick-and-mortar operations in several states and areas across the country.

They are the most visible from the roadside and usually the first place a patient goes when needing to fill a prescription. They represent, in many ways, the face of the pharmaceutical industry for many people: the friendly pharmacists working tirelessly behind the counter to fill doctors' orders for patients. Yet, in actuality, these pharmacies are really only one small part of the practice of pharmacy in the U.S. today.

Indeed, other types of community pharmacies exist -- such as the independent pharmacy, which is privately owned, usually by a pharmacist or group of pharmacists (Onuegbu 10). There are mail-order pharmacies, franchise pharmacies and department store pharmacies -- but even these only tell a small portion of the story of pharmacy practice in the U.S. Still, the fact that in today's United States there is practically a pharmacy on every corner indicates how pervasive the pharmaceutical industry has become in American society.

How did the pharmacy industry get to be so big, so expansive, and so pervasive? Part of the reason for the pervasiveness of the industry is the change in the patient-physician-pharmacist relationship (Onuegbu 21). In the old model, the patient was at the center of the relationship. The patient would receive a prescription from his or her doctor and take it to the pharmacist for filling.

In the new model, the pharmacist is at the center of the relationship and communicates directly both with the physician and patient, serving as an intermediary between the two. In other words, the pharmacist has taken on a larger role in the sector of health care. In today's realm of pharmacy practice, the patient-oriented pharmacist must maintain a high degree of drug knowledge, communication skills, and the ability to gather/analyze information in order to "help sick patients cope with their feelings" (Onuegbu 22).

In order to do that, the pharmacist must be familiar with all the new and old types of drugs available on the market, which can help treat particular symptoms, and which to offer patients looking for the least expensive drug for their particular ailment. Competition among drug manufacturers has made the pharmacist an important link in the industry-to-patient chain. Another part of the reason for why pharmacy practice has expanded into the industry it is today in the U.S.

is that technological science has made stellar advancements that have allowed pharmacy to grow and develop in ways never been seen in the world. For example, in the U.S. one can find multiple specialty practices within the overall pharmacy profession. The specialty practice of nuclear pharmacy is one such type. Nuclear pharmacy was, in fact, the first specialty practice to be recognized by pharmacy professionals (Gebo 9). This occurred in 1978 following the creation of the Board of Pharmaceutical Specialties two years earlier.

(It was not for another decade before the Board recognized a second pharmacy specialty) (Gebu 9). What this should indicate to the layman, of course, is that the pharmacy industry takes its practice very seriously and recognizes the immensely high standards that all pharmacists must adhere to in order to be considered true professional, credentialed specialists. It takes a considerable amount of time for a specialty to emerge, be proven to be effective, and be specialized enough to require a distinct set of skills from a pharmacy professional.

What does a nuclear pharmacist do? Just like in community pharmacy, this practice centers on mixing and making drugs for patients. The nuclear pharmacist is tasked with a more complex order, however, such as "incorporating a radioactive isotope (like Tc99m) into a mildly pharmacologically active non-radioactive drug for disease state diagnosis" (Gebo 11). These types of drugs are used to help physicians identify the nature of a particular problem in a patient's body.

For instance, if a patient's heart is having trouble, a diagnostic test would be ordered by the doctor and the nuclear pharmacist would provide a radiopharmaceutical that will allow the doctor to image the heart. Of course, as Busse, Chavanu, and D'Onofrio show, none of this would be possible without industrial pharmacy.

Industrial Pharmacy Industrial pharmacy is comprised of several departments which exercise a variety of functions: the executive office of a pharmaceutical company, for instance, will oversee operations; the legal and compliance division will ensure that the company adheres to FDA regulations; the research and development department will conduct tests on new drugs to measure outcomes and effectiveness and so on. It is a vastly large and multi-dimensional enterprise (Busse, Chavanu, D'Onofrio 10).

Even just a small glimpse into one aspect of industrial pharmacy gives an idea of how specialized nearly every aspect of the industry is today. A researcher employed by an industrial pharmacy company will utilize aspects of medicinal chemistry to make assessments regarding biological plausibility and toxicity before conducting human trials and making post-marketing commitments (Busse, Chavanu, D'Onofrio 10). From there, other employees of the company will reach out to pharmacists and physicians to promote the new drug to patients whose symptoms are targeted by the pharmaceutical.

An extensive interrelated web of sales, research, and healthcare is concocted -- and it is this web that has allowed industrial pharmacy to play such a dynamic role both in how drug research is conducted and legislated (the pharmaceutical industry is a major lobbyist) and how new drugs are marketed (Busse, Chavanu, D'Onofrio 14). A closer examination of how drugs are produced within industrial pharmacy reveals a much more complex process than was ever the case in human history prior to the advent of modern medicine.

As Simon Wang shows, structure-based design of pharmaceuticals such as nelfinavir (marketed as Viracept), which is used for HIV patients, plays a significant role in pharmacy practice in the U.S. today. Structure-based design begins with the preparation of a protein model. Seeds or "decoys" are used to prepare a virtual screening database for docking, scoring and ranking. This is another highly specialized form of drug manufacturing and testing that goes on in industrial pharmacy -- well behind the scenes of the friendly, local neighborhood pharmacist at the corner Rx.

Fragment-based drug design is another type of process that pharmacists engage in when manufacturing a product that involves utilizing a binding site comprising binding pockets, crystallographic screening, designing of a lead compound around a core template, and the growth of a single fragment (Wang 10). Such intricate operations is a far cry from the grinding of herbs and collecting of natural substances traditionally applied in medicinal form a thousand years ago in the various ancient cultures around the world (Wutoh 3).

As Wang shows, a great deal of pharmacy practice in the U.S. is a highly scientific that demands a deep knowledge of chemistry and molecular biology. And this is just one aspect of industrial pharmacy. Another side of this type of pharmacy practice is the marketing side, which consists of the way that new drugs are advertised (as on television), regulated by FDA authorities, and sold to potential clients, physicians, and pharmacists around the country.

Industrial pharmacy is a substantial network of multifaceted parts, each specialized within their own areas to produce maximum results for the company and for the consumer. If nuclear pharmacy was the first "recognized" specialty in pharmacy, more than thirty years later it may be safe to say that nearly every aspect of pharmacy practice is "specialized" in the sense that each places unique demands on those who pursue a career in their respective fields.

Whether one is a nuclear pharmacist, a researcher, a drug-designer, or a community pharmacist, the special skills one needs to succeed are vital. The Evolution of Specialization in Pharmacy Jerome Pittman shows just how this process of "specialization" developed over the course of the 20th century.

WW2 was primarily responsible for a lot of changes throughout the world and in America: it brought women into the workforce, altered the concept of America's role in the world, and -- for the practice of pharmacy -- it "made drugs available and accessible" on a scale previously unknown (Pittman 4). In the post-War period, clinical pharmacy began to follow precise procedures, as regulation and federal oversight exercised more stringent controls -- which in turn required pharmacists to follow specific guidelines in their profession.

Clinical pharmacists, for example, utilized the Drug Use Control Concept in which a drug is prescribed, reviewed as the drug of choice, prepared, labeled, administered and monitored "for efficacy and safety" (Pittman 9). The post-War period saw other changes in the particular practices of pharmacy. Ambulatory care pharmacists came into being: these pharmacists specialized in fulfilling the medication needs of hospital outpatients (Pittman 13).

Over time, the duties and responsibilities of ambulatory care pharmacists have expanded to include patient counseling, patient education, providing answers to drug-related questions, obtaining patient medical records/histories as well as maintaining them, evaluating drug therapies, working with other healthcare professionals, and providing therapeutic consultations (Pittman 16). Even still, this pharmacy field continues to evolve as new demands and new legislation are effected that directly and indirectly impact patients, pharmacists, physicians and their relationship.

The Affordable Care Act, for example, is one type of legislation that has significantly affected many levels of healthcare in the U.S., including pharmacy practices. With a new administration entering the White House, more changes may be yet to come. As one can see, pharmacy practice is anything but stagnant: environmental, technological, social, political, academic and economic factors all play a role in shaping the course of pharmacy practice. Even with specific types of patients, pharmacy practice has evolved.

For instance, pharmacogeriatrics is a specific type of pharmacy that focuses on treated the elderly. Elderly patients often use multiple medications -- a process defined by the term polypharmacy. (While the elderly are not the only patients to use polypharmacy, they are the most common). Taking multiple medications comes with inherent risks, as each medication can pose side effects that, when combined with other medications, can actually worsen a patient's condition.

Thus, in pharmacogeriatrics, the pharmacist needs to know which medications can be mixed with which -- as sometimes it can be a matter of life and death (Lombardo "Pharmacogeriatrics" 4). Ethics and Pharmacy With so many different types of pharmacy present in the United States today -- and with so many different persons employed in pharmacy practice -- it is natural to expect some conflicts with regard to right and wrong ways to help patients.

As Fred Lombardo points out healthcare professionals and pharmacists especially have an "obligation to make group ethical decisions as health care team members" -- an obligation that can prove particularly challenging when conflict occur among team members regarding right and wrong moral practices (Lombardo "Ethics" 15). Thus, while pharmacists have a Code of Ethics to which they are meant to adhere, the "promotion of the good for every patient" is something that can be complicated by the various philosophical underpinnings of individual pharmacists' worldview (Lombardo "Ethics" 40).

This is true not just of pharmacy but of all medical professions in the U.S. The various philosophical revolutions that have occurred in the West over the past several centuries have never fully resolved the issue of what it means to be moral or how to act rightly. Various perspectives still remain, even in the field of pharmacy practice. For example, one pharmacist may take a Utilitarian perspective -- which holds that the common good is the greatest motivator in a course of action.

Another may take a deontological perspective -- which pertains to the duties that one owes others. In pharmacy, these two perspectives can sometimes align and sometimes clash. When they do clash, it becomes important for health care team members to work together as a team to resolve any disputes. Unity of expression and conformity to a code of practice is just as important in pharmacy as it is in any other mode of health care. Independent Pharmacy Not all pharmacists work in teams, however.

Some are independent pharmacists in United States. Merlyn Crandon-Enyi notes that even as an independent pharmacist there are challenges to practicing pharmacy -- but also opportunities. Sometimes opportunities and challenges can appear as one and the same thing: for example, an independent pharmacist is responsible for formulating his or her own core values.

This does not mean that the pharmacist will hold values that conflict outright with other health care professionals -- as even an independent pharmacist will need to work and corroborate with health care practitioners, physicians, patients and drug manufacturers. Thus, it is essential to the success of the independent pharmacist that the core values he or she represents at least at a basic level mesh well with those values of the rest of the health care community.

However, an independent pharmacist may, for example, be more inclined to adopt a specific patient focus that makes his or her pharmacy unique among others. Such a pharmacist may prefer a homeopathic route to pharmacy -- a return to the ancient techniques of traditional medicine as an alternative to manufactured drugs produced in laboratories. Nor do all independent pharmacies set out to make themselves that unique, of course. Many independent pharmacists are no different from community pharmacists -- except in the fact that they are not corporately owned.

Independent pharmacy prescription sales still reach over $70 billion a year in the United States, which indicates the high level of business small pharmacies achieve (Crandon-Enyi 8). In fact, independent pharmacists consistently achieve the highest customer satisfaction ratings according to Consumer Reports (Crandon-Enyi 13). Independent pharmacists can also join any of a number of professional pharmacy associations and organizations (Mckoy-Beach 1).

From the American Pharmaceutical Association to the American College of Apothecaries to the Healthcare Distribution Alliance and the National Council on Pharmaceutical Education -- pharmacists can be part of several communities/organizations designed to support pharmacists in their relationships with patients, physicians, drug manufacturers and researchers. Many such organizations publish literature or position papers regarding timely and relevant issues in pharmacy practice. Others lobby governments and/or private businesses (Mckoy-Beach 8).

The benefits of joining such organizations or associations include having access to the latest information in pharmacy practice, the ability to maintain competency in the field, assistance with one's career planning, financial assistance, and the power to participate in governance (Mckoy-Beach 9). With all of these incentives tied to being a member of an association or organization, even the concept of independent pharmacists evolves: when it comes to pharmacy practice, all pharmacists have the opportunity to be part of a larger, wider network.

Pharmacists who choose not only to join an organization/association but also to take a professional career within that same network can do so by finding employment with a facility -- such as a hospital. Hospital pharmacy reaches back all the way to the days of the colonialists -- though in terms of advancements made both in medicines and technology today's hospital.