Harvey A.K. Whitney Award Lectures

The Discontent of Professionalism: A Call in the Night

I want to thank the Southeastern Michigan Society of Health-System Pharmacists,
ASHP, and the Harvey A. K. Whitney Lecture Award committee for this
distinct honor. I am so very grateful but also humbled. I am humbled by the
very thought of being considered among the list of recipients, all of whom I have
respected and admired for what they have done for the profession and our patients. I
am also humbled by the realization of how many others deserve such recognition,
and I accept this award on their behalf as well.

After learning that I was chosen to receive this award, I reflected on the many
colleagues and friends in pharmacy and ASHP who have contributed in so many
ways to whatever success I have enjoyed. The list of people to recognize is too long,
and I would regret leaving out even one person, so I just say “thanks” and hope to
thank each of you personally in the near future. I must thank my colleagues in the
Texas Society of Health-System Pharmacists and at the University of Texas for allowing
me to serve many years ago.

As all of you know, when someone pursues a professional passion, there is always
a price to be paid, in time, attention, and days spent away from home. I thank my
staff at Methodist Hospital and Scott and White Health System, who for many years
joined me in a wonderful journey based on a shared vision for patient care. We did
some good and had fun, too. I must thank my mom, who taught me to never quit, and
my dad, who taught me to treat others as I want to be treated.

Finally, I want to thank God for protecting our patients over many years from
serious error and for allowing me to find my real passion while on the way to medical
school. I want to thank my three children, Natalie, Billy, and John, for their love and
support; they are my proudest achievement. Most of all, I want to thank my counselor,
biggest fan, and best friend: my wife, Camellia.

A call in the night

It is the season for the annual budget battle, and this year seems even tougher, with
more pressure to reduce drug costs and cut staff and vital programs critical to patient
care. I am restless and tired but finally fall into a deep sleep, only to be awakened by
a startling sound. It is the telephone, and Gladys, the night nurse supervisor, says,
“Oh Bill, I’m glad I could reach you. We have had a serious medication error on the
pediatric unit, and you need to come to the hospital right away!”

Minutes later I am in the truck, heading toward the hospital. Between prayers that the
patient will be OK, my mind is flooded with a confessional litany of factors that could
have contributed to such a serious error, the little concessions regarding hours of service,
staffing levels, salaries inadequate to keep the most competent staff, daily checks and
balances that somehow erode ever so slightly with the incessant budget pressures. I am
also thinking of the advanced programs, like bar coding and expanded clinical coverage,
that can prevent such errors yet are postponed each year as millions of dollars are reserved
for bricks and mortar, as well as the latest diagnostic technologies and endless
information technology projects. Suddenly I am feeling anger.

After arriving at the hospital, I quickly dash up the back stairs to the pediatric unit
where I see nurses wheeling the patient out of the room toward the intensive care
unit. It is a little girl, with a portable respirator seeming to overpower her small body.
I get a horrible sick feeling, as she appears to be the age of my youngest granddaughter,
Madison. I see her parents beside her, themselves looking very young and frightened.
I then recognize that she is a cystic fibrosis patient named Amy McFarland. All
of our staff has come to love and respect her as she struggles with chronic respiratory
problems. We should be making life better for her, not worse.
The attending physician greets me by first name and then introduces me to the
parents before we briefly discuss Amy’s condition. It seems that the parents and physician
are looking to me, silently asking, “How could this happen?” They are kind
enough not to say it, but they did not have to. They just want Amy to be OK and go
home with them.

The physician and I then head to a conference room where a critical-response
team has gathered to conduct a preliminary review. More than anytime I can recall, I
feel very fearful, sad, and alone. It is clear that everyone is devastated by this event.
The chief financial officer – the administrator on call tonight and the person who has
hassled me constantly in recent weeks to cut staff – now seems very docile and genuinely
concerned but makes no eye contact with me. The attending physician is a
longtime colleague who has been an advocate for pharmacy with the exception of
one conflict over some of our expanded clinical functions. Our eyes meet, and that
issue now seems far, far away. The director of nursing and Gladys both show genuine
concern, our occasional “turf battles” seeming unimportant now. The nurse caring for
Amy can barely lift her head to discuss the details. My pharmacy staff members
appear beaten and distraught while trying to be professional. As we begin our discussion,
all eyes turn toward me. It becomes clear that the patient received the wrong
intravenous antibiotic and had a severe allergic reaction. Because the pediatric satellite
pharmacy was closed and the central pharmacy is understaffed at night, Amy’s
nurse elected to prepare the first dose, so the usual checks were circumvented. I have
nothing much to say, because what happened could have been prevented had we
only done the things we know we should have done.

Once Amy is stable, I reluctantly return home after leaving instructions to page me
if her condition changes. After falling into an uneasy sleep, I hear a loud noise and
reach for the pager on the nightstand, only to realize that it is the alarm clock. I shut
off the alarm, sit on the edge of the bed in a cold sweat, and realize that it was only a
dream. I quickly dress and settle into my favorite chair, breathe a deep sigh of relief,
and start to think.

I think about the pediatric satellite pharmacy that was not open to check the patient
profile and mix the first dose. I think about the bar-code syringe system that
would have caught the error but was never funded and about the override procedure,
which should never have been allowed, that gave the nurse access to the vial. This
mistake would be recorded as a nursing error, but in our hearts we know that pharmacy
has set the nurse up by the things we have failed to do.

I chose to share this because such dreams were common for me and the patients
and issues were always real. I wanted us to feel the experience of a serious error and
be reminded of how easily one can occur, even in our best health systems. Three
messages are clear in this dream. First, when we put faces on our patients, we realize
just how serious this business of pharmacy really is, with the potential for good or bad
things to happen to patients on the basis of what we do or fail to do in our daily
practice. Second, when we look around that conference table, it is apparent that nobody,
not even those who seem to care more about bottom lines and egos, wants bad
things to happen to patients. And third, it is brutally clear that the ultimate responsibility
for drug therapy outcomes rests with the pharmacist. No one in that conference
room had the slightest interest that night in turf battles, clinical control, budget cuts,
or contesting the pharmacist for final responsibility. So I want for us to consider that
final responsibility, how we are doing as a profession in that respect, and what we
must do to avoid a real call in the night.

Pharmacy’s quality chasms

An Institute of Medicine (IOM) report in 2001 used the term “quality chasm” to
describe the gap in quality practices in health care.(1) Pharmacy has its own version of
such chasms, including the striking disparity between the sophisticated technology
and clinical services in some hospitals and the lack of basic services in others, particularly
in small, rural, and urban charity institutions. Another disparity lies within our
advanced hospitals between the clinical care and quality checks available during certain
shifts and for patients in some areas, such as intensive care, and the lack of basics
in other areas like pediatrics, the nursery, and outpatient pharmacy. Our clinical services
are often what I call hydromorphic in that, like water, we simply allow them to
go wherever there is the least resistance rather than the most proven need. Our acceptance
of these common gaps in care demonstrates a contradiction between our
actions and words regarding what we consider to be the essential core of pharmacy
practice. One of my greatest disappointments has been our failure, after more than
30 years, to clearly define and imbed an undeniable core of clinical practice that
protects the patient in every pharmacy setting. We have educated ourselves to the
point of being almost overprepared for what we are not yet doing – providing clinical
services for all patients all of the time. We are paid better than ever for tasks, many of
which we should probably stop doing so that we can do what we truly believe will
benefit our patients.

Some good news

Despite these chasms, there is some very good news to report. Never in the history
of our profession have we been in a better position to ensure that our patients receive
safe and appropriate drug therapy. I believe we now have the technology and information
systems that can remove 90% of the error potential that lies in the distributive
process. We also have over 25 years of proven clinical practices that, if applied consistently
on behalf of all patients, have the ability to prevent over 90% of preventable
adverse drug events. Thanks to the IOM reports(1,2) and the excellent work of the
Institute for Safe Medication Practices, we have finally focused the attention of the
health care community and the public on medication safety. Pharmacy must capitalize
on this momentum before the fickle public moves on.

My greatest concern is that, despite this wonderful opportunity, 5 or 10 years from
now another pharmacist will be here describing identical or similar pharmacy chasms
that continue to put our patients at significant risk. The most recent ASHP national
survey revealed that only 1.5% of U.S. health systems use bar-code technology, which
can eliminate the errors of administering the wrong drug or a drug to the wrong
patient.(3) Such proven technology should be as basic as radar in the airline industry.
Can you imagine if only 1.5% of the airlines used radar? You and I know that there
are many reasons for this lack of implementation but I doubt Amy’s parents would
understand. Surely our job as professionals is to be discontented with anything less
than the best possible care we can provide. Patients and families do not know what
that care is, other health care professionals and administrators do not know, and,
fortunately, most lawyers do not know, but competent and conscientious pharmacists
do. It is our duty, both in our institutions and at the public policy level, to define
quality care and lead the effort to mandate the core standards of pharmacy practice.
Our patients, the health care team, and the public expect nothing less.

Failure of traditional strategies

For decades, pharmacists and pharmacy leaders could be relatively successful just
by being conscientious, working hard, avoiding conflict, quietly dispensing drugs
and related information, and doing a little “clinical” if any time was leftover. Many
believed that if we did a good job, our bosses would recognize the value of pharmacy
and intercede on our behalf in matters of budget and resources. However, competition
for resources in today’s hospitals is the ultimate zero-sum game, indicating that
this reticent professional strategy is no longer working very well. Today’s highly competitive
economic and political world requires leadership and communication skills
far beyond anything demonstrated in our past. Failure to adjust to this harsh reality
ensures that pharmacy receives minimal support and gets only the budget leftovers in
most systems. Thus, many services are gradually deteriorating into a survival mode
called mediocrity, working hard but barely holding on. Yet, a 50% increase in a typical
pharmacy staff budget would increase hospital costs by only about 1% (based on
average pharmacy costs equaling about 10% of overall hospital costs, with pharmacy
salaries plus benefits equaling about 20% of those pharmacy costs). Making this case
may be the most important thing we can do in pharmacy. Surely patients like Amy
warrant such an investment.

A new direction

According to a Chinese proverb, “Unless we change our direction, we are likely to
end up where we are headed.” Since Hepler and Strand(4) introduced the concept of
pharmaceutical care in 1990, we have been far more effective in using the terminology
than at practicing it. Many believe scarce resources and the lack of payment for
clinical services have been our greatest barriers. I believe the greater barrier resides
within the psyche of our profession. Such clinical care requires a transformation even
more fundamental than many of us realized, not just in our practice duties but in our
professional self-concept and approach to pharmacy practice. We can no longer go
behind closed doors and make such a change within our traditional sphere of influence.
The very nature of clinical practice requires a whole new level of self-confidence,
communication, and interpersonal skills. This change must occur not only in
directors, although it certainly starts there, but in all pharmacists. With today’s decentralized
operations and clinical services, the focal point for practice has permanently
moved beyond the walls of pharmacy. As a result, pharmacy middle managers, staff,
and clinicians have much the same professional demands and autonomy as yesterday’s
pharmacy directors. Few directors today can manage in a top-down fashion
because most pharmacy staff members are not physically accessible for such a management
style to work. It is now a “wind them up and turn them loose” game, with
pharmacists needing diverse abilities, such as clinical and financial expertise and skill
in human relationships.

Expectations of today’s successful pharmacist

With our practice focal point having moved outside of pharmacy, pharmacy staff
and leadership must now meet a dramatic new expectation – to develop a clear vision
and demonstrate the resulting core practices, both clinical and distributive, in the
trenches of patient care. Meeting this expectation requires the building of a coalition
of support, first within our own staff and then with other members of the health care
team.

Working with over 500 physicians for many years, I learned that clinical credibility
is achieved by demonstrating that we (1) truly care about the patient, (2) are unquestionably
competent to perform our professional duties, and (3) are absolutely committed
to fulfilling our professional responsibilities. Pharmacy leaders must carry the
same message to the chief administrators, medical staff, the board of directors, and
the public. All too often, health-system administrators believe that good pharmacy
service simply means passing inspections by the Joint Commission on Accreditation
of Healthcare Organizations, keeping reported complaints and errors to a minimum,
and holding costs below the 25th percentile of some arbitrary benchmark level. Without
an equally clear standard for quality, how can we simply use low cost as our sole
criteria? Yet, we do. However, make no mistake about it, to be successful pharmacy
directors today, we must be as good at managing the finances of pharmacy as providing
clinical services. Failure to deliver financially will virtually eliminate the opportunity
to deliver the clinical care we envision. In addition to the obvious requirement of
clinical competence, pharmacists must fulfill a myriad of expectations, including being
(1) effective communicators, able to build consensus for quality practices, (2) strategists,
tacticians, and skilled negotiators (sometimes even politicians), (3) innovators,
risk takers, and entrepreneurs, and (4) motivators, marketers, and salespersons to
generate enthusiasm for change. None of these expectations are part of the traditional
pharmacist’s psyche. Successful pharmacists project a professional attitude and appearance
that is self-confident but humble, assertive but not aggressive, always articulating
a clear message that defines quality and the requirements for delivering it.

The moral

Before we become too concerned that pharmacy, as a result of this “sea change” in
thinking, will be overrun by slick salespeople and activists – in my opinion, the snail
darter and redwood tree have more active support than medication safety – it is important
that this more assertive professional style be grounded with a critical set of
character traits.

“If you always do right,” wrote Mark Twain, “this will delight some and astonish
the rest.” Pharmacists must have character and courage, both more essential than
ever because the financial stakes and corporate influences in pharmacy have escalated,
and require an unquestionable moral compass. The necessary traits include

• A solid foundation of principles, including honesty, integrity, genuine
  concern, love, respect for others, a sound work ethic, a proper
  view of material things, and commitment to family, friends, and
  country,
• An enduring passion for the profession, including a commitment to
  something bigger than self, a paycheck, or a 7-hour, 59-minute
  workday,
• An unwavering commitment to lifelong learning and the willingness
  to change,
• An ability to stay the course, which in today’s world requires the
  courage to (1) say yes when something is the right thing to do, even
  though it may be unpopular, difficult, or have a significant risk of
  failure, (2) say no to financial or corporate pressures if patient care
  or the profession could be compromised, (3) confront a physician,
  administrator, or peer when a patient’s best interest is at risk, (4) let
  go of traditional duties that no longer are necessary, (5) persevere
  and stay at the health system for the good of the team and patient
  care when times are difficult and challenging, and (6) leave the
  institution when basic principles of practice, safety, and patient care
  are threatened and differences cannot be reconciled,
• The wisdom to take professional duties seriously while never taking
  oneself too seriously. This means having fun along the way, enjoying
  the moment and people, taking time to tell others “thank you” and
  “I care,” always giving more than required, and leaving the things
  we cannot control to divine providence, and
• The ability to make the right call during our professional “accountability
  moments” by taking a second look at a problem, spending
  extra time speaking with a patient or mentoring a colleague, listening
  to a suggestion, or fighting harder to ensure that the right thing is
  done for the patient.

I have learned from the best in our profession, many of whom are in this room,
that character can easily be described in words but can be taught only by action and
example. This was best stated by St. Francis of Assisi centuries ago when he said, “It
is no use walking anywhere to preach unless our walking is our preaching.”

A clear plan of action

Although it is our professional responsibility to be discontented with substandard
care, there is an inherent danger that we will become disillusioned, even cynical, as
we struggle with each day’s realities. The answer is to always associate with winners,
learn from them, and develop a clear and positive plan of action. Such a plan has
many components.

• We must use our experience and seasoned voices to make students,
  residents, colleagues, and educators aware of the conflict between
  our professional ideals and the economic imperatives of the world in
  which we practice.
• We must encourage, through our own actions and words,
  tomorrow’s practitioners and leaders to attack this conflict with
  action and a passion driven by the “face of the patient.” We should
  approach this campaign with the same unrelenting commitment as
  the late President Reagan, who, against popular opinion, declared
  that communism in Eastern Europe and the cold war were no longer
  acceptable. He followed with focused action, and a few years later
  the Berlin Wall fell and the cold war ended. Focused, positive
  actions by pharmacists can close our quality chasms in an equally
  profound fashion.
• We must adopt an undeniable set of core clinical practices and
  quality pharmacy services that should be provided to every patient.
• We must – from the patient care unit to the chief administrators’
  offices to the budget table – proactively and clearly define the problems,
  outline the necessary core practices, and confidently request
  support and resources. No more reticent budget strategies, no more
  waiting for validation, no more waiting for endless analyses and
  studies or for someone else to act.
• We must see that our mother ship, ASHP, expresses the voice of the
  proactive professional, a voice that commits pharmacy to the core
  practices that every patient has the right to expect. ASHP’s 2015
  Initiative and Leadership Agenda are exciting first steps, and the
  ASHP Foundation’s efforts in research and education will be the
  catalysts for change.
• We must urge ASHP to work aggressively to educate health-system
  executives about pharmacy’s vital role and the critical importance of
  positioning the professional properly within the system structure.
  Even the most effective pharmacist trapped under a weak structure
  will find this essential progress difficult, if not impossible. We must
  encourage the development of a position of chief pharmacy officer
  or equivalent, structured appropriately and responsible for the entire
  medication-use process. This professional must be held to the
  highest standards of competence and ethical values.
• We must cultivate the mind of this professional by exploring and
  teaching (1) new ways of thinking, decision-making, and creative
  problem solving, (2) techniques for communicating and dealing with
  controversy and conflict, and (3) innovative skills and techniques
  proven in other industries, such as quality management, process
  redesign, and human relationships.
• We must continue to strengthen the unique professional network,
  our band of brothers and sisters, that has served us so well for decades,
  using ASHP as the time-tested conduit to share our fears and dreams,
  successes and failures, and, most of all, our shared beliefs for improving
  patient care. This network is our greatest asset in institutional pharmacy.
  Tomorrow’s pharmacists will need it even more.

When historians look back on this era, I hope they will record the following:

As technology, clinical practice, and public awareness converged,
pharmacists made a conscious decision to permanently move beyond
the limits of practice centered on products to one centered on
people and patients. They took charge of their destiny and assumed
full responsibility for the medication-use process and drug therapy
outcomes. They learned to work with and through people, and the
quality chasms of the past were virtually eliminated. Patient outcomes
improved dramatically, and the profession grew in wisdom
and stature.

Conclusion

When the telephone rings in the middle of the night, it is most important that we
can answer that call with a calm confidence. That confidence comes only when we
know in our hearts that we have done everything possible to take care of our patients,
never failing to take a stand, confront an issue, or lead a battle to ensure that quality
care is delivered. To sustain that approach, our practice must be based on the basic
belief that pharmacy is ultimately not about technology, computers, budgets, or even
drugs but about the people we serve and our genuine love, respect, and concern for
them. It is about Amy and her parents, our pharmacy team, the nurses and physicians
we work with every day, and society and our duty to mankind. Being a pharmacist
is a privilege and a blessing bestowed by society on a relative few. With such
privilege also comes a responsibility – a sacred professional duty – to continually define
quality by our actions and never, never be content with anything less.

***

Any references cited in this lecture are available in the PDF version.

Originally published in Am J Health-Syst Pharm. 2004; 61: 1779-84.
© 2004, American Society of Health-System Pharmacists, Inc. All rights reserved.
Posted with permission.