Harvey A.K. Whitney Award Lectures

Hospital Pharmacy Looks to the Future

The first 10 years of the American Society of Hospital Pharmacists are now recorded history. In a great measure, the results of the past decade will ever stand as tribute to the inspiration and creative efforts of Harvey A. K. Whitney in whose honor the Michigan Society of Hospital Pharmacists has created this Lecture Award. Harvey Whitney’s achievements and his influences continue to leave a permanent mark on all of us who now practice hospital pharmacy, and we know it will continue for years to come. I consider myself particularly fortunate to be one of those whose efforts have been inspired by Mr. Whitney’s teachings. His sponsorship of the ASHP, his staunch support of the APhA, his pioneer work in hospital pharmacy internships, as well as his multitudinous efforts on behalf of hospital pharmacy, have been an inspiration to countless numbers in this field, as well as to me. He may well view with pride the ASHP as it begins its second decade of progressive activity.

During the past 10 years, hospital pharmacists have made a record which is recognized by all within our profession. But they are not ones to rest upon well-won laurels. While recognizing advances of the recent past, they are more interested in planning for the future. And they agree with Emerson when he said: “This time, like all other times, is a very good one if we but know what to do with it.”

As hospital pharmacy looks to the future, I hope I may be bold enough to suggest a few areas to which increasing attention should be given. These suggestions will not contain much that is new. In fact, as one attempts to find new approaches and new ideas, he is reminded of the words of the former president of Fordham University who said:

All true civilization is 90% heirlooms and memories – an accumulation of small but precious deposits left by the countless generations that have gone before us. Only the very proud or very ignorant people imagine that our muddle-headed present can begin everything all over again every day.

Tonight I shall limit my discussion to three points of what are in their entirety much larger problems. These are the expanding field of hospital pharmacy, the increase in professional responsibilities of the hospital pharmacist, and the increase in his professional consciousness.

Why is the field of hospital pharmacy expanding? Let us first look at hospitals in general for, after all, that is where hospital pharmacists function.

Hospitals are big business. In fact, they are the nation’s fifth largest industry, yielding rank only to such industries as food and steel.

Let us look further at hospitals:

This is the framework within which the hospital pharmacist functions. To say that pharmacists in hospitals play an important part in total medical care is to be conservative.

But there is very good evidence that the field of hospital pharmacy itself will expand greatly during the next few years. We know that today hospitals with less than 100 beds comprise our largest group of hospitals. But I believe this picture is changing. For example, 871 hospitals with between 50 and 99 beds reported that they were increasing their bed size in 1952 by an average of 66 beds per hospital. You can see what that will mean. In effect, it will mean that we shall have almost 900 new hospitals where full-time pharmacists will undoubtedly be employed. Of course, I don’t know where these pharmacists will come from. But it is of great significance to hospital pharmacy, to the colleges, and to pharmacy as a whole that these potential positions are available.

Further than this, 1535 hospitals with less than 50 beds reported an addition of an average of 28 beds per hospital in 1952. The effect of these figures on the future of hospital pharmacy is more difficult to evaluate because all of these hospitals are still less than 100 beds. On the other hand, today 20% of all hospitals under 50 beds and 38% of those between 50 and 99 beds do employ a pharmacist. Thus, it is not difficult to predict that of these 1500 hospitals, several hundred more will be adding pharmacists – or at least the potential is there.

There is also another large area in which expansion has taken place. A total of 933 hospitals of between 100 and 249 beds have added an average of 146 beds each during 1952. If we think in general terms of one pharmacist per 100 beds in a general, short-term hospital, then it is clear that several hundred new positions will open.

The total impact of these developments is difficult to judge precisely. However, I think we are relatively safe in predicting that there are now between 1000 and 2000 new potential jobs in hospital pharmacy.

Thus, hospital pharmacy is an expanding field, and it is a specialty which has become increasingly important to the APhA, to hospitals, and to colleges of pharmacy, as well as to manufacturers of pharmaceuticals. It is a field full of opportunity, a specialty which is only now developing its potential, a profession which has great promise for a brilliant future.

This expansion of opportunities in hospital pharmacy places obvious obligations upon the ASHP, the Division of Hospital Pharmacy, local chapters, colleges of pharmacy, and hospitals themselves. It calls for more publicity on the opportunities in our field; it means that we should devote more attention to the training of pharmacy interns; it means greater opportunities for graduate education in hospital pharmacy; it indicates a greater role than ever before for the hospital pharmacist in the distribution of drugs and an increased opportunity for hospital pharmacists to play an important role in pharmaceutical education of the future. I shall discuss none of these tonight.

One of the significant trends in hospital pharmacy today – and one which will become even more firmly established in the future – is the active role played by the hospital pharmacist in the evaluation and selection of drugs used in the hospital.

It is principally through his role as member and secretary of the pharmacy and therapeutics committee that he carries out these responsibilities. Today, more than ever before, there is a great deal of interest in the pharmacy and therapeutics committee, and an increasing number of hospitals are actively promoting the work of this committee. For some time, requests for information on the related subjects of the pharmacy and therapeutics committee and the hospital formulary have formed one of the largest single categories of information requests handled by the office of the Division of Hospital Pharmacy.

Now the pharmacist has always, in fact and by tradition, been a consultant to the physician in matters pertaining to drugs. Why then do we say that there is an increase in professional responsibility when this type of activity is nothing particularly new? It seems to me that the difference today, as it will be in the future, is one of degree rather than of new function. We know too that those pharmacists, whether in retail or hospital practice, who have served as consultants to physicians are the ones who have enjoyed the greatest professional prestige. There are several reasons today why hospital pharmacists have greater opportunities to act in a consultative capacity.

One of these is the tremendous advance in therapy accompanied by the introduction of a great number of new basic drugs. So rapid have been these advances that it is said that 90% of the prescriptions written today couldn’t have been filled 10 years ago. Is it any wonder that physicians have a difficult time keeping up with new advances?

But this is not the only reason why physicians and hospital pharmacists are working together more cooperatively. Another is the great number of product duplications and combinations introduced constantly. For example, these are the figures for 1951: firms, 86; products, 332; basic drugs, 35; duplication of basic drugs, 74; and combinations, 221.

These figures represent only those products introduced in one year. If we attempt to determine the cumulative effect of this practice for even a three-year period, we are confronted with a most confusing and chaotic situation. Over a period of but a few years, hundreds of combinations and duplications come and go, but it always seems that more come than go. And, of course, it is impossible for the physician to find his way alone through this labyrinth of complex and oftentimes controversial materia medica. He needs the assistance of the pharmacist and, to an increasing extent, those in hospital pharmacy are filling this need.

We see today that there are stirrings of a more objective approach towards sound drug therapy, and in this movement the hospital pharmacist plays an increasingly important role. In a recent article in The Bulletin, J. S. Mordell discussed very well the hospital pharmacist’s role in the support of sound drug therapy. He emphasized that the success of the program depends in large measure on the professional stature of the pharmacist. Mordell stated:

To some pharmacists, as to some physicians and dentists, this type of operation may mean a departure from deeply rooted pathways of thought and action. It calls for a new perspective in the handling of drugs. It calls for basic knowledge not only of technical pharmaceutical functions but of drug actions and use and the differences and shortcomings which may exist among drugs.

It seems to me that this trend, which is gaining momentum constantly, offers great opportunities for us as pharmacists to increase our professional responsibilities. Through our cooperative efforts with our colleagues in the medical profession, we can increase our value as professional men and women with resulting benefit not only to pharmacy but also to medicine, to our hospital, and to the patient. These are indeed goals towards which we should continue to strive. And as time moves on, I am confident that the hospital pharmacist will, through the efforts of the Society and its network of affiliated chapters, occupy an increasingly important position not only in the selection and procurement of pharmaceuticals but also as a valued consultant to the physician.

Of all groups in American pharmacy, none has increased in professional consciousness and stature during recent years more than have hospital pharmacists. Why is this? Of course, there are many reasons. One of them is the professional advancement which has come about through the development of the American Society of Hospital Pharmacists and the cooperative efforts of its members and local branches. Surely the Society with its 35 affiliated chapters and more than 2000 members, widely scattered but still working for the same prime objective, has been and continues to be an important reason for increased professional stature.

But it seems to me that there is even a more fundamental reason. And this I believe is the loyal support that hospital pharmacists give to the American Pharmaceutical Association. As you know, each active as well as associate member of the ASHP is required to be a member of the APhA. Local chapters of the ASHP have similar provisions in their constitutions and bylaws, and, as a group, they are very cooperative in enforcing this rule.

At first thought, this may appear to be a subject worthy of little emphasis. But actually it has many ramifications. To appreciate fully the implications of this strong support of the APhA, we must note one of the fundamental errors of American pharmacy. This is the error of poor professional organization, of uncoordinated activities, and of the failure of the American pharmacists to support their national professional organization. You will recall that when the American Pharmaceutical Association was founded, members of that organization went back to their home states to form state associations. These men very naively assumed that the state associations would be closely affiliated with the national organization. How sadly they were mistaken we know full well today. Hindsight is always more clear than foresight, but still it is very difficult to understand how a national organization could develop over the course of the century with so little effort given to sound organizational structure.

It is not a question of lack of organizations. Today we have at least 18 organizations which serve pharmacy nationally; nine of these are classified as professional in character and activity while the other nine are commercial. The aims and activities of these 18 organizations are uncoordinated and oftentimes in conflict. As a result, the quality and quantity of professional accomplishment are low. Not only this, but we must remember also that scarcely more than one-half of America’s 100,000 pharmacists are professionally minded enough to maintain membership in any pharmaceutical association.

It is my firm conviction that American pharmacy will not come into its own until we have a majority of our pharmacists actively supporting their national professional organization. Someone has defined an organization as a medium for the efficient movement of groups of men towards goals to which they aspire. How can we move American pharmacists towards professional goals until we enroll them in our association? Only when this is done will the association, its ideals, its ethics, its concepts of professional service become ingrained in all who practice our profession.

The state of affairs in our country is, of course, in sharp contrast to those in European countries where every pharmacist who practices must be a member of his national professional organization. As a result, pharmacists are united in their professional objectives and are powerful when they wish to sponsor a program for the welfare of the profession. For example, the National Health Service in Great Britain will eventually establish a number of clinics. But so far the Pharmaceutical Society of Great Britain, of which every British pharmacist is a member, has seen to it that patients have their prescriptions filled in an established local pharmacy. They have also required these local pharmacies to meet rather rigid requirements. A similar situation exists in France where the National Order of Pharmacists has persuaded hospital pharmacists not to fill prescriptions for outpatients in order that pharmacists as a group may more fully practice their profession. We recognize, of course, that similar attempts have been made in this country. But these have been characterized by efforts to gain certain advantages without any attempt to correct underlying difficulties.

The basic difficulty of American pharmacy has been well stated in the Pharmaceutical Survey:

Unity of purpose requires a unified utilization of power. This requirement pharmacy has not met . . . . Throughout the survey there has been an accumulation of evidence indicative of the handicaps for the professional unity and professional progress of pharmacy due to the absence of any one recognized agency that speaks to us upon matters of fundamental policy.

Historically, the American Pharmaceutical Association should be the key organization, and under certain circumstances it does represent pharmacy. Yet no more than one-seventh of the pharmacists of the country are members of this organization. Consequently, the scope and speed of its influences are limited.

It seems to me that hospital pharmacists can take justifiable pride in the fact that they are leading the way for other groups in pharmacy to correct some of our gravest errors. By requiring membership in the American Pharmaceutical Association, they have served notice on American pharmacy that they are concerned not only with hospital pharmacy but with the welfare of the profession as a whole. It is relatively easy for specialists such as hospital pharmacists to be selfish in organizational matters and to build their own organization up, at the same time forgetting the total welfare of the profession. This is the general pattern that too many in American pharmacy follow. But it is truly exceptional and heartening to see a group like the ASHP place the welfare and strength of the profession of pharmacy above and beyond that of hospital pharmacy.

Again let me quote from the Pharmaceutical Survey:

The profession must contain a far greater proportion of members who are ever sharply jealous of the high reputation of the profession and who, by energetic cooperation, are determined ever to protect that reputation.

Hospital pharmacists as a group have met this challenge. But as we look to the future, we see that if we are to continue to add strength to professional pharmacy in America, we must redouble our efforts to see that every hospital pharmacist is a member of the APhA and the ASHP. Membership in the national professional organization is the first step in increasing professional consciousness of any pharmacist.

As hospital pharmacy faces the future, let us recall the words of John Stuart Mill who said:

History shows that great economic and social forces flow like a tide over communities only half conscious of that which is befalling them. Wise statesmen foresee what time is thus bringing and try to shape institutions and mold men’s thoughts and purposes in accordance with the change that is silently coming on.

The unwise are those who bring nothing constructive to the process, and who greatly imperil the future of mankind, by leaving great questions to be fought out between ignorant change on one hand, and ignorant opposition to change on the other.

Let us in hospital pharmacy anticipate the future and prepare for it. With vision, with courage, with a true recognition of our opportunities for greater service in public health, let us aim high in hope and work as we fulfill our obligations as members of an important segment of the public health team.

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

This lecture was never published in ASHP’s journal.
© 1953, American Society of Health-System Pharmacists, Inc. All rights reserved.
Posted with permission.