Harvey A.K. Whitney Award Lectures

Intimations on a Profession: Retrospect and Prospect

The intent of the Harvey A.K. Whitney lecture series, now in its 37th year, is
to serve as a partial chronicle of the history and culture of institutional
pharmacy in the United States. The evolution and development have involved
many men and women whom I shall refer to as “pathfinders” – people who
lived the history.

My presentation will center on some observations about a few early developments
and the meaning of these developments to the present environment. Some suggestions
on unfinished business will be made.

Harvey A. K. Whitney was an original and creative pathfinder in practice and in
his broad outlook for the profession. Working with him daily was infectious and inspiring
for a lifetime.

“Uncle Harvey”, or the “Chief” as we knew him, would have blessed a short break
at an Annual Meeting such as this one, as a change from science and business, to
look broadly at what has made a group “tick” with some success. He would have
endorsed a little pause for reflection on some values and roots as he may have seen
them. Our 45 years of existence as a Society should allow us to look back and
make some judgments.

The hospital pharmacy movement within an older pharmacy profession has had its
own distinct historical turning points. Joseph A. Oddis referred to four stages of the
American movement in his Whitney Award lecture. Other stages have developed.

In my own lifetime, I have been privileged to be part of three of the stages, including
what I would call the “joy of development” and the “pain of adversity.” As an
officer of ASHP, I found joy in helping our Society, after five years, finally establish
a headquarters in Washington; volunteers were replaced by a paid staff, persons
who came from hospital pharmacy ranks. There were many satisfactions like that
for us all.

Pain came when we learned of the Society’s financial deficit. We tried, with other
executive officers, to achieve long–range solutions. This mixture of joy and pain, in
retrospect, developed in me a lifelong “labor of love” attitude towards the profession,
as cloying as that phrase may sound. Involvement brought that commitment.

From each evolutionary stage, certain characteristics developed that may have remained
for the profession and the Society to recognize today. Without any modern
fashionable jargon, these characteristics can be described as simple “fundamentals”
stemming from the thinking of many early pathfinders.

Before we move into heavier material, let us pretend that we are not pharmacists
but are outsiders looking at a group. We shall test a few areas to see where that group
of professionals came from and where they are in 1987. Then we shall examine the
significance of these areas.

One characteristic of a profession is that it has its own special body of knowledge.
The evolution of hospital pharmacy literature is a major resource and strength.

We are now a long way from the early pathfinders, Harvey Whitney and Leo Mossman,
who personally pecked at the typewriter to communicate “tips of the trade” and
editorials. The sporadic, two–page, green stenciled publication had a proud masthead
proclaiming, “Official Bulletin of the American Society of Hospital Pharmacists.”
From the beginning, these pathfinders intended that this medium would be the added
“glue” to bind people and aspirations together for professional development. Because
of that belief, many decisions were made along the way to keep the medium alive.

Having passed through many growing stages, the American Journal of Hospital Pharmacy
is the official centerpiece today – the “flagship” publication. By all professional
measures, it continues to advance in its literary quality, content, and range of technical
information. The significance of the Journal is that it has greatly enriched the body
of specialized pharmacy information while meeting the practitioner’s needs in various
historic periods.

Some people say that hospital pharmacy, to become a “profession” in itself, depends
on pharmacy in general for its theory base. Who knows but that the developing
specialized body of knowledge may eventually lead to that final rung, which would
be the evolution of our own theory base, distinct for institutional pharmacy, and
support yet unforeseen functions and techniques. It is visionary but intriguing!

The quality of editorials in the American Journal of Hospital Pharmacy has its own
significance. The editorials appear to me, as a reader, to have great value for today’s
busy practitioners by summarizing contemporary issues, all expressed in fundamental
and simple terms. Of equal importance is that the editorials serve as a major communication
link for a huge membership to achieve a unity of purpose. This unity of
purpose has been regarded as unique to, and the hallmark of, hospital pharmacy
among all of American pharmacy practice areas. Some people contend that this consensus,
cultivated very diligently, has historically been the energizing influence for
the rapid developments in this pharmacy practice area.

The body of knowledge continues to grow through a supplemental support system
of many official Society publications and programs for the practitioner. This support
system serves a paramount need for frontline pharmacists, who increasingly require
knowledge and information as their compounding role fades. Major advances in this
support system are the innovative uses of the latest in computer technology and the
beginning of consumer–designed information to extend the mission of the “safe and
appropriate use of drugs” into the hands of the public.

Two programs in the support system deserve a nod in view of their track records.
One is International Pharmaceutical Abstracts, which abstracts over 600 worldwide pharmaceutical,
medical, and health care publications. No practitioner could do that alone.
The other program is the American Hospital Formulary Service Drug Information. In my
judgment, it is the outstanding contribution of the Society to American hospitals,
other health professionals, and patients for the “safe and appropriate use of drugs.”
Most hospitals in the United States subscribe to this publication year after year, signifying
its value in providing detailed information on practically every drug in the
United States. The American Hospital Formulary Service Drug Information now has had
more than 25 years of broad national acceptance. It extends the profession’s mission
through thousands of people in most American hospitals. That is involvement in our
mission!

These foundations have expanded the body of knowledge for hospital pharmacy
and have kept pace with related, rapid advances in health sciences and health care –
no mean feat.

A profession that attempts to achieve a unity of purpose develops order through
some formal organization.

ASHP developed its thrust in the “American way,” using scattered volunteers for
the initial five years. These hospital pharmacy volunteers, with working officers and
committee members, were the “staff.” ASHP has evolved today into a sophisticated
and refined organization, with more than 100 staff people supporting 22,000 members.
The form of the organization has changed over the years to fit different times.
But each age has its fashions, concepts, values, and aspirations. The formal organization
must adapt. With its record of above–average resiliency, ASHP stays viable regardless
of changes in the players and pathfinders.

The early pathfinders applied some simple fundamentals to the organization of
effort for the Society. One of these fundamental ideas was that ASHP would do for
the practitioner what the practitioner could not do for himself. By providing information
and knowledge for the profession, educating working practitioners, and stimulating
the organization’s evolving public influence and credibility, ASHP has achieved
this goal.

Another fundamental was that the “network” of state groups in a formal organization
is the primary area for action (the grassroots). Here, health–service–oriented goals
are proved. In addition, ASHP appears to have made a conscious and deliberate
effort over the years to value the importance of each member and the affiliated organization
as the real epicenter for promoting and advancing standards and public service,
rather than establishing a central power base, except as it serves to establish unity
of purpose.

Today, we can see the growth (and retention) of a total of 49 state chapters, some
having their own staff. They maintain constant relationships with the national core.
ASHP Board and staff last year made outreach–personal contact visits to 33 of the 49
state chapters. In addition, regional sessions were held across the country for a twoway
exchange of information and attitudes on current issues.

What about the signs of support being returned from the grassroots? The two–way
liaison and local support appear to be working well. One piece of evidence is the
reported 85% response from members on recent national surveys issued from ASHP
headquarters. Another piece of evidence was demonstrated at this Annual Meeting.
As many as 90 points or current issues and policies surfaced for review through different
councils or groups (the formal organization), as officially recorded in the House
of Delegates report.

An outside estimate of the formal organization would show that it is in touch with
those older precepts, or fundamentals, and that it has strong participation from members,
with genuine support from the grassroots. These characteristics must be guarded
as a legacy for future pathfinders and leaders.

Institutional pharmacists and their Society have been cited by pharmacy media
reports as “pharmacy’s most dynamic group.” It is interesting how the informal and
social organization contributes one or two characteristics to this description.

Those of us who were on the faculty of the first “refresher course” or “institute,”
held at the University of Michigan in 1946, saw 136 hospital pharmacists almost euphoric
about the new learning experience, not because of the faculty but because of
the ability to “interchange information” – the announced purpose of the institute.
The new format also stimulated hospital pharmacists because it was a departure from
the traditional American convention program for professionals. It was a first in the
pharmacy field. It was all learning, scheduled for 4½ to 5–day sessions from 8:30 to 5
and again from 7 to 9, with educational lectures, “show and tell” hands–on demonstrations,
and spirited panel–audience interchanges. There were purposely scheduled
periods when people could cluster and “jawbone.” These “rap sessions” helped to
develop changes in patterned behavior and attitudes – a prime goal of the educational
sessions.

One characteristic of these meetings has been described as a literal “self–awakening,”
a self–motivation to reevaluate the standards of service the hospital practitioner
provided (or the employer permitted to be provided). Additionally, in the informal
contact with peers and in some “smoke–filled rooms,” other ideas arose concerning
service improvements that could be introduced and achieved back home.

A second observable characteristic of the informal sessions was described by Sister
Mary Florentine and Clifton J. Latiolais in their Whitney Award lectures as the “enthusiasms,”
“verve,” “vigor,” and “dedication” that the groups generated. A practitioner’s
view was expressed as follows: The most valuable thing I got out of the meetings
was when I got together with my friends and we talked till the wee hours of the
morning on what we heard and how we could use it back home.

The informal, programmed time helped stimulate motivation and that initial selfawakening
spark to improve services. The purposely limited size of the institutes
(125–135 attendees) fostered the intimate interchange of information.

Time and growth factors have changed the way such educational sessions are conducted.
Today, for example, the ASHP Midyear Clinical Meeting attracts the largest
gathering of pharmacists in the United States and the world – as many as 10,000.

We trust the human spirit to achieve self–awakening, and we hope that self–motivation
still accompanies the educational benefits derived from the meetings, despite the
large attendance. Only the individual participant can answer that question.

Hospital pharmacy has taken the responsibility to “train its own” to provide skilled
professionals. Like its companion profession – medicine – pharmacy’s early philosophy
maintained that “the hospital is the college,” not the lecture room or laboratory
bench alone. From the days of Edward Spease and Harvey A. K. Whitney, it took
over 40 years of advocacy by institutional pharmacists before colleges of pharmacy
fully accepted that premise.

Some of us early “interns” experienced the positives and negatives along the way,
such as misgivings about being considered “cheap labor” for the hospital; the voluntary
long hours on call; the timid and frightening curiosity of our first “post” (autopsy)
or surgical procedure as we stood beside the pathologist or surgeon; the initial thrills
of around–the–clock association with medical residents, including both work (ward
rounds) and play (billiards and squash) as we lived side by side in the “interns’ quarters”;
and the attendance in the amphitheater with more than 100 house staff physicians
at clinicopathological or specialty conferences. These events represented some
learning experiences Whitney and others thought important for future hospital pharmacists.

Across the United States, these early prototype “nonacademic internships” had
individual characteristics and variations, as designed by the pathfinder preceptors
like Whitney. Yet all of the internships in hospital pharmacy then could be counted
on two hands. Today, the growth and achievement are astounding to me. There are a
reported 188 ASHP–accredited residency programs for pharmacy in hospitals. In
one year, 1986, 400 graduates completed ASHP–accredited residencies. There have
been 4000 graduates from those foundations of “training our own.” Higher standards
have gradually evolved, including formal visiting teams for accreditation according
to refined guidelines.

The residency program has provided a major foundation and stimulus for the refinement
and long–term continuity of improved practice standards for institutional
pharmacy. Not all of the early visions of supplying manpower from this source have
been achieved; but trainees, ever since the initial programs, have had national influence
in the hospital pharmacy movement, in the affairs and events of American pharmacy
in general, and in the pace–setting hospitals in the United States. The residency
program has proved, over the long term, hospital pharmacy’s special commitment to
ensuring the continued education of skilled professionals.

One of my most vivid recollections of the evolution and development of the hospital
pharmacy movement is the continuing influential leadership and commitment of
women.

The Catholic sisters provided some of the greatest impetus and spirit of enthusiasm
for the profession and the development of programs. Many turned their pharmacies
in Catholic hospitals upside–down to provide advanced services following their
participation in institutes. Their presence was prominent in state affiliates and ASHP
committees and as ASHP officers, and they contributed much volunteer time. Their
contribution to American pharmacy, largely through ASHP, has not been told fully.

Women were in leading roles in the 11 city and state hospital pharmacy associations
even before ASHP started. They were among the strongest advocates for standards
and national development. Did you know that of the charter members of this
Society, almost 50% were women hospital pharmacists?

Women continue to be elected to key officer positions at both state and national
levels. The headquarters of the Society continues to have women with high levels of
management ability in positions of influence.

Some of the most lasting contributions, far beyond the call of duty, were made by
women pathfinders. Many foundation stones of today’s Society programs, systems,
and literature were first laid by the creativity and labor of these women. The place of
women in the affairs of the profession and in leadership contributions is an accomplishment
few other professions can match as an historical record.

Evolutionary development would have been slowed greatly without the economic
organizational development of ASHP and the stewardship of this development to
date. The method of funding the profession’s Society has been a potent force, allowing
the rapid evolution and expansion of programs and staff support and the development
of a sophisticated formal organization.

What I call the “economic organization” stemmed from the following philosophy
held by many pathfinders: Limit the burden of members’ assessments or dues whenever
possible to increase to the maximum the practitioner enrollment and thus professional
participation.

From 1200 members, a $3900 yearly fund limit, and a deficit in 1947, annual funds
now in eight figures have evolved through the efforts of many pathfinders. In 1986,
the income for the Society’s annual operating fund reached an amazing $12.3 million;
but more amazing is that almost 90% of it came from income sources other than
membership dues (e.g., publications, investments, and continuing–education programs).

What are the fruits of such an economic structure?
Two–thirds of all income is ploughed into education and professional information
(professional services); almost one–third goes into what we termed unity of purpose
(policy development). These accomplishments support the earlier ideals about the
real place of the formal organization.

The favorable and successful economic picture, as well as the continuing good
management of it, places many new horizons within reach. One new horizon is the
sending of added leadership into the international arena. A favorable economic picture
will allow for fuller participation now on a worldwide basis to help improve
health care and to work on pharmacy standards.

The results of promoting creative income sources (other than membership assessments
or dues) for the Society have been unusually successful, with prudent direction.
This strong funding base has led to extraordinary accomplishments and to accelerated
developments for institutional pharmacy and its practitioners.

A few characteristics have been examined that make up part of our history. In a
short time, historically speaking, some noteworthy accomplishments and developments
have occurred. This prompts me to suggest as “intimations” some unfinished
business for the profession as we adjust our focus towards “pharmacy in organized
health care settings” as the more recent orientation.

My first suggestion is that the formal organization, ASHP, should consider moving
more heavily to another level. ASHP should develop stronger credibility, more influence,
and added recognition at the level of public policy developments concerning
total health care, not just pharmacy.

This level of involvement would be a new horizon, beyond issues of safe and appropriate
use of drugs, although these factors would be included. It would entail helping
to resolve the broader health care needs and issues of the public. It would mean joining
and participating with newly identified leadership groups that clearly will affect health
care and national health policies, institutions, and programs. For example, ASHP should
collaborate closely with selected professional groups such as hospital administrators
(e.g., American College of Health Care Executives and American Hospital Association),
leading physician groups, health agencies (voluntary and government), and others.
A close collaboration should exist with formal organizations that have similar
stated goals of becoming more involved at the public policy level. It is my belief that
hospital pharmacy “movers and shakers” are ready to handle this new horizon.

Taking this direction would mean involvement at both community and national
levels through the ASHP’s existing network organization. It would not mean just a
liaison approach or propaganda, public relations, lobbying, protectionism, or establishment
of speakers’ bureaus to build credibility but would include strong participation
leading to the introduction of new ideas for the public health and welfare. It would
require new emphasis on an external, outward–looking approach, commitment, and
the necessary energy beyond that required for current internal professional priorities.

An accepted and a followed ethic is a core characteristic for a profession. Such an
ethic is my second suggestion.

Over the history of the hospital pharmacy movement, little or no direct attention
has been given, to my knowledge, to a deliberate implementation of our own written
set of principles for the specific guidance of institutional practitioners. I now suggest
this approach.

The mechanisms, accountability, and responsibilities of a professional organization
have not been established for the elimination of substandard practitioners and
practices. I now suggest this approach also.

The environment of “organized” health care settings can have its own distinct conflicts
of interest and deviations from ethical standards. Dealing with problems as they
arise under a generic code for all of pharmacy will underline the need for our own
standards specifically for institutional pharmacy.

I contend that a professed, guiding ethic is one of the most important foundations
yet to be developed for refinement of our profession.

My third and last suggestion for unfinished business is the prompt preparation of a
documented history of ASHP and the hospital pharmacy movement since 1952. I
understand that this suggestion may be implemented in the future. The availability of
first–source people and documents becomes more important as time goes by and
recollections fade.

But the major part of this suggestion is that the history (stated facts, events, dates,
names) include a strong parallel component of human and social interpretations, centering
on how key events came about. It should include the values, ideas, beliefs,
attitudes, customs, morals, behaviors, traditions, patterns, and systems that practitioners
as a group, and the pathfinders, attached to their profession during certain periods.
This history would begin to emphasize the foundations of a cultural perspective, along
with the purely historical facts and events.

We have available the outstanding work that Gloria Niemeyer, Alex Berman, and
Don Francke produced in Ten Years of the American Society of Hospital Pharmacists. It is,
in my estimation, a fascinating recorded history – a legacy. With their in–depth interpretations,
insights, and analyses of key events, the authors leave us with a deeper
understanding of the heritage of hospital pharmacy for the years 1942–1952. We
have had nothing comparable since 1952, a 35–year gap.

Bill Moyers, one of our contemporary documentary historians, said: “The future
being a mystery excites, but the past instructs.”

And now I must say adieu to a profession of the heart. Our professional group has
shown an enviable record of refinements. We have touched on just a few. ASHP and
its practitioners have developed a noble tradition for pharmacy, and a special dignity
of their own, in practices and professional conduct. We all turn now to the young
practitioners who are the pathfinders among us today. They are taking up the responsible
stewardship and commitment – ever onward in spirit and energy.

Harvey A. K. Whitney and his contemporaries would have said: “Ladies and gentlemen –
plus ultra! Press ahead and beyond to your own new horizons!”

Adieu. Thank you for the honor.

***

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

Originally published in Am J Hosp Pharm. 1987; 44: 1787-93.
© 1987, American Society of Health-System Pharmacists, Inc. All rights reserved.
Posted with permission.