Letters from the Edge
I have received some letters I would like to read. (These are imaginary letters.)
Message from the past: A greater purpose
Dear Mr. Ray [the first letter begins]:
I understand that your profession is conferring on you an award that honors and perpetuates the memory of one of the founders of your professional association. This is a laudable tradition, and I wish you well on this occasion.
You have asked for my thoughts regarding the following questions: (1) What is meant by a professional practice? (2) What qualifications must be met to merit the designation of a professional practice? and (3) Do the activities most pharmacists are engaged in qualify for designation as a professional practice?
Keep in mind that I am writing to you from the year 1940, and make of my comments what you will. Not having labored in your vineyard, I know very little about either the craft or the science of your profession; I will therefore not be able to respond to your third question. For my purpose in writing you, that is probably an advantage.
And I will not discuss the nature of a profession; it should suffice to say that a professional practice is predicated on a profession, and that the practitioner has mastered the fundamental theories and techniques associated with that profession. Rather, my comments will address the daily pursuit of a professional enterprise, which we call the practice.
In my era, the term practice was generally confined to the healing arts and the law. The work of two of the other traditional professions—teaching and theology—was typically referred to as a calling. In common parlance, the term professional practice refers to the transactions of the profession: the coming and going of clients, the dispensing of advice, the performance of specialized services, and the collection of fees.
A professional practice should have deeper meaning and purpose than the selling of a technical service or commodity. The ethical codes that the various professions have adopted keep us mindful of this point.
It is this deeper meaning and purpose that interest me, and I wish to approach the subject by pointing out two dangers that I fear are faced by professional people in the healing arts. The first pitfall is the insidious belief that all knowledge is gained through science. Unfortunately, the world of art has offered little in recent decades to counterbalance this notion. Science concerns itself almost exclusively with an understanding of the physical universe; it has failed, up to now, to improve our understanding of the essential human condition—of what it is to be human.
Beyond science is the unknowable—the awe-inspiring, the mysterious. It is the duty of the artist, through whatever muse he or she follows, to go ahead of us in exploration of the unknowable and return to help us understand the wholeness of the universe, the interconnectedness of man, and the inestimable value of each individual.
You who pursue occupations in healing have a dual duty, it seems to me: First, to continue your quest for scientific knowledge, mastering as best you can that which is known and aiding in the exploration of the frontiers of that knowledge, so that you move closer to truth. Second, to apply that knowledge humbly, in constant awareness that your knowledge is bounded by the limits of human consciousness. I urge you and your colleagues, therefore, to become as comfortable in the world of the poet and the philosopher as in the world of the scientist.
The second quagmire I fear your profession faces is that of imbalance between institutions, professions, and commercial corporations. My use of the term institution includes government, the university, and the church. Since you have sought me out for comment, I assume you are familiar with my views about the importance of each of these entities to Western civilization and, indeed, to our freedom, and about the risks attendant to an imbalance among these three cornerstones. Here, I will limit my remarks to the relationship between the health professions and the profit-oriented corporation. Having witnessed the intrusion of the stockholder into so many aspects of modern life, I will not be surprised if I learn that this intrusion extends eventually into the practice of the professions. Events of the past decade (i.e., the 1930s) might lead one to a different conclusion: that government, rather than the private sector, represents the greater threat to the integrity of the health professions. Yet, in the long view, I expect the profit-oriented corporation will rival government in this regard.
Let us be clear about the differences in purposes of the professions and corporations. The social value of professions is that they pursue purposes greater than personal ambition. They are predicated on theory, yet they recognize that theories are often wrong. They seek on behalf of society to refine theory and create new knowledge. Their scope rests on a defined body of knowledge, limited to what one can reasonably master. The practice of a profession—which is the subject of your inquiry—has a dual purpose: to apply the benefits of that knowledge to individual clients and to provide a crucible in which the theory is continually tested.
The social value of commercial corporations is that they provide a structure within which our free enterprise system can thrive. They enable those of modest means to participate in that system and to share in any material rewards it may produce. Because of the competitive nature of the marketplace, corporations have an incentive to constantly improve upon the goods and services they produce and to make their prices more attractive to purchasers.
It is the very notion of competition, however, that must be regarded warily by the professions. Competition leads to secrecy, controls over behavior, and, in the worst case, attacks on competitors. These conditions are inimical to professional growth. Professions thrive on shared knowledge, freedom to behave in a manner that benefits a client, and collegiality.
I hope it will be obvious that the professions and modern corporations depend on each other. Each contributes to an environment in which the other can thrive and in which society benefits. It would be great folly, in my opinion, to allow one to control the other, or to allow governments to control either.
I understand that your colleague Mr. Zellmer has written about the soul of your profession.(1) I have had an interest in the soul of nations and races of people, and of institutions such as universities and churches, but I had never given much thought to the prospect that a profession might have a soul. As I collect my thoughts in responding to your inquiry, I am prepared to say that a profession must have a soul; otherwise, it would cease to be a profession.
Not wishing to have my fame besmirched by any misinterpretation you may apply to my actual views on these matters, I respectfully request that you remind your audience that this is an imaginary correspondence. If you do so, I shall remain
Your faithful and obedient servant,
Alfred North Whitehead(a)
To which I responded,
Dear Dr. Whitehead:
It was a great honor to receive your letter. Thank you for helping us understand that a professional practitioner serves a purpose greater than his or her own ambitions.
Very sincerely,
Max D. Ray
Contemporary message: Asking hard questions
Here’s another letter I would like to share with you, this one dated April 1997.
Dear Mr. Ray:
This is in response to your recent inquiry regarding the nature of a professional practice and the degree to which pharmacy qualifies as a professional practice. I will attempt a very practical response to your questions.
I think it is commonly agreed that the following four criteria are associated with a professional practice: (1) The services provided by the practitioner must fulfill a recognized need, (2) the practitioner must be competent to conduct the practice, (3) the practice is predicated on the pursuit of the best possible outcome on the client’s behalf, and (4) the practice is based on an established method. I will offer a brief comment on each of these four criteria; perhaps these comments will help you determine the extent to which pharmacists’ activities constitute a professional practice.
Fulfilling a recognized need. It should go without saying that any successful enterprise in a market-driven economy is based on meeting consumer demands and expectations. Historically, however, the health professions have operated in a capacity-driven economy, and you have defined the needs of patients in your own terms. Think about two overlapping circles, one of which represents the needs of the public for medication-related services and the other, the activities pharmacists are currently engaged in. Ideally, the current-activities circle would be wholly contained within the current-needs circle, and would come close to filling it. Any part of your activities circle that falls outside the larger needs circle represents wasted effort. Any part of the larger circle not occupied by your activities circle represents potential for future professional growth.
During my tenure as Surgeon General of the United States, I advocated major changes in the way we deliver health care in this country, changes based on teaching healthy behaviors and combating those forces in society that destroy health, such as use of tobacco, easy access to handguns, and a damaged environment. I continue to apply my energies to such purposes. How does pharmacy contribute to the goal of health promotion and disease prevention? Do you have a plan?
One important admonishment: You should ask patients to express their needs in their own terms, rather than relying on your own intuitive sense of what those needs are. Perhaps the health professions need a “board of directors” made up of laymen to help them identify unmet needs. (I have had the thought that such a board might also help all of us in the health professions figure out how to work together more effectively, but I’ll save that for another letter.)
Competence. A professional practitioner must have mastered the knowledge and skills required to conduct the practice. In addition, I believe attitudes and values are important determinants of competence and are perhaps even more important than the knowledge and skills.
I am not very familiar with your systems in pharmacy for assessing and maintaining competence, but let me pose a few questions for your consideration. First, what do pharmacists mean by their claim to be “drug therapy experts”? Do you have some defined standard against which such a claim is measured? I hear pharmacists claim to be more knowledgeable than physicians about drugs. Do you think physicians believe this? Have you actually discussed this point with physicians?
What process do you have for ensuring your continuing competence? What assurances are you prepared to give the public on this point? What responsibility do employers have to ensure that health care professionals remain competent? For openers, I suggest that all employers of health professionals budget 10% of the time of each employee for continuing education and professional renewal. This amounts to an average of one day every other week.
Yet, it is ultimately each individual employee who must assume responsibility for his or her competence. Professional people must be capable of their own self-renewal—renewal not only of knowledge and skills, but of attitudes and values as well. I’ll leave it to others to talk about the need for self-renewal in our personal lives. Here, I will simply observe that competence to practice one’s profession derives in large measure from a capacity for self-renewal. Those worthy of the designation practitioner must be able to greet each client with freshness of purpose and approach each professional problem with renewed energy.
Practitioner–client relationship. A professional practitioner has a relationship with a client, based on a need that the client wishes to have fulfilled. The practitioner serves a client by pursuing the best possible outcome on the client’s behalf. This usually requires more than simply giving advice. Looking at pharmacy from the sidelines, it seems to me that you have had difficulty fulfilling this criterion. Is it possible for a pharmacist to establish a relationship with a patient outside the context of that patient’s relationship with a physician? Are you able to establish your own outcome objectives for a patient’s drug therapy, and pursue those objectives independent of the patient’s physician? I don’t think so. It seems to me that the future of your relationship with patients is dependent on your future relationship with physicians and the level of responsibility you are willing to assume as a member of a health care team. Perhaps you should begin exploring in earnest with physicians what sort of working relationship they would like to have with you in the future on the patient’s behalf.
Practice methodology. One hallmark of a professional practice is that it follows some sort of recognizable routine or pattern. Your clients, potential clients, and other professional people who consult you for advice or refer clients to you all need to know what you do and to be able to depend on you to do it on a consistent basis. My casual observations lead me to think that the public expects very little from pharmacy, apart from having prescriptions filled. As Surgeon General I received a number of communications from national pharmacy associations about the role of pharmacists in drug therapy problem-solving, patient education, and ensuring safe drug distribution and control systems. Are you actually doing these things? Consistently? What practice method have you adopted to achieve these objectives? Could someone look over your shoulder and observe you carrying out a series of steps that lead to these objectives? Should that observer expect to see any other pharmacist carrying out that same series of steps?
These questions are intended only to help you answer the question you raised about pharmacy’s qualification as a professional practice. I have no idea what the answers are. (I ask you to remind your audience that these comments are your supposition about what I might actually have said.)
Sincerely yours,
[The correspondent’s signature is that of a very prominent former U.S. Surgeon General.]
My response was as follows:
Dear Sir:
Your words leave me with a very unsettled feeling, but nothing would have been
accomplished with varnish. Please accept my thanks for your candor.
Sincerely,
Max D. Ray
Message from the future: New definitions in health care
Here’s the final letter I’ll read to you:
Dear Dr. Ray:
This is a voice from the future. You probably won’t remember me, but I was a member of the first class in the Western University College of Pharmacy. I graduated in the year 2000. I am writing you now from the year 2040. I am 65 years old; according to the latest actuarial printout I have 32.8 QALYs(b) still to look forward to.
So, how did the future turn out? The world in 2040 is as different from the world of 1997 as 1997 was from the time of Abraham Lincoln. I won’t have time to describe in detail the phenomenal change that has taken place. What I will say is that, of all the future projections that were whirling around in 1997, some of them have happened and many others have not. Most of what has happened wasn’t actually predicted. The human race has confronted some incredible challenges during these past 43 years, in just about every area you can imagine—a badly damaged environment, food and water shortages, disease, armed conflict, political upheaval, corporate greed—but we have also begun to solve some of these problems, and I believe we are generally better off than we were in 1997.
We began hearing in the 1990s about the “end of science.” I think that prediction had to do with the fact that the physical universe had, in the minds of some scientists, been fairly completely described. Particle physics, astrophysics, and molecular biology had developed to the point where we thought there was little left to discover about the nature of the universe and of life. And looking back, there was probably some justification for that point of view. But what we didn’t understand very well back then was the nature of what it is to be human. During the past 20 years or so we have come to realize more clearly that the paths of the scientist and the artist, the poet and the philosopher, are all headed toward the same destination.
But you are interested in the professions and professional practice issues.
Technological breakthroughs have changed all the professions. In fact, we no longer have the same distinct professions that we had back in 1997. We no longer have pharmacy schools, and guess what—nobody’s complaining about it. For that matter, we no longer have separate schools for physicians, nurses, family nurse practitioners, physician assistants, physical therapists, podiatrists, and so on. We have general programs for health care professionals, with several postgraduate options.
Today we have six levels of health care and six corresponding categories of health care personnel. The first category is a group of health promotion generalists we call population health educators. Most individuals in this category are employed in our public education system. Their function is to teach health enhancement behaviors and skills to children beginning at age three and continuing through adolescence. When we first initiated this system, we made training available to adults as well as children, in order that all members of society might benefit from such education. Although it is not mandatory that adults receive health enhancement education, there are many financial incentives for them to do so.
The second level is holistic health screening. Actually, we don’t use the term “holistic” today because of its redundancy, but I use it here to help you understand what health screening involves. Practitioners in this category identify potential health risk factors—psychological, physical, behavioral, sociological, and economic—and develop appropriate corrective plans where problems are noted.
The third level is health recovery and remediation. Practitioners in this area supervise personalized behavior-modification and recovery programs (for both physical and psychological problems).
The fourth level is what we used to call “urgent care.” Practitioners in this category treat injuries and acute episodes of illness. Some are based in community treatment facilities and others in mobile units that are equipped to respond to patients’ homes or workplaces or to the scene of an accident.
The fifth level involves remote care. Practitioners in this category provide diagnostic and triage services from remote locations, using telecommunications technology. When appropriate, they dispatch an urgent care unit to the patient’s site to provide care or to transport the patient to an intensive care facility.
The sixth level we call life crisis care. It involves cases of severe injury or massive organ-system failure. This level of care grew out of the intensive care units that we were familiar with in the 1990s, although the treatment environment looks quite different today.
Closely associated with the health care delivery system is another category of professionals who provide supportive care for those who require special assistance in their daily lives (such as the very elderly and those with physical or psychological disabilities). This group also provides hospice care.
Pharmacy over the past 40 years has been absorbed into this type of health care system. Pharmacists have had to continually broaden their purview and their skills in order to remain a part of the system. But so have physicians and other health care professionals.
We think today (in the year 2040) of “disease” as a failure of the health care system, in much the same way that we might view illiteracy as a failure of the educational system. In 1997, the health care system was still very much a disease care system, despite all the talk about health promotion and disease prevention. Still, the seeds of our current health protection system were there in 1997.
I want to return briefly to your interest in the characteristics of a professional practice and in examining the extent to which pharmacists’ activities deserve to be called a practice. Now that I have told you that 40 years from now pharmacy as you know it will no longer exist, you may be tempted to give up on your inquiry. But that would be a mistake. I encourage you to continue your inquiry, in order to prepare for future evolution. In the late 1990s, more than at any other time, it is important that you clarify your social purpose and position in order to deal effectively with the changes that you will face. Let me see if I can make this a little clearer. Let’s return to your four basic qualifications of a professional practice:
- Societal need. I encourage you to continue to monitor the needs on
which pharmacy is based. Although the fundamental needs that the
profession addresses may be constant, the public’s expectations of
pharmacy are continually changing as technology advances, economic conditions fluctuate, and social values shift. And those expectations will begin to change more rapidly in the years just ahead, for the reasons I have already mentioned. - Competence. It will become much more apparent to you in a few
more years, but I think it was already fairly obvious in 1997 that
continuing competence will require continued learning, unlearning,
and relearning. The only practical way to remain competent in any
complex field will be to integrate the continuing-education process
directly into one’s work life. You may be interested to know that in
2040 we make no distinction between work life, continuing education, and personal life. These are all part of the fabric of life. Once
we began to figure that out, and began eliminating the compartments, most of us found we were leading much more satisfying lives. - Practitioner–client relationship. I remember how we were struggling
with this point in 1997. There were two parts to the issue. First, since
we had very little independent responsibility for any component of a
patient’s care, it was difficult for us to develop an enduring relationship with patients. Second, there was no practical way to receive
compensation for providing personalized pharmacy services (such as
patient education, consultation to physicians, or even detecting and
resolving life-threatening medication-related problems). It is critical
that you resolve these problems, because even your short-term
survival as a profession depends on it. And, although it may seem
that the rest of the world has no particular interest in whether you
survive or not, I can tell you that the health of society will suffer for
some time if you do not continue to develop as therapeutic experts.
At a time when medicine is orienting itself much more broadly to
primary care, and when midlevel medical practitioners with very
little training in pharmacology and therapeutics are assuming a greater degree of responsibility, pharmacy holds the key to therapeutics. - Practice methodology. I recall that, as a pharmacy student in the last
four years of the twentieth century, I was confused by the lack of a
consistent practice model from one pharmacy practice site to another. I remember that the public had very mixed ideas about what
we did as pharmacists. And I became aware of the range of expectations physicians had of pharmacists, based (I assume) on the inconsistent level of experiences they had had with pharmacists. It is
critical that pharmacists in the late twentieth century decide what
their role is and develop a practice method that ensures a consistent
level of service delivery and a common expectation among clients
concerning what you do.
Here’s the message I want to leave with you from the year 2040. First, pharmacy won’t simply disappear one day. Society has too much at stake in pharmacy, whether or not it seems that way to you in 1997. Pharmacy will evolve—so will medicine, nursing, and the other health care disciplines. This evolution will not be linear—it will occur intermittently, in major steps, usually in response to some technological breakthrough or some great pressure that has built up. Second, there will always be a guide when you need one. You can count on it. When I was a student you taught us how Barker and McConnell arrived on the scene at a time when we needed to be shaken out of our lethargy about medication errors. How Brodie and Parker, among others, provided the vision that helped transform the profession, in relatively short order, from a product orientation to a patient orientation. And how Hepler and Strand helped us move past structure and process in our practice to a focus on drug therapy outcomes. The prophet who will solve the tough problems you face today is no doubt in your midst as you read this. The only real danger you face is in being unprepared to hear the voice of that prophet.
Since this letter could have been written by any one of my classmates, I am withholding my name to allow you to imagine that it comes from us all.
P.S.: You can tell your friend Dr. McConnell that his vision of the year 2020(2) was pretty close to the mark.
(a)Alfred North Whitehead (1861–1947) was an Anglo-American philosopher and mathematician. He taught at Cambridge and Harvard. Among his better-known works were Adventures of Ideas and Science and the Modern World. A volume titled Dialogues of Alfred North Whitehead was recorded by Lucien Price.
(b)Quality-adjusted life-years.
***
Any references cited in this lecture are available in the PDF version.
Originally published in Am J Health-Syst Pharm. 1997; 54: 1827-32.
© 1997, American Society of Health-System Pharmacists, Inc. All rights reserved.
Posted with permission.
