EDITORIAL
ACADEMIC PHARMACY PRACTICE AND RESEARCH John A. Bosso
WHY IS RESEARCH IMPORTANT to academic pharmacy practice? Why is it important that pharmacy practice faculty perform research? Why should research, in fact, be the major focus and effort of at least some of a school's pharmacy practice faculty? The driving need behind the answer to all of these questions is the legitimization of pharmacy practice as an academic discipline. The future well-being of all of academic pharmacy, particularly pharmacy practice, lies in scholarship. To elaborate on this point, a historical perspective of academic pharmacy and professional curriculum development is necessary. Hepler identified and labeled three eras in pharmaceutical education in this century that he related to the agricultural, industrial, and informational eras of American history. These, he labeled the "empirical," "science," and "patient care" eras.' The empirical era was based on pharmacognosy, as it had its roots in the agricultural era. The development of science in the early 1940s went handin-hand with the pre- and postwar industrialization of the country. The scientific disciplines of pharmacology and physical pharmacy were spawned and their development and maturation contributed greatly to the legitimization of pharmacy as an academic discipline. It must be acknowledged, however, that this important change heralded the introduction of nonphannacists (anyone who is not actively engaged in the practice of some aspect of professional pharmacy) onto the pharmacy faculty, a circumstance that is still with us today. The patient care or clinical pharmacy era began in the 1960s, with its focus on an old conceptthe pharmacist as a therapeutic advisor. What we know today as clinical or patient-oriented pharmacy had important beginnings in San Francisco in the mid 1960s with the advent of the University of California's six-year Pharm.D. program. Graduates of this program could actually make contributions to decisions about drug therapy. This breakthrough was greatly furthered at the end of that decade by the advent of some of the original post-baccalaureate Phann.D. programs (e.g., University of Kentucky). Such
JOHN A. BOSSO, Phann.D., FCCP, is a Professor, College of Pharmacy, University of Houston, 1441 Moursund St.. Houston, TX 77030. Reprints: John A. Bosso, Phann.D.
programs took an additional two to three years beyond the five-year bachelor of science in pharmacy curriculum and turned out a far superior product with even more impressive tools to bring to the patient-care arena. (Although some of these early post-baccalaureate Phann.D. programs still exist with all of their original vigor and excellence, our present lack of credible accreditation standards has led to a plethora of entry-level and post-baccalaureate programs of mixed character such that generalizations about the differing nature and quality of entry-level vs. post-baccalaureate programs are no longer possible.) The introduction and popularization of such ideas as "therapeutic advising," "provision of drug information," and "patient orientation" led to a number of new areas that needed to be incorporated into the pharmacy curriculum, Who would teach this new material-especially that which required actual experiential components in the patient-care arena? Obviously, it would be these new clinical pharmacy types who were being turned out of the post-baccalaureate Phann.D. and the clinically oriented M.S. programs. And, in fact, large numbers of such individuals were brought onto pharmacy faculties. It is critical to recognize that, at this point, the nature of pharmacy faculties had been changed as a direct result of the science era. Pharmacy was now considered to be a legitimate academic discipline and its faculty were judged along traditional academic lines: service, teaching, and research. Clinical pharmacists were added to faculties in greater numbers in the early and mid-1970s as clinical pharmacy (recently renamed "pharmaceutical care") became a highly desired option and eventually a basic requirement of the entry-level curriculum. However, the assimilation of these new faculty into the greater faculty was too often given little if any thought. Within a few years, the question of tenure came up. Some schools were prepared; they had either placed these new faculty members into a nontenure track or made the requirements and rigors of the tenure system abundantly clear. Other schools took easier ways out; they wrote separate, less-demanding promotion and tenure guidelines for these faculty, or they simply applied their usual criteria and, in effect, instituted a revolvingdoor policy for clinical pharmacy faculty.
DICP, The Annals ofPharmacotherapy
•
/991 October, Volume 25 •
lJ29
The bottom line is that schools ended up with large numbers of new faculty lumped in a discipline commonly referred to today as pharmacy practice. What academic "citizenship" do these faculty members hold? To answer that question, we first must examine the criteria for a legitimate academic discipline. In the physical and biologic sciences, it seems that legitimacy is afforded by a unique or focused body of knowledge that is generated, by-andlarge, by the members of the discipline. This definition suggests a program of scientific inquiry that requires physical resources and has the accepted, common academic result (i.e., publication in the peer-reviewed literature). The physical resources to which I refer include money, time, and space. Let's pause for a minute and focus on one of these elements-money. I stated before that the body of knowledge of an academic discipline is generated to a large extent by its own members. Externally generated research dollars fuel this enterprise. This is a reality of 2Othcentury higher education in the US. Thus, it should not be surprising that the contemporary powerbase in academic health sciences is built on externally generated research dollars. One should then ask whether academic pharmacy practice fits my definition of a true academic discipline. I would have to say "Not very often." Why not? Once again we must dust off our history books and examine the evolution of pharmacy practice in academia. Who was hired, what was the job description, and what resources were supplied to these people to carry out their charge? The who, as I've stated, were mostly post-baccalaureate Pharm.D.s-the advanced clinical practitioners who had the knowledge and skills now thought to be important for all pharmacists. The job description was to be a role model practitioner/educator for patient-oriented pharmacy practice in patient-care settings. They also were required to teach some associated didactic material such as pathophysiology, clinical pharmacology, and clinical pharmacy (collectively referred to today as pharmacotherapeutics). The job responsibilities I have just described imply a 30- to 6O-hour work week and often need to be provided 52 weeks a year. What resources were supplied to these new faculty? Generally, an office, a white coat, and maybe a beeper. Given this scenario, is it a surprise that pharmacy practice has no unique, focused, self-generated body of knowledge? Is it a surprise that pharmacy practice has no easily identified program of scientific inquiry? Is it a surprise that there is not a consistent, across-the-board record of publication by pharmacy practice faculty in the peer-reviewed literature? I think not. There are several reasons for this state of affairs. These new faculty did not have the education and training to perform the traditional tasks of the academician. They were not given the time to perform or carry out a research program of any substance, nor were they given the physical resources to perform this task (e.g., money, lab space). But some of these faculty have succeeded in this arena. They have succeeded admirably and on all fronts. It was pointed out in the pharmacotherapy petition to the Board of Pharmaceutical Specialties in 1989 that the number of pharmacotherapeutic research articles authored by pharmacists increased an amazing 343 percent between 1978 and 1982. Some members of our discipline obviously are performing credible research and succeeding in the tradi1130
•
Dltl]', The Annals ofPharmacotherapy
•
tional academic evaluation system. These individuals have learned how to do research. They have obtained the physical resources to create and maintain an active, well-funded research program. Unfortunately, they are the exception rather than the rule in too many schools of pharmacy. One or 2 individuals cannot create or mold the character of an entire pharmacy practice department. One or 2 of these individuals in a department of 15 or more members cannot create the needed academic powerbase. Why do we need an academic powerbase? It is because the people with the academic powerbase have the most influence on the professional curriculum. It is the department with an academic powerbase that can successfully compete for the college's resources and create and maintain faculty positions with a supportive environment for the growth and success of clinical scientists who then further contribute to the discipline's legitimacy and strength. Let's examine each of these points. First, departments with an academic powerbase have the most influence on the curriculum. At many schools, the basic science faculty wield this influence. By my definition, nonpharmacy practitioners dictate the professional curriculum. Please do not read this as a criticism of the basic science faculty. I am simply leading up to this question: Can we really expect nonpharmacists to have the needed insight to identify what is needed in contemporary curricula when they have no basis in contemporary pharmacy practice? Obviously not. The second point related to the creation and maintenance of a supportive climate for pharmacy practice involves the clinical scientist faculty member. The clinical scientist needs protected time, start-up money (as does the new pharmaceutics or pharmacology faculty member), and laboratory space. He also needs a reasonable teaching load and, even more importantly, limited clinical service obligations. We cannot expect a productive research program without this environment, nor can we expect the creation of an academic powerbase without a cadre of such individuals. If provided with this environment, pharmacy practice faculty should be evaluated along traditional academic lines. That means that we do not create and apply special retention, promotion, and tenure guidelines for the tenuretrack pharmacy practice faculty. They should be evaluated with the same yardsticks used for their basic science counterparts. The maturation and legitimization of the discipline will not be served by anything less. What constitutes legitimate research? This question should be approached cautiously. It is probably wise to refer to the area as "scholarship" or "scholarly activity" rather than "research," because "research" has a rather narrow definition and scope in the minds of many academicians. In any case, the answer ought to be that which is scientifically sound and adds to the body of knowledge regarding the clinical use of drugs in humans. Such work should be investigator initiated, although the source of the funding for such scholarly pursuits is largely inconsequential. At this point it should be clear why at least a critical number of clinical pharmacy or pharmacy practice faculty should fit into the traditional academician's mold and have solid research programs-to further the legitimization of our discipline. However, this position leaves an obvious, related issue unaddressed: If we give this job description to six or so pharmacy practice faculty in the average pharmacy practice department, who will teach? First, let me point
1991 October, Volume 25
Editorial
out that I did not state that such faculty would not teach. In fact, they should have reasonable teaching obligations. However, they will not succeed in the role I have described if they must teach major courses singlehandedly every semester and be "on service" most of the year providing supervision for clinical clerks. So, who will do the rest of the teaching? We obviously need some clinical faculty whose primary responsibilities are simply service and teaching. For such faculty, scholarship should be encouraged but not required. Such individuals are just as vital to the mission of the department as the clinical scientists and should have similar job security and award systems. But even departments that have good complements of these two types of faculty are either now having or in the future will have trouble meeting the experiential requirements of the contemporary pharmacy curriculum. How can this proposed model be accomplished? Just as pharmacy practitioners serve as faculty for extemship experiences in hospitals and community pharmacies, we must call upon nonacademically based clinical pharmacy practitioners to serve as preceptors for clinical pharmacy clerkships. Fortunately, the number of advanced level practitioners in nonacademic positions has increased dramati-
Of interest to practitioners, researchers, and students, this book presents various techniques, tools, and strategies to evaluate the economic contribution of specific drug therapies at a policy level and for individual patient needs. Chapters include Drug UseEconomics, CostBenefit Analysis, Cost-Effectiveness Analysis, Applications of Pharmacoeconomics for Drug Therapy Decisions, and more. 768 pages / ISBN 0-929375-02-5 / Paperbound
cally over the last two decades and represents a considerable pool of potential role model educators. Academic pharmacy must tum more and more to these individuals and their institutions to carry out its mission. At the same time, it should be realized that the notion of "volunteer" faculty may soon come to an end as the time and effort involved with the training of a clinical clerk becomes more evident to nonacademically aligned practitioners. Thus, colleges and schools of pharmacy should be prepared to start paying for such teaching services. Broad adoption of such a model for academic pharmacy practice should allow the diverse needs of academic pharmacy to be met. A critical mass of pharmacy practice faculty will be afforded environments for success as wellrounded academicians. A unique body of knowledge will emerge within pharmacy practice. Academic legitimacy will be achieved. Most important, a contemporary pharmacy curriculum will be designed and delivered, largely by pharmacist practitioners. ~ Reference I. HEPLER CD. The third wave in pharmaceutical education: the clinical movement. Am! Pharm Educ 1987;51:369-85.
Please send copies of Principlesof Pharmacoeconomics, at $29.95 per copy. Enclosed is $ - - - Name----------------Address---------------City-------------state/Country--------- ZIP - - Please bill: ( ) VISA ( ) MC Exp. d a t e ' - - - - S i g . - - - - - - - - Acct. No.
Prepayment isrequired. Send orders to:
HARVEY WHITNEY BOOKS COMPANY P.o. Box 42696 / Cincinnati, Ohio45242USA / Telephone 513/793-3555 / FAX 513/793-3600 DICP, The Annals ofPharmacotherapy •
1991 October, Volume 25 •
1131
ACADEMIC PHARMACY PRACTICE AND RESEARCH John A. Bosso
WHY IS RESEARCH IMPORTANT to academic pharmacy practice? Why is it important that pharmacy practice faculty perform research? Why should research, in fact, be the major focus and effort of at least some of a school's pharmacy practice faculty? The driving need behind the answer to all of these questions is the legitimization of pharmacy practice as an academic discipline. The future well-being of all of academic pharmacy, particularly pharmacy practice, lies in scholarship. To elaborate on this point, a historical perspective of academic pharmacy and professional curriculum development is necessary. Hepler identified and labeled three eras in pharmaceutical education in this century that he related to the agricultural, industrial, and informational eras of American history. These, he labeled the "empirical," "science," and "patient care" eras.' The empirical era was based on pharmacognosy, as it had its roots in the agricultural era. The development of science in the early 1940s went handin-hand with the pre- and postwar industrialization of the country. The scientific disciplines of pharmacology and physical pharmacy were spawned and their development and maturation contributed greatly to the legitimization of pharmacy as an academic discipline. It must be acknowledged, however, that this important change heralded the introduction of nonphannacists (anyone who is not actively engaged in the practice of some aspect of professional pharmacy) onto the pharmacy faculty, a circumstance that is still with us today. The patient care or clinical pharmacy era began in the 1960s, with its focus on an old conceptthe pharmacist as a therapeutic advisor. What we know today as clinical or patient-oriented pharmacy had important beginnings in San Francisco in the mid 1960s with the advent of the University of California's six-year Pharm.D. program. Graduates of this program could actually make contributions to decisions about drug therapy. This breakthrough was greatly furthered at the end of that decade by the advent of some of the original post-baccalaureate Phann.D. programs (e.g., University of Kentucky). Such
JOHN A. BOSSO, Phann.D., FCCP, is a Professor, College of Pharmacy, University of Houston, 1441 Moursund St.. Houston, TX 77030. Reprints: John A. Bosso, Phann.D.
programs took an additional two to three years beyond the five-year bachelor of science in pharmacy curriculum and turned out a far superior product with even more impressive tools to bring to the patient-care arena. (Although some of these early post-baccalaureate Phann.D. programs still exist with all of their original vigor and excellence, our present lack of credible accreditation standards has led to a plethora of entry-level and post-baccalaureate programs of mixed character such that generalizations about the differing nature and quality of entry-level vs. post-baccalaureate programs are no longer possible.) The introduction and popularization of such ideas as "therapeutic advising," "provision of drug information," and "patient orientation" led to a number of new areas that needed to be incorporated into the pharmacy curriculum, Who would teach this new material-especially that which required actual experiential components in the patient-care arena? Obviously, it would be these new clinical pharmacy types who were being turned out of the post-baccalaureate Phann.D. and the clinically oriented M.S. programs. And, in fact, large numbers of such individuals were brought onto pharmacy faculties. It is critical to recognize that, at this point, the nature of pharmacy faculties had been changed as a direct result of the science era. Pharmacy was now considered to be a legitimate academic discipline and its faculty were judged along traditional academic lines: service, teaching, and research. Clinical pharmacists were added to faculties in greater numbers in the early and mid-1970s as clinical pharmacy (recently renamed "pharmaceutical care") became a highly desired option and eventually a basic requirement of the entry-level curriculum. However, the assimilation of these new faculty into the greater faculty was too often given little if any thought. Within a few years, the question of tenure came up. Some schools were prepared; they had either placed these new faculty members into a nontenure track or made the requirements and rigors of the tenure system abundantly clear. Other schools took easier ways out; they wrote separate, less-demanding promotion and tenure guidelines for these faculty, or they simply applied their usual criteria and, in effect, instituted a revolvingdoor policy for clinical pharmacy faculty.
DICP, The Annals ofPharmacotherapy
•
/991 October, Volume 25 •
lJ29
The bottom line is that schools ended up with large numbers of new faculty lumped in a discipline commonly referred to today as pharmacy practice. What academic "citizenship" do these faculty members hold? To answer that question, we first must examine the criteria for a legitimate academic discipline. In the physical and biologic sciences, it seems that legitimacy is afforded by a unique or focused body of knowledge that is generated, by-andlarge, by the members of the discipline. This definition suggests a program of scientific inquiry that requires physical resources and has the accepted, common academic result (i.e., publication in the peer-reviewed literature). The physical resources to which I refer include money, time, and space. Let's pause for a minute and focus on one of these elements-money. I stated before that the body of knowledge of an academic discipline is generated to a large extent by its own members. Externally generated research dollars fuel this enterprise. This is a reality of 2Othcentury higher education in the US. Thus, it should not be surprising that the contemporary powerbase in academic health sciences is built on externally generated research dollars. One should then ask whether academic pharmacy practice fits my definition of a true academic discipline. I would have to say "Not very often." Why not? Once again we must dust off our history books and examine the evolution of pharmacy practice in academia. Who was hired, what was the job description, and what resources were supplied to these people to carry out their charge? The who, as I've stated, were mostly post-baccalaureate Pharm.D.s-the advanced clinical practitioners who had the knowledge and skills now thought to be important for all pharmacists. The job description was to be a role model practitioner/educator for patient-oriented pharmacy practice in patient-care settings. They also were required to teach some associated didactic material such as pathophysiology, clinical pharmacology, and clinical pharmacy (collectively referred to today as pharmacotherapeutics). The job responsibilities I have just described imply a 30- to 6O-hour work week and often need to be provided 52 weeks a year. What resources were supplied to these new faculty? Generally, an office, a white coat, and maybe a beeper. Given this scenario, is it a surprise that pharmacy practice has no unique, focused, self-generated body of knowledge? Is it a surprise that pharmacy practice has no easily identified program of scientific inquiry? Is it a surprise that there is not a consistent, across-the-board record of publication by pharmacy practice faculty in the peer-reviewed literature? I think not. There are several reasons for this state of affairs. These new faculty did not have the education and training to perform the traditional tasks of the academician. They were not given the time to perform or carry out a research program of any substance, nor were they given the physical resources to perform this task (e.g., money, lab space). But some of these faculty have succeeded in this arena. They have succeeded admirably and on all fronts. It was pointed out in the pharmacotherapy petition to the Board of Pharmaceutical Specialties in 1989 that the number of pharmacotherapeutic research articles authored by pharmacists increased an amazing 343 percent between 1978 and 1982. Some members of our discipline obviously are performing credible research and succeeding in the tradi1130
•
Dltl]', The Annals ofPharmacotherapy
•
tional academic evaluation system. These individuals have learned how to do research. They have obtained the physical resources to create and maintain an active, well-funded research program. Unfortunately, they are the exception rather than the rule in too many schools of pharmacy. One or 2 individuals cannot create or mold the character of an entire pharmacy practice department. One or 2 of these individuals in a department of 15 or more members cannot create the needed academic powerbase. Why do we need an academic powerbase? It is because the people with the academic powerbase have the most influence on the professional curriculum. It is the department with an academic powerbase that can successfully compete for the college's resources and create and maintain faculty positions with a supportive environment for the growth and success of clinical scientists who then further contribute to the discipline's legitimacy and strength. Let's examine each of these points. First, departments with an academic powerbase have the most influence on the curriculum. At many schools, the basic science faculty wield this influence. By my definition, nonpharmacy practitioners dictate the professional curriculum. Please do not read this as a criticism of the basic science faculty. I am simply leading up to this question: Can we really expect nonpharmacists to have the needed insight to identify what is needed in contemporary curricula when they have no basis in contemporary pharmacy practice? Obviously not. The second point related to the creation and maintenance of a supportive climate for pharmacy practice involves the clinical scientist faculty member. The clinical scientist needs protected time, start-up money (as does the new pharmaceutics or pharmacology faculty member), and laboratory space. He also needs a reasonable teaching load and, even more importantly, limited clinical service obligations. We cannot expect a productive research program without this environment, nor can we expect the creation of an academic powerbase without a cadre of such individuals. If provided with this environment, pharmacy practice faculty should be evaluated along traditional academic lines. That means that we do not create and apply special retention, promotion, and tenure guidelines for the tenuretrack pharmacy practice faculty. They should be evaluated with the same yardsticks used for their basic science counterparts. The maturation and legitimization of the discipline will not be served by anything less. What constitutes legitimate research? This question should be approached cautiously. It is probably wise to refer to the area as "scholarship" or "scholarly activity" rather than "research," because "research" has a rather narrow definition and scope in the minds of many academicians. In any case, the answer ought to be that which is scientifically sound and adds to the body of knowledge regarding the clinical use of drugs in humans. Such work should be investigator initiated, although the source of the funding for such scholarly pursuits is largely inconsequential. At this point it should be clear why at least a critical number of clinical pharmacy or pharmacy practice faculty should fit into the traditional academician's mold and have solid research programs-to further the legitimization of our discipline. However, this position leaves an obvious, related issue unaddressed: If we give this job description to six or so pharmacy practice faculty in the average pharmacy practice department, who will teach? First, let me point
1991 October, Volume 25
Editorial
out that I did not state that such faculty would not teach. In fact, they should have reasonable teaching obligations. However, they will not succeed in the role I have described if they must teach major courses singlehandedly every semester and be "on service" most of the year providing supervision for clinical clerks. So, who will do the rest of the teaching? We obviously need some clinical faculty whose primary responsibilities are simply service and teaching. For such faculty, scholarship should be encouraged but not required. Such individuals are just as vital to the mission of the department as the clinical scientists and should have similar job security and award systems. But even departments that have good complements of these two types of faculty are either now having or in the future will have trouble meeting the experiential requirements of the contemporary pharmacy curriculum. How can this proposed model be accomplished? Just as pharmacy practitioners serve as faculty for extemship experiences in hospitals and community pharmacies, we must call upon nonacademically based clinical pharmacy practitioners to serve as preceptors for clinical pharmacy clerkships. Fortunately, the number of advanced level practitioners in nonacademic positions has increased dramati-
Of interest to practitioners, researchers, and students, this book presents various techniques, tools, and strategies to evaluate the economic contribution of specific drug therapies at a policy level and for individual patient needs. Chapters include Drug UseEconomics, CostBenefit Analysis, Cost-Effectiveness Analysis, Applications of Pharmacoeconomics for Drug Therapy Decisions, and more. 768 pages / ISBN 0-929375-02-5 / Paperbound
cally over the last two decades and represents a considerable pool of potential role model educators. Academic pharmacy must tum more and more to these individuals and their institutions to carry out its mission. At the same time, it should be realized that the notion of "volunteer" faculty may soon come to an end as the time and effort involved with the training of a clinical clerk becomes more evident to nonacademically aligned practitioners. Thus, colleges and schools of pharmacy should be prepared to start paying for such teaching services. Broad adoption of such a model for academic pharmacy practice should allow the diverse needs of academic pharmacy to be met. A critical mass of pharmacy practice faculty will be afforded environments for success as wellrounded academicians. A unique body of knowledge will emerge within pharmacy practice. Academic legitimacy will be achieved. Most important, a contemporary pharmacy curriculum will be designed and delivered, largely by pharmacist practitioners. ~ Reference I. HEPLER CD. The third wave in pharmaceutical education: the clinical movement. Am! Pharm Educ 1987;51:369-85.
Please send copies of Principlesof Pharmacoeconomics, at $29.95 per copy. Enclosed is $ - - - Name----------------Address---------------City-------------state/Country--------- ZIP - - Please bill: ( ) VISA ( ) MC Exp. d a t e ' - - - - S i g . - - - - - - - - Acct. No.
Prepayment isrequired. Send orders to:
HARVEY WHITNEY BOOKS COMPANY P.o. Box 42696 / Cincinnati, Ohio45242USA / Telephone 513/793-3555 / FAX 513/793-3600 DICP, The Annals ofPharmacotherapy •
1991 October, Volume 25 •
1131
