Professional Documents
Culture Documents
Profession of Pharmacy
and Pharmaceutical
Care
Robert A. Buerki, R.Ph., Ph.D.
Louis D. Vottero, R.Ph., M.S.
In a 1989 paper titled Opportunities and Responsibilities in Pharmaceutical Care, Hepler
and Strand1 proposed a new philosophy of pharmacy practice that went far beyond the
expectations of most pharmacy practitioners, even those dedicated to the patientoriented practices embraced by the term clinical pharmacy. They reviewed the alarming
extent of drug-related morbidity and mortality in the American health care system and
concluded that this problem could only be addressed by a fundamental change in the
pharmacists professional function. They referred to this concept as pharmaceutical care,
which they defined as the responsible provision of drug therapy for the purpose of achieving
definite outcomes that improve a patients quality of life. They stressed that the practice
of pharmacy must restore what has been missing for years: a clear emphasis on the patients
welfare, a patient advocacy role with a clear ethical mandate to protect the patient from
the harmful effects of . . . drug misadventuring.
Rather than restrict the pharmacists professional role to merely supplying and monitoring drug therapy, Hepler and Strand built upon concepts of clinical pharmacy to create
a process in which a pharmacist cooperates with a patient and other health professionals
in designing, implementing, and monitoring a therapeutic plan that will produce specific
therapeutic outcomes for the patient. Central to their shared vision is the establishment
of a mutually beneficial exchange in which the patient grants authority to the provider,
and the provider gives competence and commitment to the patient. Leaders in pharmacy have embraced the concept of pharmaceutical care because they see within it an
opportunity to respond to critical health care needs of society and to renew the sense of
professional purpose in American pharmacy practice.
Pharmaceutical care involves professional care decisions beyond enhanced therapeutic outcomes. Practitioners who embrace the concept of pharmaceutical care will encounter increasingly complex moral and ethical situations which will require not only a deeper
professional and personal commitment to patients as individuals but also a higher level of
clinical knowledge as they deal with more complex patient care decisions. As a result, the
status of the practice of pharmacy will be further enhanced as a socially necessary health
care profession.
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What Is a Profession?
Professions are found wherever humans live together in socialized groups. Professions
emerged in the Middle Ages when specialized practitioners began to develop and provide
an array of significant, unstandardized personal services that were central to human values. These servicessuch as health, education, religion, and welfarewere adapted to
meet the needs of individuals and required knowledge and skills that the typical person
did not possess. Pharmacy is among the oldest of the healing professions and its practitioners
provide unique, personalized services that meet the fundamental needs of individuals,
communities, and society.
One approach to understanding the purpose of professions in our society is to examine these unique, individual service needs and how an organized body of professionals
meets those needs. We will begin by examining the nature of professions in general. We
will then explain how professions differ from other service occupations and from strictly
commercial enterprises. Finally, we will examine the unique power professionals possess,
as well as their special prerogatives, duties, and obligations, and explain why pharmacy is
properly considered to be a profession.
The word profession means to testify on behalf of or to stand for something.
Members of a profession pledge or profess their fundamental commitment to serving
society. People who are professionals stand for something and vow not only to provide
their clients with knowledge but also to use a particular body of learning to solve a specific
range of human problems.2 In this context, pharmacists not only profess to be experts on
drug therapy but also vow to help people make the best possible use of drugs.
Origins of Professions
In the medieval world, the term professional was not applied to lawyers, physicians,
priests, or academics, who professed their commitment to apply their respective bodies of
knowledge to the service of human need, but to monks, who professed their faith in God
when they took up the contemplative life.2 In the West, we trace our professional lineage
more directly to late medieval cities in Europe, especially Italy. As Europe became more
urbanized, artisans broke away from the manor estates and took up middle-class occupations. Pharmacy was one of a number of occupations that developed guild-like associations during this period.3 At about the same time, occupations that had been confined to
the learned world of the medieval clergy became secularized.
Toward the close of the twelfth century, the physicians and pharmacists of Florence,
together with some others, formed a single guild. Supervision was rigid. During annual
inspections of pharmacies, guild commissions confiscated drugs not meeting the guild
requirements and excluded the culprits from professional practice for varying periods.4
The separation of pharmacy/medicine practitioners and organization into different guilds
was a prerequisite to professionalization; actual professionalization came more slowly.
Historians date the legal recognition and regulation of pharmacy in the West, as an occupation separate from medicine, to the thirteenth century.3
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unrecognized by members of the public. The results of professional functions take the
form of products, services, advice, opinion, and even a physical presence on behalf of
another person or group.5
There is a uniquely public nature to the work of professionals. Professionals must use
their knowledge not simply to display their virtuosity but also to serve human needs.
Professionals serve not only the needs of friends but also those of strangers. Professionals
must act altruistically. The seventeenth-century idea of hanging out ones shingle symbolized this readiness to go public and to serve the needs of strangers.2
Secondly, there is a special nature to the functions professionals perform. These functions are always more complex than the mechanical activities a client may observe. The
seemingly simple chest tapping involved in auscultative percussion, for example, belies
years of clinical experience. Furthermore, it is not unusual for professionals to practice in
relative isolation from the routines of daily life and provide their services to society in
abstract ways.5
Finally, there is an exclusive nature to the functions professionals perform. Professionals, through a representative body of peers sanctioned by the state, are given the unusual
authority to determine who may be permitted to practice and under what conditions. For
example, state boards of pharmacy define the kinds of activities pharmacists are allowed to
perform, outline the social privileges and professional prerogatives they may claim, and
establish controls to guarantee that these privileges and prerogatives are not abused.5
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Moreover, professionals often attempt to enhance their power of knowledge by transforming the formal knowledge base that is at the heart of their profession into a complex
vocabulary of technical terms.7
Society grants varying amounts of discretionary power to each profession based on
the value of the goods and services provided by the profession. These powers of position,
once given, are very difficult to revoke. For example, pharmacists wield a certain power by
controlling access to potent, often dangerous drugs. Physicians wield power by deciding
which types of patients they will treat. Society often has difficulty controlling or limiting
such discretionary power even when this power exceeds the best interests of society.5
Society also grants each profession certain functional powers that can have a profound impact on the professionalclient relationship. In pharmacy, these powers go far
beyond the traditional power to dispense to include developing and managing systems of
drug distribution that provide access points to patients and ensure drug safety and compliance with legal and professional standards. These powers also extend to providing other
cognitive services solidly based on professional knowledge and skills. Health professionals
should employ these powers to effect a good outcome for their patients as determined
by patients individual life-plans, their understanding of their illness, and their concept of
what constitutes appropriate treatment.8 With this in mind, pharmaceutical care encourages pharmacists and physicians not only to agree upon a therapeutic plan but also to
share their functional power with their patients by including the patients in both the
formulation and the implementation of the plan.
Attributes of a Profession
Dictionary definitions for the term profession more or less agree that a profession involves specialized, intellectual learning that is used to render a particular service either by
guiding or advising others or by practicing an art.3 A. M. Carr-Saunders and P. A.
Wilson9 point out that there is no single test or touchstone for professionalism, characterizing it as a complex of characteristics. Roy Lewis and Angus Maude10 have written that
a moral code is the basis of professionalism. Beyond this common thread of morality,
however, the promulgation of a satisfactory definition of the term has progressed little
beyond the five criteria proposed by Abraham Flexner11 in 1915 and elaborated upon by
Isador Thorner12 in 1942: 1) a relatively specific, socially necessary function upon the
regular performance of which the practitioners depend for their livelihood and social
status; 2) a special technique, competence in which is demanded, resting upon; 3) a body
of knowledge embracing generalized principles the mastery of which requires theoretical
study; 4) a traditional and generally accepted ethic subordinating its adherents immediate private interest to the most effective performance of the function; and 5) a formal
association fostering the ethic and improvement of performance.
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Becoming a Professional
The process of becoming a professional begins with admission to a professional school
where students are exposed to a variety of educational materials and problem-solving
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skills that will enable them to function within the current standards of the profession.16
Students gradually develop a professional self-image in the course of their training. This
professional development consists of learning and assimilating the traits they will need in
order to play the role of the professional after graduation.17 Rene C. Fox18 has analyzed
the professional development of medical students and Mary Jean Huntington has shown
that with each succeeding year in school medical students were more likely to say that, on
the occasion of their last contact with a patient, they thought of themselves more as a
doctor than a student.19
Functioning as a Professional
Professionals behave in a manner that embodies both their technique and their commitment to provide individualized service. Professionals also subscribe to a traditional and
generally accepted ethic which subordinates their immediate private interests to the most
effective performance of their professional function.12 It is not unusual, for example, for a
pharmacist to be called in the middle of the night to fill an emergency prescription. In a
broader sense, professionals also use their knowledge and skill to benefit mankind. Many
health professionals volunteer to serve on lay health advisory boards or participate in
community health screening programs.
Professional Responsibility
Professionals develop a public and moral sense of responsibility to others by internalizing
a clear sense of purpose, a strong commitment to serve the public, and a deep understanding of the ethic of the profession. This responsibility is reflected in the way professionals
behave toward their clients and toward each other. The true professional will understand
and practice the virtues of his or her profession. Society expects its physicians to be competent, its lawyers to hold confidences, and its pharmacists to be trustworthyvirtues all
these professions share, to be sure. Professionals also strive to maintain their professional
competencegenerally through self-study or organized continuing professional education activitiesto improve their service to the public.
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professional prerogatives, demonstrating the voluntary nature of this activity.21 The concept of professional autonomy is a basis for exercising professional prerogatives. That is,
professionals practice in a manner that cannot accommodate external interference. In
daily practice, the knowledge and skills needed are esoteric, the tasks performed are complex, and the professional judgments made are sophisticated; thus professionals could not
practice effectively if they had to contend with such interference.5
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11
12
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Attitudes
Professional Behavior
Altruism
Commitment
Compassion
welfare of others)
Generosity
Perseverance
Equality
Fairness
Self-esteem
rights, privileges,
Tolerance
or status)
health care
Esthetics
Appreciation
(qualities of objects,
Creativity
Sensitivity
Openness
(capacity to exercise
Self-direction
choice)
Self-discipline
Human Dignity
Empathy
Kindness
Maintains confidentiality
uniqueness of an
Trust
individual)
Justice
Integrity
(upholding moral
Morality
Truth
Accountability
(faithfulness to
fact or reality)
Honesty
Rationality
a
Adapted from American Association of Colleges of Nursing. The Essentials of Baccalaureate Education for Professional Nursing Practice. Washington, DC: American Association of Colleges of
Nursing; 1998.
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manner. For this reason, professional pharmacists need to both identify the basic values
that impinge upon their professional practice and use these values in a consistent, rational
manner when they make professional judgments.
14
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government regulation.36 During this time, the practice of pharmacy has undergone dramatic changes as well: in the 1950s, most pharmacists either enjoyed the freedom of
owning their own pharmacy or worked in small groups in the burgeoning institutional
and drug chain settings, reporting directly to another pharmacist; professional decisions
related to patient care reflected the personal values and ethics of one or, at most, a handful
of pharmacists. In todays practice environment, whether they practice in community,
institutional, mail-order, or Internet settings, a majority of American pharmacists are
employed by corporations that are controlled by executives and administrators who make
business decisions calculated to satisfy their stockholders. Many of these executives do
not have a professional background in pharmacy, and their corporate policies tend to
reflect a bottom-line mentality. Corporate employee pharmacists are often torn between
exercising their personal value system and complying with a corporate ethic that may be
far removed from the individual pharmacistpatient encounter.
For example, corporate pharmacists may be asked to dispense generic equivalent
products routinely without regard for the wishes of their patients or downplay the offer to
counsel patients guaranteed by federal law. This is not to say that corporate practice is
ethically challenged by definition. Many corporations have pioneered systems which improve both the efficiency of drug distribution and the scope of patient-oriented health
care services while respecting and supporting their employee pharmacists personal value
systems; still, many pharmacists are asked to carry out corporate policies that are in direct
conflict with their own deeply held personal valuessuch as dispensing a morning after
contraceptive medicationat the risk of being dismissed for not complying with a corporate policy. In all cases, pharmacists must decide whether they are advocates for their
patients or merely agents of their employer.
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Covenant or Contract?
In a contractual relationship, two parties agree upon some joint project in which both
derive some benefit for the goods or services contributed by each party. Are the goods and
services offered by pharmacists to their patients defined by such a relationship and reduced to simple transactional events? Doesnt the practice philosophy of pharmaceutical
care imply a pharmacistpatient relationship that extends beyond a mere contractual arrangement?
Some of the aims of a contractual relationship might be desirable in the context of
pharmacy practice: a clear expression of rights, clearly defined self-interests, the possibility of legal enforcement. Unfortunately, a contractual relationship suppresses the gift of
trust that is essential in professional relationships. Furthermore, a contractual relationship may undermine pharmacists attitudes toward professional behavior by encouraging
a restrained response to patient care. Pharmacists could construe such a relationship to
mean that they should do no more for their patients than what their contract calls for or
to perform only specified services for certain fees, no more, no less.
Professional services in the health professions are directed to subjects who are by nature
rather unpredictable as they deal with their own sickness or the ills of their loved ones. These
services cannot be exhaustively specified in advance for each patient; pharmacists must be
ready to deal with the contingent, the unexpected. Patients may require services that exceed
those anticipated in the contract or incur additional costs beyond those originally agreed
upon. Moreover, the services associated with pharmaceutical care are more likely to achieve
the desired therapeutic results if they are delivered in the context of a fiduciary relationship
in which patients have full trust in the pharmacists serving them.38
16
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upon the safe distribution of drugs or even upon expanded clinical functions to justify its
societal function, it may also learn it cannot solely rely upon the enhanced service mandate suggested by the concept of pharmaceutical care for its raison dtre.
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