Cipolle, 1986

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EDITORIALS
DRUGS DON'T HAVE DOSES-PEOPLE HAVE DOSES!
A Clinical Educator's Philosophy
Robert J. Cipolle
I AM REFLECTING ON MORE THAN A DECADE of involve-
ment in pharmacy education. In essence, a generation
of pharmacy practitioners has passed beneath my tute-
lage. I consider that a great honor as well as an enor-
mous responsibility to my profession. Those of us who
are charged with transmitting highly specialized knowl-
edge to those who will form the next generation con-
tinue to soul search. We are trying to discover the
formula that will allow us to mix a cup of students, a
pound of information, and a pinch of wisdom into one
of our delicate souffles that we call a pharmacy prac-
titioner.
I offer the following approach to pharmacy educa-
tion that is simple, straightforward, and seems to work.
First, each student must have a deep-rooted understand-
ing of what a pharmacist does. This may sound overly
simplistic, but ask a group of 10 students and you will
get 9-11 different responses. If you really want to get
depressed, ask a group of 10 pharmacy faculty mem-
bers, "What is the primary function of a pharmacist?"
I believe that if you really understand something you
should be able to explain it briefly enough so it fits on
a bumper sticker. The foundation for all pharmacy edu-
cation must be based on the premise that the primary
function of the pharmacist is to ensure that each patient
receives the right amount of drug. Sometimes the right
amount of drug is no drug. All of our educational efforts
must be based on this premise. It is clear, concise, and
all-encompassing. How does one prepare students to
make sure people get the right amount of drug? One
needs two more piecesof bumper sticker philosophy and
a half-dozen steps to therapeutic problem-solving.
The next important idea for the aspiring pharmacy
student to understand is that the question is always the
same! People always ask, "How much drug X should
ROBERT J. CIPOLLE, Pharm.D., F.C.C.P.• is Associate Professor and ViceChair-
man, Department of Pharmacy Practice, College of Pharmacy, University of Min-
nesota, Health Sciences, Unit F, 308 Harvard St., Minneapolis, MN 55455. Reprints:
Robert J. Cipolle, Pharm.D.
I take (or give) to patient Y in situation Z?" People
often disguise the question by asking things like, "What
is the half-life of gentamicin in renal failure?" They
really do not want to know, but they think if you tell
them the half-life of gentamicin in renal failure then they
will be able to answer their real question: "How much
gentamicin does this septic patient in renal failure
require?"
Now, is it not logical to think that if a pharmacist
has a singular purpose and continually addresses the
same question there should be a logical, consistent
approach to resolving the therapeutic problems phar-
macists are increasingly being asked to solve? I believe
there is such an approach. Each pharmacy student must
be taught to apply the following problem-centered proc-
ess in learning and in practice. 1 This system always starts
with the problem-just like learning does in life.
1. Pharmacist problem list-Identify problems
associated with or potentially associated with drug
therapy.
2. Collection of relevant data-This information will
be of two types: (a) information describing how drugs
affect the patient's status, and (b) information
describing how the patient's status might affect drug
therapy.
3. Desired therapeutic outcomes-What are the
desired goals for each problem?
4. Therapeutic alternatives-List all forms of drug
therapy (not just the drug of choice) that have the
potential to produce the desired outcome for each
problem.
5. Pharmacist's recommendation for drug therapy-
Which of the therapeutic alternatives have you cho-
sen to provide optimal benefit to the patient, consider-
ing efficacy, safety, and expense?
6. Plan for continued monitoring of drug therapy-
What tests and other information are required and
at what frequency to ensure that the desired outcomes
Drug Intelligence and Clinical Pharmacy 1986 NOVEMBER VOL 20 881
are occurring and the undesired toxicities are
minimized?
If you know your job and the question, you formu-
late a problem list consisting of therapeutic problems
or potential problems that are your responsibility to
resolve. You must then gather information concerning
the effects of drugs on a patient's status and the
influence of any altered physiologic state on the dispo-
sition of the drugs you recommend. You establish a
desired goal for each problem, review and consider all
possible alternative solutions, and decide which ther-
apeutic alternative to pursue. Lastly, and most impor-
tantly, you must design a therapeutic drug monitoring
plan to ensure that the desired outcomes of your drug
therapy are occurring and that you are not producing
undesirable toxicity. If your drug therapy is not produc-
ing the desired results or is inducing an undesired
DICP-20th ANNIVERSARY
response, you have a new therapeutic problem to
resolve.
There is one last piece of bumper sticker philosophy
that will help determine if you have considered all neces-
sary information and have confidence that you made
the best possible decision in each situation: only do to
patients what you would do to your own grandmother.
This standard for professional practice has certainly
withstood the test of time, is amazingly consistent from
practitioner to practitioner, is undeniably cost effective,
and represents a standard our patients expectand deserve.
Reference
I. STRAND LM, MORLEY PC, CIPOLLE RJ. A problem-based student-
centered approach to pharmacy education. Am J Pharm Ed (in
press).
CONTROLLING THE METAMORPHOSIS OF PHARMACY
Harvey A.K. Whitney, Jr.
MUCH HAS BEEN WRITTEN about specialization in phar-
macy; moreover, this journal has focused extensively
on the subject this year. We believe an important deci-
sion for the future of pharmacy will be made by the
Board of Pharmaceutical Specialties when it decides to
accept, reject, or otherwise dispose of the petition for
recognition of clinical pharmacy as a specialty! (see page
907). Consequently, we want to keep our readers as well
informed as possible on the various points of view on
this subject.
Some years ago, George P. Provost, then editor of
the American Journal ofHospital Pharmacy, put forth
his personal thoughts about specialization. Much of
what he wrote for DICP over a decade ago still has cur-
rency today. The best parts of it are excerpted below.
Provost raises a number of interesting points, one of
which is the idea of whether we need two separate and
distinct types of pharmacists. I do not believewe do and
have repeatedly advanced this argument. One of the first
times I addressed this issue was as part of an editorial
that excoriated pharmacy's basic scientists. Parts of it
follow Provost's article.
I include this criticism of faculties, even though much
improvement has occurred, because the problem per-
sists. We are still preparing students to be both "drug-
delivery specialists" (dispensers) and "drug-therapy
specialists" (clinical pharmacists). Until the profession
puts forth a concerted effort to make technicians into
drug-delivery specialists, and to provide them with the
formal education they need, we will continue to propa-
gate two classes of pharmacists. Now 15 years later, I
regret to say that it is not only the basic scientists but
some clinical educators who lack the vision and chutz-
pah necessary to transform pharmacy schools from
"chainstore heiresses" into meccas for clinical research
and practice education.
This will not happen on a broad scale until the need
for dispensing pharmacists is met by qualified pharmacy
technicians. Academic programs must be established
throughout the country to meet each state's need for
well-educated andtrained technicians. Certification
of technicians as qualified drug delivery specialists
must occur before state boards of pharmacy will no
longer continue to insist that pharmacists function as
technicians.
The metamorphosis of pharmacy is apparent to all
who are involved with it. What is not clear is the final
form that pharmacy will have. Clinical educators, prac-
titioners, and others who are concerned must take con-
trol over the metamorphosis, so that we willend up with
a butterfly and not a toad.
Reference
I. Association news: BPS announces process for CCPS petition
(News and Comments). Drug Intell Clin Pharm 1986;20:519.
882 1986 NOVEMBER VOL 20 Drug Intelligence and Clinical Pharmacy