History of clinical pharmacy
Three major changes in pharmacy allowed for the clinical side of pharmacy to develop. This included changes in work responsibilities, changes in the education of pharmacists and post-graduate training.
Going back to 1965, the practice of pharmacy had changed very little over the past 50 years. The major roles of the pharmacist used to be preparing and distributing drug products. Work responsibilities changed when the pharmaceutical companies began making more and more ready to use products. The pharmacist no longer had to devote much time to compounding and could focus their energy elsewhere. Clinical pharmacy is believed to have its roots from the University of Michigan. In 1962, a student named David Burkholder graduated from the University of Michigan and founded the first academic drug information center at the University of Kentucky.1
Additionally, the education model began to change. In 1975, the Millis Commission was released and provided guidance on the future of pharmacy. In essence, they concluded that pharmacy was heading towards becoming a clinical profession. Pharmacy schools began changing their degree to award doctorate of pharmacy degrees upon completion of the program. Finally, in 1992, The Pharm.D. degree became the only professional degree in pharmacy, doing away with the Bachelor of Science in Pharmacy degree.2
The final big change was with post-graduate residency training. Residencies are intense post-graduate training that allows the resident to have multiple experiences in many areas of a hospital or health system. It packs a lot of information in a short period of time and allows the pharmacist to spend more time working directly with providers and nurses. This can be a big advantage when looking for clinical jobs. But, it does come at a cost, quite literally. The average pharmacy resident makes $42,000. With that being said, pharmacy residencies are on the rise. Many pharmacists are willing to take a pay cut for a year or two to advance their career. There were around 600 residencies programs in the year 2000 and there are more than 2,600 today.3
Residencies led the way for pharmacists to specialize in a certain area of medicine much like physicians do. There are second year residencies in ambulatory care, cardiology, critical care, drug information, emergency medicine, infectious diseases, psychiatry and more. This allows for pharmacists to become expects in drug therapies for specific disease states.
Many hospitals now have dedicated clinical pharmacists in a multiple areas. This allows for each pharmacist to be extremely knowledgeable in one area, rather than all of the pharmacists being somewhat knowledgeable in multiple areas. For example the hospital that I work in has pharmacists that cover the the main pharmacy, but also has pharmacy specialists in psychiatry, cardiology, critical care, internal medicine, infectious diseases, and pediatrics.
These changes in pharmacy flipped the script. Previously, the doctor would write the medication order. It would be sent to the pharmacy where the pharmacist would review the order. The problem was when something was incorrect. The pharmacist would have to call up to the floor and try to reach the doctor to make a recommendation. If the doctor already left, nothing could be done. Also, this was a slow process in emergencies. But with a pharmacist present on rounds with the doctor, the problem could be addressed before it even began. It changed a reactive approach to a much more effective proactive approach. The idea of involving the pharmacist in the decision-making process was met with enthusiasm to enhance patient care.
What does a clinical pharmacist do?
First, I will walk you through my typical day as a psychiatric clinical pharmacist. I get into my office around 8AM. I login to the electronic medical record and review all of the patients on the inpatient psychiatry unit. I read the notes, look at the medications and labs and I start a list of recommendations that I want to make during rounds. Interdisciplinary rounds start at 9:15 AM. Many team members are present such as psychiatrists, nurses, social workers, OT, students and more. As we talk about the patients I make my recommendations to the team. Some common recommendations are to stop a medication that isn’t needed, to get a blood level of a medication, or to restart a home medication. I then talk to a few patients on my own when I need to clarify information further. Next, I help fix any medication access problems and then I leave the unit.
Then I start my outpatient and teaching responsibilities. I will see some patients who are out of the hospital to follow their mental health needs long-term. I meet with the patients, adjust medications, and write notes. Also, I do group sessions with psychiatric patients. Finally, I work on some of my lectures and then leave for the day.
Clinical pharmacists can fill a lot of different roles within the hospital but there are some commonalities when we make medication recommendations. A few of the most commonly accepted recommendations that clinical pharmacists make are to monitor therapy, and to stop a medication.4 By stopping medications and reviewing drug interactions pharmacists make a big impact. Clinical pharmacists participating in medical rounds in hospital were found to reduce preventable ADEs by 66% to 78%.5 This translates to saving lives and another study estimated that pharmacists save the lives of 112,000 seniors every year.6 This benefits add up, and for certain conditions, for every $1 spent on pharmaceutical care, the healthcare system saves $3.98.5
- Miller RR. History of clinical pharmacy and clinical pharmacology. J Clin Pharmacol. 1981 Apr;21(4):195-7. doi: 10.1002/j.1552-4604.1981.tb05699.x. PMID: 7016931.
- Carter BL. Evolution of Clinical Pharmacy in the USA and Future Directions for Patient Care. Drugs Aging. 2016;33(3):169-177. doi:10.1007/s40266-016-0349-2
- Stolpe SF, Adams AJ, Bradley-Baker LR, Burns AL, Owen JA. Historical development and emerging trends of community pharmacy residencies. Am J Pharm Educ. 2011;75(8):160. doi:10.5688/ajpe758160
- Somers A, Robays H, De Paepe P, Van Maele G, Perehudoff K, Petrovic M. Evaluation of clinical pharmacist recommendations in the geriatric ward of a Belgian university hospital. Clin Interv Aging. 2013;8:703-709. doi:10.2147/CIA.S42162.
- Chen CC, Hsiao FY, Shen LJ, Wu CC. The cost-saving effect and prevention of medication errors by clinical pharmacist intervention in a nephrology unit. Medicine (Baltimore). 2017 Aug;96(34):e7883. doi: 10.1097/MD.0000000000007883. PMID: 28834903; PMCID: PMC5572025.