EARNED NOT GIVEN

"A clinical pharmacist is just one surgery away from being a medical doctor." One of my friends once asserted boldly. Now, you do not have to agree with this, in fact, I did not agree with her at that time and I still don't. But I definitely got the message; the roles of pharmacists have expanded steadily over the years. And pharmacists now do far more than just sitting moodily behind a counter and dispensing drugs.

 

When we hear "desert," sand and dust instantly float into our minds that we almost sneeze in response. Similarly, people always think about drugs when the word "Pharmacist" is mentioned. In fact, the word "drug" (or drugs) is present in nearly all the definitions of a pharmacist. As for those definitions that do not have drugs, the word "medicine" (or medicines) stands in its place. As a result, phrases like "Legal Drug Dealer" and "Custodian of Drugs" have become fancy titles for pharmacists.

 

Despite these fancy titles, pharmacists did not actually do much, asides compounding and dispensing. This compounding role is responsible for the  mortar and pestle which is generally regarded to be the symbol of the pharmacy profession, even though this compounding role has thankfully been taken over by industrial chemists and whatnot with pharmacists gladly assuming the all-important role of quality control officers in these industries.

 

Apart from compounding and dispensing, other traditional roles of pharmacists were..., well they were largely non-existent. Pharmacists could not even prescribe at that time and patient counselling was neither considered to be important nor was it considered to be the job of a pharmacist. Imagine manufacturing something but being unable to tell people how and when to use what you just manufactured. Unfortunately, in certain countries (Nigeria obviously not included), pharmacists are still not allowed to prescribe and in most of the countries where they are allowed to prescribe, they can only do so for "minor" illnesses, whatever that means. Meanwhile, other medical professionals such as nurses, podiatrists and even psychologists do not face these restrictions when prescribing drugs, which is quite distressing since pharmacy is the third largest health profession.

 

In those pharmaceutical dark ages,  so to speak, doctors and pharmacists rarely saw eye-to-eye, both literally and metaphorically. The only means of communication between the doctor and the pharmacist was the prescription which the pharmacist received through the nurse. It was expected that the pharmacist would simply dispense the drugs, smile sweetly at the nurse and wish her a nice day. This trend continued for quite sometime until something happened.

 

But before it happened, rapid technological advancement meant that more and more drugs were being produced that even the doctors could not keep track of them. And several of these drugs either had a narrow therapeutic range or were extremely toxic. Then it happened; people began to die, not from their illnesses but from the drugs they were prescribed to manage the illnesses. It was observed too that when certain drugs were administered together to patients, the patients suddenly found themselves a few kilometers away from the afterlife. Even more worryingly, drugs blatantly refused to work and treat the conditions they were prescribed for and some drugs even provided a different response from what was required from them . And nobody knew why.

 

Then naturally, a search began for a group of healthcare professionals who had thorough knowledge of drugs, down to the molecular level; for individuals who knew which drugs could be administered together and which drugs could not; for people who knew how to adjust the doses of drugs to get the required response regardless of the patient's age, weight, gender or metabolic rate. Yes, the world basically needed pharmacists. And right there, at that particular moment, pharmacists went from counting ascorbic acid tablets (though not all, some pharmacists still dispense and there is nothing wrong with dispensing by the way), to being important members of healthcare management teams and an authority whose opinions were usually sought before, during and after treating patients. To put it simply, the role of pharmacists expanded and it did so exponentially.

 

The first major offspring of this expansion was patient counselling. This alone solved most of the issues regarding drug interactions and drug ineffectiveness as a result of improper usage. Now, the pharmacist does not simply say:

"Take one tablet in the morning and one tablet again at night" and then obtusely bid the patient Godspeed. Rather there is a much more richer patient counselling session and its attendant rapport building between the patient and the pharmacist. And after the pleasantries must have been exchanged, typical instructions from the pharmacist to the patient now sound like this:

"Take this drug every twelve (12) hours and take it two (2) hours after this other one. This drug right here would make you feel sleepy so do not take it if you intend to drive or if you are a driver by occupation. Take this  drug with enough food and do not take this other one with milk. Can you see this white one? You may experience itching when you start taking it. But do not worry, the itching would stop when you are done with the drug. But if it doesn't stop, you can take this other one for the itching. Any questions?"

 

It may not seem like much, but these "little " additional information are the difference between drug therapy failure and success. This goes without saying that there are several other routes of administration asides the oral route. And it is now the duty of the pharmacist to properly explain how and through which route drugs are to be taken. Otherwise, patients may end up using salbutamol inhalers through the nose (the name says inhaler after all) or even swallowing pessaries (certain pessaries look similar to oral tablets).

 

Perhaps, the greatest expansion in the roles of pharmacists has been in the field of research and development. Of course, it has always been the job of pharmacists to synthesize new drug molecules, but it was only recently that the idea of "Targeted Drug Delivery" was developed. With this, drugs which are usually toxic can be safely delivered to their sites of action directly, without having to harm the innocent nearby healthy cells. The importance of this cannot be overemphasized, and in fact, intensive research is still ongoing in this regard.

 

Asides this, pharmacists are now, more than ever before, involved in clinical decision making and in formulating a treatment plan. In plain English, this means that pharmacists must approve and contribute to any treatment regimen before it is applied to the patient. Actually, during the duration of therapy, it is the job of the pharmacist to ensure appropriate therapeutic outcomes. So in addition to monitoring and evaluating the patient's response to therapy and assessing the effectiveness of the medications, the pharmacist can also request for laboratory tests in order to monitor the safety of the medications. It is not even uncommon now for pharmacists to request for a patient's serum creatinine levels or glomerular filtration rate before certain prescriptions are made. This is due to the fact that pharmacists are now being trained to deal with patients and not just drugs.

 

The field of pharmacogenomics, is also an offspring of patient-centered care. It has long been realized that an identical dose of the same drug would produce varying effects in different individuals and this is mostly due to the fact that genetic composition varies greatly from person to person. Therefore, pharmacists have devoted serious time and effort into this field to ensure that the dosages of drugs are tailored specifically to the individual taking them rather than relying on the arbitrary and seriously flawed system of using a general adult dose without recognizing the facts that even apart from the differences in genetic makeup and in the levels of drug-metabolizing enzymes, certain adults weigh nearly twice the so-called "standard adult" weight.

 

The shift to patient-centered care obviously does not imply that pharmacists have abandoned drugs completely. Because, as mentioned earlier, many pharmacists still prescribe and dispense drugs. But in addition to this, it is the responsibility of the pharmacist to ensure that the drugs dispensed are dispensed in the right conditions. Certain drugs are photosensitive and others are thermolabile, so it is simply not enough to write "Keep away from sunlight" or "Store in a cool dry place" on the drugs. These drugs have to actually be stored in the recommended conditions if they are to retain their pharmacological activity.

 

Many drugs have been switched or have had their doses increased by doctors due to their perceived ineffectiveness when the actual reason has been that the drugs were improperly stored and at the time they were being administered, they were not so different from placebos due to the degradation of the active ingredients. Patients and even doctors sometimes complain that certain vaccines or insulin preparations are not "working" only for it to be discovered that the said drugs were not stored at their recommended temperatures. It is now the duty of pharmacists to ensure this.

 

Another vital role pharmacists now have is public health advocacy. Pharmacists now deliver lectures on both drugs and health in general as well as on the importance of healthy living and lifestyle modifications in the treatment of some chronic disease conditions such as diabetes and hypertension.

 

All these do not of course imply that pharmacists would fully assume the responsibilities of doctor and even act as substitutes for them. No please. The work of a pharmacist is stressful enough and adding the work of doctors to it is a death sentence actually. The point is, in today's world, the pharmacist now seats at the table where the important decisions about a patient's health are made, rather than being relegated to the dispensary alone. Obviously, pharmacists would never have to perform surgeries, but they would have to be consulted before surgeries are carried out. Hence, the pharmacist's respect is one that is earned not given or demanded.

 

How then can anyone possibly say that pharmacists are not important?

 

By Otaru Testimony Afigie