Pharmacoprudence

If you are looking for a single word to describe the varied job functions of the clinical pharmacist, that word is "pharmacoprudence".

 We, members of the Apothecary fraternity, have inherited a very fortunate heritage; a word to describe any field of particular study or endeavour, old or new, of a natural origin or acquired, may be formed by simply prefixing the root morpheme " pharmaco-" (obtained from the Greek pharmakon, for drug) to a tail word with a suggestive character. Hence we have in our lexicon words such as pharmacology, pharmacognosy, pharmacokinetics, pharmacodynamics, pharmacopoeia, pharmacopaedia, pharmacotherapy, pharmacogenomics, pharmacoepidemiology, pharmacovigilance, et cetera; words which are each pregnant with ideas which otherwise could only have been expressed sufficiently through elaborate usage of common vocabulary.

 The word "pharmacoprudence" first appeared in the year 2012 in an article published as an Idea Paper in the online journal INNOVATIONS in Pharmacy. In that seminal paper the word "pharmacoprudence" was originally suggested as the terminological equivalent of the word "jurisprudence" and was conceived to carry parallel connotations.

 Jurisprudence, as used in common notion, means the study of the nature and administration of law. On the same level pharmacoprudence may be explained simply as the study of the components and administration of healthcare. In that seminal paper the term "pharmacoprudence" was defined as 'the science and practice of the rational, efficient, efficacious and economical utilization of therapeutic agents'. It embodies such interrelated concepts, specialized learning and activities as clinical pharmacology, pharmacotherapeutics, pharmacoeconomics, pharmaceutical compounding, complementary and alternative therapy, rational drug utilization, medical records management, medication use reviews, pharmacovigilance, pharmacoepidemiology, pharmaco-medical information systems management, medical sociology, et cetera.

 In parallel with the lawyer who is the advocate of a client in the administration of law, the clinical pharmacist is the advocate of the patient in particular, and the whole healthcare system in general, to safeguard against abuse and misuse in the process of delivery of healthcare services. Like the former the services of the latter should have to be solicited for by a client, when pharmacoprudence is practised in a private office, but where the clinical pharmacist is an employee of a healthcare institution the performance of the role of pharmacoprudence becomes a professional obligation. Again, like the lawyer, the clinical pharmacist should have to specialize and confine his/her practice to a few, selected medical and/or pharmaceutical specialties to ensure concentrated learning and activity.

 Indeed so much similarities may be found upon detailed analysis of the job functions of both the lawyer and the clinical pharmacist that the juxtaposition of the terms jurisprudence and pharmacoprudence is more than apt. Furthermore, the term "pharmacoprudence" is more excellent in beauty in comparison with the phrase "clinical pharmacy", in the sense that the former circumvents a very serious ambiguity that inheres in the usage of the latter; the fact that the phrase "clinical pharmacy" naturally restricts this field of practice to only practitioners within conventional healthcare institutions, to the exclusion of community pharmacists and pharmacists who may perform same job functions in private business offices. In contrast, the term pharmacoprudence captures all these practice settings.

 Therefore I commend the term "pharmacoprudence" to you as preferred to the traditional phrase "clinical pharmacy", for your usage both in your lay and technical discussions, so that you avoid unnecessary ambiguity and carry your communications forcefully.


 References:
Adjei M. Clinical Pharmacy: A Theoretical Framework for Practice. Innov Pharm. 2012; 3(3): Article 83. http://pubs.lib.umn.edu/innovations/vol3/iss3/2.

Decision making in clinical practice

In one hospital setting a doctor calls the Pharmacy Unit on the phone, and when the pharmacist’s assistant picks up he furiously passes on this message: “Tell your pharmacist never to change my prescriptions, okay”. The pharmacist upon taking delivery of this display of overt interprofessional animosity decided to query the disturbed doctor. The case in reference was a known hypertensive patient who presented with upper respiratory tract infection (URTI) on the previous visit, for whom this doctor had prescribed a full-dose regimen of an ephedrine-containing cough mixture to be taken at home over a period of seven(7) days. The pharmacist apparently got alarmed to the adrenergic effects of ephedrine and the possibility for the said formulation further raising this patient’s blood pressure(BP) and his intervention was substitution with a generic formulation having both expectorant and antitussive effects. In this hospital the pharmacy staff are deprived of patients’ medical folders at the point of service delivery, so that this pharmacist did not have information on the patient’s BP as well as the presenting symptoms at the time and so his action was based on pure theoretical judgment.

In the dialogue that ensued between the pharmacist and doctor the former explained the theoretical reasoning behind his action, whilst the latter on his part intimated that the former should have conferred with him on that point prior to any such action. And the doctor quickly added a remark to the effect that, in all cases, the final authority for therapeutic decision-making resides with a doctor and that a pharmacist is duty-bound to dispense any prescription regardless of his/her opinion on it. The pharmacist could simply not accept this assertion, of course not in this era of the clinical pharmacy movement when the hospital pharmacist is fervently seeking to establish the concept that therapeutic decision-making is not the prerogative of the medical profession, but a shared responsibility among the healthcare team.

The twist which occurred on the doctor’s side of the dialogue is the most fascinating. Admittedly, the pharmacist committed an ethical error in not consulting with the doctor on his opinion on the choice of cough mixture and about his intended action prior to it, by which means he could have effected a perpetual positive change in the doctor’s practice in first pass. Notwithstanding, for the doctor to appropriate to himself alone the final authority for therapeutic decision-making is a fallacy which requires remediation. The prevailing idea within the medical profession that a doctor’s thoughts are superior to those of all other healthcare professionals is yet another consequence of the rather outmoded concept of the healthcare team, the hierarchy model, wherein the doctor is placed at the top of therapeutic decision-making. It is against some of these fallacies and old-fashion models that pharmacists today should deal with if the clinical pharmacy movement will make further inroads.