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Ergasia majta

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1515762/pdf/califmed00068-0052.pdf

Medicine in SocietyPart III: A Role for Medicine inModern SocietyMALCOLM S. M. WATTS, M.D.San Francisco

THE PRECEDING SECTION of this inquiry into "Medicine in Society" drew attention to somevast and largely irreversible social, eronomic and political effects of the application of scientificadvances in both medicine and society. Specialization in the function of individuals, a necessaryconsequence of this great progress, produces greater social, economic and political interdependencewithin and between both medicine and society. The problems created by these changingrelationships are many and as yet they are poorly understood. But they clearly affect both medicineand our culture in most fundamental fashion. A few of the "dimensions" of modern medicine in

modern society were briefly discussed.These new interdependencies among people and among functions are not to be escaped in an

age dominated by science. The net effect has been to produce a complex system, which like anycomplex physical, biological or social system, must sooner or later develop some order anddirection within itself if it is to perform effectively. Much of what is at stake in this developmentis the role which the individual as such will play. In medicine, the issue is found in the survivalThis is part III of a communication in three parts. Parts I and II appeared in the December 1964 andJanuary 1965 issues. of individualized medical care directed by a physician whose first interest ishis patient versus depersonalized statistically oriented mass medicine directed by the government orsomeone else "in the public interest." In society, the issue can be expressed in such terms as thesocial trend toward the security of conformity versus the protection and enhancement of freedomfor the nonconformist; the economic concepts of free-enterprise versus the planned economy ofsocialism; or, in the political sphere, the extent to which the minority will be compelled to submit tothe will of the majority, or perhaps vice versa. For many reasons medicine is vitally concerned withall these problems. The preservation of freedom of expression and freedom of action for the humanindividual be he doctor, patient or citizen, as well as the inescapable need to find means to giveorder and direction to an increasingly complex biosocial system are each of the greatest importanceto human health and to good medical care. The broad social responsibility of modern medicine inthis modern society now requires re-examination. So far medicine has offered surprisingly little inthe way of leadership or constructive advice. Yet the role which medicine will ultimately play willsurely depend CALIFORNIA MEDICINE 133 upon the effectiveness of its leadership and its

performance at this time.

A. A Basis for Medicine's Roll

It would seem that the basis for medicine's social role must be found in the root purpose of themedical profession itself. These have been defined by the American Medical Association as "to

promote the art and science of medicine and the betterment of public health." This objective impliesthat medicine is fundamentally concerned with the health and welfare of the human individual, thatit has a basic commitment to progress, and that its social role and professional performance must be

based upon its special competence in the very broad field of human biology. Concern with thehuman individual, commitment to progress, and competence in human biology are closelyinterrelated. It is suggested that together they serve as a sound basis from which to derive a role for

modern medicine in modern society.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1515762/pdf/califmed00068-0052.pdfhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC1515762/pdf/califmed00068-0052.pdf


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1. The Human Individual

The art and science of medicine are historically focussed upon the human individual and upon themaintenance and betterment of his health. The raison d'etre of the medical profession is this humanindividual. The tradition of our Western culture also places a high value upon each individual life.It is this common interest which gives society its legitimate interest in medicine and medicine itslegitimate interest in society. Medicine has been surprisingly consistent in its support of what it

believes best for the individual, both in its professional activities and also in the socio-economic andpolitical positions it has taken. For example, it clearly recognizes that in most circumstancesthe patient is better served when the individual is treated on a personal basis and not regarded as a

probability statistic. But in those situations where the individual interest is for practical purposesidentical with the greatest good for the greatest number, medicine supports collective ormass approaches to medical care. This has generally occurred in situations where the possible needfor medical care may exceed the capability of personal medicine to meet the demand, as in militarymedicine, disaster medicine, prevention and control of epidemics, and in certain situations wherefor economic or geographical reasons medical care is best approached on a less personal orcollective basis. But any mass or collective program must tend toward emphasis on the statistical

probability, at the expense of the statistical improbability, and this may be contrary to the particular

need of any given individual at any given time. Personal medicine, however, aims to give equalattention and service to both the probable and improbable in individualized care. Support of

personal medicine is, therefore, a logical position for the medical profession to take in the interest ofeach human individual. This ongoing concern with the health and welfare of the human individualunderlies the attitude of medicine toward such things as "free choice" for both doctor and patient, its

belief that the doctor should be working for the patient and not someone else, as expressed in theindividual responsibility and fee-for-service principles, and its resistance to "third party"interference, which of necessity introduces a collective interest into what in its highest expressionshould be an individual and personal relationship. But as the health and welfare of the humanindividual develop wider and wider ramifications in society, many of these traditional attitudesrequire modification in a changing situation. But for each instance, the position of medicine can

be logically based upon what it believes is best for the human individual in the given circumstances.Society, on the other hand, has tended to substitute the majority interest, the collective interest orthe "public interest" for the individual interest. This gradual shift from an earlier emphasis onindividual rights toward the present and increasing emphasis on collective rights was predicted byde Tocqueville who clearly pointed out over a hundred years ago that rule by majority voteinevitably strengthens conformity at the expense of an individual's freedom to be different.Collective interests also are more easily organized into pressure groups. These tend to dominate andsuppress "uncollectible" individual interests in independence and personal freedom which do not soeasily band together to express their "collective" interests in individuality and freedom to bedifferent. These trends have perhaps been accelerated by the social impact of the scientific

revolution on a necessary interdependent society. In any case, even the courts now tend more andmore to support conformity at the expense of freedom,and the right of organized collective interestseven though a minority, to impose their will upon all. In this political setting, medicine finds itselftending often to support "unpopular" uncollectible interests of the individual as such, rather than the

better organized and therefore more "popular" collective interests. Thus many physicians findthemselves in ideological and political opposition to such things as compulsory retirement at the ageof 65 regardless of capability, and in favor of such things as right-to-work laws, less governmentregulation of daily living, and less government spending and more take-home pay for the humanindividual. The common need of everyone, whether doctor, patient or just plain citizen, forindividual freedom and self-expression is a "collective" self-interest which nowadays seeks moreeffective recognition and craves more adequate leadership. It also happens to be essential to the best

medical care and to the betterment of human health. This common interest of medicine and theindividuals who comprise society could become a basis for extraordinarily effective socio-economicand political action. The county, state and national organization of medicine can give "collective"


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expression to "uncollectible" interests shared by all individuals. Positions taken by medicine, whenbased upon its professional knowledge and the needs of all individuals and when soundly conceivedand effectively presented, may be counted upon to gain popular support. The full possibilities ofcollectively representing the uncollectible individual interests of all have yet to be explored.

2. Progress

The commitment "to promote the art and science of medicine" is fundamentally a commitment toprogress. To the physician progress means advances or improvement for the human being, forsociety, or both, in a biological and cultural sense. This meaning does not refer to the "progress" ofany conceptual social, economic or political theory, doctrine or belief in the sense in which thewords "progressive" and "liberal" are commonly used in the present scene.The physician-scientist knows that biological, scientific and cultural progress is based on theoutcome of many trials of new and different ideas, rather than conformity to conceptual theory.Most of these experiments fail, but some succeed. Those which fail are a price which is paid for theadvantages gained from those which succeed. Progress is most rapid when there are manyexperiments. It is slower when they are restricted and infrequent. Thus, medicine's commitment to

progress through experimentation places it not only squarely in the social struggle between

individual freedom and collective conformity, but also between advocates of the relativelyunplanned free enterprise system, and those who would plan and carefully regulate society.Medicine, therefore, also finds itself in the midst of the semantic confusion which currentlysurrounds the use of the words "progress," "liberal," "freedom," "security," "free enterprise,""socialistic," "conservative," "reactionary" and the like.In its commitment to progress through experiment,medicine also maintains its primary concernwith what is best for the individual. This is true for scientific experiments where careful attention isgiven to the safety and welfare of the individual. It has also been true for experimentation andresearch in methods of financing medical care and of delivering medical services, where it hasresisted and opposed experiments which it felt could not be in the best interest of the individual; orwhich would lead to regulation, restriction and control, which would in turn prevent furtherexperimentation; or which once undertaken could not be either abandoned or reversed. It is this aimwhich has placed medicine in diametric opposition to much present day "progressive" and "liberal"thinking which in reality is perhaps more truly "reactionary," in the sense of inhibiting progress,than "liberal."Is it not this support of freedom to experiment and freedom to progress which makes a free andoutspoken medical profession so often an anathema to those who would impose their conceptualsociologic, economic and political theories upon society?Perhaps medicine can capitalize to a greater extent upon this commitment to true biological andcultural progress.

3. Competence in Human BiologyMedicine's competence in the biology of human nature and human behavior exceeds that of anyother profession. It is this knowledge of human biology which is brought to bear in medical

practice and medical care. But this same human nature and human behavior is an essentialingredient of any social, economic or political system. It is noteworthy that many biological

principles, such as birth, growth, maturation, form, adaptation, senescence, death and evolutionthrough survival of the fittest, apply not only to the species but also to human institutions, humansociety and its culture. It would appear that competence in human biology is increasingly importantin the field of social interrelationships in modern society.The doctor, who is the biologist for man and his society, therefore has many new as well as oldresponsibilities. There are responsibilities to the individuals of the species who alone can give rise

to real progress; responsibilities for encouraging conditions and circumstances under whichbiological man can make progress without damage to himself, to his fellow man or to his species;and there are new responsibilities in broad and fascinating new areas of biological and cultural


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evolution which are rapidly becoming possible because of scientific progress. Clearly, thephysician must play a central role in these developments and make certain that the conditions forindividual human fulfillment and further progress remain favorable.It is suggested that concern with the human individual, commitment to progress and competence inhuman biology are the foundations upon which medicine's role in society can be built.

B. A Crucial Decision for the Medical ProfessionIn this inquiry the term "medicine" has been used broadly and somewhat loosely. It has beenused broadly to encompass many very old and some very modern facets of the relationship

between society and those to whom society gives responsibility for its health and welfare. It has been used loosely to include not only medical science and technology, but also the medicalprofession, medical practice and all the ramifications of medical care in modern society. It is quiteclear that in this broad definition "medicine" does in fact play a central and utterly essential role inany society. It is also clear that although "medicine" may change its shape and form, this centraland essential function of "physician" in society can never really be destroyed.But it is not so clear as to just where in the shape and form of modern "medicine" lies theresponsibility for the health and welfare of those persons who comprise society. It is not certain just

who is the responsible "physician" to our modern culture. The physician in his nostalgic traditionalrole seems to have all but disappeared, and the public senses that somehow society has lost itsdoctor. Understandably, and like any patient, society is now seeking a "physician" to fill its needsand one whose performance will prove satisfactory.There are a number of candidates. None has yet been selected. Curiously, and perhaps portentously,the medical profession itself is divided concerning the role it should play. It has been immersed in,in fact almost inundated by, the great wave of science and technologic advance. Perhaps this is thereason many doctors see the role of medical profession as confined quite simply to the science andtechnology of medicine. But these physicians do not seem to realize that this must inevitably maketechnicians of doctors and that this in turn has inescapable professional, social, economic and

political consequences both for the physician and for society. Yet the profession still clings inprinciple to the traditional concept of its role in society. This is evidenced by its instinctive andsometimes violent reaction to any attempt by others to assume any of the prerogatives of thistraditional role. As a result a number of major needs of society have not been met and a vacuum of

performance has developed. Social, economic and political pressures will inevitably insist thisvacuum be filled. The mantle of the "physician," like any mantle of leadership, eventually passesfrom those who do not perform to those who do.The decision to be made seems clear. Is the medical profession to fill this vacuum of leadershipand perform, or is it to relinquish its role of "physician" to society and confine its area ofcompetence and performance to the science and technology of medicine? If this latter occurs thenthe role of "physician" and most of the responsibility for "medicine" in society must pass to other

hands and the doctor of medicine will simply become a technician in medical practice and at best atechnical advisor on the scientific aspects of medical care.The large responsibilities of "physician" will necessarily be assumed by specialists in other fieldssuch as perhaps health education, public health, health care economics, social welfare or someother category of social or political scientist.At such a moment of decision it is wise to be guided by basic goals and objectives. If the role ofthe medical profession in modern society is truly to be founded upon its concern with the humanindividual, its commitment to progress and its competence in human biology, then its decision isclear. These responsibilities cannot be carried out by a mere technician in medical science. Theycan only be discharged by whoever is to become "physician" to society.It is the thesis of this discussion that the medical profession should and must assume this central

role in society. This crucial decision cannot be put off much longer.


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C. A Suggestion for Organized Medicine

The instrument through which the doctor and the medical profession can fill the role of "physician"to society is organized medicine. If organized medicine is to play this role, the physician, throughorganized medicine, must demonstrate that by exercising freedom, by utilizing the free enterprisesystem and by accepting responsibility, a free medical profession can solve the social problemscreated by the scientific revolution as fast as they appear.

This is quite an order in an organization comprised of 20,000 (in California), 200,000 (in theUnited States) highly independent, highly individualistic,highly educated and hard workingdedicated doctors. Yet these rapidly accumulating problems must be solved within this voluntary,free enterprise system or society will demand that they be solved by government regulation andcontrol. The ultimate decision will be based upon whether free enterprise organized medicine can

perform satisfactorily. Perhaps itis time for organized medicine to come to grips with theserealities. It would seem necessary that it first address itself to the difficulties which the free,voluntary democratic political system has in finding acceptable solutions to the complex social andenvironmental problems which are the direct result of the impact of scientific progress. Perhapscompetent in the field of human biology, it can borrow for itself a leaf from the book of biologicalevolution and apply some of its principles to the evolutionary process of which it is a part. In the

animal kingdom there are still free and independent cells, but the higher forms of life have found itnecessary to develop specialization and interdependence among cells. These more complex

biological systems have made possible advanced forms of life and of living. A major key to thisimproved performance among specialized and interdependent cells has been the developmentof the specialized functions of communications within the organism and with its environment, andof a mechanism to deal with an environment which changes from moment to moment, from day today and over much longer periods of time. This important mechanism is a brain or an intelligence.The parallel to the problems of modern medicine in modern society is close. Medicine too has itsfree and independent cells which are yet specialized and interdependent. Perhaps organizedmedicine too needs some sort of better intelligence system to deal with its internal and external

problems in a changing environment, to recognize them when they occur, and hopefully toanticipate them before they arise. At the moment organized medicine somewhat resembles anamoeba, moving every which way and almost without direction, except when stronglyattracted or strongly repelled. Doctors are intelligent and as homogeneous as any group of highlyeducated, free and independent generally hardworking and dedicated individuals can be. Perhapsthere is a real opportunity to study, experiment with and strengthen the democratic political systemwithin the framework of organized medicine. If successfully accomplished this could have

profound effects upon both medicine and society.

D. Assets for Leadership in Medical Care

Once the decision is made to assume a role of leadership in medical care, and the very real

difficulties of adapting the internal "biosocial" structure of medicine to the ecological requirementsof modern medicine in modern society have been overcome, the many assets of modern medicinecan be brought more effectively to bear in support of medicine's leadership, and the role of"physician to society" can become a reality for organized medicine. A number of these many assetsare worth noting.1. Medicine has a proven record of superbly applying its scientific knowledge in daily patient care.2. Public interest in medicine is very great. There is no need to create a demand or a market.3. Medicine is an important instrument through which the public can immediately and directlyrealize tangible personal results from its tremendous financial and emotional investment inscientific progress.

4. Physicians are highly respected in the community. They are intelligent and educated. They have

a common goal and a traditional selfless interest in bettering the health and welfare of people.

5. Medicine has unusual communications resources. The medical profession has direct and


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intimate contact with all cultural groups. It has roots and branches which reach into virtually everyaspect of society. Its members are skilled in convincing individuals to do what is in their bestinterest. Its subject matter is readily adaptable to and widely used by mass communications media.Communications channels exist between doctor and patient, between doctor and citizen and

between organized medicine and the public.

6. Medicine and the public have a common interest in the human individual, his health, hiswelfare, his individuality and his freedom to progress. Public opinion and the voter at the ballot

box are strong determinants in the evolution of our society. The voter and public opinion areinfluenced by emotion, beliefs, information, personal experience and by what other people think.These influences are transmitted by communication. Medicine and the public have a commoninterest which can provide the framework for the communication of information, experience andadvice based on competence in the broad field of human biology.

7 . Organized medicine is perhaps paradoxicallyin the position of being a relatively strong "collective" national organization, with state and countycomponents whose roots and branches reach into almost every facet of life, yet whose primary

concern and responsibility is with the health and welfare of the "uncollected" individual, with allthis implies in modern society. Medicine has yet to develop the full meaning and full power of this

perhaps unique position in our society.8. In "organized medicine" doctors, concerned with the individual, committed to true biologicaland cultural progress competent in human biology and dedicated to the betterment of health, are

banded together in fairly cohesive societies in over 1800 counties across the nation. These arefederated to form the state medical associations which in turn comprise the AMA. Inherent in thisorganization of highly educated and highly individualistic yet dedicated physicians must lie thecapability to preserve what we know as freedom and yet solve the social problems created by theimpact of scientific progress in medical care, if indeed this can be accomplished within ademocratically constituted professional organization.9. To regain its position of leadership as "physician to society" medicine will probably need toadapt its structure to be more fit in its new and changing environment, and also adapt many nowunfamiliar disciplines in the social and behavioral sciences to the needs of patients, to the healthand welfare needs of the individual in society and of society itself. But this process of adaptingitself and of adding new disciplines of knowledge to its armamentarium is nothing new for themedical profession. It has done this from time immemorial, and it can do it now.

E. Conclusion

In conclusion it is suggested that organized medicine address itself to the responsibilities of modernmedicine in modern society, and arrive at a determination of the role which it wishes itself to play.

It should decide whether it will perform as "physician" to society or abdicate this essential functionto the most powerful contestant. It should also decide whether it will assume the responsibility ofresolving the social problems resulting from scientific progress in medicine and in society bystrengthening order, direction and leadership within the dimensions of the free enterprise system orwhether, through disinterest, disunion, procrastination or failure to perform, it will in effect bringabout government regulation and control by its own default. The future complexion, not only ofmedicine, but of our society itself, may very well hang upon these decisions and what is done toimplement them.


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Life is short, and Art long;the crisis fleeting; experience perilous, and decision difficult.The physician must not only be prepared to do what is right himself,

but also to make the patient, the attendants, and externals cooperate. First aphorism ofHippocrates, circa 400BCE, from the Hippocratic Corpus online (translated byFrancis Adams)

Desired behaviour

Interviews with patients have indicated that the ideal physician would be confident, empathetic,humane, personal, forthright, respectful, and thorough. Incorporating clues to such behaviors maycreate a betterdoctor-patient relationship.

Undesired behaviors are essentially the opposites, specially being insensitive or disrespectful, e.g.arrogance in dismissing the patient's input, disinterest in the patient as an individual, impatience inanswering a patient's questions or callousness in discussing the patient's prognosis. Anotherundesired behavior is seemingly providing excellent service in the original visit but then failing to

meet the created expectations about the speed or quality of follow-up service.Still, when having to choose between high technical quality and high interpersonal quality, twothirds of patients choose high technical quality. Nevertheless, the level of technical quality may behard for a non-professional to assess, which in reality results in a tendency of patients to primarily

judge physicians on behavior. wiki pedia

--------Your first question: What are the duties of an ideal doctor towards his patients & towards his

profession. Towards your patients you must work towards the betterment of their health. You mustwork with your patients as partners in that goal. It is your job to explain, to the best of your

understanding, what health threats they face, and provide them the options (giving both the positiveand negative consequences) for each option that they have. You must respect their decisions,whether or not you agree with them, and you must maintain confidentiality about most things thatthe patient tells you. The duties towards your profession include working together with other

physicians to create a healthier community, country, and world for everyone to live in.

Your second question: What is the role of a doctor in our society. This answer is fairlystraightforward. Doctors work to increase the health of their patients. This includes listening toemotional stresses and helping to alleviate them if possible. Society tends to hold physicians in highregard. Because of this, doctors have influence (perhaps unfounded) in many areas. Doctor should

be very careful not misuse the trust placed in them.

Your third question: How can doctors contribute to improving healthy living conditions & how cana doctor contribute to effection political decisions that effect medi-care and medical conditions inhospitals or other ethical decisions take by our governments. Again, doctors have a lot of influencein society. It is not usually part of a doctor's job to be a politician, and so to be politically active,doctors must use their free time if they want to work for improvement. Most doctors work very longdays, and therefore do not have time to use this influence to bring about improvements. However,those that do tend to have a big impact. Some doctors write letters to the government, or even meetdirectly with politicians. Others work hard in their own communities, volunteering at free clinics for

poorer patients. There is a lot that a doctor can to, but it can take a great deal of energy toaccomplish these things. It is important to note here, that anyone can have a large impact of politicsand in their own communities. It is my view that everyone should work towards improving theircommunities.
http://en.wikipedia.org/wiki/Hippocrateshttp://classics.mit.edu/Browse/browse-Hippocrates.htmlhttp://classics.mit.edu/Browse/browse-Hippocrates.htmlhttp://en.wikipedia.org/wiki/Doctor-patient_relationshiphttp://en.wikipedia.org/wiki/Hippocrateshttp://classics.mit.edu/Browse/browse-Hippocrates.htmlhttp://classics.mit.edu/Browse/browse-Hippocrates.htmlhttp://en.wikipedia.org/wiki/Doctor-patient_relationship


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Your Fourth question: Why does any ideal doctor wanted to become a doctor. I want to know whatis the motivation that motivates most people to study medicine (Not good income or stable life).

An ideal doctor wants to become a doctor because they enjoy working with people and they findmedicine very interesting. There are many jobs in which you would get to work with people and

being a doctor is one of them. I will not say that an ideal doctor wants to help people, because I

think that most people want to help others, and accomplish it in a variety of different ways. Forexample, a scientist may discover a new medicine that cures many more people than one doctorcould help during his life time. A politician may negotiate a peace treaty that saves millions of lives.Certainly no typical doctor could see a million patients in his life time. There are many ways to help

people, but they do not always allow the helper to work directly with people.

Being a doctor is like being a mechanic except that a mechanic works to fix a machine and a doctorworks to fix a person. Because people are far more complicated and valuable than most machines,there is a higher standard demanded of doctors than of mechanics. The training is a lot longer, forexample. In the end, however, society needs mechanics as badly as it needs physicians, teachers,scientists, and everyone else.

It is important to be humble about being a doctor. Being a doctor does not make a person smarter,wiser, kinder, or in any other way better than others. Unfortunately many people do not realize this.Sometimes patients will forgive a doctor for acting badly simply because they are a doctor.Sometimes doctors become arrogant because people give them so much respect without needing toearn that respect. Doctors are normal people who have extensive training in the diagnosis andtreatment of disease, and they usually work very hard with good intentions. I think that most peoplework very hard with good intentions whether they are a doctor or not.

Now I will pick out one attribute that deserves emphasis in physicians. While compassion is a virtueall people should practice, when doctors do not practice compassion, they can become very cruel. Ihave seen very good doctors, who are also good people, forget to be compassionate with their

patients and end up being cruel.

While it is easy to be compassionate to most children, and also to people who are kind and good, itis more difficult to be compassionate to people that you have difficulty liking. For example, my first

patient was a prisoner that had committed many crimes. While we both spoke English, the way wespoke it was quite different and I had trouble communicating with him over the two weeks that hestayed in the hospital. He was often very angry. Yet it was important for me to continue giving himthe best care that I could while he healed from the surgery that had been performed on him. Whenthe patient was ready to leave the hospital we needed to write him prescriptions to control the pain

he had. The doctor I was working under was angry at the patient and wanted to give him a weakmedicine that would not control his pain as well as a stronger medicine. After I argued with thisdoctor, he changed his mind, and remembered to be compassionate.

I have also seen a great difficulty that many doctors have with being compassionate with psychiatricpatients. If a person is under tremendous emotional stress, they can feel pains in their bodies. Thepain is very real to these patients, but no pain relievers can make the pain go away. Because thesepatients can feel the pain, they are offended by the idea that the pain is generated in their brainsrather than in the peripheral nerves of the body. Because of this misunderstanding, it can be verydifficult to convince some patients that visiting a psychiatrist would help eliminate their pain.Doctors sometimes become tired of these patients, and lose compassion for them.

In your career you will encounter all kinds of people. Some of them will make you angry, but it willbe very important not to judge them, and to remain compassionate. It will be your job to help them


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as well as you can, no matter how badly you dislike them. I wish you luck in your studies, and Ihope that find enjoyment in your work as a doctor.http://www.madsci.org/posts/archives/nov2001/1005776941.Me.r.html

The Consensus Statement on the Role of the Doctor

Doctors alone amongst healthcare professionals must be capable of regularly taking ultimateresponsibility for difficult decisions in situations of clinical complexity and uncertainty, drawing ontheir scientific knowledge and well developed clinical judgement. The doctor's role must be defined

by what is in the best interest of patients and of the population served.

Based on the definition of the role of a medical doctor proposed by the International LabourOrganisation it is agreed that:

"Doctors as clinical scientists apply the principles and procedures of medicine to prevent, diagnose,care for and treat patients with illness, disease and injury and to maintain physical and mentalhealth. They supervise the implementation of care and treatment plans by others in the health careteam and conduct medical education and research."

All healthcare professionals require a set of generic attributes to merit the trust of patients thatunderpins the therapeutic relationship. These qualities include good communication skills, theability to work as part of a team, non judgemental behaviour, empathy and integrity. In addition to

possessing these shared attributes doctors must be able to:

assess patients' healthcare needs taking into account their personal and social circumstances

apply their knowledge and skills to synthesise information from a variety of sources in orderto reach the best available diagnosis and understanding of the patient's problem, or to knowwhat steps need to be taken to secure such an outcome

support patients in understanding their condition and what they might expect, including in

those circumstances when patients present with symptoms that could have several causes identify and advise on appropriate treatment options or preventive measures

explain and discuss the risks, benefits and uncertainties of various tests and treatmentsand where possible support patients to make decisions about their own care.

The nature of these core requirements emphasises the need to select those with theappropriate attributes for training.

Medical undergraduate education must provide a strong grounding in relevant science and inclinical practice as well as providing opportunities to develop an appreciation for research. Doctorsmust have the ability to assimilate new knowledge critically, have strong intellectual skills andgrasp of scientific principles and be capable of dealing effectively with and of managing

uncertainty, ambiguity and complexity.They must have the capacity to work out solutions from first principles when the pattern does notfit. All doctors must be demonstrably committed to reflective practice, monitoring their contributionand working continually to improve their own and their team's performance.

Doctors must all be committed to playing a part in the education and support of the next generationof medical practitioners and of facilitating the advancement of evidence based practice.

The doctor needs to be capable of assessing and managing risk; this requires high level decisionmaking skills and the ability to work outside defined protocols when circumstances demand.Doctors must also be able to make informed decisions about when supportive care is moreappropriate for the patient than intervention.

The doctor must possess the ability to work effectively as a member of a healthcare team,recognising and respecting the skills and attributes of other professions and of patients. Patients
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with long term and disabling conditions are particularly likely to be experts in their own conditionand should be supported to keep as healthy and independent as possible.

All doctors have a role in the maintenance and promotion of population health, through evidencebased practice. Some will enhance the health of the population through taking on roles in healtheducation or research, service improvement and re-design, in public health and through healthadvocacy.

Notwithstanding the primacy of the individual doctor:patient relationship, the doctor mustappreciate the needs of the patient in the context of the wider health needs of the population. For alldoctors the patient must come first but they will achieve this in different ways and in differentsettings. As the critical decision maker with responsibility for significant health resources the doctormust be capable of both management and leadership and of taking ultimate responsibility forclinical decisions. Within a world where the capacity to treat is growing but financial resources arefinite, doctors have a duty to use resources wisely and effectively and engage in constructive debateabout such use. They should ensure that their own and others' skills and knowledge are deployed to

best possible effect.

Doctors have a key role in enhancing clinical services through their positions of responsibility.Some will move on from clinical leadership and management to leadership roles withinorganisations at various levels - service, institutional, national and international.

The role of the doctor is changing and will continue to change alongside the needs and expectationsof patients. Patients are increasingly better informed and act as partners in their own healthcare. Thedoctor serves as advisor, interpreter and supporter in this endeavour.

http://www.nhsemployers.org/PlanningYourWorkforce/MedicalWorkforce/Future-of-the-medical-workforce/Pages/Role-of-doctor-consensus.aspx

PHARMACY

Though environmental factors, like the increasing number of senior citizens or the advancements inpharmaceuticals, have played a role in encouraging this evolution, the change can primarily betraced to the passage of the Omnibus Budget Reconciliation Act of 1990. This legislation, in part,required pharmacists to perform a drug use review, patient counseling and documentation in someform of patient profile.

According to Stephen L. Foster and Jerry R. Phipps in their paper "Counseling on new drugs," thelaw required pharmacists to screen for:

Therapeutic appropriateness.

Over- and underutilization.

Appropriateness of generic products. Therapeutic duplication.

Drug-disease contraindications.

Drug-drug interactions.

Incorrect drug dosage or duration of drug treatment.

Drug-allergy interactions.

Clinical abuse or misuse.

In addition, patient consultation was mandated to include:

The name and description of the medication.

The route, dosage form, route of administration and duration of therapy.
http://www.nhsemployers.org/PlanningYourWorkforce/MedicalWorkforce/Future-of-the-medical-workforce/Pages/Role-of-doctor-consensus.aspxhttp://www.nhsemployers.org/PlanningYourWorkforce/MedicalWorkforce/Future-of-the-medical-workforce/Pages/Role-of-doctor-consensus.aspxhttp://www.nhsemployers.org/PlanningYourWorkforce/MedicalWorkforce/Future-of-the-medical-workforce/Pages/Role-of-doctor-consensus.aspxhttp://www.nhsemployers.org/PlanningYourWorkforce/MedicalWorkforce/Future-of-the-medical-workforce/Pages/Role-of-doctor-consensus.aspx


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Special directions and precautions for preparation, administration and use by the patient.

Common severe side effects, adverse effects, interactions or therapeutic complications that may beencountered, including their avoidance and the action required if they occur.

Techniques for self-monitoring drug therapy.

Proper storage.

Prescription refill information.

Action to be taken in the event of a missed dose.

http://pharmrep.findpharma.com/pharmrep/Selling+to+Pharmacists/The-evolving-role-of-the-pharmacist/ArticleStandard/Article/detail/113520

http://en.wikipedia.org/wiki/Pharmacist

Pharmacists are health professionals who practice the science ofpharmacy. In their traditional role,

pharmacists typically take a request formedicines from a prescribing health care provider in theform of a medical prescription, evaluate the appropriateness of the prescription, dispense themedication to thepatient and counsel them on the proper use and adverse effects of that medication.In this role pharmacists act as a learned intermediary between physicians and patients and thusensure the safe and effective use of medications. Pharmacists also participate in disease-statemanagement, where they optimize and monitor drug therapy or interpret medical laboratory results

in collaboration with physicians and/or other health professionals. Advances into prescribingmedication and in providing public health advices and services are occurring in Britain as well asthe United States and Canada. Pharmacists have many areas of expertise and are a critical source ofmedical knowledge in clinics, hospitals, medical laboratory and community pharmacies throughoutthe world. Pharmacists also hold positions in thepharmaceutical industry as well as in

pharmaceutical education and research and developmentinstitutions.

In much of the United Kingdom and the British Commonwealthpharmacists are customarilysometimes referred to as chemist (ordispensing chemists),[1] a usage which can, especiallywithout a context relating to the sale or supply of medicines, cause confusion with scientists in thefield ofchemistry. This term is a historical one, since some pharmacists passed an examination inPharmaceutical Chemistry (PhC) set by the then Pharmaceutical Society of Great Britain in 1852and these were known as "Pharmaceutical Chemists". This title is protected by the Medicines Act1968 section 78.

The 1852 Pharmacy Act, June 30 established a Register of Pharmaceutical Chemists in GreatBritain , restricted to those who had taken the Societys exams. However, the Act did not restrict the

practice of pharmacy to examined and registered people, nor provide a legal definition for the tradeand practice of pharmacy. This was first done by the Pharmacy Act of 1868.[2]

In the near future it is proposed by the Draft Pharmacy Order 2009 that the title "pharmacist" berestricted to those who register with a new Regulatory body - the General Pharmaceutical Council -due to be established to take this role over from the Royal Pharmaceutical Society of Great Britainin 2010.

History

In ancient Japan, the men who fulfilled roles similar to those of modern pharmacists were respected.The place of pharmacists in society was settled in the Taih Code (701) and re-stated in the Yr

Code (718). Ranked positions in the pre-Heian Imperial court were established; and thisorganizational structure remained largely intact until the Meiji Restoration (1868). In this highlystable hierarchy, the pharmacistsand even pharmacist assistantswere assigned status superior to
http://pharmrep.findpharma.com/pharmrep/Selling+to+Pharmacists/The-evolving-role-of-the-pharmacist/ArticleStandard/Article/detail/113520http://pharmrep.findpharma.com/pharmrep/Selling+to+Pharmacists/The-evolving-role-of-the-pharmacist/ArticleStandard/Article/detail/113520http://en.wikipedia.org/wiki/Pharmacisthttp://en.wikipedia.org/wiki/Health_professionhttp://en.wikipedia.org/wiki/Pharmacyhttp://en.wikipedia.org/wiki/Pharmacyhttp://en.wikipedia.org/wiki/Medicinehttp://en.wikipedia.org/wiki/Medical_prescriptionhttp://en.wikipedia.org/wiki/Patienthttp://en.wikipedia.org/wiki/Biological_pharmacisthttp://en.wikipedia.org/wiki/Pharmaceutical_industryhttp://en.wikipedia.org/wiki/Pharmaceutical_industryhttp://en.wikipedia.org/wiki/Research_and_developmenthttp://en.wikipedia.org/wiki/Research_and_developmenthttp://en.wikipedia.org/wiki/British_Englishhttp://en.wikipedia.org/wiki/British_Englishhttp://en.wikipedia.org/wiki/Chemisthttp://en.wikipedia.org/wiki/Dispensing_chemisthttp://en.wikipedia.org/wiki/Pharmacist#cite_note-0http://en.wikipedia.org/wiki/Chemistryhttp://en.wikipedia.org/wiki/Pharmacist#cite_note-royal-1http://en.wikipedia.org/wiki/Taih%C5%8D_Codehttp://en.wikipedia.org/wiki/Y%C5%8Dr%C5%8D_Codehttp://en.wikipedia.org/wiki/Y%C5%8Dr%C5%8D_Codehttp://en.wikipedia.org/wiki/Heian_periodhttp://en.wikipedia.org/wiki/Meiji_Restorationhttp://pharmrep.findpharma.com/pharmrep/Selling+to+Pharmacists/The-evolving-role-of-the-pharmacist/ArticleStandard/Article/detail/113520http://pharmrep.findpharma.com/pharmrep/Selling+to+Pharmacists/The-evolving-role-of-the-pharmacist/ArticleStandard/Article/detail/113520http://en.wikipedia.org/wiki/Pharmacisthttp://en.wikipedia.org/wiki/Health_professionhttp://en.wikipedia.org/wiki/Pharmacyhttp://en.wikipedia.org/wiki/Medicinehttp://en.wikipedia.org/wiki/Medical_prescriptionhttp://en.wikipedia.org/wiki/Patienthttp://en.wikipedia.org/wiki/Biological_pharmacisthttp://en.wikipedia.org/wiki/Pharmaceutical_industryhttp://en.wikipedia.org/wiki/Research_and_developmenthttp://en.wikipedia.org/wiki/British_Englishhttp://en.wikipedia.org/wiki/Chemisthttp://en.wikipedia.org/wiki/Dispensing_chemisthttp://en.wikipedia.org/wiki/Pharmacist#cite_note-0http://en.wikipedia.org/wiki/Chemistryhttp://en.wikipedia.org/wiki/Pharmacist#cite_note-royal-1http://en.wikipedia.org/wiki/Taih%C5%8D_Codehttp://en.wikipedia.org/wiki/Y%C5%8Dr%C5%8D_Codehttp://en.wikipedia.org/wiki/Y%C5%8Dr%C5%8D_Codehttp://en.wikipedia.org/wiki/Heian_periodhttp://en.wikipedia.org/wiki/Meiji_Restoration


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all others in health-related fields such as physicians and acupuncturists. In the Imperial household,the pharmacist was even ranked above the two personal physicians of the Emperor.[3]

Nature of the work

Historically, the fundamental role of pharmacists is to distribute drugs that have been prescribed by

a healthcare practitioner to patients. In more modern times pharmacists advise patients and healthcare providers on the selection, dosages, interactions, and side effects of medications. Pharmacistsmonitor the health and progress of patients to ensure the safe and effective use of medication. Insome cases, pharmacists may practice compounding (mixing ingredients to form medications);however, most medicines are produced by pharmaceutical companies in a standard dosage and drugdelivery form. In some jurisdictions, pharmacists have prescriptive authority to either independently

prescribe under their own authority or in collaboration with a primary care physician through anagreed upon protocol .

Pharmacists are trained inpharmacology,pharmacognosy, chemistry,pharmaceutical chemistry,microbiology,pharmacy practice (including drug interactions, medicine monitoring, medication

management),pharmaceutics,pharmacy law,physiology,anatomy,biochemistry,pharmacokinetics, drug delivery, pharmaceutical care, nephrology, hepatology, and compoundingmedications. Additional curriculum covers diagnosis with emphasis on laboratory tests, disease statemanagement, therapeutics and prescribing (selecting the most appropriate medication for a given

patient).

One of the most important roles that pharmacists are currently taking on is one of pharmaceuticalcare . Pharmaceutical care involves taking direct responsibility for patients and their disease states,medications, and the management of each in order to improve the outcome for each individual

patient. Pharmaceutical care has many benefits that include but are not limited to:

Decreased medication errors

Increased patient compliance in medication regimen Better chronic disease state management

Strong pharmacist-patient relationship

Decreased long-term costs of medical care

Pharmacists are often the first point-of-contact for patients with health inquiries. This means thatpharmacists have large roles in the assessing medication management in patients, and in referringpatients to physicians. These roles may include, but are not limited to:

clinical medication management

the assessment of patients with undiagnosed or diagnosed conditions and for decisions about

the clinical medication management required. specialized monitoring of disease states

reviewing medication regimens

monitoring of treatment regimens

delegating work

general health monitoring

compounding medicines

general health advice

providing specific education to patients about disease states and medications

oversight of dispensing medicines on prescription

provision of non-prescription medicines counseling and advice on optimal use of medicines

advice and treatment of common ailments
http://en.wikipedia.org/wiki/Pharmacist#cite_note-2http://en.wikipedia.org/wiki/Pharmacist#cite_note-2http://en.wikipedia.org/wiki/Pharmacologyhttp://en.wikipedia.org/wiki/Pharmacognosyhttp://en.wikipedia.org/wiki/Chemistryhttp://en.wikipedia.org/wiki/Pharmaceutical_chemistryhttp://en.wikipedia.org/wiki/Microbiologyhttp://en.wikipedia.org/wiki/Pharmacy_practicehttp://en.wikipedia.org/wiki/Pharmacy_practicehttp://en.wikipedia.org/wiki/Interactionhttp://en.wikipedia.org/wiki/Pharmaceuticshttp://en.wikipedia.org/wiki/Pharmaceuticshttp://en.wikipedia.org/w/index.php?title=Pharmacy_law&action=edit&redlink=1http://en.wikipedia.org/wiki/Physiologyhttp://en.wikipedia.org/wiki/Physiologyhttp://en.wikipedia.org/wiki/Anatomyhttp://en.wikipedia.org/wiki/Biochemistryhttp://en.wikipedia.org/wiki/Biochemistryhttp://en.wikipedia.org/wiki/Biochemistryhttp://en.wikipedia.org/wiki/Pharmacokineticshttp://en.wikipedia.org/wiki/Nephrologyhttp://en.wikipedia.org/wiki/Hepatologyhttp://en.wikipedia.org/wiki/Pharmacist#cite_note-2http://en.wikipedia.org/wiki/Pharmacologyhttp://en.wikipedia.org/wiki/Pharmacognosyhttp://en.wikipedia.org/wiki/Chemistryhttp://en.wikipedia.org/wiki/Pharmaceutical_chemistryhttp://en.wikipedia.org/wiki/Microbiologyhttp://en.wikipedia.org/wiki/Pharmacy_practicehttp://en.wikipedia.org/wiki/Interactionhttp://en.wikipedia.org/wiki/Pharmaceuticshttp://en.wikipedia.org/w/index.php?title=Pharmacy_law&action=edit&redlink=1http://en.wikipedia.org/wiki/Physiologyhttp://en.wikipedia.org/wiki/Anatomyhttp://en.wikipedia.org/wiki/Biochemistryhttp://en.wikipedia.org/wiki/Pharmacokineticshttp://en.wikipedia.org/wiki/Nephrologyhttp://en.wikipedia.org/wiki/Hepatology


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referrals to other health professionals if necessary

dosing drugs in renal and hepatic failure

pharmacokinetic evaluation

education of physicians and other health care providers on medications and their proper use

limited prescribing of medications only in collaboration with other health care professionals

providing pharmaceutical information

promoting public health by administering immunizations

http://www.who.int/mediacentre/news/new/2006/nw05/en/index.html

New tool to enhance role of pharmacists in

health care23 NOVEMBER 2006 | GENEVA -- The traditional role of pharmacists is to manufacture and

supply medicines. More recently, pharmacists have been faced with increasing health demands: anever-growing and complex range of medicines, and poor adherence to prescribed medicines, haveforced the evolution of the pharmacists role into a more patient centred approach (known as

pharmaceutical care). Adherence to long-term therapy for chronic conditions in developed countriesaverages 50%, with even lower rates for developing countries.

To address this need, the World Health Organization (WHO) and the International PharmaceuticalFederation (FIP) are publishing the first edition of a handbook onDeveloping pharmacy practice -

A focus on patient care. "Pharmacists have an important role to play in health care, which is muchmore than selling medicines," said Dr Hans V. Hogerzeil, WHO Director of Medicines Policy andStandards.

The role of the pharmacist is summarized through the WHO/FIP seven-star concept in which apharmacist is described as a caregiver, communicator, decision-maker, teacher, lifelong learner,leader and manager. For the purpose of this handbook, the function of researcher has been added.

The pharmacist is an integral member of the health care team and assumes varied functions rangingfrom the procurement and supply of medicines to pharmaceutical care services, helping to ensurethe best treatment for patients. The pharmaceutical care process involves establishing a relationship

between the patient and the pharmacist, developing an evidence-based care plan for medicinetherapy and follow-up on the patient's expected health outcome.

Founded on the principles of the seven-star pharmacist, this interactive handbook providespractical examples and care models so that it can be used for self-directed learning. It contains a

wide variety of illustrative case studies to meet the needs of different users. It is designed to guidelearners towards specific educational outcomes, and enable them to undertake tasks which require acombination of knowledge, skills and attitudes.

"Pharmaceutical care delivered by pharmacists seeks to optimize patient outcomes and is key to theeffective, rational and safe use of medicines. This handbook serves as a timely and accessibleresource for pharmacists, educators and students worldwide to develop patient-centred services andskills to meet local patient needs," said Ton Hoek, General Secretary and CEO of the InternationalPharmaceutical Federation.

Developing pharmacy practice - A focus on patient care is designed to meet the changing needs ofthe pharmacist, setting out a new paradigm for pharmacy practice. The handbook is written for

pharmacists, educators and students all over the world in all health care settings. To reach as widean audience as possible the handbook is available in English and French will be available soon in

both electronic and print formats.
http://www.who.int/mediacentre/news/new/2006/nw05/en/index.htmlhttp://www.who.int/mediacentre/news/new/2006/nw05/en/index.html


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document is a report of a WHO consultative group meeting held in New Delhi during December 13-16, 1988 and highlights professional role of pharmacists.

If the committee is of the option that 'mixing medicines' is the only job which a pharmacist issupposed to do, then it can be argued that the learned members have incomplete comprehension ofthe role of pharmacist in the healthcare system.

Over the years the professional role of pharmacists have evolved considerably. The WHO reportstates "Effective medicine can be practiced only where there is efficient drug management." Thereport further states, "Time and again, in less affluent settings, inadequacies in the provision of

primary health care are attributable to shortcomings within the drug distribution chain. Only whenthe pharmacist has been accepted as a vital member of the healthcare team can the necessarysupporting services be organized with the professionalism that they demand."

The WHO report further clarifies that pharmacists are uniquely qualified because:- They understand the principles of quality assurance as they are applied to medicines;- They appreciate the intricacies of the distribution chain and the principles of efficient stock -

keeping and stock - turnover;- They are familiar with the pricing structures applied to medicinal products obtained within themarkets in which they operate;- They are the custodians of much technical information on the products available on their domesticmarket;- They are able to provide informed advice to patients with minor illnesses and often to those withmore chronic conditions who are on established maintenance therapy;- They provide interface between the duties of prescribing and selling medicines and in so doing,they dispose of any perceived or potential conflict of interest between these two functions.

In a diverse country like India, with more than 70,000 pharmaceutical formulations in the market,maintenance of standards for quality of drugs is a stupendous task both for central and stateauthorities related to drug-control. Preventing proliferation of adulterated, misbranded or counterfeitdrugs itself is an uphill task.

There is no doubt that distribution of drugs has to be eased out and drugs should be readily availableto the average consumers. However the best policy instrument to achieve the laudable objective isto follow the policy of essential drugs as suggested by the World Health Organization (WHO) way

back in 1977. A large number of developing countries have followed the policy. The state of Delhihas followed the policy of essential drugs; but with irrational policy and drugs being sold in otherstates of India, an isolated state may not be able to make enough dents in the easy availability of

drugs to average consumers.

The right remedy for many ills in the distribution of the drugs is to scale down the number of drug-formulations in Indian market to a minimum of say 1,000 instead of more than 70,000. Our countrycertainly does not need such a huge number of formulations. More the number of formulations,more is the administrative load over drug-control and more is the number of manpower needed tomonitor it.

In the post-liberation years, the size of government is reducing gradually and with the dictum of"That government is best which governs least", availability of really needed minimum number ofdrugs in Indian market will reduce the burden of government authorities over control of drugs.

It is irony of fate in our country that the ministry of chemicals and fertilizers rather than ministry ofhealth declare the drug policy. Probably there is a feeling in Central block that chemicals and


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fertilizers rather than lifestyle are more intimately related to health.

The remark of the standing committee that "Pharmacist is the main hurdle in easy accessibility ofmedicines" is certainly unfounded. With the kind of political, administrative and social structure inour country, there is a lot to be done in distribution of drugs.

The WHO report on "The role of the pharmacist in the healthcare system" states that thecompetence of the pharmacist is already proven and evident:- In the direction and administrative of pharmaceutical services;- In drug regulation and control;- In the formulation and quality control of pharmaceutical products;- In the inspection and assessment of drug manufacturing facilities;- In the assurance of product quality through the distribution chain;- In drug procurement agencies and- In National and institutional formulary committees.

Unfortunately because of following factors, pharmacists have not been able to pursue their

international mandate in our country.- Lack of understanding of the role of pharmacist in health care.- Lack of identification of 'Health-care-team' as a policy concept and center-stage role only tomedical professionals in the maintenance of heath.- More stress on curative measures rather than preventive measures for health related issues.- Lack of national objectives of professional education being reflected in policy implementation.- Peripheral role of pharmacist in health care only towards manufacture and distribution of drugs.In developed countries like USA the role of pharmacist is next to the clergyman and he is looked asthe main source of correct information and availability of drugs. He is never a "hurdle", and in factwill prove a boon in distribution of drugs.

Medication errors are a big issue even in developed countries like USA and pharmacist has a centralrole in preventing medication errors and improving life expectancy of average consumers. It isestimated that in USA, injuries caused by medical management are 2.9 to 3.7%. Preventableadverse event is a leading cause of death in USA. When extrapolated to over 33.6 millionadmissions to US hospitals in 1997, it was observed that between 44000 - 98000 Americans die inhospitals each year as a result of medication errors. It is the eighth leading cause of deathcomparable to deaths caused by motor vehicles (43458), breast cancer (42297) or AIDS (16516).Medication errors can certainly be minimized with more and more involvement of pharmacists inthe administration of drugs.

There is enough evidence for the economic value of pharmacists in developed countries like USA.A growing body of literature has emerged that supports the value of pharmacist's patient careinterventions in a wide range of patient groups, health care settings, and disease states.- Over 20 studies and demonstration projects confirm that pharmacists add value to the health caresystem by improving care and decreasing cost.- During a six months period pharmacists joined doctors, residents and other members of the patientcare team on patients round in the intensive care unite at a large, urban teaching hospital. Resultshowed that- Preventable adverse drug events decreased by 66%- A projected $ 270,000 related to adverse drug events could be saved annually- 366 of the 400 pharmacist interventions were related to medication errors.

- Pharmacist interventions helped prevent incomplete orders, incorrect dosages and frequency, less-than - optimal drug choices, and duplicate prescriptions.- Pharmacists working in their communities produced a 74% increase in vaccination rate by


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advising high-risk patients of infection risk and describing where to go to be vaccinated.- Patient acceptance was excellent, with pharmacists administering 1060 doses of influenzavaccinations and 198 pneumococcal vaccinations to 1067 patients.- Pharmacist reviewed drug therapy and found ways to improve medications used in nearly 65% ofall patients.- The bulk of savings were not related to drug costs, rather they were associated with fewer

unscheduled physician visits and fewer hospital days.- Consultant pharmacist-conducted drug regimen review increases the number of patients whoexperience optimal therapeutic outcomes by 43% and saves as much at $ 3.6 billions annually incosts associated with medication - related problems.- Pharmacists working with patients in their community provided targeted patient education,systematic patient monitoring, patient feedback and behavior modification.- Savings for monthly medical cost ranged from $ 143.96 to $ 293.39 per patient per month.

The result of these studies suggest that a broad range of hospital-based pharmacist-provided patientcare activities either save lives or reduce health care costs or both. In a study evaluating the effect ofclinical pharmacists on the economic outcomes of patient care an average benefit of $ 16.70 of

value to the health care system was realized for each $ 1 invested in clinical pharmacy service. Drugtherapy changes based on pharmacists' recommendation reduced unscheduled hospital visits, urgentcare visits, emergency room visits and hospital days, saving over $ 640 per year in health cost perindividual ($ 280,000 per year per pharmacist).

In order to have such an important role for pharmacist in Indian health care, objective basededucation oriented towards the purpose needs to be implemented.

In a multifaceted country like India, what happens in politics is reflected in all walks of life.Division amongst people is advantageous to certain sections of society. The same policy is beingunfortunately implemented in the health profession. Physicians, pharmacists, nurses and otherhealth-related professionals should work in harmony towards the central benefit of "PATIENTS".Patients, rather than any professionals should be at the center-stage of health policy and

professionals should not quarrel amongst themselves for their central or peripheral role in the wellbeing of patients.

It is the lack of this understanding on part of honorable members of the standing committee that haslead to the belief that "Pharmacist is the main hurdle in easy accessibility of medicines". World over

pharmacist is one of the important member of the health-team including clinical research. If Indianpharmacist is not fulfilling this role, then he should be appropriately trained and be oriented as ahealth - care provider to the vast rural population. He can be used intelligently as an alternative

manpower towards the sacred goals of:- Immunization- Minor dressings- Family planning- Preventing tropical diseases- Providing drug-information- Monitoring adverse drug reactions- Monitoring and minimizing adverse drug interactions- Preventing misuse of drugs- Preventing medication errors- Preventing abuse of tobacco, alcohol

Much of the role of preventive and social medicine can be attributed to pharmacists. In factpharmacists can be real 'bare-foot' doctors to average consumers of rural India. What we need is the


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vision of policy-makers rather than marginalizing role of any professional in the health-care team.Pharmacist is certainly not a "Hurdle but can be a boon and facilitator in the process of efficientdrug - distribution.

http://www.shepscenter.unc.edu/rural/pubs/finding_brief/FB88.pdfA Joint Publication of The North Carolina Rural Health Research & Policy Analysis Center(1)

and The RUPRI Center for Rural Health Policy Analysis (2)

The Key Role of Sole Community Pharmacists in

Their Local Healthcare Delivery SystemsAndrea Radford, Dr.P.H.(1), Indira Richardson, M.P.A.(1), Michelle Mason, M.A.(2), Stephen Rutledge(1)

OVERVIEW

Sole community independent pharmacists provide essential services to residents of small towns andisolated communities. Anecdotal reports indicate their role within the local health care community

isoften multi-faceted, extending beyond the provision of prescription and nonprescription medicationsattheir retail stores. In 2008, we surveyed 401 community pharmacists that are the only retail providerintheir community to document their extended relationships with other health care providers and theadditional health care services these pharmacists provide to their patients. Pharmacist-owners inindependent pharmacies located at least 10 miles from the next closest retail pharmacy wereinterviewedto determine the presence in their community of other types of health care organizations that require

pharmaceutical support i (such as hospitals, long-term care facilities, hospice providers, home health

agencies and community health centers), their level of involvement with those facilities, and thetypes ofclinical services (other than dispensing and counseling) the pharmacists offered to their own

patients.KEY FINDINGS

Most sole community pharmacists (83%) provided important services for otherhealth care providers and facilities in their communities.

Almost all (92%) of the communities served by a single independent retail pharmacy arealso served by at least one other type of inpatient or outpatient health care organization.

Skilled nursing or long-term care facilities, hospice providers and home health agencies,all of whom serve predominately elderly patients, were the most common types of healthcare organizations in the communities surveyed.

Almost half of all pharmacists (42%) offered additional clinical and educational servicesto community residents including blood pressure checks, screening for cholesterol andosteoporosis, glucose screening and diabetes counseling, tobacco cessation programs, andimmunizations.i Private physician practices were not in included in this study, as they typically do not provide the type of services thatrequire on-site pharmacy support.

Findings Brief March 20092

PRESENCE OF OTHER COMMUNITY HEALTH CARE ORGANIZATIONS

Almost all (92%) of the sole community pharmacists interviewed reported the presence of one ormore


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different types of health care organizations in their community. The most commonly reported wereskilled nursing or long-term care facilities (66%), hospice providers (62%) and home healthagencies(54%). Fewer communities were served by a local hospital (32%) and community health centers(29%).The most common types of other health care providers located in these communities skilled

nursing/long-term care, hospice, home health agencies are organizations whose patients are predominatelyelderly. While hospitals were reported less frequently in these communities they also providecriticalservices to the rural elderly. Given the higher use of pharmaceuticals by older patients, theavailabilityof local pharmacy support is critical for health care providers who serve elderly patients.PHARMACISTS INVOLVEMENT WITH OTHER COMMUNITY HEALTH CARE

ORGANIZATIONS

The majority of pharmacists (83%) reported working with one or more of the other health careorganizations

in their community. They provided services most frequently to hospice providers (94%), to skillednursing or long-term care facilities (79%) and to home health agencies (74%). Services were

providedless frequently to local hospitals and community health centers (Figure 1).Figure 1. Provision of Services to Other Health Care Organizations by Sole Community

Pharmacies (when other health care organizations are present in the community)SERVICES PROVIDED TO OTHER COMMUNITY HEALTH CARE ORGANIZATIONS

Pharmacists were asked about what types of services they provided to other health careorganizations intheir communities. Not unexpectedly, providing medications was the most common service

provided,ranging from 96% who reported providing medications for hospice patients to 69% who provideddispensingservices at their local hospital. Some of the other types of services pharmacists reported

providing to the different types of health care organizations present in their communities includedthefollowing:HOSPICE:

delivery of medications (58%) on-call services (54%)

compounding (39%)


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SKILLED NURSING FACILITIES/LONG TERM CARE:

fi lling medication cassettes/unit dose dispensing (87%) monthly chart reviews (35%)HOME HEALTH:

delivery of medications (60%)

provision of durable medical equipment (40%)HOSPITALS: pharmaceutical inventories (57%) billing for medications (24%) rounding on hospital patients (12%)COMMUNITY HEALTH CENTERS:

dispensing 340B medications (46%) counseling diabetic patients (30%).

ADDITIONAL SERVICES PROVIDED TO THEIR OWN PATIENTSPharmacists were also asked whether they provided additional clinical services other thandispensingmedications and counseling to their own patients. Of the pharmacists surveyed, 42% stated theyofferedone or more additional clinical services. The most common services provided were blood pressurechecks (12.9%), diabetes counseling and blood glucose testing (12.4%), immunizations (9.7%) and

providingeducational classes or participating in health fairs (8.2%). Other less commonly reported servicesincluded offering tobacco cessation programs and providing screening tests for osteoporosis,asthma,

hearing, and cholesterol. Medication delivery for their own patients and as a service to othercommunityhealth care organizations was also frequently reported by these sole community pharmacy


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providers.DISCUSSION

For purposes of this study sole community pharmacies were defi ned as independent retailpharmacieslocated 10 or more miles from the next closest pharmacy. Despite the distance from other retail

pharmacy options, most of the communities in which sole community pharmacists provide

pharmacyservices have other health care facilities that require pharmaceutical support, ranging from inpatientcare providers such as long-term care facilities and hospitals to outpatient providers such as homehealthagencies and community health centers. All of these health care providers need supportive

pharmacyservices to function, the most basic being access to medications needed by their patients. Solecommunity

pharmacies provide this support and more to these partner agencies and help ensure access toimportant health care services for residents of their community.Sole community pharmacists also provide health monitoring and preventive care services such as

bloodpressure or glucose screening and immunizations for local residents. These important monitoringfunctions are particularly valuable in areas where primary care providers are less common andresidentsmay otherwise have to travel long distances for simple screening procedures.The fi ndings from this study document the important role sole community pharmacists play in theirlocalhealth care delivery systems, and supports the notion that the survival of sole community

pharmacies notonly ensures retail access to pharmaceuticals and patient counseling but also, in many cases, accesstoother important health care services that are particularly needed in communities with limited healthcareoptions.4

This study was funded under a cooperative agreement with the Federal Offi ce of Rural Health Policy

(ORHP),

Health Resources and Services Administration, U.S. Department of Health and Human Services,

Grant Number U1GRH07633. The conclusions and opinions expressed in this paper are the

authors alone; no endorsement by the University of North Carolina, the University of Nebraska, ORHP,

or other sources of information is intended or should be inferred.

STUDY METHODS

A semi-structured interview protocol was used in this study. To be included in the survey,pharmacieshad to be independently owned and located 10 miles or more from the next closest pharmacy. Asubsetof pharmacies likely to meet these criteria were identifi ed using data from the National Council forPrescription Drug Programs, Inc., which contains information about the 74,108 pharmacies in theU.S.with active provider numbers. Pharmacies with the following characteristics were identifi ed:independentlyowned (including franchise licenses); operating as a community retail pharmacy; the only

pharmacy within its ZIP code; and the only pharmacy within a ten mile or more Euclidian buffer

fromthe next closest pharmacy. Application of these criteria resulted in a fi nal sample of 1,148

pharmacies.


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The pharmacys eligibility to participate in this study was verifi ed during the initial telephonecontact.The study goal was to complete 400 interviews. Attempts were made to contact the owners of all the

pharmacies in the sample. No contact was made with 5 pharmacies (no answer or busy signal), for151

pharmacies the pharmacist-owner was never reached in ten or more attempts, 43 stores were confi

rmedclosed, and 68 did not meet the study criteria. Of the remaining 881 pharmacies, 401 participatedfor aresponse rate of 46%.ADDITIONAL NCRHR & PAC AND RUPRI PUBLICATIONS ON INDEPENDENT

PHARMACIES AND MEDICARE PART D

Available at: http://www.shepscenter.unc.edu/research_programs/rural_program/index.html

Findings Brief No 87. Sole Community Pharmacies and Part D Participation: Implications for RuralResidents. (2009).Findings Brief No. 83. One Year In: Sole Community Rural Independent Pharmacies and MedicarePart

D. (2007).Final Report No 92. One Year In: Sole Community Rural Independent Pharmacies and MedicarePart D.(2007).Final Report No 87. The Experience of Sole Community Rural Independent Pharmacies withMedicarePart D: Reports from the Field. (2006).

Available at: http://www.unmc.edu/ruprihealth/

Brief No. 2009-2. Rural Enrollment in Medicare Part D is Growing Slowly. (2009).Brief No. 2008-5. Eligible But Not Enrolled? Potential for Targeting Over a Half-Million RuralMedicareBenefi ciaries for Enrollment in the Low-Income Subsidy Prescription Drug Program. (2008).Brief 2008-2. Independently Owned Pharmacy Closures in Rural America. (2008).The authors wish to acknowledge the valuable assistance of the RUPRI staffin preparing the sample of pharmacies and conducting interviews.

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