ASHP, together with the ASHP Research and Education Foundation, conducted a conference in 1985 to examine the progress we had made up to that point in establishing pharmacy as a clinical profession and to offer recommendations to guide the future development of clinical practice in pharmacy. This conference, titled “Directions for Clinical Practice in Pharmacy,” was held at Hilton Head Island, South Carolina, and has since been commonly referred to within pharmacy circles as the Hilton Head Conference.
As we mark the 30th anniversary of the Hilton Head Conference, some pharmacists may see fit to reflect on the progress we have made during the past three decades in achieving the vision and the goals that were expressed at that conference. The reflections recorded here are intended to help in that regard, although admittedly one pharmacist’s recollections and interpretations cannot begin to tell the whole story.
The proceedings of the Hilton Head Conference are available online (www.ashp.org/DocLibrary/PPMI/1985HiltonHead.aspx) and in AJHP.1 A review of these proceedings will help the reader understand the historical and professional context of these reflections.
As a preface, two important points need to be made. First, clinical pharmacy practice was already well established prior to the Hilton Head Conference. This point is made to dispel any notion that the concept of clinical pharmacy was somehow “invented” at the Hilton Head Conference or developed as a result of this conference. In fact, the conference was convened to take stock of where we were as a profession some 20 years into the development of clinical pharmacy practice. Second, this conference was not a first for ASHP. Throughout its history prior to the Hilton Head Conference (beginning with the Society’s establishment in 1942), ASHP had convened a number of study groups, blue-ribbon panels, and special conferences to help guide the development of hospital pharmacy in such areas as minimum standards for hospital pharmacy, training standards and guidelines for the hospital pharmacy work force, establishment of hospital drug formularies, and modernization of drug distribution systems. The Society undertook several such initiatives on its own and collaborated with related organizations in certain other ones (e.g., the 1971 ASHP–AACP Invitational Workshop on Clinical Pharmaceutical Practice and Education, jointly convened by the Society and the American Association of Colleges of Pharmacy2).a
Conference objectives and desired outcomes
The Hilton Head Conference planners established several specific conference objectives, which are enumerated in the proceedings.1 These objectives may be summarized as (1) identification of the goals of clinical pharmacy, (2) assessment of the profession’s commitment to clinical pharmacy practice, (3) consideration of the need for a definition of clinical pharmacy or, alternatively, for a modernized definition of pharmacy, and (4) identification of major obstacles to the attainment of the goals embodied in clinical pharmacy and strategies for overcoming those obstacles.
The 1985 clinical pharmacy landscape
How was the stage set, in 1985, for the work of the Hilton Head Conference participants?
First, there was a palpable level of energy surrounding the vision of “pharmacy as a clinical profession,” as some would have it, or of “clinical pharmacy as a specialty,” as others saw it. In either case, it seemed undeniable that the future of pharmacy practice was destined for considerable change. In the opening conference address, Parker3 commented, “It seems hardly possible that the term ‘clinical pharmacy’ was not a part of our vocabulary 20 years ago. Yet, who would deny that the term represents the most important concept of practice, education, and professional philosophy in the history of our profession.” That statement was indicative of the level of energy that had developed in pharmacy in support of clinical pharmacy as a new mission for the profession. Indeed, by the time of the Hilton Head Conference, a number of exciting developments had already taken place; these are described at various places in the literature, but a pertinent summary was provided by Smith4 in his 1982 Harvey A. K. Whitney Lecture.
Second, pharmacy education was in a period of transition from the five-year baccalaureate degree to a six-year (or longer) Pharm.D. degree as the entry-level degree for pharmacy practice. It had not yet been decided, in 1985, when (or if) schools and colleges would be required to complete the transition from a B.S.Pharm. to a Pharm.D. program. This uncertainty—and the tensions it created—were part of the backdrop of the Hilton Head Conference. Since the Pharm.D. curriculum had a stronger clinical emphasis than the B.S.Pharm. curriculum, it was assumed by many practitioners that “clinical pharmacist” was synonymous with “Pharm.D.” This growing perception left many baccalaureate-trained pharmacists, and even M.S.-trained pharmacists, feeling marginalized.
The degree-transition issue was complicated by the competing allegiances of pharmacists who championed making the Pharm.D. degree the single entry-level degree and those who advocated the continuation of a post-B.S.Pharm. doctoral program of two or more years’ duration. Proponents of both views were represented among the conference participants. (It is worth noting that there were already 35 postbaccalaureate Pharm.D. programs in existence in 1985b; at least 3 of those were also offering an entry-level Pharm.D. degree.)
Third, ASHP had recently approved an accreditation standard for residency programs in clinical pharmacy practice (distinct from the standard for traditional hospital pharmacy residency programs). This new standard established the Pharm.D. degree “or equivalent experience” as an admission requirement. (Precisely what constituted equivalent experience was at that time subject to wide interpretation.) Part of the rationale for this decision was that the clinical practice component of the residency should build on rather than duplicate the experience gained in Pharm.D. “clerkships” (i.e., professional practice rotations). This change may have further contributed to the growing sense of marginalization among many baccalaureate-prepared pharmacists.
Other key elements of the 1985 clinical pharmacy landscape included the following:
The Health Care Financing Administration (now called the Centers for Medicare and Medicaid Services) had in 1983 established a diagnosis-related group system of reimbursement for the care of Medicare patients; this fixed-rate compensation system was quickly adopted by private insurance companies. One dramatic effect was that health-system pharmacy departments became more of a cost center than a source of revenue generation and were subject to unprecedented cost-containment pressures.
The reception of clinical pharmacists by physicians in patient care settings had been mixed (ranging from support to overt antagonism).
Clinical pharmacy practice was at the time based largely in acute care (inpatient) settings, associated in most cases with medical specialties, and limited primarily to teaching hospitals (including university and Veterans Affairs facilities).c
In many hospitals where Pharm.D. students were being trained, there was considerable tension between hospital pharmacy directors and college of pharmacy administrators, as well as between clinical pharmacy faculty members and pharmacy staff members, regarding the roles and responsibilities of the faculty members. Part of this tension arose from questions about responsibility for the clinical services provided by faculty members and how these services were integrated into the overall service programs of the hospital pharmacy department.
Technicians had not yet become widely accepted as an integral part of the health-system pharmacy work force; among the complicating factors were the lack of consensus on what technicians’ roles should be and how they should be trained, regulatory barriers established by state boards of pharmacy, and resistance from many pharmacists (who presumably felt that technicians represented a job threat). Pharmacists at that time had to perform many tasks that today we readily relegate to technicians. Thus, valuable pharmacist work hours were diverted from clinical activities to tasks that required much less judgment.
Many health-system pharmacy directors of the day lacked the vision, the leadership and management abilities, or the interest in transforming their departments from drug distribution–focused operations to clinically based pharmacy service organizations (This problem was cited at the Hilton Head Conference as a major obstacle to the development of pharmacy as a clinical profession).
Most state boards of pharmacy at the time questioned whether clinical pharmacy activities were permitted under state law and regulation. Some boards viewed the functions of clinical pharmacists as part of the practice of medicine (functions that pharmacists were not licensed to perform). The removal of legal and regulatory barriers to clinical pharmacy practice would be slow to come.
Information technology was very much in its infancy in the early 1980s. Commercial Internet service providers did not yet exist, the World Wide Web had not yet been established, Windows technology (Microsoft Corporation, Redmond, WA) had not yet been released, biomedical libraries had not yet been digitized, and such computer applications as e-mail and search engines were still unknown. The electronic medical record had not yet become a reality. Medication order entry and review were still largely manual processes.
Automation technology was also in the very early stages of development. Most of the routine functions of pharmacists (unit dose drug distribution, preparation of intravenous admixtures, maintenance of patient medication profiles, and generation of medication history summaries) were still performed manually.
Thus, the Hilton Head Conference was convened at a time of unprecedented growth and optimism within the profession, but it was also a time of considerable tension and uncertainty. The profession was clearly seeking answers to key questions about its basic responsibilities to society and about the roles of pharmacists in fulfilling those responsibilities. An overarching goal of the conference was to reach consensus on the answers to such questions.
Conference findings and recommendations
Conference workshops were organized to consider four broad sets of questions dealing with (1) pharmacy’s societal purpose (and the place of clinical pharmacy practice within that purpose), (2) barriers faced by the profession in further development of clinical practice, (3) the relationship between colleges of pharmacy and clinical training sites (which were at that time principally hospitals), and (4) pharmacy’s relationship with other health professions. Separate workshop sessions were devoted to each of these topics. Prior to each workshop, participants attended a plenary session address (each presented by a carefully chosen speaker) that explored the assigned topic in some depth (philosophical, analytical, historical, and contextual [i.e., within the context of contemporary practice]). These addresses (given by Hepler, Walton, Ivey, and Miller) are included in the conference proceedings.1 Conference participants also received background papers on each topic and a set of key questions for each of the four workshop topics.
The workshops generated a total of 112 statements regarding the purpose and the breadth of responsibility of the profession, the responsibility of colleges of pharmacy in the experiential component of clinical education, perceived barriers to the development of clinical pharmacy and recommendations for addressing those barriers, and the relationship between pharmacy and medicine (and other health professions). At the completion of the four workshop sessions, all workshop participants (in a full conference assembly) completed questionnaires indicating their level of agreement with each of the 112 statements, with response options ranging from 1 (strongly disagree) to 5 (strongly agree); the midpoint rating of 3 denoted an undecided viewpoint. Of these 112 statements, 97 received a composite consensus score of 3.5 or higher, and 63 received a composite score of 4 or higher. Most of the statements that received a score of less than 4 were proposed solutions to perceived barriers. Practically all the statements pertaining to the purpose and responsibilities of the profession received a score of 4 or greater. The complete survey results are included in the conference proceedings.1 (This level of operational detail regarding the Hilton Head Conference is provided here simply to help the reader form an opinion about the level of credibility of the conference findings.)
What were the key messages from the Hilton Head Conference? The space allocated to this article does not allow for more than a very general summary. In my view, the central (and perhaps the most enduring) message was that pharmacy is an inherently clinical profession and that future planning for pharmacy practice should be predicated on that assumption. This message, then, seemed to provide a counterbalance to the initiative that was then underway to gain recognition (by the Board of Pharmaceutical Specialties) of clinical pharmacy as a specialty. I intend no criticism here of anyone who was a part of that movement; in fact, I quite understand the reasoning given the seemingly insurmountable problems of redirecting the energies of an entire profession largely geared to a mission of drug distribution and control. Yet, the Hilton Head Conference vision was that clinical practice (i.e., a focus on patients and their medication-related needs) was a core purpose of the profession of pharmacy and not the purview of some subset of pharmacists.
What progress have we made in 30 years?
The overall trajectory of pharmacy over the past 30 years has undeniably been clinical, meaning that the profession has become increasingly concerned with the use of medications in individual patients and with issues of the safety and appropriateness of medications. This trajectory has led in recent years in the direction of personal responsibility and accountability (by pharmacists) for the outcomes of patient medication use.d The philosophical foundation for this overall direction that was established (or validated) at the Hilton Head Conference has been continually reinforced since then through other key conferences, through vision papers, and through the conscientious work of thousands of individual pharmacists. Two recent initiatives of ASHP that have helped solidify the commitment of health-system pharmacists to such a direction are the Pharmacy Practice Model Initiative5 and the 2014 Ambulatory Care Summit conference.6
Clinical pharmacy is now woven into the fabric of pharmacy practice to the extent that most of us might agree that the adjective “clinical” is redundant. Yet, we have a considerable distance to travel before reaching our full potential as a profession. We do not yet have consistently applied standards of practice, our services in many settings are offered sporadically, and we are still all too often positioned downstream from where therapeutic decisions are made (rather than participating in those decisions). As a result, I fear that in many cases our services remain in the “optional” or “nice to have” category rather than in the “essential” category. (Certain recent initiatives within the profession offer reason for optimism in this regard; one example is the 2014 ASHP statement on the Pharmacists’ Patient Care Process,7 which has been endorsed by all U.S. national pharmacy organizations and highlights ASHP’s current focus on development of new or revised practice models.)
Many of the environmental changes that have shaped pharmacy practice during the past three decades (advances in information technology, introduction of major new categories of drugs into the market, and growing cost-containment pressures, among others) have occurred outside our control. “Change management” has become something of a byword in the profession as we have dealt with such changes. In other cases, pharmacists have had an opportunity to help shape and direct change (e.g., incorporating quality theory into our practices, providing input into the design of automated dispensing equipment, advising various standard-setting organizations on matters related to pharmacy practice). Among all the changes that the profession has contended with during this time, most were unforeseen at the time of the Hilton Head Conference. It is perhaps remarkable, therefore, that the profession has been able to continue on the path envisioned at the Hilton Head Conference as well as it has.
Considerable progress has been made in pharmacy education during the past 30 years. The issue of the entry-level degree was settled (perhaps not to everyone’s satisfaction), and since 2000 the Pharm.D. degree has been the entry-level degree. The Pharm.D. curriculum has continued to improve throughout this 30-year period, most notably in the area of experiential education. Although some friction still exists among schools of pharmacy and their affiliated clinical practice sites, it is my impression that such problems have been greatly ameliorated. I see the current emphasis in the accreditation standards of the Accreditation Council for Pharmacy Education on interprofessional collaboration and team-based patient care as a very positive direction—one consistent with several of the recommendations from the Hilton Head Conference.
Our relationships with physicians have improved tremendously since the mid-1980s, although, as noted above, many still view us as a nice-to-have but optional resource. This can change only when we establish standards of service that physicians know they can consistently depend on.
Other notable areas of progress during the past 30 years include the training and utilization of technicians (although regulatory barriers are still a problem); involvement of pharmacists in clinical research and in the development of standardized treatment protocols; growth in residency training, including training in a number of specialized areas of practice; and expansion of clinical pharmacy practice to ambulatory care settings, community hospitals, extended care facilities, and other areas.
Reflecting on the progress we have made and the changes we have endured (or championed), I believe our growth has been more incremental than radical. The elements of pharmacy practice have not changed in any fundamental way, although we have learned how to perform those functions much more effectively and with a greater sensitivity to and focus on the medication needs of individual patients. Along the way, most of us have accepted that we do, indeed, have a personal responsibility for what happens to the patient who receives a medication.
Humbly tendered recommendations
I shall conclude these reflections with a few thoughts about some unfinished business from the Hilton Head Conference and some recommendations for consideration as we move forward. Although some of these recommendations are not tied directly to the conference report, they seem to me important to our further growth as a clinical profession.
First, I find myself going back from time to time to the following consensus statement from the Hilton Head Conference: “A fundamental purpose of the profession of pharmacy is to serve as a force in society for safe and appropriate use of drugs.” This was the only statement to receive a perfect consensus score; that is to say, 100% of participants rated it a 5. However, I think it is fair to ask ourselves periodically, What progress have we made in becoming a force in society? I can think of several forces that eclipse our efforts in achieving the goal of safe and appropriate use of drugs. The pharmaceutical industry undoubtedly exerts a much greater force on the way medications are used than pharmacy does, and, arguably, so do insurance companies and benefits managers (by deciding what drugs and related services will be paid for). With respect to clinical research on medications, medicine still serves as a much greater force than pharmacy does: Physicians typically serve as principal investigators, and major findings (e.g., treatment guidelines and protocols) tend to be published in the medical literature. So, in 2015 I think we should reexamine the vision of pharmacy as a force in society, develop new ways of thinking about what this means, and establish objective criteria for measuring our progress.
Second, it seems obvious that healthcare will increasingly be delivered through integrated healthcare systems. This trend, I believe, will create unprecedented opportunities for pharmacists, for which we should position ourselves appropriately. Healthcare systems, as they grow (both in number and in size), will provide comprehensive healthcare to commensurately larger segments of the population. Pharmacists in these systems will be in a better position than ever to practice as members of interprofessional teams, to manage patients’ medication therapy in both inpatient and ambulatory care settings, to ensure continuity of care, and to measure the outcomes of care. However, a major part of the pharmacy work force is employed in settings that are remote from and unrelated to healthcare systems. It remains uncertain at this time how (or whether) community pharmacists will become engaged with health systems.
Third, I think it is time for the profession to address head-on the need for a structured plan for lifelong learning and continuous professional growth and development. In fact, we need to begin thinking of pharmacy education as a continuum beginning with the prepharmacy curriculum and extending throughout a pharmacist’s professional lifetime. Careful thought should be given to the patterns of growth that are needed to develop a new Pharm.D. graduate from an entry-level, “practice-ready” state to the status of clinically mature practitioner.
Fourth, I feel we need to find a fundamentally new way to work with physicians. For example, we need to agree on how physicians and pharmacists will share in the responsibility for medication-use treatment decisions and outcomes. The consultation and referral roles of pharmacists should be formalized. Pharmacists should routinely be involved at the point where treatment decisions are made rather than downstream from that point. The relationship between physician and pharmacist should be that of doctoral-level colleagues. The growing emphasis on interprofessional, team-based care may help get us to the point I have in mind, but we need a plan to guide us. Above all, such a plan should be directed toward helping physicians view us and our services as essential rather than optional.
In relation to that fourth point, I think we need to make a strong, concerted effort to determine what physicians need and want us to do. We base our practice on what we think those needs are, but how often do we validate our understanding of those needs with physicians themselves? Perhaps if we did a better job of asking physicians to articulate the problems they experience with medications, we might arrive at a point where they have acknowledged a need for services we are well suited to provide, or we might discover in the process that there is a mismatch between what they need or want and what we typically offer. A similar process might be followed with patients (comparing their needs with what we offer).e
Fifth, I urge that we position ourselves at the forefront of the clinical applications of pharmacogenomics. Our professional instincts should lead us in that direction without any prompting. The prospect of moving from a “blunt instrument” approach to drug therapy to one that is tailored to the unique clinical status of each patient is really exciting.
My final point of reflection on the past 30 years is that pharmacists have continued to show that they are people of goodwill—decent, hardworking, generous, and professionally motivated. I am very proud to have been a part of this profession for the past 53 years, and I have every confidence that we are sufficiently grounded to face another 30 years (and more) of unpredictable change without being blown too far off course.
The helpful suggestions of William A. Zellmer, B.S.Pharm., M.P.H., and William E. Smith, Pharm.D., Ph.D., M.P.H., are gratefully acknowledged.
The author has declared no potential conflicts of interest.
↵a Two other study groups that helped lay the foundation for pharmacy’s future as a clinical profession were the 1975 Study Commission on Pharmacy, commissioned by AACP, and the 1979 Pharmacy in the 21st Century Conference, conducted by Project HOPE.
↵b Information provided by AACP.
↵c There were, however, some well- established clinical pharmacy programs in community hospitals during this time, particularly in California and Washington.
↵d Pharmacists’ personal responsibility for medication-use outcomes was a key message in the now famous Hepler–Strand article on pharmaceutical care (Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm. 1990; 47: 533–43).
↵e Some interesting work was recently conducted by the European Association of Hospital Pharmacists in developing consensus among hospital pharmacists, physicians, nurses, and the public on the role of the pharmacist. A report on this work is available online (www.ejhp.bmj.com/content/21/5/256.full.pdf+html).
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