Clinical Pharmacy Foundations & Professional Development

Clinical Pharmacy in India

Need for Clinical Pharmacy in India

• Focus: Promotes effective, safe, and economical drug therapy.
• Scope of Pharmacy Practice: A broader term encompassing clinical pharmacy and patient-care activities by pharmacists in hospitals and communities. These activities include:
  • Dispensing and drug distribution
  • Drug information
  • Health promotion
  • Patient counselling
  • Pharmacovigilance
  • Medication reviews
  • Academic detailing
  • Sterile and non-sterile manufacturing
• Evolution: Clinical activities, initially confined to hospitals, are now well-developed in community settings in some countries.
• Patient Benefit: Clinical pharmacists assist medication adherence through counselling in local languages and by identifying and resolving non-adherence factors, especially given that many literate Indians cannot understand English labels.
• Community Pharmacist Role: Utilize clinical pharmacy knowledge for patient counselling, identifying drug interactions, managing drug-related problems (DRPs), advising on minor ailments, and referring patients to doctors when necessary.
• Government Role: Government support is crucial for pharmacists to play a meaningful role in healthcare.

Clinical Pharmacy Education in India

• Programmes: Postgraduate programmes like M.Pharm (Pharmacy Practice) and Pharm D prepare pharmacists for expanded roles.
• Foundations: Significant focus on pathophysiology, applied therapeutics, and pharmacy practice.
• Core Subjects (M.Pharm Practice):
  • Pathophysiological basis of various diseases.
  • Patient data analysis (interpreting laboratory tests and clinical data).
  • Applied therapeutics (drug safety, efficacy, rational selection).
  • Clinical pharmacokinetics (drug kinetics, dosing in renal/hepatic impairment).
  • Communication skills (patient counselling, interaction with healthcare professionals).
• Infrastructure Needs: Adequate library resources, journals, electronic databases, and computer resources are essential for teaching and drug information needs.
• Quality Challenges: Building, monitoring, reviewing, and upgrading the quality of Pharm D and M Pharm programmes is a major concern. Needs-based, practice-oriented programmes require expertise and transparency. Accreditation is vital for maintaining international standards.

Relationship with the Medical Profession

• Acceptance and Advancement: Depends on good professional relationships with medical practitioners.
• Earning Respect: Pharmacists must demonstrate commitment to patient welfare and respond professionally to patient and staff needs. This involves focusing on patient needs, adding pharmaceutical value, acknowledging other staff’s abilities, and supporting their roles.
• Communication: Clinical pharmacists gain understanding of medical language on ward rounds, enabling effective communication with doctors.

Future Challenges and Opportunities

• Research Potential: Clinical pharmacy research can identify and address drug use problems specific to India, raising awareness in the medical community. Training in clinical research methodology and biostatistics is needed.
• Professional Recognition: The Kelkar Committee recommended professional/dispensing fees for pharmacists demonstrating professional services (e.g., labelling, counselling).
• Employment: Lack of hospital-funded positions for clinical pharmacists slows uptake of services. More opportunities in patient care and hospital pharmacy are needed to sustain growth. Most postgraduates currently work in clinical research organisations, medical literature development, or the pharmaceutical industry.
• Healthcare Teams: Clinical pharmacists should be primary members of multidisciplinary healthcare teams.
• Public Expectation: Patient demand for safer and more effective drug therapy, coupled with greater recognition of pharmacist’s expertise, will drive future development.

Clinical Pharmacy: An International Perspective

Origins and Evolution

• Clinical Pharmacologists: Emerged around the same time as clinical pharmacists in the 1960s, initiated by the medical profession. They primarily influence patient outcomes through consultation requests from other medical practitioners.
• Clinical Pharmacists: Are better positioned to contribute positively to individual patient care by identifying problems and issues without specific consultation requests.
• Global Development: Clinical pharmacy has been evolving for over 50 years, with recent introduction and expansion of education and practice in countries like India. Services are also expanding beyond hospitals to other healthcare settings internationally.

Key Competencies for Clinical Pharmacy Practice

Core Roles and Competencies

• Scenario 1 (Ward Rounds): A clinical pharmacist suggests drug treatment regimens by applying knowledge of:
  • Disease being treated
  • Recommended drugs and their role in disease management
  • Results of relevant investigations and procedures
  • Patient’s medical history and current co-morbidities
  • Patient demographics
  • Patient’s wishes and attitude towards illness
  • Communicates conclusions clearly and logically to the medical team.
• Scenario 2 (Patient Interaction): The pharmacist explains:
  • Why a selected drug has been chosen
  • Expected beneficial and adverse effects
  • Ensures patient/carer clear understanding of how to take/use the drug
  • Aims for effective, safe, and economic drug use.
• Essential Skills:
  • Sound knowledge of therapeutics and disease state management.
  • Good communication skills.
  • Ability to formulate logical opinions on drug treatment strategies using various information sources.
  • Clinical Acumen: The ability to apply evidence to an individual patient’s treatment, recognising when treatment is unsuitable.
  • Literature Evaluation: Critically evaluate published studies and extrapolate results to patients.
  • Biomedical Statistics.

Specific Competencies

• Diagnosis: Generally, clinical pharmacists should avoid diagnosing, with exceptions for possible drug-related illnesses.
• Communication Skills: Crucial for effective interaction with medical practitioners (by understanding “medical language”) and patients (for counselling and reinforcing messages).
• Drug Information Provision: A core activity. Requires knowing reliable information sources, formulating written/verbal responses, and critically evaluating literature.
• Specialised Practice: Pharmacists may attach to specialist units (e.g., respiration, psychiatry, nephrology, oncology) to educate patients/junior staff and act as a therapeutic resource.

Continuing Professional Development (CPD)

Importance of CPD

• Maintaining Competency: Essential for maintaining competency in clinical pharmacy practice. Undergraduate education is a foundation; life-long learning is critical.
• Professional Responsibility: Sociologists define professions by specialized knowledge and commitment to service. CPD is often a mandatory requirement for pharmacist registration in many countries (e.g., UK, Australia), with personal records subject to auditing.
• Adapting to Change: Rapid developments in therapeutics necessitate continuous education.
• Influencing Prescribing: Pharmacists need to keep abreast of medical literature (what prescribers are reading) to understand and influence prescribing decisions.

Activities Contributing to CPD Programmes

• Flexibility: CPD programmes should be tailored to individual pharmacists’ specific goals for knowledge and skill development.
• Diverse Activities:
  • Formal lectures by professional societies.
  • Journal readings (including mainstream medical journals for original references).
  • Specialist seminars.
  • Online training.
  • Journal Clubs: Regular meetings to discuss recently published articles that influence prescribing practice, new drugs, or new indications.
  • Specialisation Courses: Offered by tertiary institutions and professional organisations (e.g., BPS certification in pharmacotherapy, oncology, geriatric pharmacotherapy). Distance learning is a feasible option.
• Information Technology: Computer literacy, web information retrieval, and electronic communication are essential. Many reputable online CPD activities are available, some free.
• Evidence-Based Medicine (EBM): A practice directed by evidence, complementing clinical skills. The Cochrane Library (www.cochrane.org) is a valuable online source for EBM, including systematic reviews.
• Abstracting and E-mail Services: Provide structured abstracts, full-text articles, and automatic email notifications from journals for rapid updates on medical advances.
• Practice Guidelines: Produced by independent organisations and expert groups (often including pharmacists), these frequently revised guidelines serve as important educational resources.

Key Skills Developed Through CPD

• Critical Appraisal: Essential for independently evaluating research findings and applying them to patients, rather than being swayed by pharmaceutical industry claims.
• Literature Searching: Ability to effectively search for and retrieve reliable information is critical, especially when an immediate answer is not known.
• Information Management: Skills to retrieve and store information are crucial in a rapidly changing IT environment.