Contents
Editorial
Guest Commentaries
Peer-Reviewed Articles
Peer-Reviewed Student Articles
Effective Writing Revisited
Likely, hundreds of articles and books have been written on the subject of writing skills, effective writing, good scholarship, methods to improve your writing, etc. It is probable that nothing new will be stated in this brief editorial; however, I feel that it is necessary to "revisit" several good principles and observations of effective writing. I think a good definition of effective writing would be "to convey a clear, concise idea, specifically designed for the reader." In the following paragraphs, I will address some general principles, issues, and problem areas regarding effective writing, especially those principles that pertain to scientific writing.
How do you improve your writing? It is improved by practice. Writing is a skill, not a talent. It does not come naturally to most people. Do not expect--or most of us should not expect--to write on the first attempt meaningful sentences with great clarity. It must be practiced over and over again. Personally, I was never a good writer, much less an effective writer. I always seem to struggle with meaningful and coherent sentences until I had a supervisor that recognized my lack of fluent writing skills and forced me to write most all of the office correspondence. I detested him for forcing me to perform this awful and dreadful task-now I would like to thank him. Practice writing about anything. "What you write is not as important as that you write."[1(p15)]
Reader-based
Clarity
Passing the "Who-Cares" Test
Grandiose Conclusions
Article Rejection
Other Effective Writing Qualities
Summary
References
2. Strunk, Jr W, White, EB. The Elements of Style. 3rd ed. New York, NY: MacMillian Publishing Co; 1979.
3. Huth EJ. How to Write and Publish Papers in the Medical Sciences. 2nd ed. Philadelphia, PA: Williams & Wilkins; 1990:5.
4. Weller AC. Editorial Peer Review: Its Strengths and Weaknesses. Medford, NJ: Information Today; 2002:54.
Consumer Value and Professional Opportunity in Nonprescription Drug Therapy
Self-care with nonprescription (also referred to as over-the-counter [OTC]) drugs is deeply embedded in American society and the American health care system. Consumers are seeking higher levels of ownership and more active roles in assisting in the management of their own health care. Further, consumers are becoming intellectually empowered with more and better health information via the print and electronic press. The new "Drug Facts" label format facilitates consumer understanding of core facts about nonprescription drug therapy.
Approximately 100,000 nonprescription drugs and combinations of drugs are utilized to manage or assist in the management of over 450 medical conditions. Many of these conditions (e.g., headache, fever, heartburn, constipation, diarrhea, the common cold, allergic rhinitis [seasonal and perennial], acne, superficial wounds, dysmenorrhea, sunburn, athlete's foot, vaginal candidiasis, head lice, motion sickness) occur millions of times each year. All of these conditions, if not treated, can produce significant discomfort, impair quality of life and decrease workplace productivity.
Consumer beliefs, attitudes and actions demonstrate confidence in nonprescription drugs. The FDA has added to that confidence with the approval ("switch") of drugs that were formerly prescription-only to nonprescription status. Among formerly prescription drugs that have been converted to nonprescription status are Advil, Afrin, Drixoral, Aleve, Pepcid AC, Zantac 75, Nicorrete, Rogaine, Lamisil (topical), Claritin, Claritin D and Prilosec OTC. Historically the FDA has moved products from prescription-only to nonprescription status at a fraction of the dose most commonly prescribed. However, the last three FDA "Rx to OTC" switches have been at the most commonly utilized prescription dose. These products include Prilosec OTC (omeprazole, 20 mg), Claritin, (loratidine, 10 mg) and Pepcid AC Maximum Strength (famotidine, 20 mg).
Nonprescription drugs, in addition to meeting FDA criteria for safety and effectiveness, frequently create consumer value by relieving society of the economic burden associated with unnecessary medical office visits and overtreatment of many self-limited clinical conditions with unnecessary and much more expensive prescription drugs. Nonprescription drugs frequently cost less than an insured patient's copayment for a prescription drug, and in many cases the nonprescription drug will produce an equivalent or superior therapeutic effect over certain prescription drugs. The underinsured and uninsured are particularly dependent on cost-effective nonprescription drug therapy for the appropriate management and symptomatic relief of scores of medical conditions.
A variety of health care issues cannot be addressed adequately by the "Drug Facts" label or self-help information available in print or via the Internet. There are many situations surrounding prudent use of nonprescription drug therapy that require the acquisition and assessment of patient information; analysis regarding proper nonprescription drug selection and use (e.g., contraindications, warnings/precautions, adverse effects, drug interactions); and clinical judgment regarding the appropriateness of either nonprescription drug therapy or referral for further medical evaluation. Issues surrounding patient comorbidity and polypharmacy are virtually infinite. There is no label, treatment protocol, or algorithm that can address issues that require clinical judgment. This reality necessitates access to a "learned intermediary."
That "learned intermediary" is most logically the community-based pharmacist. The pharmacist is the only health professional who receives formal education and training in nonprescription drug therapy. The pharmacists' professional role in self-care is upon fostering the safe, appropriate, effective and economical use of nonprescription drugs.
The pharmacist possesses knowledge and skill that can greatly assist patients in diagnosing self-treatable conditions, guiding nonprescription drug selection, use and monitoring and/or triaging the patient for further medical evaluation. In the practice domain of nonprescription drug therapy, the pharmacist often functions as a primary care practitioner or "gatekeeper." Community-based pharmacists often serve as the portal-of-entry into the health care system. Also, patients often have several health care encounters with pharmacists between physician office visits.
As a self-care "gatekeeper" or primary care practitioner, pharmacists have the opportunity to provide vital pharmaceutical care services. The pharmaceutical care process in managing nonprescription drug use involves four (4) key steps. These are:
In gathering and evaluating patient information, pharmacists must realize that they have a responsibility to physically assess or "diagnose" the self-medicating patient. This does not involve a hands-on diagnostic process, but does involve a physical assessment utilizing clinical observation and interview. This informed diagnostic "search for clues" by the pharmacist with a good knowledge of pathophysiology and pharmacotherapy will generally allow the differentiation of self-treatable conditions from those requiring medical evaluation. The pharmacist can then advise and counsel the patient on the proper course of action (e.g., nondrug approaches to symptom management, self-treatment with one or more nonprescription products, or referral to a physician or other caregiver).
In developing a care plan, referral for medical evaluation by the pharmacist is highly appropriate if symptoms are severe, symptoms are progressively worsening and not amenable to nonprescription drug therapy, symptoms return repeatedly and worsen over time, the patient's health status is vague or the patient's overall health status is fragile due to age, coexisting disease and/or complexity of drug therapy. In developing a care plan, if self-treatment is deemed appropriate, nondrug approaches (e.g., dietary, lifestyle) to patient management should be considered. If nonprescription drug therapy is warranted, OTC drugs should be selected based on symptoms and other patient variables (e.g., pediatric, geriatric, pregnancy, breast feeding, comorbidity, concurrent Rx, OTC or herbal therapy).
In implementing a care plan, information provided to the patient should include the following:
In the monitoring and follow-up phase of the pharmaceutical care process, efforts should be made to assure the patient used the nonprescription drug correctly and determine whether the patient received an effective therapeutic response. Queries regarding any prescription or nonprescription drug problems (e.g., adverse effects, allergies, drug interactions) are strongly encouraged. Guidelines for proper drug use should always be reinforced. Alternative medication(s) or medical referral should always be a consideration in the monitoring and follow-up phase of providing pharmaceutical care.
Nonprescription drug therapy has traditionally been a profit center for American pharmacy, but is becoming significantly more important to pharmacy because of various market forces (e.g., the "baby boomer" bubble, shrinking reimbursement and profit margins on prescription drugs, excellent gross profit margins on both private label and national brand OTC drugs). Further, payment for nonprescription drugs is "first-party." There are negligible third party constraints on nonprescription drug sales.
In the realm of self-care and pharmacotherapy with nonprescription drugs, most consumers would benefit substantially from a meaningful interface with a pharmacist committed to the provision of value-based, patient-focused, health outcome oriented pharmaceutical care. Opportunities for community-based pharmacists to provide higher levels of diagnostic and pharmacotherapeutic self-care interventions are vast. Additional initiatives are needed by the profession of pharmacy and individual pharmacists to serve the self-care interest of the public. Such an opportunity, when acted upon, provides both clinical and economic dividends for individual patients and the professional and business interests of the profession of pharmacy.
Pharmacy and the Future, Options and Opportunities
The 2003 Kenneth L. Waters Lecture, The University of Georgia, College of Pharmacy, Athens, Georgia, August 21, 2003. At the time of this presentation, Jack E. Fincham, Ph.D. was dean and professor at the University of Kansas School of Pharmacy, Lawrence, Kansas
It is a very great honor for me to have been asked to be the 2003 Kenneth L. Waters Lecturer. Dean Waters was a dynamic and visionary leader who was so very instrumental in stimulating the research, teaching, and service missions here at the University of Georgia College of Pharmacy. Dean Waters would be pleased with the progress the College has made, and the stature in which it is held in the state, region, nation, and beyond.
From an historical perspective, I feel it is useful to examine how pharmacy has changed in Georgia in the past 100 years. Dean Wilson in the text: Drugs and pharmacy in the life of Georgia 1733-1959,[1] noted numerous interesting facets of health and health care in the last century. A State Board of Health was created in 1875, ceased to function 2 years later due to a lack of funding, and 25 years later was resurrected with an annual appropriation. Finally, a century ago, one woman applied for pharmacy licensure in Georgia. No doubt some remarkable changes have ensued since then.
Today, I would like to examine three major issues affecting pharmacy:
In the context of opportunities, individuals have options. These options can include doing the same amount, less, or more. The need for involvement in medication related issues: compliance, counterfeit drugs, drug use in the elderly, drug errors, and impacting reimbursement has never been greater. Pharmacy education can impact all of what is being discussed today, but dealing with ethics, service learning, and the scope of pharmacy practice are immediate concerns. Finally, I would like to discuss public health, specifically bioterrorism, the enhanced use of epidemiology, preventive health, and tobacco use. Pharmacists can choose the option of partially impacting each of the above. I sincerely hope that pharmacists can choose the option of seizing these opportunities to advance the health and well-being of their patients.
Health insurance entities offering drug benefits, regardless of type (public or private) have seen costs increase. Pharmacy costs in the Kansas Medicaid program have reached 33% of costs incurred; this has followed a steady increase in drug costs over the past decade.
Georgia is not immune to these increases, recent reports indicate a $172 million shortfall in the Georgia Medicaid program. Drugs are heavily used in the Georgia Medicaid program ($760 million), but surprisingly, only 69% of eligible recipients used services in FY2002.[5] Researchers at Georgia State suggest 1% of Medicaid recipients account for 23% of expenditures.[5] Disease management has been suggested as a way to stem rising costs. The Georgia Board of Pharmacy recognizes four pharmacist disease management certifications (anticoagulation, asthma, diabetes, and dyslipidemia).
Marketing driven usage of prescription drugs has come under increasing scrutiny concerning the use of costly alternatives rather than less expensive therapies that might be equally advantageous.[6] More and more of these types of comparisons are appearing in the lay press (magazines and newspapers).[7] A good share of the success of the pharmaceutical industry is due to lobbying efforts, which have been substantive and effective. Unlikely advocates for cost containment have emerged. The US Food and Drug Administration (FDA), the agency charged with regulation of the drug approval process in the US, has recently been a proponent of generic drug usage.
In the book, The Merck Druggernaut,[8] written by Fran Hawthorne, Merck and Company, arguably the most successful of US pharmaceutical manufacturers, has fallen from champion to an often chastised company. The praise for discovering a treatment for river blindness in Africa (transmitted by black flies that breed in fast-flowing rivers) and then providing ivermectin free of charge was hailed as an example of outstanding public service. The long-standing criticism of the purchase of Medco (a major pharmacy benefit management (PBM) company) has made Merck one of the most criticized pharmaceutical industry companies. In hindsight, this was a major public relations and economic mistake. A judgment against Medco for $42.5 million for inappropriate marketplace activities was recently awarded.[9]
Much attention has been focused on the price of drugs obtained from Canada as cross-border sales have reached almost $1 billion per year. The number of sales representatives has tripled in the past decade. Some suggest that this is but one reason for drugs being so much more expensive in the US as opposed to elsewhere. The Canada drug connection has been troublesome for manufacturers, pharmacists, and the FDA. The Canada drug issue, has led some manufacturers to limit how their manufactured drugs can be purchased.[10] Some cities have promoted drugs from Canada in order to save costs on municipal sponsored benefit programs. Springfield, MA has sponsored programs to have employees receive drugs from Canada.[11]
Pharmacists can play a major role in cost containment activities, but without some effort to control costs at a global level, the extent to which costs can decrease is not what it could conceivably be. The United States is the remaining industrialized country without some type of price controls on drugs.
Compliance issues. Patient noncompliance with prescription regimens is one of the most understated problems in the health care system. The effects of noncompliance have enormous ramifications for patients, caregivers, and health professionals. Compliance with medications is a worldwide problem, and impacts in one country may not have applicability elsewhere.
In the recently released book on worldwide compliance issues (Adherence to Long-term Therapies, Evidence for Action), [12] published by the World Health Organization (WHO), researchers indicate the problem of noncompliance is worse in countries in the developing world when compared with the countries comprising the industrialized world. Many parts of the US have similar morbidity and mortality profiles as do countries in the third world. Specific disease states may have significant additional, noncompliance ramifications due to the development of drug resistant strains of bacteria.[13] Many times what is necessary is referral to specific caregivers for individualized treatment and monitoring to enhance compliance.
Counterfeit drugs. The unsavory topic of drug counterfeiting is a topic unanticipated in the past. The FDA has seen the number of counterfeit drug cases increase in the past 6 years [14]. The concern is pressing and unprecedented. It has reached the point where the integrity of the nation's drug supply is suspect. Counterfeit drugs have been suggested to account for 10% of the supply of drugs worldwide.[14] Continuing problems in the future may require drug validation and control by pharmacists as yet unseen. These validations may include the use of color changing inks, or invisible bar coding. Coupled with this important issue of counterfeiting is the unsavory consideration of unscrupulous and unethical pharmacists.
Numerous reasons exist for why counterfeiting has increased in the US. The upsurge in the number of secondary wholesalers has made it easier for counterfeited drugs to enter the channel of distribution for pharmaceuticals. Secondary, wholesales are ostensibly set up to provide legitimate drugs for sale at reduced prices. In fact, secondary wholesalers make an easy entry point for substandard drugs. Increasingly, the type of drugs counterfeited has moved from obscure, expensive drugs to more commonly used drugs at lower price echelons (e.g., Lipitor®). Fakes are becoming more sophisticated (Serostim®) in package design and presentation. And unfortunately, to carry this issue one step further, the presence of organized crime and/or terrorist groups playing a role has been suggested.[15] The willful sale of substandard products with adulterated content, and the intent to harm can now more easily occur in the US with imported drugs. The near and far term future will see substandard drugs flooding the US market from India and China.[14]
Drug use in the elderly. Various components of drug usage in the elderly are worth noting. Problems with health literacy are more common with the elderly.[16] The burgeoning population of the elderly coupled with health literacy problems is an indication that this issue will increase in intensity in the future.[16] A vast majority of seniors have one chronic condition, and 50% have two.[17] Seniors on average consume 23.5 prescriptions per year while seeing on average 8 different physicians for health care needs.[17] The average rate of prescription drug utilization increased by about two prescriptions per patient per year for the four year period between 1997-2000.
Drug noncompliance is increasing in the elderly, not because of age per se, but because of age related factors that may include:
The structure of any drug benefit program at this point is not well defined. Prescription drug cards have been promoted as a stopgap measure between 2004 and 2006 when the Medicare benefit will be in place. There are stipulations that some, but not all, savings attributable to card programs should be passed on to consumers, along with modest requirements pertaining to the rate of occurrence of price increase. The implementation of a Medicare drug benefit in 2006 would require an annual premium, and an annual drug cost of $3,160 for seniors would reduce the amount spent to slightly over $1,760 per year.[19]
A Medicare drug benefit can have the potential to enhance the delivery of health care to seniors. The federal government through market clout and sheer market share should theoretically be positioned to obtain the best price on drugs, obtain discounts currently provided to others, and optimally allow all pharmacies to compete on an equal footing. Finally, reining the variance in operating procedures of PBMs could benefit patient and provider alike.
Embedded requirements in current Medicare proposals provide a significant opportunity for pharmacists to provide non-distributive, cognitive services for patients. A medication therapy management program will be established through the drug discount card program beginning in 2004. Pharmacists and other health professionals will be eligible to participate, and can be compensated for such services. The goal of this program will be to provide cost and drug utilization management, quality assurance, and a reduction in medication errors and adverse drug reactions. Collaborative efforts are included to reach various health professions. An e-prescribing program is to be in place by 2007.[19] It is certain that e-prescribing will become more prominent in the future. Pilot studies have implemented this technological enhancement for physician order entry (via personal data assistant (PDA) or through web access to pharmacies) in order to reduce drug errors. Findings have indicated that there are decreases in calls for clarification of physician orders, and data indicates a time saving of an average of one hour per pharmacist per day.[19] The savings in time are due to a lessening need to follow up on questions pertaining to drug orders.
The bottom line is that the quality of care in the US needs improvement, seniors do not receive preventive inoculations (pharmacists can immunize in Georgia); and myocardial infarction patients do not receive necessary, standard therapies.[20] About 30% of persons with diabetes are not assessed for blood sugar levels.[20] And surprisingly, only 50% of recommended medical care procedures are received.[20]
Medication errors. Brass,[21] commenting on prescription to over-the-counter switching of medications, notes problems with polypharmacy, and specific problem drugs which will not surprise anyone today. These problem drugs include: analgesics, sleep preparations, pseudoephedrine, caffeine, cough and cold preparations, and laxatives. These problem drugs have been also noted in studies elsewhere.[22] Inaccurate self-diagnosis leads to suboptimal therapy, high patient cost, and more adverse effects and/or drug interactions.[21]
Barker and colleagues,[23] have found an error rate of 19% in a multi-institutional study of long-term care and hospital facilities. Also found was a 4% rate of unauthorized (unordered) drug use, and a rate of harmful error occurrence of 7%, amounting to forty harmful errors occurring daily in a typical 300 bed facility. In a study examining Cox-2 use and occurrence of gastropathy, it was determined that an increase in gastropathy occurred with Cox-2 usage.[24] Surprisingly, concomitant use of nonsteroidal anti-inflammatory drugs (NSAIDs) and Cox-2s was found.[24] Elsewhere, it was found that the occurrence of errors by physicians and others is often not reported to patients, and surprisingly, 23% of physicians and 11% of patients in one study did not feel that physicians should report such occurrences of errors to patients.[25]
Pharmacists are at a crucial juncture as we face an uncertain, yet promising future. We need to pursue non-dispensing activities and move toward delivery of pharmaceutical care in all practice settings, not just in institutional settings. Expanding the types of services provided, seeking reimbursement for such, and continuing to document economic and clinical benefits will be even more important in the future than they are at present.
Ethics. Both Deans Waters[26] and Wilson[27] noted the need for professionalism and high ethical standards in the pharmacy profession. Not surprisingly, these needs exist today to an even greater extent. The pharmacy profession was rocked in 2002 by the revelation of greedy, egregious, and illegal actions, including drug dilution schemes, of a pharmacist, Robert Courtney, in Kansas City, MO. Whether this incident is an isolated one, or just one of several, immediate and sustained efforts are needed to avert this and similarly devastating activities from happening ever again.
Service learning. The strategic plan crafted here at the University of Georgia College of Pharmacy provides a template to implement service-learning programs for students through complementary educational opportunities.[28] Dr. Nichols-English and colleagues have written of the bridging of community based pharmacy outreach with service learning principles.[29] These activities are very important for exposure to students in training. Students come from communities, they study at our universities, and then they return to a community. These activities that benefit individuals, institutions, and society also benefit the provider. Providing these options for pharmacists in training is vitally important for them and for the greater profession.
Scope of pharmacy practice. As the scope of pharmacy practice has changed, pharmacy education must change to meet even more dramatic educational and practice needs for the future. Current and future pharmacists need to have the ability to: make tough decisions; communicate effectively with patients, other providers, and administrators; serve an ever aging population; help to ensure appropriate drug utilization; help to manage drug therapies; and work to harness technology to meet patient and practitioner needs.
A continuing focus on the outcomes of drug use will be even more important in the future. Demands for appropriate clinical, economic, and humanistic outcomes of health care delivery will rely heavily on practitioners able to evaluate therapies from these multiple standpoints. Pharmaceutical care must be applicable and useful for patients and their well-being. If the implementation of pharmaceutical care can pass these hurdles, it will become useful in all patient care settings. Pharmaceutical care will need to be implemented in rural and urban parts of Georgia. The process can be enabled through residencies and fellowships in varying practice settings: community, health-system, and managed care milieus.
Pharmacists will increasingly be called upon to monitor the positive and negative effects of drug therapy. Monitoring for patient compliance will expand as drug coverage expands to meet more patient needs. Post-dispensing review of therapies and their effects upon the quality of life of patients will be not only suggested, but in many cases required. An increasing number of pharmacists will have staff positions in outpatient facilities and medical practices in an evaluative role with no dispensing responsibilities.
Patients with chronic conditions, such as dyslipidemia, have been shown to experience improved outcomes with pharmacist interventions and monitoring. The Stanford Coronary Risk Intervention Project (SCRIP) study indicated better cholesterol management in high risk patients with pharmacist involvement.[30] Disease state management certification in dyslipidemia is a recognized certification by the Georgia Board of Pharmacy. One of the benefits of pharmacy education is applicable to practitioners through assistance in collecting and collating results of interventions. This is occurring through the clinical outcomes research group (CORG), and the community pharmacist research network (CPR-Net) facilitated by several of your faculty at present throughout Georgia.
Pharmacy colleges are being called upon more and more to be responsive to pharmacy practice clinical, political, and economic needs. One of the best ways to ensure that these needs are met is to structure curricula that have pertinence to future practitioners, as well as current pharmacy practitioners.
Bioterrorism. The unfortunate specter of bioterrorism points to several needs that pharmacists can readily meet.[31] The anthrax crisis highlighted the lack of preparedness in many sectors of the health care system. Data management and epidemiological foci on outbreaks and intensity can allow for other disease conditions to be tracked as well in a similar fashion, i.e., cluster analysis to analyze cancer and locations of intense occurrence.[31] Information and referral needs highlight communication processes that need enhancement.[31] Pharmacist directed drug information centers with a compelling history of success will no doubt be called upon to answer yet unanticipated needs related to disease outbreaks, natural or contrived. Vaccination requirements will allow pharmacists to fill much-needed gaps in current processes for immunization and prevention of certain diseases.
Biochemical terrorism is not something that has been addressed in the past in curricula. This has changed recently, Ali and Warren[32] suggest sound concepts for pharmacists to employ to meet such disasters: planning, science based plans, using pharmacy resources, working with local networks of providers, and identifying local resources for assistance.[32] Schulz and colleagues[33] note that few hospitals are prepared to manage sequelae of biochemical terrorism, fewer still are capable of meeting patient, logistic, and educational needs. The unfortunate anthrax crisis serves as an example of how pharmacists can serve in the midst of uncertainty as resource persons and active clinicians involved in education and prescribing in institutional settings[34].
Epidemiology and preventive health. The University of Georgia College of Pharmacy strategic plan approved in May 2002[28] outlines the need for strong community programs in disease management, and wellness activities through prevention and screening. Using epidemiologic tools to assess where diseases are occurring, and then structuring an organized effort to impact morbidity can help patients and pharmacy providers. Expanding the recognized disease management options for pharmacists can utilize cluster analysis and other techniques to identify underserved areas, and thus allow for planning to implement structured means to address unmet needs. Preventive health activities and educational programming [28] can tie in nicely with health plan employer data and information sets (HEDIS) guidelines that point to 5 areas where pharmacists can actively participate in either preventive or active treatment programs.
Active participation in health screening activities allows pharmacists to impact hypertension, dyslipidemia, diabetes, and osteoporosis, as well as other potential conditions. Future use of epidemiologic techniques can allow pharmacists and schools of pharmacy to target how resources can be applied to meet both educational and practice based outreach activities.
Using several disease states as examples helps to clarify the need. The prevalence of diagnosed diabetes in the US in general, and in Georgia in particular, is steadily increasing.[35] Obesity in the US population has increased significantly in the recent past.[36] Data indicates that Georgia has experienced the highest increase in rates of obesity in the US between 1991 (9.2%) and 1998 (18.7%).[36] This 102% increase is an indicator of the need for pharmacist involvement. Coupling diabetes and obesity influences many organ systems, conditions, and outcomes. In fact, according the WHO, chronic disease has more of an impact now than does infectious disease throughout the world, and obesity is the causative factor.
Other public health issues
Health literacy, indigent care
Immunization. Much work remains to accomplish the full immunization of young children everywhere, including Georgia.[40] In Georgia, slightly over 70% of immunizations for diphtheria, polio, chickenpox, measles, and hepatitis B is provided through private providers. The rate of success in immunizing children 2 years of age is slightly less than 80% in Georgia.[40] Pharmacists can help close this coverage gap and help to provide tangible success immediately.
Human immunodeficiency virus, acquired immunodeficiency syndrome (HIV/AIDS). The number of cases in the rural south is increasing, and is disproportionately occurring among people of color and the rural poor.[41,42] Georgia ranks among the top 10 states in prevalence of HIV/AIDS. Pharmacists could have such a major impact from educational and preventive perspectives with HIV/AIDS.
Rural health care. Spending for drugs in Medicaid programs varies from rural to urban areas, with spending being greater for drugs in rural states.[44] Pharmacists can play an active role in enhancing health care in rural areas of the US, many rural communities struggle to maintain economic and social viability. Often, rural communities retain a community pharmacy as the only health care entry point for care. Working with such pharmacies to document outcomes, encourage preventive activities, and encourage drug therapy management activities is a vital role for colleges in which to become engaged.
Maintenance of health benefits. A major concern of many health insurance enrollees is the ability to maintain health insurance coverage. This so called "security of benefits" is important to many who have coverage, or who have limited coverage for intermittent periods.[45] It is a significant concern to 34% of consumers who indicate that they are worried about continuation of benefits.
The University of Georgia College of Pharmacy has a distinguished record for both basic and applied research. What I have spoken about today concerns health policy and clinical research. They are important research components that will allow pharmacists to choose to exercise proactive options for opportunities that will arise in the future. Patients and practitioners view the College of Pharmacy as located not in one locale, but across the entire state. Through response to their known and unknown future health needs, the College can meet the important missions outlined by Deans Wilson and Waters and supported so strongly and vigorously by succeeding deans.
When faced with future opportunities, I hope pharmacists choose the option of proactive involvement in the health and health care needs of people in Georgia and elsewhere.
References
1. Wilson RC. Drugs and pharmacy in the life of Georgia 1733-1959. Atlanta,GA: Foote & Davies, Inc; 1959:237.
2. Spending for Prescribed Medicines Rose Sharply from 1997 Through 2000. Agency for Healthcare Research and Quality, Rockville, MD. Available at: http://ahrq.gov/news/press/pr2003/rxspendpr.htm. Accessed August 10, 2003.
3. Schneeweiss S, Walker A, Glynn R, Maclure M, Dormuth C, Soumerai, SB. Outcomes of Reference Pricing for Angiotensin-Converting-Enzyme Inhibitors. N Engl J Med. 2002;346:822-829.
4. Kaiser Family Foundation, Prescription Drug Trends, March 2003:1-2.
5. Georgia Department of Community Health, FY2002 Annual Report, Atlanta, Georgia, 2003.
6. Arthritis drug rofecoxib (VIOXX) linked to increased risk of coronary heart disease. Worst pills, best pills.2002;8(12):93,94.
7. Stolberg SG, Harris G. Measure to ease imports of drugs gains in House, The New York Times, July 22, 2003:A1.
8. Hawthorne F. The Merck druggernaut: the inside story of a pharmaceutical giant. Hoboken, NJ: John Wiley & Sons, 2003:4-5.
9. Company News; Judge approves settlement of drug insurance suit. New York Times. August 5, 2003:C4.
10. Harris G. Pfizer moves to stem Canadian drug imports, The New York Times. August 7, 2003:C1.
11. Dembner A. Canada fills prescriptions for Springfield employees, Boston Globe. July 30, 2003:B1.
12. Sabaté E, ed. Adherence to long-term therapies, evidence for action. World Health Organization. Geneva: WHO. 2003.
13. Chesney MA. Morin M, Sherr L. Adherence to HIV combination therapy. Social Science and Medicine. 2000, 50:1599-1605.
14. New FDA Initiative to Combat Counterfeit Drugs. Available at: http://www.fda.gov/oc/initiatives/counterfeit/backgrounder.html. Accessed August 10, 2003.
15. GlobalOptions, An analysis of terrorist threats to the American medical supply. Washington, DC: Signature Book Printing, 2003:65-77.
16. US Census Bureau, National Population Projections, I. Summary Files, 13 January 2000. Available at: www.census.gov/population/www/projections/natsum-T3.html (4 September 2002). Accessed August 21, 2003.
17. Parker RM, Ratzan SC, Lurie N. Health literacy: a policy challenge for advancing high-quality health care. Health Aff. 2003; 22(4):147-153.
18. Fincham JE. The Drug Use Process. In: Smith MI, Wertheimer AI, Fincham JE, eds. Pharmacy and the US Health Care System. 3rd ed. Binghamton, NY: Pharmaceutical Products Press, In press, 2004.
19. Medicare Drug Benefit Calculator. Available at: http://www.kaisernetwork.org/static/kncalc.cfm. Accessed August 10, 2003.
20. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635-45.
21. Brass EP. Changing the status of drugs from prescription to over-the-counter. N Engl J Med. 2001;345:810-816.
22. MacFayden L, Eadie D. McGowan T. Community pharmacists' experience of over-the-counter medicine misuse in Scotland. J R Soc Health. 2001;121(3):185-192.
23. Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL. Medication errors observed in 36 health care facilities. Arch Int Med. 2002;162:1897-1903.
24. Fincham JE, McNeese GE. NSAID induced gastropathy. Western Medicaid Pharmacy Administrators Association Annual Meeting, San Antonio, Texas, October 2, 2000.
25. Blendon RJ, DesRoches CM, Brodie M, et al. Views of practicing physicians and the public of medical errors. N Engl J Med. 2002;347:1933-1940.
26. Waters KL, Braucher CL. Continuing education in pharmacy in Georgia. AJPE. 1959;23:19-22.
27. Wilson RC. Educational extension services. AJPE. 1940;4:534.
28. Charting our Course: A Strategic Plan, UGA College of Pharmacy, May, 2002.
29. Nichols-English G, White CA, Brooks PJ. Bridging community based pharmacy outreach
with service-learning principles. AJPE. 2002; 66(Summer):124-131.
30. Tsuyuki RT, Johnson JA, Koon, KT, et al. A randomized trial of the effect of community pharmacy pharmacist intervention on cholesterol risk management. Arch Int Med. 2002; 162:1149-1155.
31. Hearne S, Segal L. Leveraging the nation's anti-bioterrorism investments: foundation efforts to ensure a revitalized public health system. Health Affairs 2003, 22(4): 230-234.
32. Ali M, Warren F. Biochemical terrorism: information for pharmacists. Mich Pharm. 2002; Jan/Febr:28-35.
33. Schultz CH, Mothershead JL, Field M. Bioterrorism preparedness I: the emergency department and hospital. Emerg Med Clin North Am. 2002; 20:437-455.
34. Haffer AST, Rogers JR, Montello MJ et al. 2001 anthrax crisis in Washington, D.C.: clinic for persons exposed to contaminated mail. Am J Health Syst Pharm. 2002;59:1189-1192.
35. Prevalence of Diabetes-Georgia, 2003. Available at: http://www.cdc.gov/diabetes/statistics/ maps/map2.htm. Accessed August 10, 2003.
36. Mokdad AH, Serdula MK, Dietz WH, et al. The spread of the obesity epidemic in the United States, 1991-1998. JAMA. 1999, 282(16): 1519-1522.
37. Baker DW, Parker RM, Williams MV, et al. Health literacy and the risk of hospital admission. J Gen Int Med. 1998;13:791-798.
38. Chisholm MA, Reinhardt BO, Vollenweider LJ, et al. Medication assistance programs for uninsured and indigent patients. Am J Health Syst Pharm. 2000; 57(Jun 15):1131-1136.
39. Glied S, Little S. The uninsured and the benefits of medical progress. Health Aff. 2003;22(4):210-219.
40. Georgia children have high immunization coverage rates. Associated Press, April 20, 2003. National Council of County and City Health Officers (NCCCHO).
41. Sowell R, Seals G, Wilson B, Robinson C. Evaluation of an HIV/AIDS continuing education program. J Contin Edu Nurs.1998; 29(2):85-93.
42. DiIorio C, Van Marter DF, Dudley WN. An assessment of the HIV/AIDS knowledge, attitudes, and behaviors of adolescents living in a large metropolitan area. Ethn Dis. 2002;12(Spring):178-185.
43. Yusuf HR, Rochat RW, Baughman WS, et al. Maternal cigarette smoking and invasive meningococcal disease: a cohort study among young children in metropolitan Atlanta, 1989-1996. Am J Publ Health. 1999; 89(5):712-717.
44. Fincham JE. Rural Pharmacy Research, Jack E. Fincham, From Research to Practice; A Conference on Rural Mental Health Research, National Institute of Mental Health, April 26, 1997, Oxford, Mississippi.
45. Institute for the Future. Health and health care 2010: the forecast, the challenge. 2nd ed. Hoboken, NJ: Jossey-Bass, 2003:149-163.
A Cross Sectional Survey of UK Community Pharmacists' Views on Continuing Education and Continuing Professional Development
Rutter P. BPharm, PhD, Senior Lecturer, Pharmacy Practice Division, University of Portsmouth, Portsmouth, United Kingdom
Methods: A pre-piloted self-administered postal survey was distributed to all registered community pharmacists residing in the counties of Hampshire and the Isle of Wight, United Kingdom (n=573). Repeat mailings were conducted after four weeks to non-responders. The survey was divided into five sections representing three themes: understanding of CE and CPD, extent of participation, and attitudes toward CPD.
Results: Three-hundred and twelve surveys were received but 41 were unusable, leaving 271 to be analyzed; a usable response rate of 47%. Sixty-one per cent of respondents had a clear understanding of continuing education compared to just 21% (n=58) for CPD, although female respondents had a significantly better understanding of CPD. The Pharmaceutical Journal was the main source used by respondents for their CE/CPD needs. Over three quarters (78%, n=211) of respondents had conducted some CE/CPD in the last 12 months but only 32% completed 30 or more hours CE/CPD as advised by the professional body, the Royal Pharmaceutical Society of Great Britain (RPSGB). Locum pharmacists and proprietors were most likely not to have undertaken any CE/CPD. Competence reassessment was seen as the most appropriate way to address non-compliance with CPD when the RPSGB make it mandatory.
Conclusion: There is considerable variation in current levels of understanding and participation in CE and CPD amongst UK community pharmacists that were sampled.
Key Words: Community pharmacy, continuing education, continuing professional development
Introduction
The concept of maintaining and improving clinical competence is not new. Professional bodies throughout the world have for sometime stipulated that their members should engage in continuing education activities to ensure fitness to continue to practice.[1-2] The RPSGB (the UKs professional and regulatory body) refers to CE (continuing education) as "the traditional methods of learning such as attending workshops, following diploma or distance learning courses, or structured reading."[3] However, it has become increasingly recognized that CE does not necessarily equate to learning, and gaps in knowledge and skills may well exist. It is through these shortcomings of CE that CPD (continuing professional development) is increasingly being adopted by the profession world-wide as being the one way to ensure professional competence.[4]
Many definitions of CPD exist, but is exemplified by the definition in a UK (United Kingdom) government white paper entitled, A First Class Service, as "a process of lifelong learning for all individuals and teams which meets the needs of patients, delivers the health outcomes and health care priorities of the population, and which enables professionals to expand and fulfill their potential."[5] More specifically, CPD as defined by the RPSGB states "CPD includes everything that a pharmacist learns which makes his or her better able to do his or her job. It is a cyclical process of reflection, planning, action and evaluation."[3] CPD therefore differs from CE, which is just one element of the CPD process[6-7] and is all about developing one's practice. The question should be what am I going to do differently tomorrow as a result of today's CE experience, which in effect, is then CPD.
The adoption of CPD rather than CE has been, in part, influenced by government expectations of all health care providers to ensure high standards of health care are delivered.[5,8] Furthermore, the current CPD requirements for members from many countries is moving from a voluntary to a compulsory undertaking.[6,9-10] The Canadian National Association of Pharmacy Regulatory Authorities has introduced a national mandatory competency assessment for re-registration recently and the RPSGB will introduce a mandatory system based on portfolio of evidence in 2004/5.[11] Despite these significant educational developments affecting the profession there has been little published regarding the attitudes, perceptions, and understanding of pharmacists about CPD.
Mottram et al[12] and Bell et al[13] surveyed practicing pharmacists in England and Northern Ireland from all sectors of the profession in 2000 and 2001. Respondents from both studies were deemed to have a good understanding of what constituted CPD (61% and 57% respectively) and they also believed CPD to be essential, but a lack of time was cited as the main obstacle in completing CPD.
This study differs from previously published work as the target population consisted solely of community pharmacists. This decision was taken because during the CPD pilot organized by the RPSGB education department, community pharmacists were found to be the most difficult group to recruit.[14] It was therefore thought prudent to concentrate on determining community pharmacists attitudes and approaches to CE/CPD as this group appears to be the least motivated to comply with RPSGB requirements to remain professionally up-to-date.
Methods
All community pharmacists residing in two counties of central Southern England (Hampshire and the Isle of Wight) were asked to complete a self-administered postal survey in 2002. These counties were chosen as they had not been selected by the RPSGB in any CPD pilots and thus represented a cohort of pharmacists whose attitudes and beliefs were not subject to unnecessary bias. The names and addresses of the sample population were obtained from the RPSGB database as those pharmacists who stated they were primarily employed in the community sector. This yielded a sample size of 573. Prior to the survey being distributed a 5% random sample was obtained and used to pilot the survey.
The survey (Appendix 1) consisted of three sections. Section A (Section 1 on survey) sought demographic information from respondents; Section B (Sections 2, 3 and 4 on survey) focused on the respondents' understanding of CE and CPD, the resources they used to complete their CE/CPD and to what extent they participated in CE/CPD; and Section C (section 5 on survey) investigated respondents' attitude toward CPD and how they undertook and recorded it. Questions on the survey instrument consisted mainly of multiple response and closed questions, although a small number of open-ended questions were used to allow respondents to express their views to avoid introducing bias. Analysis of this data was investigated for themes and reorganized with similar responses grouped together.
Quantitative data were analyzed using SNAP version 6 (Mercator) questionnaire analysis package. Statistical tests were conducted using Minitab 13 (Minitab Inc.) chi-square analysis.
Results
Three hundred and twelve surveys (55%) were returned after two mailings. However, 32 of the surveys were returned from retired pharmacists and 9 from pharmacists who no longer worked in the community sector. These surveys were excluded from analysis rending a usable response rate of 47% (n=271). Table 1 illustrates the demographic details of respondents.
Respondents were asked to define the terms CE and CPD via open-ended questions. Table 2 details respondent replies. Content analysis allowed respondent definitions to be categorized into those that had a clear understanding, those with a partial/confused understanding and those that had demonstrated a total lack of understanding. Examples of respondent replies and categorization are given in Appendix 2.
Marked differences in respondents understanding of CE and CPD were highlighted. One hundred and sixty six (61%) respondents illustrated a clear understanding of CE compared to only 58 (21%) respondents for CPD. A significantly higher (X 2 9.4, df = 1, p = 0.002) proportion of females demonstrated an understanding of CPD than their male counterparts and proprietors showed the poorest understanding of CPD (X 2 10.1, df = 2, p = 0.007), compared to employee and locum pharmacists. Only 25 (9%) respondents illustrated no understanding of CE compared with 113 (42%) for CPD.
Table 3 highlights the sources of information respondents accessed when completing CE/CPD. Three primary sources were identified: The Pharmaceutical Journal; distance learning packs via the Centre for Postgraduate Pharmacy Education (CPPE), which is a national UK provider of CE for registered pharmacists, and attendance at CPPE workshops.
Confirmation that CPPE provides a pivotal role for pharmacists CE needs was further substantiated when the respondents were asked how often they had used CPPE resources in the last 12 months. One hundred and sixty-three (60%) respondents stated they had requested at least one distance-learning pack and 177 (65%) had attended a CPPE workshop. Analysis of open-ended questions resulted in three emergent themes being identified as to why respondents attended workshops sessions: they wanted to learn more about the topic, they enjoyed networking and sharing ideas with other pharmacists, and the guest speakers were informative. However, family commitments, especially among female respondents and business commitments of male respondents and pharmacy proprietors were two disincentives for non-attendance at CPPE workshops.
In addition to the three primary sources used, a wide range of other sources was also accessed, ranging from traditional sources, for example textbooks (60%), to more modern mediums of delivery, such as the Internet (28%) and computer aided learning CD-ROMS(11%).
The RPSGB advise that all UK registered pharmacists should complete a minimum 30 hours CE/CPD each year. However, Table 4 shows how respondents from this study fell well short of this target.
Only 211 (78%) respondents reported they had completed some form of CE/CPD in the previous 12 months, with just 88 (32%) respondents meeting the RPSGB advised 30 hours of CE. Cross tabulation of this data with the demographic profiles of respondents showed that the most likely profile of respondents to have achieved this were female employee pharmacists who had been registered between 11 to 20 years. Forty-six respondents (17%) stated they had completed no CE/CPD in the last 12 months; 22 were locums, 15 proprietors and 9 employees. Statistical analysis showed locum or proprietor pharmacists (X 2 = 23.7, df = 2, p<0.001) to be the most likely group not to conduct CE/CPD.
Respondents were also asked if and how they recorded their CE/CPD activities and the findings are summarized in Table 5. Personal recording was most frequently cited, along with completion of the RPSGB CE logbook (issued free by RPSGB to all members), and using portfolios supplied by the respondent's employer. However, a substantial minority (18%) made no record at all of their activities.
Table 6 illustrates the benefits respondents believed CPD would bring. The majority did believe CPD would have a positive effect for the individual and profession.
Two hundred and twenty-two respondents (82%) thought that CPD would help to improve their ability to perform their role and 161 (59%) and 132 (49%) respondents believed CPD would enhance the status of the pharmacy profession with other health care professionals and raise respectively the profile of the pharmacy profession with the public. Finally, 66 respondents (24%) thought CPD would further their career prospects but 29 respondents (11%) could see no benefits at all from CPD. On further analysis of these 29 respondents, 27 were found not to undertake any CE/CPD and 24 had been registered for over twenty years.
Table 7 highlights respondents views to the final question on what sanctions should be applied to those pharmacists who fail to meet the RPSGB criteria for CPD when it becomes mandatory.
Reassessment of competence, along with remedial training and counseling were the three most preferred options. Interestingly, a significantly higher proportion of respondents who suggested no action at all were locum or proprietor pharmacists (X 2 = 16.95, df = 1, p < 0.001).
Discussion
The aim of this study was to determine community pharmacists approach to conducting CE/CPD and to ascertain their current understanding and perception of CPD. The usable response rate to this survey, although not high, is higher than the recent CPD articles[12-13] and comparable to other studies that sampled community pharmacists.[18-19]
A key finding of this study was the poor understanding respondents had of what constituted CPD. This finding differs from other studies that reported much higher levels of understanding. However, the study by Bell et al[13] defined the terms CE and CPD for respondents and Mottram et al[12] simply asked if the respondents understood the difference. Both studies, therefore, either prompted or assumed that respondents could differentiate between CE and CPD and may account for the higher figures reported. In this study, respondents had to say what each term meant and probably depicts a more accurate reflection of their understanding.
If this lack of understanding could be generalized to all UK community pharmacists, then it would appear that attempts by the RPSGB to raise awareness and understanding of CPD through articles in the Pharmaceutical Journal has largely failed.[11,20-21] This is a concern since respondents indicated that The Pharmaceutical Journal was the major source of acquiring CE/CPD. This journal is distributed to all UK registered pharmacists and published weekly. It is possible that although CPD articles were published, respondents' missed them due to the journals' publication frequency. The other major source of CE/CPD was CPPE. This is hardly surprising as the organization was specifically introduced with government funding to meet the educational needs of community pharmacists in 1991.[22] Since that time, CPPE has become the most prominent provider of CE/CPD, whether by distance learning or attendance at workshop sessions. Other organizations offer similar provision, for example employer training (most notably large chain multiple pharmacy companies), the National Pharmaceutical Association (a body to represent all community pharmacy but specifically for the independent proprietor) and the profession's own organization, the RPSGB, but these were utilized by respondents in this study more infrequently.
Despite the plethora of potential providers of CE/CPD and opportunities for independent study , only three quarters of respondents undertook any CE/CPD and just one third indicated they had completed 30 or more hours as suggested by the RPSGB in the 12 months prior to the survey. It is difficult to know if this figure is an accurate representation of their actual CE/CPD as memory recall questions are known to have poor validity.[23] However, it has been reported that in 1986 less than 10% of the profession was meeting their CE responsibilities,[24] which had risen to a third of UK pharmacists in 1997. Therefore, it appears that an upward trend in CE/CPD participation by pharmacists has been apparent for sometime. This study and other recent studies[12-13] seem to suggest that this upward trend is real.
Locum pharmacists and proprietors were the people who were most likely not to undertake any CE/CPD. This is unsurprising since they have little or no support from an organization to help them with their CE/CPD. Up until recently the locum workforce in UK community pharmacies has tended to consist of older pharmacists, particularly in the 50 to 59 years age group.[25] It could be argued that these respondents believe that experience outweighs CE/CPD or that they are close to retiring so have little motivation to undertake CE/CPD.
However, in the UK there has been a growing trend for newly qualified pharmacists to locum[25] as earning potential of locums can be far in excess of employee pharmacists with the added attraction for many of less managerial responsibility. This possible trend for newly qualified pharmacists not to participate in CPD is of concern as they represent the future of the profession. It is possible that they may believe recently acquired undergraduate knowledge is sufficient for them to remain competent to practice, although Ward et al identified competing demands on time, both professional and personal, as the main barrier to the CPD/CE for newly qualified pharmacists.[26]
The majority of respondents kept some form of record of their CPD completion, however one-third used the RPSGB CE logbook or made their own notes. This indicates that these community pharmacists were recording their CE activities but were not completing the continuous cycle recommended in CPD to reflect and evaluate their learning. This may have potentially reinforced the confusion respondents' had over what constitutes CPD. It could be that these respondents think CPD is just keeping a record of their CE and not how their learning has affected their overall practice. The majority of UK large multiples now issue their employees with CPD portfolios, which are more exhaustive than the RPSGB CE logbook as they tend to define and give examples of CPD, along with sheets to record significant events. If similar support packs were issued to all pharmacists by the RPSGB rather than the logbook, then the concept of CPD may be better understood.
Interestingly, the preferred sanctions that respondents thought appropriate for pharmacists failing to comply with mandatory CPD were those that offered support and guidance, but were also opposed to a sanction of punishment. Respondents who suggested no action at all were either locums or proprietors, which is hardly surprising since these were the groups of respondents who were most likely not to be currently undertaking any CE/CPD. Removal from the register received very little support. Currently the RPSGB has not outlined what they intend to do about those pharmacists who do not comply. Competence reassessment has yet to be defined but it could involve resubmission of a CPD portfolio identifying the core competencies required for practice.
Limitations
The study did have some limitations. First, the study was based on a small sample that yielded a usable response rate of 47%. Therefore, it may not be a good representative of the sample and the findings should not be generalized to the total UK community pharmacist population. Second, some questions relied on memory recall over the last 12 months. It is acknowledged that memory recall questions suffer from low validity and may have influenced the findings.
Conclusion
The majority of respondents did not understand how CE and CPD differ. In addition, only a third of respondents completed the RPSGB advised 30 hours or more of CE/CPD in the previous twelve months. These two key findings should be of concern to the RPSGB as they make CPD mandatory. If the profession does not fully participate in CPD, let alone know what CPD is, then how will the RPSGB address issues of non-compliance.
References
1. Medicines, Ethics and Practice Guide: A Guide for Pharmacists. London: Pharmaceutical Press, 2003:107
2. Alexander A. Wake the sleeping beast-the challenge for continuing professional development. Pharm J. 2002;269:171-173.
3. RPSGB CPD Plan and Record. Available at: http://www.rpsgb.org.uk/pdfs/cpdplanrec.pdf. Accessed October 30, 2003).
4. Thompson CA. France hosts international pharmacists group-FIP differentiates continuing professional development from education. Am J Health-Syst Pharm. 2002;59:2152.
5. NHS Executive. A First Class Service: Quality in the new NHS (hsc 1998/113). London: HMSO, 1998. Available at: http://www.open.gov.uk/doh/coinh.htm. Accessed August 24, 2003.
6. Grout C. Pharmacists need to move towards a planned approach to learning. Pharm J. 2001;267: 569-573.
7. Duggan C, Dhillon S. Clinical governance and pharmacy: is there a place for policy in our profession? Pharm J. 1999;263:570.
8. Eton M. Climbing the professional ladder. Aust J Pharm. 2001;82:168-173.
9. Low J. Ensuring professional competence. Aust J Pharm. 1994;75:1048.
10. National Model Continuing Competence Program for Canadian Pharmacists, 2002. Available at: http://www.napra.org/docs/0/96/191.asp. Accessed August 29, 2003.
11. Lumb J. Prepare yourself for mandatory CPD. Pharm J. 2002;268:723-725.
12. Mottram D, Rowe P, Gangani N, Al-Kahmis Y. Pharmacists' engagement in continuing education and attitudes towards continuing professional development. Pharm J. 2002; 269: 618-622.
13. Bell HM, Maguire TA, Adair CG, McGartland LF. Perceptions of CPD within the pharmacy profession. Int J Pharm Pract. 2001;9 (Suppl):R55.
14. Progress of Society's CPD Pilot. Pharm J. 2001;266:674.
15. Hassell K, Fisher R, Nichols L, Shann P. Contemporary workforce patterns and historical trends: the pharmacy labour market over the past 40 years. Pharm J. 2002;269:291-296.
16. Pharmacy workforce census. Overview of main findings. Pharm J. 2003;270:314-315.
17. Hassell K, Shann P. The national workforce census: (3) The part-time pharmacy workforce in Britain. Pharm J. 2003;271:58-59.
18. Cantrill JA, Weiss MC, Kishida M, Nicolson M. Pharmacists' perceptions and experiences of pharmacy protocols: a step in the right direction. Int J Pharm Pract. 1997;5:26-32.
19. Kennedy E, Moody M. An investigation of the factors affecting community pharmacists' selection of over the counter preparations. Pharm World Sci. 2000;22:47-52.
20. Hancox D. Making the move from continuing education to continuing professional development. Pharm J. 2001;268:26-27.
21. Farhan F. A review of pharmacy continuing professional development. Pharm J. 2001;267:613-615.
22. Promoting better health: The government's programme for improving primary health, Cm 249. London: HMSO, 1987.
23. Smith F. Research Methods in Pharmacy Practice. London: Pharmaceutical Press; 2002: 55-57.
24. Pharmacy; the report of a committee of inquiry appointed by the Nuffield Foundation. London: Nuffield Foundation, 1986.
25. Hassell K, Shann P. The national workforce census: (1) Locum pharmacists and the pharmacy workforce in Britain. Pharm J. 2003;270:658-659.
26. Ward PR, Seston EM, Wilson P, Bagley L. Perceived barriers to participating in continuing education: the views of newly registered community pharmacists. Int J Pharm Pract. 2000;8:217-224.
Anxiety Screening In The Community Pharmacy Setting: A Pilot Study
Marshall Cates, Pharm.D., BCPP, FASHP, Associate Professor of Pharmacy Practice, Samford University, McWhorter School of Pharmacy,Birmingham, AL
Sponsoring Faculty: Marshall Cates, Pharm.D. This research project was accomplished by Dr. Moore while she was a pharmacy student at Samford University, McWhorter School of Pharmacy, Birmingham, AL
Community pharmacists are becoming increasingly involved with screening for medical disease states, but they are not routinely involved in screening for mental disorders. The objective of this pilot study was to administer a patient questionnaire at community pharmacies in order to explore the potential role of pharmacists in screening for anxiety and in making various therapeutic interventions. The patient questionnaire, which included a screening tool for anxiety (Beck Anxiety Inventory), was distributed to three community pharmacies in Alabama. One hundred and two patients completed the survey over a two-month period. The results point to several potential roles of community pharmacists in the management of anxiety, including the need to educate anxious patients concerning caffeine use, follow-up on patients with inadequately treated anxiety, and refer anxious patients who had failed to discuss symptoms with their physician or who failed to receive anxiolytic therapy.
Key Words: anxiety, Beck Anxiety Inventory, community pharmacy, disease screening
Introduction
Anxiety is an unpleasant feeling of apprehension or fearful concern. It can be a normal response to a stressful situation or perceived danger, or it can be an excessive, irrational state that indicates a mental disorder. There are a variety of anxiety disorders specified by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), including panic disorder, generalized anxiety disorder, obsessive-compulsive disorder, posttraumatic stress disorder, social phobia (also known as social anxiety disorder), and others.[1] Anxiety disorders are extremely important to consider because of several factors. First, they are the most common mental illnesses, affecting 9% of the adult population.[2] Next, they are associated with high rates of comorbidity, including other anxiety disorders, depression, substance abuse, and suicidality.[2] Finally, they can cause significant impairment in terms of both quality of life and psychosocial functioning.[3]
Over the years community pharmacists have expanded their roles in patient care, including screening for disease states such as hypertension, diabetes, dyslipidemias, and osteoporosis.[4,5] Unfortunately, community pharmacists are not routinely involved in screening for mental disorders. It has been noted that pharmacists could have a role in managing anxiety by being cognizant of patients' presenting symptoms and being aware of available referral services.[2] Further accentuating the need for pharmacist involvement in the detection and referral of anxiety is that a wide range of medical illnesses and medications, especially prescription, over-the-counter, and herbal stimulants, can cause or exacerbate anxiety.[6]
Our goal was to administer a patient questionnaire at community pharmacies in order to explore the potential role of pharmacists in screening for anxiety and in making various therapeutic interventions. As such, we hoped to demonstrate the feasibility and potential public health value of anxiety screening in the pharmacy setting.
Methods
Because this project was conducted in a community pharmacy setting, the survey instrument had to meet several prerequisites. It had to be self-administered with no verbal instructions, sufficiently brief (e.g., approximately 5 minutes) to encourage participation, and be simply and quickly scored. The Beck Anxiety Inventory (BAI) [7] was chosen as the screening tool. (The BAI is a U.S. registered trademark of Harcourt Assessment, Inc., 19500 Bulverde Road/ San Antonio, TX 78259, 1-800-211-8378.) The BAI is a 21-item self-report questionnaire that focuses on the somatic symptoms of anxiety and was specifically developed to discriminate between anxiety and depression. It has been noted that the BAI may be useful as a screening tool for anxiety in general medical settings.[8] For each item the patient was required to evaluate how much the symptom had affected them within the last week. The point scale for each item is 0 (not at all), 1 (it did not bother me much), 2 (it was very unpleasant, but I could stand it), and 3 (I could barely stand it). The total score is the sum of scores from each item; thus, scores can range from 0-63. The total score represents the degree of anxiety: 0-7 is minimal, 8-15 is mild, 16-25 is moderate, and 26-63 is severe. For the purpose of this study, we defined "significant" anxiety as those scores that indicated the presence of moderate or severe anxiety.
In addition to the BAI portion of the questionnaire, we added questions concerning current medications (i.e., prescription, OTC, and herbal), caffeine consumption, whether the patient discussed the anxiety symptoms with their physician, and whether the patient felt that the anxiety symptoms required treatment. The questionnaires were distributed to two chain pharmacies and one independent pharmacy in different Alabama cities. The timeframe was January-February 2003. Questionnaires were placed in visible areas along with signs containing explanations and instructions. The initial section of the questionnaire was dedicated to statements relating to its purpose, voluntary nature, requirements, and instructions. Requirements included ages > 18 years old, presentation of a prescription at the pharmacy, and completion of only one survey per person. Pharmacists and technicians were asked to encourage patient participation and to collect completed questionnaires. Large manila envelopes were provided for storage of completed forms, which were obtained by the researchers at the conclusion of the study.
The Samford University Institutional Review Board approved the study. Because the questionnaire was completed anonymously, there was no consent form for subjects.
Results
Table 1 below presents the findings from 102 completed questionnaires. The mean BAI score for all patients was 10.3. Approximately one-fourth of patients surveyed scored in the significant anxiety range, with 17 patients scoring in the moderate range and 9 patients scoring in the severe range. Notably, 42% of patients with significant anxiety were not receiving anxiolytic therapy.
Forty-six percent of the patients indicated that they had discussed their symptoms with their physician. Not surprisingly, the mean BAI score for patients who discussed their symptoms with the physician was much higher than that for patients who did not discuss their symptoms with their physician (16.2 vs. 6.7, respectively). The overwhelming majority of patients with significant anxiety discussed their symptoms with their physician (23/26), but there were 15 patients with mild anxiety who had not discussed their symptoms. Nearly one-half of the patients who discussed their anxiety symptoms with their physician were receiving anxiolytic therapy.
Almost one-third of the patients indicated that their symptoms required treatment. The mean BAI score of patients who felt that their symptoms warranted treatment was more than triple that of patients who did not feel that their symptoms warranted treatment (19 vs. 6.2, respectively). The vast majority of patients with significant anxiety scores felt as though their symptoms required treatment (20/26). Almost one-half of the patients who felt that their anxiety symptoms warranted treatment were not receiving anxiolytic therapy; conversely, about one-tenth of those patients receiving anxiolytic therapy did not feel as though their anxiety symptoms warranted treatment
In general, as the number of caffeine-containing products used per day increased, so did the mean BAI score. An interesting finding was that greater than 80% of subjects with significant anxiety used caffeine-containing products, and greater than 50% used at least 4 caffeine products per day. Almost one-third of the patients who reported using at least 4 caffeine products per day were receiving anxiolytic therapy.
Twenty-four patients were receiving anxiolytic therapy. Fifteen of these patients scored in the moderate to severe range of anxiety, thus indicating the possibility that the pharmacotherapy was inadequate to relieve anxiety symptoms. Due to the study population, all patients received medication therapy of some type, but there were no clear examples of cases in which patients may have had medication-induced anxiety.
Discussion
Pharmacists are the most accessible health resource available for patients, so it stands to reason that they would be involved in disease screening.[4] The role of the pharmacist in screening for various disease states continues to evolve. Medical disease states such as hypertension, diabetes, dyslipidemias, and osteoporosis are well suited to this process due to the availability of diagnostic devices.[5] However, pharmacist screening for mental illnesses, such as anxiety disorders, is conceptually more difficult due to their subjective nature. In particular, anxiety disorders are more likely to present with symptoms than with overt signs [9], and are very likely to present with a myriad of somatic complaints that makes detection difficult.[10,11] Thus, pharmacists have not been routinely involved in the screening of anxiety states, and we are unaware of any published studies that have examined this topic.
The present pilot study was an attempt to establish the feasibility of pharmacist screening for anxiety in the community setting. The results point to numerous potential roles of community pharmacists in the screening and management of anxiety. At least eleven patients in this sample of 102 (i.e., those with significant anxiety who were not receiving anxiolytic therapy) were appropriate for referral to mental health treatment. Patients with mild to moderate anxiety who had not discussed their symptoms with the physician could have been encouraged to do so or referred to mental health treatment. The discordance between those patients who felt their symptoms required treatment and those who actually received anxiolytic therapy demonstrated a further need for appropriate referral. Pharmacists could have followed-up on those patients who experienced significant anxiety despite receiving anxiolytic therapy. The anxious patients who consumed caffeine products may have benefited from counseling and education.
We propose that another study be conducted that would more definitively explore these roles of community pharmacists. Pharmacists could use the BAI as a screening instrument and ask the questions included in the questionnaire in order to make assessments and consequent clinical interventions. We would suggest that particular referral sites be involved so that their ultimate clinical interventions could be included in the analysis as well.
Limitations
This pilot study has several limitations, some of which were partially due to time constraints, and others partially due to data collection procedures. There were a relatively limited number of completed questionnaires, and there was no way to confirm that requirements and instructions were followed accurately. Although the questionnaire was designed to require no verbal instructions, we have no way of knowing whether patients had questions, asked questions of the pharmacy personnel, or were provided correct and consistent answers in the event that they did ask questions. Given the distribution of the three pharmacies involved, it is unknown whether these results may be extrapolated to other populations within the state or beyond. The timeframe of the project was relatively narrow, and there is no way of knowing whether results may have been different had the project occurred in other seasons of the year. Finally, selection bias is possible in that patients who completed the questionnaire may not have been representative of those patients who were eligible to participate. Specifically, individuals with anxiety may have been more likely to complete the questionnaire than were individuals without anxiety.
Conclusions
This pilot study found that community pharmacists may very well have a role in the screening and management of anxiety. The BAI offers several advantages in the screening of anxiety in the pharmacy setting, and thus may play a key purpose in the process. Further studies are needed to more definitively examine pharmacist screening of anxiety in the community setting.
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9. Andrews G, Hunt C. Treatments that work in anxiety disorders. Med J Aust. 1998;168:628-634.
10. Stein MB. Attending to anxiety disorders in primary care. J Clin Psychiatry. 2003;64(Suppl 15):35-39.
11. Kroenke K. Patients presenting with somatic complaints: epidemiology, psychiatric comorbidity and management. Int J Methods Psychiatr Res. 2003;12:34-43.
Updated
Bob Schrimsher, EdD, Editor
One of the best descriptions of good writing qualities I have read is from Deborah St. James' book, Writing and Speaking for Excellence,[1(p14)] which states that the qualities of good writing are: reader-based, purposeful, clear, concise, correct, and simple. All these qualities are excellent, but of foremost importance is reader-based. If the writer will always keep this first principle in mind, most of the other problems will dissipate. If the reader begins to ask "Why am I reading this?" then, likely they will not read it. Be very mindful of what you are asking the reader to read.
Clarity cannot be over emphasized, especially in scientific writing. In fact, Strunk--which every serious writer should have and read frequently--emphasizes "Clarity, clarity, clarity. When you become hopelessly mired in a sentence, it is best to start fresh; do not try to fight your way through against the terrible odds of syntax." [2(p79)] No truer words could be spoken.
Huth[3] describes a very powerful audience test of "who cares." He explains that you should look at the message of your paper and ask, "Who will care?" when they see it in print. Who will want the answer your paper offers? Papers are read mainly by persons who need answers to questions. Will it be practitioners, specialists in a small field, or a handful of technicians? Most of us as authors think that our articles will merit the attention of far more readers than in fact it will receive. The important issue is who will read it, not who, in our opinion, should read it.
Grandiose conclusions not supported by the research performed is a serious issue. Although somewhat indirectly related to effective writing, the conclusion section of a scientific article is extremely important because many readers will only read the conclusion (or perhaps the abstract, which contains the conclusions). If the conclusions are exaggerated or inferred to a larger population that is not supported by the data and the reader only reads the conclusions, one can readily see how false or incorrect assumptions may be derived. It is best to avoid unqualified statements and conclusions. Another reason this issue is mentioned is that reviewers and editors are normally very watchful of grandiose conclusions. Even at the slightest hint of unqualified conclusions, some editors may reject an article outright.
There are two kinds of authors: those that have had articles rejected and those that will have articles rejected. Often, the reasons for rejection are not clear. In summarizing several studies focusing on the peer review process, Weller found that both poor writing skills and methodological problems were identified as primary reasons for manuscript rejection.[4] Thus, poor writing skills, as well as ineffective writing can and very often result in article rejection. Speaking from experience and conversing with other editors, upon reviewing the first few pages of a manuscript, if it is poorly written, it will likely be read no further. When you submit a scientific article for publication consideration, it is neither the role of editor, nor the reviewers, nor the copyeditor, to rewrite your manuscript to make it correct, thus publishable.
There are numerous other noteworthy traits of effective writing, which Strunk lists:[2(p70-82)] place yourself in the background, write in a way that comes naturally, work from a suitable design, write principally with nouns and verbs, etc. Every serious writer should have a copy of The Elements of Style, or other similar books, and habitually reread it. Even frequent writers need to revisit these good qualities of effective writing. If not used, they trend to fade rapidly.
Effective writing is writing with a defined purpose for the reader, thus it should be reader-based. To become an effective writer, one first has to practice.
1. St. James D. Writing and Speaking for Excellence: A Brief Guide for the Medical Professional. West Haven, CT: Bayer Pharmaceutical; 1996.
Tim Covington, MS, PharmD., Professor of Pharmacy Practice, Director of Managed Care Institute and the Anthony and Marianne Bruno Professor of Pharmacy, McWhorter School of Pharmacy, Samford University, Birmingham, AL
Adherence to the "Drug Facts" label should be encouraged. Finally, it is very important for the pharmacist to validate patient understanding and allow time for the patient to ask questions or express concerns.Jack E. Fincham, Ph.D., R.Ph., Albert W. Jowdy Professor of Pharmacy Care, Department of Clinical and Administrative Pharmacy, The University of Georgia, College of Pharmacy, Athens, Georgia 30602
Key words: Kenneth L. Waters Memorial Lecture, pharmacy, future, and opportunities
1. medication issues
2. pharmacy education
3. public health concerns
Drug costs. Spending for prescription drugs in the US has skyrocketed in the recent past.[2] An increase of spending to the magnitude of 43% (in dollars) has stressed financing of the health care system. Americans pay the highest price for prescription drugs anywhere in the world.[3] US prices are 72% higher than those in Canada, and 102% higher than those in Mexico.[3] An increase of 25% in percentage expenditures for prescription drugs as a percentage of all health care costs has occurred over the past 5 years. The Kaiser Family Foundation suggests that the reasons for these large increases include an increased volume of prescription drug usage (47%), changes in the types of drugs used (27%), and manufacturer price increases (26%).[4]a. social isolation
Over the next decade, seniors will spend $1.8 trillion on prescription medications. Medicare proposals to provide a drug benefit for seniors have been suggested to cost $400 billion over a 10-year period. Thus the most elaborate of the current drug programs will pay only 22% of seniors' drug costs.
b. aforementioned occurrence of chronic disease
c. multiple and complex drug regimens
d. the degree of morbidity associated with chronic diseases[18]
Pharmacy education has been and is being called upon to impact problems identified today. Increased demand for services, diminished resources, and the need for applied research in order to examine outcomes have come together at this juncture for our profession. A half century ago, Dean Wilson captured the essence of needs pertaining to pharmacy education and the future with 3 objectives dealing with education, pharmacy practice, and research.[1]
Historically, pharmacy has participated in public health activities in a sporadic fashion. This is an area where passive participation will no longer be an option for any health profession, including pharmacy. Past and current opportunities will evolve into options that pharmacists must grasp, and pharmacy education can play a role in empowering pharmacists to play more active roles.
The negative influence of health illiteracy has tangible outcomes in higher rates of hospitalization with lower rates of health literacy.[37] Dr. Chisholm and colleagues have identified a role for pharmacists to play in indigent care through advocacy, intervention, and serving in a liaison role between interested parties.[38] Mapping occurrence and demographics at a macro level can allow for local interventions and subsequent successes. The impact of much of the elaborate technology in the US health care system is not available for the uninsured. It is projected that $1.1 billion per year in additional expenditures is needed to deal with under treatment of myocardial infarction, cataracts, and depression.[39]
The ability to impact students in training, conduct state of the art, cutting edge research, and impact the lives of a majority of members of society was eloquently noted by Dean Wilson in the past. The promotion of pharmacy through the College's Strategic Plan as the primary drug therapy resource for other professions and for society in general would no doubt please him.
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Hull H. MSc, Senior Lecturer, Pharmacy Practice Division,School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, PO1 2DT, United Kingdom
Abstract
Objectives: To investigate pharmacists' attitudes and approaches to continuing education (CE) and continuing professional development (CPD).
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Malia Moore, Pharm.D.,Drug Information Resident, University of Tennessee, Memphis College of Pharmacy/ Methodist Healthcare
Abstract
April 2004