To get a picture of what is happening in the way we practice pharmacy, I have been encouraging pharmacy students to write about their internship experience. Early this year, I finally got one from among our long-term interns. She had her short-term internship in another hospital and this is what she wrote:

I am a student of (name of school)... I have chosen (name of hospital) as my hospital minor internship expecting that... it would expose me to various cases that entails the application of my knowledge in pharmacy. Unfortunately, I was disappointed.

From our university, they accepted 20 students to have their internship, aside from students in other universities. In my perception, the number of students is not a question if only the pharmacy could accommodate all of us, but it seems that the large number of students would not purposely teach us but instead formed a crowd and hindrance inside the pharmacy.

Our major daily activity was to [dispose of] expired donated drugs. I agree that it was part of the proper disposal and management of drugs, however bulk of expired medicines were disposed due to their control of dispensing of these medicines. As I observed, there are drugs that are still available and yet they told the patients that they have none and should buy the medicines outside. This system of dispensing could be the cause of bulk of medicines stored, disposed and did not serve its purpose.

Once I was assigned [to] a night shift from 6 PM to 6 AM. The pharmacy [was] open 24 hours daily but the pharmacists on duty did not attend to [their]... responsibility by sleeping after 10 o'clock. As a result, the students could creep easily outside the pharmacy... [non-pharmacy personnel could get inside and may [steal] items that [may be] used [for purposes] unknown to me.

The issues [that arise] from the things I mentioned above are only part of my experiences in the said hospital but as I have talked to students from [another] university who were interns prior to my stay, said that there was a case that they were asked to erase the expiry date and dispensed it to patients. I understand, a six months allowance of the real expiry date is acceptable but I [am] opposed to the idea that the patients are not receiving the proper medication they needed.*

... I am [concerned] with [the] succeeding batch [of interns] that would experience these things. Supposedly, the ideal practice [taught] in... school should be the system in the field of work. [Although], I could not blame if in the... hospital like (name of hospital), cases like this happen because I know it could be lack of fund in the part of our government. However, there are news I received from my schoolmates that other hospitals have common idea about the internship, that we are tasked to clean the pharmacy, buy them favors to earn the hours we need and enclosed to clerical works than learn the pharmacist's responsibilities.

I am appealing not for my personal interest but for the succeeding students and future pharmacists and for the patients who could [hardly] buy medicines but [were victims] of [self-interest] of higher intellegence.

I would like to [address] this problem for the upliftment of our pharmacy course [and] to be known as part of the health care team and to improve the quality of pharmacists here in our country.

As a student, I have already talked to our internship [coordinators] about this issue and they agree not to recommend the said hospital for internship. They can only monitor the activities of the student through activity reports as always but I guess the problem [is] deeply rooted from the pharmacists today that tolerated the students not to learn the essence of discipline in the field of work.

I am blessed that I have been accepted as an intern in your institution... I hope other hospitals have the same internship program, have the same concern and appreciation to interns and the same protection of the welfare and interest to our course.

_________________

pinoypharmacist's note:

* The Bureau of Food and Drugs has already issued BFAD Advisory No. 00-04 dated May 10, 2000 "Warning against Dispensing Expired Drugs." For the full text of the Advisory, visit the BFAD website at www.bfad.gov.ph

Last year, I made a comment on an article that was featured in the April-June issue of Health.Care magazine. Surprisingly, my comment was published in the "letters to the editor" section of that magazine sometime in July 2006.

Here is what I wrote to the editor:

I just would like to comment on the article "Unibranded medicines: Affordable Treatment for Better Health" which appeared on the April-June 2005 issue of the Health.Care (vol.3, no.2, p. 50).

It is true that "a lot of patients are not aware...that failure to complete their antibiotic treatment may contribute to bacterial resistance". However, patients' awareness to the proper use of antibiotics should be provided by health professionals as part of the entire health care plan (e.g., during consult with a medical doctor, at the time the antibiotic is dispensed by a pharmacist and when a nurse administers the drug).

A patient who is not properly informed about his or [her] medications reflects a discrepancy in the quality of health care provided by health professionals.

It has been said that improper antibiotic use is prevalent in the Philippines and "is a result of misconceptions, financial constraints, prescription recycling and widespread self-medication." (1)

As a pharmacist, my concern regarding the inappropriate use of antibiotics is about "the practice by pharmacists and drug sellers of conducting transactions without a prescription [that] unfortunately reinforces the behavior". (1)

I really feel that we "strictly implement the Pharmacy law" and "restrict over-the-counter availability of antimicrobials". (2)

A patient who has no access to antimicrobials (or any other prescription drugs) over the counter has a lesser chance to self-medicate. There will be no prescription recycling if pharmacists retain prescriptions that are fully filled.

This should be the pharmacist's contribution to affordable treatment to better health.

_____________________

References:

1. "Improper antibiotic use prevalent in Philippines." Philippine Daily

Inquirer 9 Jan. 1999, Sec D:3.

2. Carlos, Celia C. "The problem of antimicrobial resistance:RDU Update vol.4 No. 3 1995:1-4.

Last month four interns gave me a gift I will never forget. It was a beautifully framed prayer which they gave out of their appreciation for the opportunity and memorable experience they have in our institution. (Well, you know who you are!)

Sometimes I feel guilty for not having enough time to guide them during their internship because of my busy schedule and workload but I hope that the little things I shared with them they will not forget.

I also hope that once in a while, whatever it is that they will be doing in their professional life, they will still have time to say...

A PHARMACIST'S PRAYER

O God, great Master

Of the healing arts,

Bless my slow unwieldy hands;

Make skilled and sensitive

My fingertips for all demands;

As counter for disaster,

Fill my mental starts

With keenness; let me live

That other lives may through

Deft Medium of my science,

Pursuance find in health.

Let each capsule that I count

Yield strength rewarding wealth;

Each ointment for appliance,

In all and each amount

Be healing prayer.

Let me ne'er forget

Thy generous Providence

Held within my trembling hands.

Help me justly execute, dispense.

And be cautious of my ware --

And while Life's hour-glass yet

Runs, with the doctor guide its sands.

Place within my heart

Alert and wholesome fear,

Lest I misweigh a single grain,

And Death comes stalking from my shelves.

Make impotent limbs to walk; pain

And sorrow's counterpart

With my potions disappear;

And God's give Hope unto themselves.

- Sister Mary Juanilla, O.S.F.

In 1999, I was invited to talk in a class of Pharmacy students about the "Problems and Prospects of an Improved Hospital Pharmacy Practice in the Philippines." I refused the invitation at first because I know that I am not in the best position to speak about the subject matter. The students, however, begged that I give them my time or they might fail in that subject. I finally agreed.

The discussion was informal. Their professor was there, too. Most of what I told this class was based on my personal experience, observation, reading and interaction with pharmacy interns. Nevertheless, it was still not an expert's opinion.

The students later asked for a summary of what I discussed with them. I have already forgotten what I wrote. I don't even remember where I keep the copy but early this year I found it somewhere in one of my files. This is what it says...

The greatest challenge facing hospital pharmacists in the Philippines today is the establishment of a clinical pharmacy program that is comparable to the standards of other countries where clinical pharmacy has reached a level of maturity.

The current concept of pharmaceutical care all over the United States further overwhelms our pharmacists in hospital settings.

The problems confronting us are many and any attempt to improve our present status is not easy. It greatly depends on the attitude of every practicing pharmacist.

The fact is, we lack skilled pharmacists for clinical functions. "If we can just see the problem and admit to it, we can fix it..." (Bleech and Mutchler)

More so, the future of our profession (at least, in our country) will be influenced also by the way we educate our future pharmacists.

The qualities of our graduates, according to Milap C. Nahata, a doctor of Pharmacy, should be the following:

1. knowledgeable
2. creative
3. effective communicator
4. motivated professional who is ready to learn new concepts, and
5. must be able to function as a team player

The probable future (i.e., the prospect/s) of a more advanced hospital pharmacy practice in our country will find our pharmacists actively and directly participating in patient care with other health professionals in a clinical setting if decentralization of our medication distribution system is applied...

We have to improve on our medication distribution system with emphasis on our unit dose drug distribution. I consider it an effective first step in bringing the pharmacy service closer to its clients. How to keep it even closer is another [step].

We have to remember that "many administrators as well as other professionals view drug distribution as the primary reason for a pharmacist's existence and poor performance in this area can undermine support for all other pharmacy programs."

Whether we admit it or not, support from outside the boundaries of pharmacy practice is vital. We need it even more towards pharmaceutical care, the future of clinical pharmacy.

Support is our first requirement if we must meet the challenge of pharmaceutical care. It is best exemplified by establishing a program that focuses on the improvement of the current systems in clinical pharmacy. Such program should consider not only the type of training and education, but the time a staff pharmacist should spend in a given clinical area, and entirely functioning as a clinician. Exposure and experience are provided in this setting and would facilitate greater advancement in the learning process.

Lack of incentive is often a problem in encouraging staff pharmacists to pursue further training. It is another hindrance to the concept of pharmaceutical care and is one of the major reasons why pharmacists are still reluctant to embrace clinical functions.

Availability and access to technology that would render the fastest, most accurate and up-to-date delivery of information will enhance the capability to provide pharmaceutical care. The establishment of a comprehensive and reliable drug information service is not only necessary but truly indispensable to its application.

Standardization in the practice of our profession should be made visible. The lack of it prevents pharmacists to view themselves on a professional level that encourages re-evaluation of systems that might drastically change the ever-existing picture of pharmacists as mere sellers and/or providers of medicines.

The present status of clinical pharmacy in the Philippines badly needs some overhauling before meeting the challenge of pharmaceutical care. The call for change is addressed not only to practicing pharmacists in hospitals, but in other fields within the pharmacy profession, especially in the academe.

What future pharmacists need is an improved curriculum that permits in-depth and hands-on training and not just concepts presented and confined within the classroom.

The demands of students for improved teaching methods, modernized technical facilities and upgraded reference materials, among others, should be taken into consideration. Pharmacy interns, either in community, hospital or pharmaceutical laboratory, are continually dissatisfied with their training. Some are even doing activities that are totally irrelevant and far less important to the practice of pharmacy. I believe that the change should make its mark in the way we educate our future pharmacists and how we view this profession in general.

"Success in clinical pharmacy can only come about by change in atttude and by the ability of the pharmacists to communicate with members of the health care team." This is still true in the concept of pharmaceutical care. If we are dedicated to the advancement of pharmacy practice in our country, our contributions to the present trends will make it a reality.

_______________

References:

1. Bleech, James M. and Mutchler David G., Let's Get Results, Not Excuses! Hollywood: Lifetime Books, Inc., 1997.

2. Brown, T.R. and Smith, M.C. Handbook of Institutional Pharmacy Practice, 2nd ed. Baltimore, MD: Williams & Wilkins, 1986.

3. Bailey, David E. and Plein, E.M. "A study of clinical pharmacy practice in a small private hospital," Lippincott's Hospital Pharmacy, vol. 5 No. 8 (August 1970): 5-14.

4. Durgin, Sr. Jane and Hanan, Zachary. Pharmacy Practice for Technicians. New York: Delmar Publishers, Inc. 1994.

5. Nahata, Milap C. "Issues Facing Clinical Pharmacy Education for Undergraduate Students." DICP: The Annals of Pharmacotherapy, vol 23 no. 3 (March 1989): 250-251.