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Medicine in Society
Part III: A Role for Medicine inModern Society
MALCOLM S. M. WATTS, M.D.San Francisco

THE PRECEDING SECTION of this inquiry into "Medicine in Society" drew attention to some
vast and largely irreversible social, eronomic and political effects of the application of scientific
advances in both medicine and society. Specialization in the function of individuals, a necessary
consequence of this great progress, produces greater social, economic and political interdependence
within and between both medicine and society. The problems created by these changing
relationships are many and as yet they are poorly understood. But they clearly affect both medicine
and our culture in most fundamental fashion. A few of the "dimensions" of modern medicine in
modern society were briefly discussed.
These new interdependencies among people and among functions are not to be escaped in an
age dominated by science. The net effect has been to produce a complex system, which like any
complex physical, biological or social system, must sooner or later develop some order and
direction within itself if it is to perform effectively. Much of what is at stake in this development
is the role which the individual as such will play. In medicine, the issue is found in the survival
This is part III of a communication in three parts. Parts I and II appeared in the December 1964 and
January 1965 issues. of individualized medical care directed by a physician whose first interest is
his patient versus depersonalized statistically oriented mass medicine directed by the government or
someone else "in the public interest." In society, the issue can be expressed in such terms as the
social trend toward the security of conformity versus the protection and enhancement of freedom
for the nonconformist; the economic concepts of free-enterprise versus the planned economy of
socialism; or, in the political sphere, the extent to which the minority will be compelled to submit to
the will of the majority, or perhaps vice versa. For many reasons medicine is vitally concerned with
all these problems. The preservation of freedom of expression and freedom of action for the human
individual be he doctor, patient or citizen, as well as the inescapable need to find means to give
order and direction to an increasingly complex biosocial system are each of the greatest importance
to human health and to good medical care. The broad social responsibility of modern medicine in
this modern society now requires re-examination. So far medicine has offered surprisingly little in
the way of leadership or constructive advice. Yet the role which medicine will ultimately play will
surely depend CALIFORNIA MEDICINE 133 upon the effectiveness of its leadership and its
performance at this time.

A. A Basis for Medicine's Roll

It would seem that the basis for medicine's social role must be found in the root purpose of the
medical profession itself. These have been defined by the American Medical Association as "to
promote the art and science of medicine and the betterment of public health." This objective implies
that medicine is fundamentally concerned with the health and welfare of the human individual, that
it has a basic commitment to progress, and that its social role and professional performance must be
based upon its special competence in the very broad field of human biology. Concern with the
human individual, commitment to progress, and competence in human biology are closely
interrelated. It is suggested that together they serve as a sound basis from which to derive a role for
modern medicine in modern society.
1. The Human Individual
The art and science of medicine are historically focussed upon the human individual and upon the
maintenance and betterment of his health. The raison d'etre of the medical profession is this human
individual. The tradition of our Western culture also places a high value upon each individual life.
It is this common interest which gives society its legitimate interest in medicine and medicine its
legitimate interest in society. Medicine has been surprisingly consistent in its support of what it
believes best for the individual, both in its professional activities and also in the socio-economic and
political positions it has taken. For example, it clearly recognizes that in most circumstances
the patient is better served when the individual is treated on a personal basis and not regarded as a
probability statistic. But in those situations where the individual interest is for practical purposes
identical with the greatest good for the greatest number, medicine supports collective or
mass approaches to medical care. This has generally occurred in situations where the possible need
for medical care may exceed the capability of personal medicine to meet the demand, as in military
medicine, disaster medicine, prevention and control of epidemics, and in certain situations where
for economic or geographical reasons medical care is best approached on a less personal or
collective basis. But any mass or collective program must tend toward emphasis on the statistical
probability, at the expense of the statistical improbability, and this may be contrary to the particular
need of any given individual at any given time. Personal medicine, however, aims to give equal
attention and service to both the probable and improbable in individualized care. Support of
personal medicine is, therefore, a logical position for the medical profession to take in the interest of
each human individual. This ongoing concern with the health and welfare of the human individual
underlies the attitude of medicine toward such things as "free choice" for both doctor and patient, its
belief that the doctor should be working for the patient and not someone else, as expressed in the
individual responsibility and fee-for-service principles, and its resistance to "third party"
interference, which of necessity introduces a collective interest into what in its highest expression
should be an individual and personal relationship. But as the health and welfare of the human
individual develop wider and wider ramifications in society, many of these traditional attitudes
require modification in a changing situation. But for each instance, the position of medicine can
be logically based upon what it believes is best for the human individual in the given circumstances.
Society, on the other hand, has tended to substitute the majority interest, the collective interest or
the "public interest" for the individual interest. This gradual shift from an earlier emphasis on
individual rights toward the present and increasing emphasis on collective rights was predicted by
de Tocqueville who clearly pointed out over a hundred years ago that rule by majority vote
inevitably strengthens conformity at the expense of an individual's freedom to be different.
Collective interests also are more easily organized into pressure groups. These tend to dominate and
suppress "uncollectible" individual interests in independence and personal freedom which do not so
easily band together to express their "collective" interests in individuality and freedom to be
different. These trends have perhaps been accelerated by the social impact of the scientific
revolution on a necessary interdependent society. In any case, even the courts now tend more and
more to support conformity at the expense of freedom,and the right of organized collective interests
even though a minority, to impose their will upon all. In this political setting, medicine finds itself
tending often to support "unpopular" uncollectible interests of the individual as such, rather than the
better organized and therefore more "popular" collective interests. Thus many physicians find
themselves in ideological and political opposition to such things as compulsory retirement at the age
of 65 regardless of capability, and in favor of such things as right-to-work laws, less government
regulation of daily living, and less government spending and more take-home pay for the human
individual. The common need of everyone, whether doctor, patient or just plain citizen, for
individual freedom and self-expression is a "collective" self-interest which nowadays seeks more
effective recognition and craves more adequate leadership. It also happens to be essential to the best
medical care and to the betterment of human health. This common interest of medicine and the
individuals who comprise society could become a basis for extraordinarily effective socio-economic
and political action. The county, state and national organization of medicine can give "collective"
expression to "uncollectible" interests shared by all individuals. Positions taken by medicine, when
based upon its professional knowledge and the needs of all individuals and when soundly conceived
and effectively presented, may be counted upon to gain popular support. The full possibilities of
collectively representing the uncollectible individual interests of all have yet to be explored.

2. Progress
The commitment "to promote the art and science of medicine" is fundamentally a commitment to
progress. To the physician progress means advances or improvement for the human being, for
society, or both, in a biological and cultural sense. This meaning does not refer to the "progress" of
any conceptual social, economic or political theory, doctrine or belief in the sense in which the
words "progressive" and "liberal" are commonly used in the present scene.
The physician-scientist knows that biological, scientific and cultural progress is based on the
outcome of many trials of new and different ideas, rather than conformity to conceptual theory.
Most of these experiments fail, but some succeed. Those which fail are a price which is paid for the
advantages gained from those which succeed. Progress is most rapid when there are many
experiments. It is slower when they are restricted and infrequent. Thus, medicine's commitment to
progress through experimentation places it not only squarely in the social struggle between
individual freedom and collective conformity, but also between advocates of the relatively
unplanned free enterprise system, and those who would plan and carefully regulate society.
Medicine, therefore, also finds itself in the midst of the semantic confusion which currently
surrounds the use of the words "progress," "liberal," "freedom," "security," "free enterprise,"
"socialistic," "conservative," "reactionary" and the like.
In its commitment to progress through experiment,medicine also maintains its primary concern
with what is best for the individual. This is true for scientific experiments where careful attention is
given to the safety and welfare of the individual. It has also been true for experimentation and
research in methods of financing medical care and of delivering medical services, where it has
resisted and opposed experiments which it felt could not be in the best interest of the individual; or
which would lead to regulation, restriction and control, which would in turn prevent further
experimentation; or which once undertaken could not be either abandoned or reversed. It is this aim
which has placed medicine in diametric opposition to much present day "progressive" and "liberal"
thinking which in reality is perhaps more truly "reactionary," in the sense of inhibiting progress,
than "liberal."
Is it not this support of freedom to experiment and freedom to progress which makes a free and
outspoken medical profession so often an anathema to those who would impose their conceptual
sociologic, economic and political theories upon society?
Perhaps medicine can capitalize to a greater extent upon this commitment to true biological and
cultural progress.

3. Competence in Human Biology

Medicine's competence in the biology of human nature and human behavior exceeds that of any
other profession. It is this knowledge of human biology which is brought to bear in medical
practice and medical care. But this same human nature and human behavior is an essential
ingredient of any social, economic or political system. It is noteworthy that many biological
principles, such as birth, growth, maturation, form, adaptation, senescence, death and evolution
through survival of the fittest, apply not only to the species but also to human institutions, human
society and its culture. It would appear that competence in human biology is increasingly important
in the field of social interrelationships in modern society.
The doctor, who is the biologist for man and his society, therefore has many new as well as old
responsibilities. There are responsibilities to the individuals of the species who alone can give rise
to real progress; responsibilities for encouraging conditions and circumstances under which
biological man can make progress without damage to himself, to his fellow man or to his species;
and there are new responsibilities in broad and fascinating new areas of biological and cultural
evolution which are rapidly becoming possible because of scientific progress. Clearly, the
physician must play a central role in these developments and make certain that the conditions for
individual human fulfillment and further progress remain favorable.
It is suggested that concern with the human individual, commitment to progress and competence in
human biology are the foundations upon which medicine's role in society can be built.

B. A Crucial Decision for the Medical Profession

In this inquiry the term "medicine" has been used broadly and somewhat loosely. It has been
used broadly to encompass many very old and some very modern facets of the relationship
between society and those to whom society gives responsibility for its health and welfare. It has
been used loosely to include not only medical science and technology, but also the medical
profession, medical practice and all the ramifications of medical care in modern society. It is quite
clear that in this broad definition "medicine" does in fact play a central and utterly essential role in
any society. It is also clear that although "medicine" may change its shape and form, this central
and essential function of "physician" in society can never really be destroyed.
But it is not so clear as to just where in the shape and form of modern "medicine" lies the
responsibility for the health and welfare of those persons who comprise society. It is not certain just
who is the responsible "physician" to our modern culture. The physician in his nostalgic traditional
role seems to have all but disappeared, and the public senses that somehow society has lost its
doctor. Understandably, and like any patient, society is now seeking a "physician" to fill its needs
and one whose performance will prove satisfactory.
There are a number of candidates. None has yet been selected. Curiously, and perhaps portentously,
the medical profession itself is divided concerning the role it should play. It has been immersed in,
in fact almost inundated by, the great wave of science and technologic advance. Perhaps this is the
reason many doctors see the role of medical profession as confined quite simply to the science and
technology of medicine. But these physicians do not seem to realize that this must inevitably make
technicians of doctors and that this in turn has inescapable professional, social, economic and
political consequences both for the physician and for society. Yet the profession still clings in
principle to the traditional concept of its role in society. This is evidenced by its instinctive and
sometimes violent reaction to any attempt by others to assume any of the prerogatives of this
traditional role. As a result a number of major needs of society have not been met and a vacuum of
performance has developed. Social, economic and political pressures will inevitably insist this
vacuum be filled. The mantle of the "physician," like any mantle of leadership, eventually passes
from those who do not perform to those who do.
The decision to be made seems clear. Is the medical profession to fill this vacuum of leadership
and perform, or is it to relinquish its role of "physician" to society and confine its area of
competence and performance to the science and technology of medicine? If this latter occurs then
the role of "physician" and most of the responsibility for "medicine" in society must pass to other
hands and the doctor of medicine will simply become a technician in medical practice and at best a
technical advisor on the scientific aspects of medical care.
The large responsibilities of "physician" will necessarily be assumed by specialists in other fields
such as perhaps health education, public health, health care economics, social welfare or some
other category of social or political scientist.
At such a moment of decision it is wise to be guided by basic goals and objectives. If the role of
the medical profession in modern society is truly to be founded upon its concern with the human
individual, its commitment to progress and its competence in human biology, then its decision is
clear. These responsibilities cannot be carried out by a mere technician in medical science. They
can only be discharged by whoever is to become "physician" to society.
It is the thesis of this discussion that the medical profession should and must assume this central
role in society. This crucial decision cannot be put off much longer.
C. A Suggestion for Organized Medicine
The instrument through which the doctor and the medical profession can fill the role of "physician"
to society is organized medicine. If organized medicine is to play this role, the physician, through
organized medicine, must demonstrate that by exercising freedom, by utilizing the free enterprise
system and by accepting responsibility, a free medical profession can solve the social problems
created by the scientific revolution as fast as they appear.
This is quite an order in an organization comprised of 20,000 (in California), 200,000 (in the
United States) highly independent, highly individualistic,highly educated and hard working
dedicated doctors. Yet these rapidly accumulating problems must be solved within this voluntary,
free enterprise system or society will demand that they be solved by government regulation and
control. The ultimate decision will be based upon whether free enterprise organized medicine can
perform satisfactorily. Perhaps it- is time for organized medicine to come to grips with these
realities. It would seem necessary that it first address itself to the difficulties which the free,
voluntary democratic political system has in finding acceptable solutions to the complex social and
environmental problems which are the direct result of the impact of scientific progress. Perhaps
competent in the field of human biology, it can borrow for itself a leaf from the book of biological
evolution and apply some of its principles to the evolutionary process of which it is a part. In the
animal kingdom there are still free and independent cells, but the higher forms of life have found it
necessary to develop specialization and interdependence among cells. These more complex
biological systems have made possible advanced forms of life and of living. A major key to this
improved performance among specialized and interdependent cells has been the development
of the specialized functions of communications within the organism and with its environment, and
of a mechanism to deal with an environment which changes from moment to moment, from day to
day and over much longer periods of time. This important mechanism is a brain or an intelligence.
The parallel to the problems of modern medicine in modern society is close. Medicine too has its
free and independent cells which are yet specialized and interdependent. Perhaps organized
medicine too needs some sort of better intelligence system to deal with its internal and external
problems in a changing environment, to recognize them when they occur, and hopefully to
anticipate them before they arise. At the moment organized medicine somewhat resembles an
amoeba, moving every which way and almost without direction, except when strongly
attracted or strongly repelled. Doctors are intelligent and as homogeneous as any group of highly
educated, free and independent generally hardworking and dedicated individuals can be. Perhaps
there is a real opportunity to study, experiment with and strengthen the democratic political system
within the framework of organized medicine. If successfully accomplished this could have
profound effects upon both medicine and society.

D. Assets for Leadership in Medical Care

Once the decision is made to assume a role of leadership in medical care, and the very real
difficulties of adapting the internal "biosocial" structure of medicine to the ecological requirements
of modern medicine in modern society have been overcome, the many assets of modern medicine
can be brought more effectively to bear in support of medicine's leadership, and the role of
"physician to society" can become a reality for organized medicine. A number of these many assets
are worth noting.
1. Medicine has a proven record of superbly applying its scientific knowledge in daily patient care.
2. Public interest in medicine is very great. There is no need to create a demand or a market.
3. Medicine is an important instrument through which the public can immediately and directly
realize tangible personal results from its tremendous financial and emotional investment in
scientific progress.
4. Physicians are highly respected in the community. They are intelligent and educated. They have
a common goal and a traditional selfless interest in bettering the health and welfare of people.

5. Medicine has unusual communications resources. The medical profession has direct and
intimate contact with all cultural groups. It has roots and branches which reach into virtually every
aspect of society. Its members are skilled in convincing individuals to do what is in their best
interest. Its subject matter is readily adaptable to and widely used by mass communications media.
Communications channels exist between doctor and patient, between doctor and citizen and
between organized medicine and the public.

6. Medicine and the public have a common interest in the human individual, his health, his
welfare, his individuality and his freedom to progress. Public opinion and the voter at the ballot
box are strong determinants in the evolution of our society. The voter and public opinion are
influenced by emotion, beliefs, information, personal experience and by what other people think.
These influences are transmitted by communication. Medicine and the public have a common
interest which can provide the framework for the communication of information, experience and
advice based on competence in the broad field of human biology.

7 . Organized medicine is perhaps paradoxically

in the position of being a relatively strong "collective" national organization, with state and county
components whose roots and branches reach into almost every facet of life, yet whose primary
concern and responsibility is with the health and welfare of the "uncollected" individual, with all
this implies in modern society. Medicine has yet to develop the full meaning and full power of this
perhaps unique position in our society.
8. In "organized medicine" doctors, concerned with the individual, committed to true biological
and cultural progress competent in human biology and dedicated to the betterment of health, are
banded together in fairly cohesive societies in over 1800 counties across the nation. These are
federated to form the state medical associations which in turn comprise the AMA. Inherent in this
organization of highly educated and highly individualistic yet dedicated physicians must lie the
capability to preserve what we know as freedom and yet solve the social problems created by the
impact of scientific progress in medical care, if indeed this can be accomplished within a
democratically constituted professional organization.
9. To regain its position of leadership as "physician to society" medicine will probably need to
adapt its structure to be more fit in its new and changing environment, and also adapt many now
unfamiliar disciplines in the social and behavioral sciences to the needs of patients, to the health
and welfare needs of the individual in society and of society itself. But this process of adapting
itself and of adding new disciplines of knowledge to its armamentarium is nothing new for the
medical profession. It has done this from time immemorial, and it can do it now.

E. Conclusion
In conclusion it is suggested that organized medicine address itself to the responsibilities of modern
medicine in modern society, and arrive at a determination of the role which it wishes itself to play.
It should decide whether it will perform as "physician" to society or abdicate this essential function
to the most powerful contestant. It should also decide whether it will assume the responsibility of
resolving the social problems resulting from scientific progress in medicine and in society by
strengthening order, direction and leadership within the dimensions of the free enterprise system or
whether, through disinterest, disunion, procrastination or failure to perform, it will in effect bring
about government regulation and control by its own default. The future complexion, not only of
medicine, but of our society itself, may very well hang upon these decisions and what is done to
implement them.
Life is short, and Art long;
the crisis fleeting; experience perilous, and decision difficult.
The physician must not only be prepared to do what is right himself,
but also to make the patient, the attendants, and externals cooperate.
— First aphorism of Hippocrates, circa 400BCE, from the Hippocratic Corpus online (translated by
Francis Adams)

Desired behaviour
Interviews with patients have indicated that the ideal physician would be confident, empathetic,
humane, personal, forthright, respectful, and thorough. Incorporating clues to such behaviors may
create a better doctor-patient relationship.
Undesired behaviors are essentially the opposites, specially being insensitive or disrespectful, e.g.
arrogance in dismissing the patient's input, disinterest in the patient as an individual, impatience in
answering a patient's questions or callousness in discussing the patient's prognosis. Another
undesired behavior is seemingly providing excellent service in the original visit but then failing to
meet the created expectations about the speed or quality of follow-up service.
Still, when having to choose between high technical quality and high interpersonal quality, two
thirds of patients choose high technical quality. Nevertheless, the level of technical quality may be
hard for a non-professional to assess, which in reality results in a tendency of patients to primarily
judge physicians on behavior. wiki pedia

Your first question: What are the duties of an ideal doctor towards his patients & towards his
profession. Towards your patients you must work towards the betterment of their health. You must
work with your patients as partners in that goal. It is your job to explain, to the best of your
understanding, what health threats they face, and provide them the options (giving both the positive
and negative consequences) for each option that they have. You must respect their decisions,
whether or not you agree with them, and you must maintain confidentiality about most things that
the patient tells you. The duties towards your profession include working together with other
physicians to create a healthier community, country, and world for everyone to live in.

Your second question: What is the role of a doctor in our society. This answer is fairly
straightforward. Doctors work to increase the health of their patients. This includes listening to
emotional stresses and helping to alleviate them if possible. Society tends to hold physicians in high
regard. Because of this, doctors have influence (perhaps unfounded) in many areas. Doctor should
be very careful not misuse the trust placed in them.

Your third question: How can doctors contribute to improving healthy living conditions & how can
a doctor contribute to effection political decisions that effect medi-care and medical conditions in
hospitals or other ethical decisions take by our governments. Again, doctors have a lot of influence
in society. It is not usually part of a doctor's job to be a politician, and so to be politically active,
doctors must use their free time if they want to work for improvement. Most doctors work very long
days, and therefore do not have time to use this influence to bring about improvements. However,
those that do tend to have a big impact. Some doctors write letters to the government, or even meet
directly with politicians. Others work hard in their own communities, volunteering at free clinics for
poorer patients. There is a lot that a doctor can to, but it can take a great deal of energy to
accomplish these things. It is important to note here, that anyone can have a large impact of politics
and in their own communities. It is my view that everyone should work towards improving their
Your Fourth question: Why does any ideal doctor wanted to become a doctor. I want to know what
is the motivation that motivates most people to study medicine (Not good income or stable life).

An ideal doctor wants to become a doctor because they enjoy working with people and they find
medicine very interesting. There are many jobs in which you would get to work with people and
being a doctor is one of them. I will not say that an ideal doctor wants to help people, because I
think that most people want to help others, and accomplish it in a variety of different ways. For
example, a scientist may discover a new medicine that cures many more people than one doctor
could help during his life time. A politician may negotiate a peace treaty that saves millions of lives.
Certainly no typical doctor could see a million patients in his life time. There are many ways to help
people, but they do not always allow the helper to work directly with people.

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

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

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

While it is easy to be compassionate to most children, and also to people who are kind and good, it
is more difficult to be compassionate to people that you have difficulty liking. For example, my first
patient was a prisoner that had committed many crimes. While we both spoke English, the way we
spoke it was quite different and I had trouble communicating with him over the two weeks that he
stayed in the hospital. He was often very angry. Yet it was important for me to continue giving him
the best care that I could while he healed from the surgery that had been performed on him. When
the patient was ready to leave the hospital we needed to write him prescriptions to control the pain
he had. The doctor I was working under was angry at the patient and wanted to give him a weak
medicine that would not control his pain as well as a stronger medicine. After I argued with this
doctor, he changed his mind, and remembered to be compassionate.

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

In your career you will encounter all kinds of people. Some of them will make you angry, but it will
be very important not to judge them, and to remain compassionate. It will be your job to help them
as well as you can, no matter how badly you dislike them. I wish you luck in your studies, and I
hope that find enjoyment in your work as a doctor.

The Consensus Statement on the Role of the Doctor

Doctors alone amongst healthcare professionals must be capable of regularly taking ultimate
responsibility for difficult decisions in situations of clinical complexity and uncertainty, drawing on
their scientific knowledge and well developed clinical judgement. The doctor's role must be defined
by what is in the best interest of patients and of the population served.
Based on the definition of the role of a medical doctor proposed by the International Labour
Organisation it is agreed that:
"Doctors as clinical scientists apply the principles and procedures of medicine to prevent, diagnose,
care for and treat patients with illness, disease and injury and to maintain physical and mental
health. They supervise the implementation of care and treatment plans by others in the health care
team and conduct medical education and research."
All healthcare professionals require a set of generic attributes to merit the trust of patients that
underpins the therapeutic relationship. These qualities include good communication skills, the
ability to work as part of a team, non judgemental behaviour, empathy and integrity. In addition to
possessing these shared attributes doctors must be able to:
• assess patients' healthcare needs taking into account their personal and social circumstances
• apply their knowledge and skills to synthesise information from a variety of sources in order
to reach the best available diagnosis and understanding of the patient's problem, or to know
what steps need to be taken to secure such an outcome
• support patients in understanding their condition and what they might expect, including in
those circumstances when patients present with symptoms that could have several causes
• identify and advise on appropriate treatment options or preventive measures
• explain and discuss the risks, benefits and uncertainties of various tests and treatments
and where possible support patients to make decisions about their own care.
• The nature of these core requirements emphasises the need to select those with the
appropriate attributes for training.
Medical undergraduate education must provide a strong grounding in relevant science and in
clinical practice as well as providing opportunities to develop an appreciation for research. Doctors
must have the ability to assimilate new knowledge critically, have strong intellectual skills and
grasp of scientific principles and be capable of dealing effectively with and of managing
uncertainty, ambiguity and complexity.
They must have the capacity to work out solutions from first principles when the pattern does not
fit. All doctors must be demonstrably committed to reflective practice, monitoring their contribution
and working continually to improve their own and their team's performance.
Doctors must all be committed to playing a part in the education and support of the next generation
of medical practitioners and of facilitating the advancement of evidence based practice.
The doctor needs to be capable of assessing and managing risk; this requires high level decision
making skills and the ability to work outside defined protocols when circumstances demand.
Doctors must also be able to make informed decisions about when supportive care is more
appropriate for the patient than intervention.
The doctor must possess the ability to work effectively as a member of a healthcare team,
recognising and respecting the skills and attributes of other professions and of patients. Patients
with long term and disabling conditions are particularly likely to be experts in their own condition
and should be supported to keep as healthy and independent as possible.
All doctors have a role in the maintenance and promotion of population health, through evidence
based practice. Some will enhance the health of the population through taking on roles in health
education or research, service improvement and re-design, in public health and through health
Notwithstanding the primacy of the individual doctor:patient relationship, the doctor must
appreciate the needs of the patient in the context of the wider health needs of the population. For all
doctors the patient must come first but they will achieve this in different ways and in different
settings. As the critical decision maker with responsibility for significant health resources the doctor
must be capable of both management and leadership and of taking ultimate responsibility for
clinical decisions. Within a world where the capacity to treat is growing but financial resources are
finite, doctors have a duty to use resources wisely and effectively and engage in constructive debate
about such use. They should ensure that their own and others' skills and knowledge are deployed to
best possible effect.
Doctors have a key role in enhancing clinical services through their positions of responsibility.
Some will move on from clinical leadership and management to leadership roles within
organisations at various levels - service, institutional, national and international.
The role of the doctor is changing and will continue to change alongside the needs and expectations
of patients. Patients are increasingly better informed and act as partners in their own healthcare. The
doctor serves as advisor, interpreter and supporter in this endeavour.

Though environmental factors, like the increasing number of senior citizens or the advancements in
pharmaceuticals, have played a role in encouraging this evolution, the change can primarily be
traced to the passage of the Omnibus Budget Reconciliation Act of 1990. This legislation, in part,
required pharmacists to perform a drug use review, patient counseling and documentation in some
form of patient profile.
According to Stephen L. Foster and Jerry R. Phipps in their paper "Counseling on new drugs," the
law required pharmacists to screen for:
• Therapeutic appropriateness.
• Over- and underutilization.
• Appropriateness of generic products.
• Therapeutic duplication.
• Drug-disease contraindications.
• Drug-drug interactions.
• Incorrect drug dosage or duration of drug treatment.
• Drug-allergy interactions.
• Clinical abuse or misuse.
In addition, patient consultation was mandated to include:
• The name and description of the medication.
• The route, dosage form, route of administration and duration of therapy.
• Special directions and precautions for preparation, administration and use by the patient.
• Common severe side effects, adverse effects, interactions or therapeutic complications that may be
encountered, including their avoidance and the action required if they occur.
• Techniques for self-monitoring drug therapy.
• Proper storage.
• Prescription refill information.
• Action to be taken in the event of a missed dose.

Pharmacists are health professionals who practice the science of pharmacy. In their traditional role,
pharmacists typically take a request for medicines from a prescribing health care provider in the
form of a medical prescription, evaluate the appropriateness of the prescription, dispense the
medication to the patient and counsel them on the proper use and adverse effects of that medication.
In this role pharmacists act as a learned intermediary between physicians and patients and thus
ensure the safe and effective use of medications. Pharmacists also participate in disease-state
management, where they optimize and monitor drug therapy or interpret medical laboratory results
– in collaboration with physicians and/or other health professionals. Advances into prescribing
medication and in providing public health advices and services are occurring in Britain as well as
the United States and Canada. Pharmacists have many areas of expertise and are a critical source of
medical knowledge in clinics, hospitals, medical laboratory and community pharmacies throughout
the world. Pharmacists also hold positions in the pharmaceutical industry as well as in
pharmaceutical education and research and development institutions.
In much of the United Kingdom and the British Commonwealth pharmacists are customarily
sometimes referred to as chemist (or dispensing chemists),[1] a usage which can, especially
without a context relating to the sale or supply of medicines, cause confusion with scientists in the
field of chemistry. This term is a historical one, since some pharmacists passed an examination in
Pharmaceutical Chemistry (PhC) set by the then Pharmaceutical Society of Great Britain in 1852
and these were known as "Pharmaceutical Chemists". This title is protected by the Medicines Act
1968 section 78.
The 1852 Pharmacy Act, June 30 established a Register of Pharmaceutical Chemists in Great
Britain , restricted to those who had taken the Society’s exams. However, the Act did not restrict the
practice of pharmacy to examined and registered people, nor provide a legal definition for the trade
and practice of pharmacy. This was first done by the Pharmacy Act of 1868.[2]
In the near future it is proposed by the Draft Pharmacy Order 2009 that the title "pharmacist" be
restricted to those who register with a new Regulatory body - the General Pharmaceutical Council -
due to be established to take this role over from the Royal Pharmaceutical Society of Great Britain
in 2010.
In ancient Japan, the men who fulfilled roles similar to those of modern pharmacists were respected.
The place of pharmacists in society was settled in the Taihō Code (701) and re-stated in the Yōrō
Code (718). Ranked positions in the pre-Heian Imperial court were established; and this
organizational structure remained largely intact until the Meiji Restoration (1868). In this highly
stable hierarchy, the pharmacists—and even pharmacist assistants—were assigned status superior to
all others in health-related fields such as physicians and acupuncturists. In the Imperial household,
the pharmacist was even ranked above the two personal physicians of the Emperor.[3]

Nature of the work

Historically, the fundamental role of pharmacists is to distribute drugs that have been prescribed by
a healthcare practitioner to patients. In more modern times pharmacists advise patients and health
care providers on the selection, dosages, interactions, and side effects of medications. Pharmacists
monitor the health and progress of patients to ensure the safe and effective use of medication. In
some cases, pharmacists may practice compounding (mixing ingredients to form medications);
however, most medicines are produced by pharmaceutical companies in a standard dosage and drug
delivery form. In some jurisdictions, pharmacists have prescriptive authority to either independently
prescribe under their own authority or in collaboration with a primary care physician through an
agreed upon protocol .
Pharmacists are trained in pharmacology, pharmacognosy, chemistry, pharmaceutical chemistry,
microbiology, pharmacy practice (including drug interactions, medicine monitoring, medication
management), pharmaceutics, pharmacy law, physiology, anatomy, biochemistry,
pharmacokinetics, drug delivery, pharmaceutical care, nephrology, hepatology, and compounding
medications. Additional curriculum covers diagnosis with emphasis on laboratory tests, disease state
management, therapeutics and prescribing (selecting the most appropriate medication for a given
One of the most important roles that pharmacists are currently taking on is one of pharmaceutical
care . Pharmaceutical care involves taking direct responsibility for patients and their disease states,
medications, and the management of each in order to improve the outcome for each individual
patient. Pharmaceutical care has many benefits that include but are not limited to:
• Decreased medication errors
• Increased patient compliance in medication regimen
• Better chronic disease state management
• Strong pharmacist-patient relationship
• Decreased long-term costs of medical care
Pharmacists are often the first point-of-contact for patients with health inquiries. This means that
pharmacists have large roles in the assessing medication management in patients, and in referring
patients to physicians. These roles may include, but are not limited to:
• clinical medication management
• the assessment of patients with undiagnosed or diagnosed conditions and for decisions about
the clinical medication management required.
• specialized monitoring of disease states
• reviewing medication regimens
• monitoring of treatment regimens
• delegating work
• general health monitoring
• compounding medicines
• general health advice
• providing specific education to patients about disease states and medications
• oversight of dispensing medicines on prescription
• provision of non-prescription medicines
• counseling and advice on optimal use of medicines
• advice and treatment of common ailments
• referrals to other health professionals if necessary
• dosing drugs in renal and hepatic failure
• pharmacokinetic evaluation
• education of physicians and other health care providers on medications and their proper use
• limited prescribing of medications only in collaboration with other health care professionals
• providing pharmaceutical information
• promoting public health by administering immunizations

New tool to enhance role of pharmacists in

health care
23 NOVEMBER 2006 | GENEVA -- The traditional role of pharmacists is to manufacture and
supply medicines. More recently, pharmacists have been faced with increasing health demands: an
ever-growing and complex range of medicines, and poor adherence to prescribed medicines, have
forced the evolution of the pharmacist’s role into a more patient centred approach (known as
pharmaceutical care). Adherence to long-term therapy for chronic conditions in developed countries
averages 50%, with even lower rates for developing countries.
To address this need, the World Health Organization (WHO) and the International Pharmaceutical
Federation (FIP) are publishing the first edition of a handbook on Developing pharmacy practice -
A focus on patient care. "Pharmacists have an important role to play in health care, which is much
more than selling medicines," said Dr Hans V. Hogerzeil, WHO Director of Medicines Policy and
The role of the pharmacist is summarized through the WHO/FIP seven-star concept in which a
pharmacist is described as a caregiver, communicator, decision-maker, teacher, lifelong learner,
leader and manager. For the purpose of this handbook, the function of researcher has been added.
The pharmacist is an integral member of the health care team and assumes varied functions ranging
from the procurement and supply of medicines to pharmaceutical care services, helping to ensure
the best treatment for patients. The pharmaceutical care process involves establishing a relationship
between the patient and the pharmacist, developing an evidence-based care plan for medicine
therapy and follow-up on the patient's expected health outcome.
Founded on the principles of the ‘seven-star pharmacist’, this interactive handbook provides
practical examples and care models so that it can be used for self-directed learning. It contains a
wide variety of illustrative case studies to meet the needs of different users. It is designed to guide
learners towards specific educational outcomes, and enable them to undertake tasks which require a
combination of knowledge, skills and attitudes.
"Pharmaceutical care delivered by pharmacists seeks to optimize patient outcomes and is key to the
effective, rational and safe use of medicines. This handbook serves as a timely and accessible
resource for pharmacists, educators and students worldwide to develop patient-centred services and
skills to meet local patient needs," said Ton Hoek, General Secretary and CEO of the International
Pharmaceutical Federation.
Developing pharmacy practice - A focus on patient care is designed to meet the changing needs of
the pharmacist, setting out a new paradigm for pharmacy practice. The handbook is written for
pharmacists, educators and students all over the world in all health care settings. To reach as wide
an audience as possible the handbook is available in English and French will be available soon in
both electronic and print formats.
The role of pharmacists
Pharmacists are experts in the use of medicines and must complete a four year degree and one
practical training to qualify. It is widely agreed that better use could be made of pharmacists’
skills and
knowledge; the new pharmacy contractual framework sets out the Government’s plans on how
to achieve this. Because community pharmacists operate within a commercial environment,
questions have been raised
about whether they are best placed to decide if a patient requires a medicine and if so, which
one? However, one of the key responsibilities within a pharmacist’s code of ethics is to act at all
times in the best interests of the patient5. Pharmacists are expected to assess whether a
prescription or an over-the-counter medicine is
appropriate. The public appears comfortable with a pharmacist’s dual roles of retailer and
professional. In a survey more than half the respondents disagreed with the assertion that
pharmacists sometimes recommend products that are not strictly necessary in order to make a
Pharmacists’ skills
Over the past five years a number of schemes have been established to better integrate
pharmacists into primary care and the new contractual framework will further encourage this.
In general these schemes have been considered a success and have been integrated into the
new pharmacy contractual framework. They offer easier and faster access to services for
people as well as reducing a GP’s workload. For example, the Care at the chemist scheme in
Bootle resulted in a reduction in GPs’ minor ailment workload from 8.9% of consultations to
6.6%7. Repeat dispensing by pharmacists is also likely to reduce GPs’workloads. Currently
about 75% of GPs’ prescriptions are for repeat medicines.


Role of pharmacist in the healthcare system

Dr S B Bhise

The recently published 29th report of standing committee on Petroleum and Chemicals (2002)
under Ministry of Chemicals and Fertilizers (Department of Chemicals and Petrochemicals) has
once again sidelined the professional role of a pharmacist.

In the report, presented to Lok Sabha on November 25, 2002, the committee has recommended that
"The Govt. should explore the possibility of relaxing the provisions of The Drugs and Cosmetic
Act, 1940 so that educated persons other than pharmacists could sell the medicines after some short
training through "public distribution system" or "sarvapriya scheme".

According to the standing committee, the clause of employing pharmacists was more relevant when
the statutory acts were written in 1940 because the drugs were dispensed by the chemists by
compounding and mixing whereas now most of the medicine are available in ready to use form."

The committee further stated that "The pharmacist is the main hurdle in easy accessibility of
medicines and this move will provide better job opportunities to educated persons other than

The learned members of the committee have probably not gone through the document `The Role of
the pharmacist in the health care system' published by World Health Organization (WHO). The
document is a report of a WHO consultative group meeting held in New Delhi during December 13-
16, 1988 and highlights professional role of pharmacists.

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

Over the years the professional role of pharmacists have evolved considerably. The WHO report
states "Effective medicine can be practiced only where there is efficient drug management." The
report further states, "Time and again, in less affluent settings, inadequacies in the provision of
primary health care are attributable to shortcomings within the drug distribution chain. Only when
the pharmacist has been accepted as a vital member of the healthcare team can the necessary
supporting services be organized with the professionalism that they demand."

The WHO report further clarifies that pharmacists are uniquely qualified because:
- They understand the principles of quality assurance as they are applied to medicines;
- They appreciate the intricacies of the distribution chain and the principles of efficient stock -
keeping and stock - turnover;
- They are familiar with the pricing structures applied to medicinal products obtained within the
markets in which they operate;
- They are the custodians of much technical information on the products available on their domestic
- They are able to provide informed advice to patients with minor illnesses and often to those with
more chronic conditions who are on established maintenance therapy;
- They provide interface between the duties of prescribing and selling medicines and in so doing,
they dispose of any perceived or potential conflict of interest between these two functions.

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

There is no doubt that distribution of drugs has to be eased out and drugs should be readily available
to the average consumers. However the best policy instrument to achieve the laudable objective is
to follow the policy of essential drugs as suggested by the World Health Organization (WHO) way
back in 1977. A large number of developing countries have followed the policy. The state of Delhi
has followed the policy of essential drugs; but with irrational policy and drugs being sold in other
states of India, an isolated state may not be able to make enough dents in the easy availability of
drugs to average consumers.

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

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

It is irony of fate in our country that the ministry of chemicals and fertilizers rather than ministry of
health declare the drug policy. Probably there is a feeling in Central block that chemicals and
fertilizers rather than lifestyle are more intimately related to health.

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

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

Unfortunately because of following factors, pharmacists have not been able to pursue their
international mandate in our country.
- Lack of understanding of the role of pharmacist in health care.
- Lack of identification of 'Health-care-team' as a policy concept and center-stage role only to
medical professionals in the maintenance of heath.
- More stress on curative measures rather than preventive measures for health related issues.
- Lack of national objectives of professional education being reflected in policy implementation.
- Peripheral role of pharmacist in health care only towards manufacture and distribution of drugs.
In developed countries like USA the role of pharmacist is next to the clergyman and he is looked as
the main source of correct information and availability of drugs. He is never a "hurdle", and in fact
will prove a boon in distribution of drugs.

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

There is enough evidence for the economic value of pharmacists in developed countries like USA.
A growing body of literature has emerged that supports the value of pharmacist's patient care
interventions in a wide range of patient groups, health care settings, and disease states.
- Over 20 studies and demonstration projects confirm that pharmacists add value to the health care
system by improving care and decreasing cost.
- During a six months period pharmacists joined doctors, residents and other members of the patient
care team on patients round in the intensive care unite at a large, urban teaching hospital. Result
showed that
- Preventable adverse drug events decreased by 66%
- A projected $ 270,000 related to adverse drug events could be saved annually
- 366 of the 400 pharmacist interventions were related to medication errors.
- Pharmacist interventions helped prevent incomplete orders, incorrect dosages and frequency, less-
than - optimal drug choices, and duplicate prescriptions.
- Pharmacists working in their communities produced a 74% increase in vaccination rate by
advising high-risk patients of infection risk and describing where to go to be vaccinated.
- Patient acceptance was excellent, with pharmacists administering 1060 doses of influenza
vaccinations and 198 pneumococcal vaccinations to 1067 patients.
- Pharmacist reviewed drug therapy and found ways to improve medications used in nearly 65% of
all patients.
- The bulk of savings were not related to drug costs, rather they were associated with fewer
unscheduled physician visits and fewer hospital days.
- Consultant pharmacist-conducted drug regimen review increases the number of patients who
experience optimal therapeutic outcomes by 43% and saves as much at $ 3.6 billions annually in
costs associated with medication - related problems.
- Pharmacists working with patients in their community provided targeted patient education,
systematic patient monitoring, patient feedback and behavior modification.
- Savings for monthly medical cost ranged from $ 143.96 to $ 293.39 per patient per month.

The result of these studies suggest that a broad range of hospital-based pharmacist-provided patient
care activities either save lives or reduce health care costs or both. In a study evaluating the effect of
clinical pharmacists on the economic outcomes of patient care an average benefit of $ 16.70 of
value to the health care system was realized for each $ 1 invested in clinical pharmacy service. Drug
therapy changes based on pharmacists' recommendation reduced unscheduled hospital visits, urgent
care visits, emergency room visits and hospital days, saving over $ 640 per year in health cost per
individual ($ 280,000 per year per pharmacist).

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

In a multifaceted country like India, what happens in politics is reflected in all walks of life.
Division amongst people is advantageous to certain sections of society. The same policy is being
unfortunately implemented in the health profession. Physicians, pharmacists, nurses and other
health-related professionals should work in harmony towards the central benefit of "PATIENTS".
Patients, rather than any professionals should be at the center-stage of health policy and
professionals should not quarrel amongst themselves for their central or peripheral role in the well
being of patients.

It is the lack of this understanding on part of honorable members of the standing committee that has
lead to the belief that "Pharmacist is the main hurdle in easy accessibility of medicines". World over
pharmacist is one of the important member of the health-team including clinical research. If Indian
pharmacist is not fulfilling this role, then he should be appropriately trained and be oriented as a
health - care provider to the vast rural population. He can be used intelligently as an alternative
manpower towards the sacred goals of:
- Immunization
- Minor dressings
- Family planning
- Preventing tropical diseases
- Providing drug-information
- Monitoring adverse drug reactions
- Monitoring and minimizing adverse drug interactions
- Preventing misuse of drugs
- Preventing medication errors
- Preventing abuse of tobacco, alcohol

Much of the role of preventive and social medicine can be attributed to pharmacists. In fact
pharmacists can be real 'bare-foot' doctors to average consumers of rural India. What we need is the
vision of policy-makers rather than marginalizing role of any professional in the health-care team.
Pharmacist is certainly not a "Hurdle but can be a boon and facilitator in the process of efficient
drug - distribution.
A Joint Publication of The North Carolina Rural Health Research & Policy Analysis Center (1)
and The RUPRI Center for Rural Health Policy Analysis (2)
The Key Role of Sole Community Pharmacists in
Their Local Healthcare Delivery Systems
Andrea Radford, Dr.P.H.(1), Indira Richardson, M.P.A.(1), Michelle Mason, M.A.(2), Stephen Rutledge
Sole community independent pharmacists provide essential services to residents of small towns and
isolated communities. Anecdotal reports indicate their role within the local health care community
often multi-faceted, extending beyond the provision of prescription and nonprescription medications
their retail stores. In 2008, we surveyed 401 community pharmacists that are the only retail provider
their community to document their extended relationships with other health care providers and the
additional health care services these pharmacists provide to their patients. Pharmacist-owners in
independent pharmacies located at least 10 miles from the next closest retail pharmacy were
to determine the presence in their community of other types of health care organizations that require
pharmaceutical support i (such as hospitals, long-term care facilities, hospice providers, home health
agencies and community health centers), their level of involvement with those facilities, and the
types of
clinical services (other than dispensing and counseling) the pharmacists offered to their own
• Most sole community pharmacists (83%) provided important services for other
health care providers and facilities in their communities.
• Almost all (92%) of the communities served by a single independent retail pharmacy are
also served by at least one other type of inpatient or outpatient health care organization.
• Skilled nursing or long-term care facilities, hospice providers and home health agencies,
all of whom serve predominately elderly patients, were the most common types of health
care organizations in the communities surveyed.
• Almost half of all pharmacists (42%) offered additional clinical and educational services
to community residents including blood pressure checks, screening for cholesterol and
osteoporosis, glucose screening and diabetes counseling, tobacco cessation programs, and
i Private physician practices were not in included in this study, as they typically do not provide the type of services that
require on-site pharmacy support.
Findings Brief March 2009
Almost all (92%) of the sole community pharmacists interviewed reported the presence of one or
different types of health care organizations in their community. The most commonly reported were
skilled nursing or long-term care facilities (66%), hospice providers (62%) and home health
(54%). Fewer communities were served by a local hospital (32%) and community health centers
The most common types of other health care providers located in these communities – skilled
long-term care, hospice, home health agencies – are organizations whose patients are predominately
elderly. While hospitals were reported less frequently in these communities they also provide
services to the rural elderly. Given the higher use of pharmaceuticals by older patients, the
of local pharmacy support is critical for health care providers who serve elderly patients.
The majority of pharmacists (83%) reported working with one or more of the other health care
in their community. They provided services most frequently to hospice providers (94%), to skilled
nursing or long-term care facilities (79%) and to home health agencies (74%). Services were
less frequently to local hospitals and community health centers (Figure 1).
Figure 1. Provision of Services to Other Health Care Organizations by Sole Community
Pharmacies (when other health care organizations are present in the community)
Pharmacists were asked about what types of services they provided to other health care
organizations in
their communities. Not unexpectedly, providing medications was the most common service
ranging from 96% who reported providing medications for hospice patients to 69% who provided
services at their local hospital. Some of the other types of services pharmacists reported
providing to the different types of health care organizations present in their communities included
• delivery of medications (58%)
• on-call services (54%)
• compounding (39%)
• fi lling medication cassettes/unit dose dispensing (87%)
• monthly chart reviews (35%)
• delivery of medications (60%)
• provision of durable medical equipment (40%)
• pharmaceutical inventories (57%)
• billing for medications (24%)
• rounding on hospital patients (12%)
• dispensing 340B medications (46%)
• counseling diabetic patients (30%).
Pharmacists were also asked whether they provided additional clinical services other than
medications and counseling to their own patients. Of the pharmacists surveyed, 42% stated they
one or more additional clinical services. The most common services provided were blood pressure
checks (12.9%), diabetes counseling and blood glucose testing (12.4%), immunizations (9.7%) and
educational classes or participating in health fairs (8.2%). Other less commonly reported services
included offering tobacco cessation programs and providing screening tests for osteoporosis,
hearing, and cholesterol. Medication delivery for their own patients and as a service to other
health care organizations was also frequently reported by these sole community pharmacy
For purposes of this study sole community pharmacies were defi ned as independent retail
located 10 or more miles from the next closest pharmacy. Despite the distance from other retail
pharmacy options, most of the communities in which sole community pharmacists provide
services have other health care facilities that require pharmaceutical support, ranging from inpatient
care providers such as long-term care facilities and hospitals to outpatient providers such as home
agencies and community health centers. All of these health care providers need supportive
services to function, the most basic being access to medications needed by their patients. Sole
pharmacies provide this support and more to these partner agencies and help ensure access to
important health care services for residents of their community.
Sole community pharmacists also provide health monitoring and preventive care services such as
pressure or glucose screening and immunizations for local residents. These important monitoring
functions are particularly valuable in areas where primary care providers are less common and
may otherwise have to travel long distances for simple screening procedures.
The fi ndings from this study document the important role sole community pharmacists play in their
health care delivery systems, and supports the notion that the survival of sole community
pharmacies not
only ensures retail access to pharmaceuticals and patient counseling but also, in many cases, access
other important health care services that are particularly needed in communities with limited health
This study was funded under a cooperative agreement with the Federal Offi ce of Rural Health Policy
Health Resources and Services Administration, U.S. Department of Health and Human Services,
Grant Number U1GRH07633. The conclusions and opinions expressed in this paper are the
authors’ alone; no endorsement by the University of North Carolina, the University of Nebraska, ORHP,
or other sources of information is intended or should be inferred.
A semi-structured interview protocol was used in this study. To be included in the survey,
had to be independently owned and located 10 miles or more from the next closest pharmacy. A
of pharmacies likely to meet these criteria were identifi ed using data from the National Council for
Prescription Drug Programs, Inc., which contains information about the 74,108 pharmacies in the
with active provider numbers. Pharmacies with the following characteristics were identifi ed:
owned (including franchise licenses); operating as a community retail pharmacy; the only
pharmacy within its ZIP code; and the only pharmacy within a ten mile or more Euclidian buffer
the next closest pharmacy. Application of these criteria resulted in a fi nal sample of 1,148
The pharmacy’s eligibility to participate in this study was verifi ed during the initial telephone
The study goal was to complete 400 interviews. Attempts were made to contact the owners of all the
pharmacies in the sample. No contact was made with 5 pharmacies (no answer or busy signal), for
pharmacies the pharmacist-owner was never reached in ten or more attempts, 43 stores were confi
closed, and 68 did not meet the study criteria. Of the remaining 881 pharmacies, 401 participated
for a
response rate of 46%.
Available at:
Findings Brief No 87. Sole Community Pharmacies and Part D Participation: Implications for Rural
Residents. (2009).
Findings Brief No. 83. One Year In: Sole Community Rural Independent Pharmacies and Medicare
D. (2007).
Final Report No 92. One Year In: Sole Community Rural Independent Pharmacies and Medicare
Part D.
Final Report No 87. The Experience of Sole Community Rural Independent Pharmacies with
Part D: Reports from the Field. (2006).
Available at:
Brief No. 2009-2. Rural Enrollment in Medicare Part D is Growing Slowly. (2009).
Brief No. 2008-5. Eligible But Not Enrolled? Potential for Targeting Over a Half-Million Rural
Benefi ciaries for Enrollment in the Low-Income Subsidy Prescription Drug Program. (2008).
Brief 2008-2. Independently Owned Pharmacy Closures in Rural America. (2008).
The authors wish to acknowledge the valuable assistance of the RUPRI staff
in preparing the sample of pharmacies and conducting interviews.