UP From the Basement

UP FROM THE BASEMENT

How Clinical Pharmacy Came to UIC

BY MICHAEL DHAR

Hospital pharmacists used to dwell in the basement. There, they’d count pills into bottles of 100, and send them up to the main floors, where nurses handled the actual dispensing of medication. “This,” said UIC Pharmacy Dean Jerry Bauman, “led to all kinds of errors.”

For that and other reasons, a wave of reform swept through the country in the 1960s and ‘70s, putting pharmacists in a more active position. The new paradigm came to be known as clinical pharmacy.

Two leaders at UIC — Herb Carlin and Richard Hutchinson — captained that change in Illinois, creating what remains the biggest clinical pharmacy program in the country, by number of clinical faculty, and one consistently ranked among the best.

RICHARD HUTCHINSON

“It’s been pretty well documented saving several lives a year with pharmacists on the floor and saving several hundreds of thousands of dollars in cost of care.”

RICHARD HUTCHINSON

UIC’s national voice

The national push toward clinical pharmacy arose, in part, from the expansion of healthcare through Medicaid and Medicare in the ‘60s, said Hutchinson, who led the UIC’s transition, starting in 1973. This expansion raised the need for “physician-extender” roles, he said.

“There was kind of a whole evolution at the time going on in healthcare,” he said. “And clinical pharmacy was just part of that evolution.”

Aside from the need to handle increased patient numbers, pharmacists simply had an expertise that other healthcare professionals needed, as nurses and physicians received little training in drug therapy, Hutchinson said.

One of the early, national voices pushing for change was Herb Carlin, pharmacy director at UIC from 1962 to 1972. He made a major impact, both at UIC and across the country, writing and otherwise advocating for a new direction, Bauman said.

“He was a national leader in pharmacy,” elected to presidencies at both the American Society of Health Systems Pharmacists and the American Pharmacists Association, “which is highly unusual,” Bauman said.

Carlin’s dedication to advancing clinical pharmacy was clear to those around him, too, said Judy Marth, Carlin’s daughter and a pharmacist herself.

During his time at the college, Carlin made a number of novel reforms that set the stage for clinical pharmacy at UIC. Pharmacists took over preparation of IVs in parts of the hospital; the first clinicaloriented coursework began, and the UIC hospital’s Drug Information Center arose, set up to answer nurses and doctors’ drug questions.

HERB CARLIN

“It was his passion. Herb Carlin thought it was very good for the patient to have the expertise of the pharmacist, along with the nurses and the doctors. … He lived and breathed it.”

JUDY MARTH, CARLIN’S DAUGHTER

Carlin also installed a satellite pharmacy on the hospital’s 12th floor. While pharmacists there still mostly filled traditional roles, the move marked an important step, Bauman said.

“It put the pharmacists in proximity, literally, to physicians and nurses — and the patient,” Bauman said. “And you could participate in morning rounds. … So getting the pharmacists up to where care was being delivered was a really crucial step.”

Another level

One more initiative began during Carlin’s time, the unit-dose program, set up part of the funding apparatus needed to bring clinical pharmacy to UIC. Under unit-dose, pharmacists send up drugs for individual patients, instead of in bulk, increasing both patient safety and pharmacy revenue. (Carlin began unit-dose and IV administration in sections of the hospital; Hutchinson later expanded the programs.)

Unit-dose helped convince Hutchinson to come to UIC in the first place, he said.

“Basically, the funding was there … and there was some support outside the pharmacy for a change in pharmacy direction,” he said. “So the environment was ripe for the development of clinical pharmacy in Illinois.”

Still, there were obstacles. While most of the hospital pharmacy staff accepted change, a few fought against it, Hutchinson said. It became clear, however, that reforms were coming, he said, and so some people simply left.

Hutchinson then used the unit-dose funding to hire a trove of PharmDs, and turned the residency program begun under Carlin into one of the country’s first clinically-focused pharmacy residencies. Young pharmacists now joined doctors and nurses on daily rounds. In 1980, the program added a novel on-call component.

“He really transformed the residency,” Bauman said. “And then took clinical pharmacy to another level at UIC, and expanded on the things that Herb Carlin started.”

Some of the first UIC clinical pharmacy residents brought aboard by Hutchinson experienced institutional pushback of their own, Bauman said.

“When I first started rounding… it was extremely hard to gain acceptance by physicians. There was reluctance to allow pharmacists to create notes in the patient’s chart,” he said. “There were a lot of trials and tribulations in the early years.”

Clinical pharmacy takes hold

In overcoming those trials, however, UIC took its place among the country’s clinical pharmacy pioneers. UIC’s program, “together with early programs like those in Buffalo, northern and southern California, Kansas City, Kentucky, Minnesota, Philadelphia, South Carolina, and Texas, helped seed other schools of pharmacy with their early clinical faculty,” according to “Clinical Pharmacy in the United States: Transformation of a Profession” (American College of Clinical Pharmacy, 2009).

With time, what seemed like novel ideas came to be accepted — even expected.

“Most of the medical staff in Illinois would be totally upset if the pharmacists left the floor,” Hutchinson said. “I don’t know if they would even tolerate going back to the way it was 20 years ago.”

Even just a few years after Bauman’s class, residents saw growing respect among physicians.

“I remember one day I walked up on the floor, and immediately, one of the medical residents said, ‘Oh, good, here’s a PharmD, I can ask him,” said Stan Reents, a clinical resident in 1982-83. “They were very comfortable with it, and obviously they were getting really great, reliable advice.”

That acceptance likely came from the way early residents proved themselves, saving lives and preventing serious adverse effects nearly daily, Bauman said. In just one example, Bauman himself prevented a case of drug toxicity, because the physician had overprescribed.

“If you dedicate your entire day to the patient’s drug therapy, you can prevent a lot of mistakes and errors,” he said.

Research has shown what that dedication means for hospitals and patients. Clinical pharmacists saved the UIC hospital an estimated $364,900 annually and made 36 interventions that saved lives or preserved organ function over a total of five weeks, according to research co-authored by Hutchinson (Drug Intelligence and Clinical Pharmacy, 1988).

As a result, UIC’s clinical pharmacy program has always been treated as vital, said Frank Paloucek, head of the current residency program and a resident himself in 1984. During the mortgage crisis, pharmacy had to sacrifice some positions, he said, but the hospital Chief Medical Officer demanded oncall residency positions stay.

“He said those cannot be cut — we are too dependent on their activities and their presence,” Paloucek said.

The UIC clinical pharmacy program’s continued success, and demonstrated value, would make Herb Carlin proud, Marth said.

“I think he would be greatly pleased and impressed as the clinical pharmacy program has flourished I think even beyond his early vision,” she said. “It is making a difference in patients’ lives, and that would please him the most.”