The Beginnings

The Beginnings

The Beginnings

The Beginnings

The Beginning of Something Magnificent.

A radical departure from the existing system of one centralized pharmacy

 


In the fall of 1965, four professors met to discuss a plan that proposed the establishment and staffing of satellite pharmacies on various floors of the hospital. 

  • UCSF was the first major medical centers to place pharmacists on the nursing units in 1966.
  • Major national pharmacy leaders, such as Jere Goyan, William Smith and Toby Herfindal were major contributors to the success of the 9th floor project.
  • The success of the clinical pharmacy project lead to major changes in the school of pharmacy curriculums throughout the United States.

 

The Initial Planners of the World's First

Clinical Pharmacy Service


Left to Right: Jere Goyan, Sidney Riengelman, Donald Sorby, and Eric Owyang.
All photographs were taken during the late 1960s and early 1970s.

If you wander down the corridor connecting the 9th Floor of the UCSF Medical Science building with the Moffitt Hospital, you will eventually encounter an imposing set of closed doors. A sign posted above them makes it clear that their intention is to discourage casual visitors. It reads, ominously, "Intensive Care Unit."

The doors swing open at the press of a button on a nearby wall and a quick glimpse can be caught of a center island workstation, peopled by an assortment of health professionals, adorned in outfits of various colors, each with the usual hardware looped around their necks or hanging from their pockets.

Although the people sitting at, or passing by the station don't know it, nor do many of the pharmacists (and probably all of the student pharmacists who move about the hospital) this former general surgery floor is hallowed ground for the profession of pharmacy, for it was here, on September 7, 1966, that clinical pharmacy officially came in the world.

Like any newborn, this one was conceived many months earlier and first began to take shape in the fall of 1965 when professors Jere E.Goyan '52,Sidney Riegelman, Donald Sorby and UCSF chief pharmacist Eric Owyang '41,met to discuss a plan the latter three had concocted that proposed the establishment and staffing of satellite pharmacies on various floors of the hospital. They suspected, correctly so, that the nursing staff, frustrated by the error-prone, snail-paced existing system of acquiring drugs from the central pharmacy, would love, therefore support the idea. But there was far more to this scheme than a desire to please nurses. A major motivating factor was that the pharmacists who staffed the floor pharmacies would, for the first time in the history of the profession, be given routine access to an inner circle of health care where decisions involving drug therapies were made by the minute. While there, they would be able to poke around and from this could come an understanding of where and how the pharmacist could, at long last, assume a role in drug therapy. Maybe.

This was not a new aspiration. For generations, various pharmacy leaders around the nation had urged the profession to step beyond its traditional dispensing role and become drug therapy consultants to physicians. Unfortunately, not one of them had the slightest clue as to, 1) what this meant in terms of an actual practice model, 2) what physicians needed or wanted to know when they made drug therapy decisions, 3) whether physicians were willing to share this portion of their pie with another health professional and 4) whether pharmacists were capable of providing whatever it was that physicians wanted or needed to know.

In the minds of the four planners, the pharmacists who were attached to the satellite pharmacies would be in a position to supply many, if not all of the answers to the aforementioned unknowns. Furthermore, whatever was learned could then be translated into an appropriate curriculum, whose faculty and graduates, it was hoped, would sally forth and not only prove the concept in the broader context of health care, but infect the profession with it.

All that remained was getting approval and funding, not the easiest of tasks because then as now, UCSF was a bureaucracy stacked with layers of cost-conscious administrators, and this would be a very expensive project with no assured economic advantages. But fortunately, the members of the planning team were all well respected members of the UCSF community and when they argued that the project could contribute positively to health care (or at least the expediency thereof), they were heard. The final approval came from acting chancellor and Department of Surgery chair J. Englebert Dunphy, who liked the idea so much that he suggested that a trial satellite pharmacy be housed in his surgical ward where the nursing staff was also conducting an experiment.

At this point, William E.Smith,Jr.'65, entered the picture. Smith, a former student leader, recent resident and current staff pharmacist, was assigned the task of performing the preliminary footwork and coordinating the implementation of what had become known as the 9th Floor Pharmaceutical Service Project, and he did so with astute intensity.This entailed numerous organizational steps and meetings over the ensuing months with a committee (comprised of four nurses, a surgeon and a dietitian) that worked out the various details for the smooth insertion of pharmacists and a unique pharmacy service on a ward that had never known either. This effort, combined with input from others, including some soon-to-be-mentioned newcomers, led to the following decisions:

  • This service, unlike any other in the nation, would be open and staffed by a pharmacist 24 hours a day, seven days a week.
  • All drug orders would go through the pharmacist who, after reviewing them, would fill them from available unit doses, or transmit the order to the central pharmacy. The former was not easily accomplished because unlike today, very few drugs were available from manufacturers as a unit dose. Therefore, the majority of them (tablets, oral liquids, parenterals) were initially packaged by the pharmacists (and eventually, a technician) in one of the School's 9th floor teaching laboratories.
  • The pharmacist would prepare all admixtures (these were previously done by nurses), standardize and regulate time schedules for drug administration, instruct patients on discharge meds and provide inservice education to the nursing and medical staff.
  • Upon admission, the pharmacist would interview all patients and take a "drug history" that would be incorporated into a "pharmaceutical service record," to be used for something soon to be called "patient drug monitoring."

If this list strikes you as unimpressive, you are either too young to appreciate (or you have forgotten) that in 1966 these responsibilities amounted to a nuclear assault on the status quo. Controversial? Right down to the last period. Even some pharmacists were shocked to the point of protest because, well, pharmacists (at least they) didn't do, didn't want to do, or shouldn't do those kinds of things. Until then, every profession had its strictly enforced territorial lines and pharmacy's geography began with the receipt of a prescription and ended when a label was affixed to a container. On the 9th floor of the UCSF Moffitt Hospital, however, the lines were less certain and the enforcements less rigid because, as mentioned earlier, nursing was also conducting an experiment, and the air was charged with expectations of change. That is why if you study the list, you will realize that it was designed to inject the pharmacist at non-traditional key points in the scheme of things-specifically at places he (there were only males, then) had never been before-giving him multiple opportunities to identify possible roles and if necessary, to intercede. And intercede, he did.

But before we go there, some introductions.


It's time to meet the first batch of pharmacists-all UCSF graduates-who blazed the trail for that which was already being called "clinical pharmacy." Three of them, Richard F. de Leon '65, Joseph L. Hirschmann '65, and Robert A. Miller '64, were "new hires," picked up specifically for the project, whereas the fourth, Donald Holsten '58, was a UCSF staff pharmacist, who wanted to be part of this exciting new effort and joined the team voluntarily. Along with Bill Smith, this was the energetic and idealistic squad that was recruited before the clinical pharmacy service was launched and charged with the task of making it work.

On the evening shift, two weeks after the opening of the 9th floor satellite pharmacy, the team interceded mightily. A patient had contracted a virulent infection that seemed resistant to everything thrown at it. She was on the critical list and in desperation had been transferred from Marin General Hospital when Holsten-then serving as the project's night pharmacist-realized that the two antibiotics that she had been receiving via admixture were chemically incompatible. Holsten informed Hirschmann on the day shift, who subsequently notified the prescriber. When the physician ignored his advice, Hirschmann alerted de Leon when he came on for the swing shift, who subsequently discussed it with Holsten. DeLeon then informed the patient’s husband a physician, and a former chief resident at the hospital. New orders were written and in less than 24 hours, the patient’s temperature dropped to 38 C for the first time in six days.

In 2006, this episode may not seem particularly compelling, because although a life was probably saved, this is what hospital-based pharmacists routinely do. Rather than provide a description of the state of the art of the profession in 1966, you will simply have to take it on faith that in 1966, pharmacists did not do this, routinely or otherwise. What the team did was radical in every regard and particularly the part where they end-ran the prescriber, who in those days was considered the supreme and final authority on drug therapy.

The only side effects were that the tale buzzed around the hospital, and the clinical pharmacy service acquired some admirers and at least one lifelong ally.

The next many months brought adventure, excitement, frustrations, rewards and exhaustion to the pathfinders as the service was shaken down, improved and expanded. One such expansion was the inclusion of a pharmacist on the hospital's Code Blue (cardiopulmonary resuscitation) Team, who, while lugging what was initially a few vials in his pocket (that quickly evolved into an increasingly heavy box of drugs) joined physicians and nurses in treating patients experiencing cardiovascular events anywhere in the hospital. Various sources have attributed this to Holsten who, while attending a Code Blue, noted that the nurses and physicians often ran out of essential supplies.

Overall, because of their flexibility, hard work and determination, the service worked well and they soon became fully accepted members of the 9th floor health care team. And, like a dream come true, the expertise they offered was in demand. Also nice was the fact that influential people across the nation began to pay attention. Some came to visit.

In 1967, Smith left to establish a clinical pharmacy program at Long Beach Memorial Hospital, and Miller succeeded him. During that year Eric C. (Toby) Herfindal '65 and Dennis Mackewicz '64 came aboard, and a small room in the library was set aside to house a growing textbook collection and facilitate the write-up of "drug information consults." Then, the first pharmacy students were permitted on the floor, all of them handpicked and watched.

In 1968, that small room in the library grew into the DIAS (The Drug Information and Analysis Center), headed by Hirschmann, from which flowed detailed, documented and opinionated responses to patient-specific drug questions ("answers with an attitude," someone later observed), as well as critical evaluations of drugs being considered for inclusion in the hospital formulary by the pharmacy and Therapeutics Committee.

In a short while, other UCSF graduates would become part of the pioneering team, including Donald Kishi ‘68, Robert H. Levin ‘64 and Mary Anne Koda-Kimble ‘69.

From its very outset, the 9th Floor Project lived up to the expectations of its initial planners. It pleased the nursing staff, enabled its practitioners to discover ways in which they significantly and beneficially influenced drug therapy, and it also served as a major source of information on how the curriculum needed to be altered. A November 1966 report from Smith to Dean Troy Daniels addresses the question of whether the existing curriculum prepared the 9th floor pharmacists to perform adequately in clinical areas: “The answer, expressed by each pharmacist in the pilot program is 'yes and no.' (Although the curriculum did not specifically prepare them) the strong biological science background allows the pharmacist to self-study and prepare himself. The big deficiency in pharmaceutical education today is (that it does not) bring together all the biological sciences and drug therapy principles as they relate to the care of patients in such a manner that the pharmacist understands the problems of drug use in patients and is able to communicate his knowledge to other health care professionals."

As time passed, the clinical faculty steadily informed the faculty of their experiences and the new roles they assumed. They proposed changes to the curriculum that were incorporated and in August 1970, the faculty unanimously adopted the clinical pharmacy curriculum, the most radical curriculum change in the history of pharmacy education.

Thus we have arrived at 1970. Although this was still the beginning of clinical pharmacy for the School and the nation, this chapter of its tale ends here. Our intention was not to provide an extensive history-indeed, many facts have been left out and important contributors have not been mentioned - but to acknowledge the 40th anniversary of something magnificent that took place on a surgical floor at UCSF, spread around the world, and forever changed the practice of pharmacy. But most of all, its purpose is to thank and pay homage to those dedicated UCSF faculty and practitioners who made it all possible.

 

Thanks to Robert L. Day, PharmD (UCSF Class of 1958) for this submission.