reforms in pharmacy education and opportunity to practise clinical pharmacy

Arnold Birenbaum, Roslyn Bologh andHenry LesieurReforms in pharmacy education andopportunity to practise clinical pharmacy

Abstract The impact on 357 newly licensed pharmacists, graduates of twocolleges, of efforts to tum pharmacy into a clinical profession,was examined by way of a self-administered questionnaire.Perceptions and expectations about work, differences inconsulting practices, relationships between practice andattitudes, and the presence or absence of an identifiable generalvalue orientation (which could account for spedfic perceptionsand attitudes), were examined. Results indicated that hospitalpractice was more likely to be associated with clinical pharmacyand clinical pharmacy practice was more likely to meet theexpectations of recently graduated pharmacists. In addition, 52per cent of the community-based pharmacists were found toengage in patient counseling, as compared with 39 per cent ofhospital-based pharmacists. Newly licensed pharmacists aredeepening the existing divisions in the profession, while movingtoward a revision of their place in the health care deliverysystem.

Introduction

Traditional sodological analyses of the professions rarely haveconsidered how, under what conditions, and with what consequences,an established profession seeks to change its position within a singleindustry. In the structural-functional perspective (Goode, 1960;Greenwood, 1966; Parsons, 1968) an occupation becomes a professionwhen granted autonomy and receives recognition from sodety forpossessing a technical knowledge-base, demonstrating effectiveperformance, developing a lengthy and superior education, andespousing ethical commitments to the common good. This list ofattributes does not take into account that new technology can takefunctions away from established professional practitioners, new

Sociology of Health & Illness Vol. 9 No. 3 1987 ISSN 0141-9889

Reforms in pharmacy education 287

market and organizational structures may delegate tasks to lessertrained occupations, and other occupations may try to encroach on aprofession by increasuig educational requirements and adopting a codeof ethics. Fadng these threats, leaders of an established professionmay advocate reforms in education to permit reprofessionalization.

An altemative approach (but within the same tradition) issuggested by Wilensky (1964), in which reprofessionalization isdesignated a social and poUtical process. Herein some professions(with particular attributes) actively take on the task of gettinggreater sodetal recognition, usually tiu^ough developing comprehensiveeducational programmes which are connected with universities,national organizations to represent the interests of the occupation,and codes of ethics.

It can be said that educational reforms may be achieved morerapidly than changes in professional practice. Reprofessionalizationmovements within an occupation are usually led by university basedelites capable of taking risks to bring about the future desired legalsupport and sodal recognition. What happens when non-elites -responding to the initiatives of elites - attempt to take on newresponsibihties? And what kinds of responses do they receiveintemal to the profession and from other professions with which adivision of labour is shared?

This paper examines the impact on newly licensed pharmadsts ofefforts to tum pharmacy into a clinical profession. Advocates ofreprofessionalization define this new role as:

. . . the application of pharmaceutical service emphasizing integrationand coordination of the patient's total drug regimen, using all availablemeans to achieve maximum effectiveness and safety of drug therapy inthe context of the patient's total environment (Provost, 1971).

Despite this clear definition of a complex task, this author went onto assert that in the future pharmacy would no longer need thislabel, or any other, provided that the profession '. . . embraces theopportunity to offer services . . . only temporarily, distinguishedfrom other parts of pharmacy' (Provost, 1971). In other words, inthe future all pharmadsts, including those in the community, wouldbe professionally engaged in clinical practice.

Clearly, there is a movement within this profession to gain moreauthority in health care settings. Professionalization in pharmacyhas been characterized as incomplete because of ongoing andsometimes incompatible business and service orientations, the lackof exclusive control over the social object which is its reason for

288 Amold Birenbaum, Roslyn Bologh and Henry Lesieur

existence (i.e., the drug), and failure to achieve widespreadrecognition as a knowledge-based field (Denzin, 1972).

The historical source for the movement toward clinical pharmacyin the United States came from efforts to make structural changes inthe management and delivery of medications to hospitalisedpatients. Citing the high rates of errors committed by nurses indispensing, hospital pharmadsts designed and evaluated 'unit dose'systems to assure accuracy in the administration of drugs to patients(Philip H. Greth, et al., 1965; Black and Tester, 1964).

Conditions outside of hospital practice reforms, including the endof compounding of most prescription drugs, automated dispensing,the increased competition in retail pharmades from discount chainstores, more salaried employment for pharmadsts in hospitals andnursing homes, along with increasing utilization of pharmacytechnidans and assistants, has raised the spectre of reducedeconomic opportunities in the future without a new direction forpharmacy (Birenbaum, 1982). In the early 1970s the colleges ofpharmacy, whose faculty would also be threatened by reducedenrollment, commissioned an investigation of how they could bestprepare pharmadsts for their future role in health care.

Encouraged by the widely acclaimed Millis Report on the needfor reform in pharmacy education, many colleges of pharmacyrevised their curriculum to refiect a new emphasis on the drugadvisory activities of pharmadsts in hospitals and in the community.By the middle of the past decade, colleges of pharmacy began tostress that their graduates would be performing clinical frinctions inrelation to patients and physidans, since pharmadsts were expertsin drug information. In essence, function would follow educationreform.

Newly educated pharmacists have been employed in varioussettings for a number of years. Currently, however, clinical practicein pharmacy takes place in relatively few hospitals, mainly thosewith a tradition for innovative health care services. Conducted in1978, a national sample survey of pharmaceutical services at 815acute care hospitals suggests that clinical services are most costeffective at large hospitals (Stolar, 1979). Based on projections fromthe sample, only 150 hospital pharmades in the United Statesprovided a comprehensive clinical service programme in 1978. Mostof these hospitals were large (over 400 beds) and are located in NewEngland or on the Padfic coast. (Although information was notprovided, it is likely that these hospitals are affiliated wdth medicalschools).


The most recent studies of levels of satisfaction among hospitalpharmacists indicate that the professional sodalization experiencemay not be able to withstand the situational constraints of hospitalpractice, with little opportxmity to act as dinidans. Johnson,Hammel and Heinen (1977) compared the responses of Midwestemhospital pharmacists to professional managerial and nonprofessionalworkers surveyed nationally on working conditions and job satisfac-tion. There was '. . . an overall pattem of less satisfaction amonghospital pharmacists than among workers included in the Michigansurveys' (Johnson, Hammel, and Heinen, 1977: 241). SpedficaUy,pharmadsts were least satisfied with the lack of opportunity foradvancement, staffing practices, employer's polides and practices,and compensation practices. Interestingly, those who got to practiceclinical pharmacy were far more satisfied than staff pharmadsts.This pattem of dissatisfaction was also noted in a study of Israelipharmacists (Shuval and Gilbert, 1978), wherein cynidsm wasfound to be consistent with the subjects' reduction of expectationsof rewards from future practice.

In another survey of recent graduates of eight American collegesof pharmacy, respondents were found to be strongly committed totheir work but often expressed less feeling of accomplishment atwork compared to a 1973 national sample survey of workers (Curtis,Hammel and Johnson, 1978:1516). Furthermore, when institutionaland hospital pharmadsts were compared with community pharmacists,no differences in satisfaction were found. However, one exceptionto this overall result was that practitioners in ethical pharmades -where no sundries are sold - reported higher levels of satisfactionthan pharmadsts in other settings.

Impressionistic evidence provided by a veteran pharmacy educatoralso suggests that there is widespread disillusionment amongpharmacy graduates who '. . . are full of idealism when they leavethe campus in search of jobs. But in a year or so their attitudechanges. Most of them will sell anything to make a quick buck'(Siegelman, 1978: 5).

How does it come to be that professionzdism is impractical incommunity pharmacy? Are there some conditions under whichidealism is maintained? Under what conditions does hospitalpharmacy encourage or discourage feelings of accomplishment?

These issues are not merely spedfic to pharmacy practice.General concem over the discontinuity between education ancpractice is found among many educational spedalists in the field ohealth care. A work group on the education of the healtl

290 Amold Birenbaum, Roslyn Boiogh and Henry Lesieur

professions and the nation's health, made up of a cross-section ofleaders in that field, noted that there is little research on howsodalization of providers affects their productivity (Magraw, et al.,1978). In the profession of pharmacy, it would be necessary, first, todetermine how much of the education of recent graduates is utilizedin their work, particularly in the Chnical areas, before investigatingtheir effects on the health of individuals or groups. In line with themore realizable recommendation of the work group to identify the'. . . contributions of education and practice to professional behaviourand their effect on health services. . .' (Magraw, et al., 1978: 540),this report examines the discrepandes and continuities in pharmacypractice.

There is some evidence that context can make a difference:Continuity between education and practice is encouraged in someenvironments and discouraged in others. Opportunities to engage inclinical practice, such as consulting with patients and physidans, wasviewed more favourably by younger than older pharmadsts, buteffectiveness in performance varied very httle by age (Watkins andNorwood, 1977)i Moreover, the settings found in communitypharmacy can encourage or discourage consulting behaviour.Significantly higher consultant behaviour scores were found amongrespondents employed in service-oriented than discount pharmadsts(Watkins and Norwood, 1978).

When environment was held constant, however, no significantdifferences in consulting behaviour were found between older andyounger pharmadsts. Respondents who had information used it in theservice of the patient. Pharmadsts of all ages, when knowledgeable,advised patients about potential difficulties with prescriptions.Patient consultation was not followed by physidan consultation,however, when pharmadsts were aware of potential problems.

Watkins and Norwood also found a significant difference inconsulting behaviour between pharmadsts located in a service-oriented and discount pharmades. Pharmadsts practidng in theservice-oriented locations were more likely to advise physidansabout potential problems than their equally knowledgeable counter-parts in the discount stores (1978).

It is important to collect data on discontinuities betweeneducation and practice in order to detennine not only what settingsencourage the practice of clinical pharmacy, but what strategies areemployed by newly employed pharmadsts to accompl^h thisobjective. Moreover, recent graduates constitute an appropriatesample because they are less likely to have become cynical about


professionalism than more veteran pharmadsts. Finally, samplingfrom recent graduates makes possible the inclusion of a variety ofvocational experiences and reactions to them by respondents.

Method

The only two pharmacy colleges in New York City were interestedin finding out more about the experiences of their recent graduatessince they implemented curriculum reform. Hardly Eastem 'establish-ment' universities, Amold and Marie Schwartz College of Pharmacy(Long Island University) and the College of Pharmacy and AlliedHealth of St. John's University provide the bulk of the new recruitsto hospital and community pharmacy in much of the metropolitanarea made up of lower New York State, northem New Jersey andsouthem Connecticut. All 1975 through 1979 graduates inclusivereceived a mailed self-administered questionnaire with fixed altemativeanswers. Discussion with pharmacy faculty led to the developmentof a prestested instrument. The questions were designed to elicitattitudes and perceptions about the profession of pharmacy,opportunities to utilize skills acquired through undergraduateeducation, and whether, after several years of employment, theclinical emphasis of their education was reflected in their occupationalorientation. The response rate was thirty per cent, with somerespondents now located not only in the Northeast but all sections ofthe United States. The results reported below were based on 357completed questionnaires.

The respondents appear representative of newly licensed phar-madsts. Neither college could be considered as a locus for thegeneration of new practices in clinical pharmacy. Both lacked closecontact with medical school teaching hospitals where many of theservice innovations recently reported in pharmacy joumals takeplace. Increasingly, colleges of pharmacy were admitting andgraduating more women, as the traditional barriers to entry to thisprofession by women were lowered. Unlike other technical supportoccupations, pharmacy's commercial avenues to success made it ahighly desired vocation for men while long hours in retail owner/operated establishments in the community made it unattractive towomen. With opportunities shifting toward salaried employmentand away from entreprenurial endeavours, these trends towardfeminization should continue.

Results were analyzed to determine (1) the recently employed


pharmadsts' perceptions of their profession and expectations aboutwork, (2) whether there were differences in consulting practices, (3)the relationship between practice and attitudes, and (4) whetherthere was an identifiable general value orientation which accountedfor particular perceptions and attitudes.

Results

Perceptions of the profession of pharmacy and work expectationsMany respondents (43%) viewed the profession of pharmacy aschanging, mainly as a result of the new clinical directions imdertaken.Others (36%) found it hard to judge whether pharmacy waschanging because of structural divisions in the profession, includingdistinctions between community and hospital pharmacy, universityaffiliated innovators and others, and because of sharply perceivedgenerational differences. In addition, 21 per cent felt the professionwas not changing.

The lack of consensus found above in the tripartite distribution ofresponses is related to the widely shared view that lack of cohesionamong pharmadsts is the most serious problem of the profession.Eighty-two per cent of the respondents saw fragmentation asweakening their profession.

Despite a substantial minority's recognition that pharmacy wasbecoming more clinical, more than half the sample (54%) did notfeel their current work met their expectations. Most were disappointedprimarily because 'my knowledge goes far beyond filling prescriptions.'Only seven per cent mentioned not being well paid as a source ofdissatisfaction. Moreover, of the 37 per cent of the respondents whowere satisfied with their current work situation, half claimed thattheir work was clinical in nature and the other half said they wereusing their knowledge to fill prescriptions. Thus, no more than 19per cent of this sample of recent graduates of colleges of pharmacywhich now follow a revised curriculimi, saw themselves as clinicalpharmadsts.

When asked if they were utilizing their training, 67 per cent didindicate positively that their work dep>ended on what they leamed.While not naming their work activities clinical pharmacy, manyrespondents mentioned that they used their knowledge of how dmgswork, eduated nurses and doctors in pharmacology, interviewedpatients to acquire drug histories and explained to patients how touse medications properly, what the side effects of these dmgs are


and the potential interactions of these drugs v^th other medications.Exposure to a new education and new practices helped some of

the respondents maintain their 'new breed' image. A large majorityof respondents saw themselves as different from older pharmadsts,who they claimed held different expectations from recent graduatesof five year programmes. In the main, they attributed thedifferences mostly to the older pharmadsts holding a concept of thefield as a business rather than a profession (43%). In addition, theymentioned that young pharmadsts could maintain their professionalorientation because they were better trained in pharmacology andclinical practices. However, 25 per cent held to the view that doingthe same job and experiendng the same problems and stressesreduced the differences between the younger and older practitioners.

Doing more clinical work made respondents feel more professionalthan their more experienced colleagues, yet they still did not feelthat their work fully met their expectations. In response to aquestion as to whether, given their training and knowledge, therewere some further contributions that they could make, 62 per centresponded affirmatively. And almost all respondents who sawthemselves underutilized thought they could do more advising ofdoctors and nurses about drugs, have more direct contact withpatients, and assist physidans in selecting the correct medicationsfor patients; a small number (9%) indicated that they could educateyouth about the harmful effects of drug abuse.

Clinical training was eclipsed by the routine aspects of theiremployment. Respondents complained about extensive paper work,mere counting of pills and labelling containers ('SpUl, fill, lick andstick.'). Further complaints centered on their lack of authority andresponsibility, which limited the use of their knowledge. Thesesources of dissatisfaction were mentioned by 89 per cent of thesample.

It is reasonable to expect that different organizational settingswould or would not promote work satisfaction. We hypothesizedthat expectations regarding work would be more likely met inhospital rather than community pharmades. Differences werestatistically significant when the two settings were compared. Of thehospital pharmacists, 52 per cent reported their work as meetingexpectations as compared with 41 per cent of the communitypharmacists (Yule's O = 22, S < .05).^

Reflecting the influence of the educational stress on clinical work,the opportunity to practice clinical pharmacy should discriminatebetween those who find the work meeting expectations and those


who do not, regardless of hospital or clinical setting. This hypothesiswas confirmed: Of all pharmadsts who reported practidng clinicalpharmacy, which included slightly more than half the respondents,the majority said that the work was meeting their expectations(58%), in contrast with only 33 per cent of those who reportednot practidng clinical pharmacy (Yule's O = 47, S ^ .001).Furthermore, hospital pharmadsts are much more likely to reportdoing clinical work (70%) than are community pharmadsts (42%)(Yule's O = .47, S ^ .001).

In sum, hospital practice is more likely to be assodated withclinical pharmacy and clinical pharmacy is more likely to meet theexpectations of recently graduated pharmacists.

Differences in pharmacists' consulting practices There are severalcomponents to clinical pharmacy, with hospital and communitylocations encouraging different consulting practices. When counsellingpatients is considered part of clinical practice, 52 per cent of thecommunity-based pharmadsts were found more likely to engage inthis practice, as compared with 39 per cent of the hospital-basedpharmadsts (Yule's Q = .25, S ^ .05).

Counselling patients is a satisfying activity, with 55 per cent of therespondents who engage in this practice feeling that their workmeets their expectations as compared to 39 per cent who do notcounsel feeling the same way (Yule's O = .32, S ^ .01). Counsellingrefiects not only greater responsibility at work, often a source ofsatisfaction, but greater control over how one performs at work,which also provides a sense of autonomy. Those who report havingenough time to consult with patients are more likely to say that thejob meets their expectations (59%) than respondents who claimthey have no time to perform this clinical task (42%) (Yule's O =.34, S < .01).

Performing the tasks of clinical phcirmacy (e.g. counsellingpatients), even without formal recognition of these functions as partof one's job description, encourages work satisfaction, independentof location. When organizational setting was held constant, hospitalpharmadsts who practiced clinical pharmacy were more satisfiedthan their peers who did not; and similar results were obtainedamong their community-based colleagues.

Counselling patients was a more important source of jobsatisfaction among community than hospital pharmadsts. Indeed,the relationship between counselling patients and job satisfactionamong the latter was not statistically significant, whereas it was


among the former group. Community pharmadsts who counselpatients were far more likely to say their work meets theirexpectations (54%), as compared to those who do not counsel(27%) (Yule's O = .52, S < .001).

Satisfaction among hospital pharmadsts may be based on workingclosely with physicians. Using questionnaire items about relationswith physidans, including whether the respondent ever questioned aphysidan's dedsion on a prescription, we developed a three pointindex of pharmacist-doctor communication. Hospial pharmadsts(51%) had much higher scores than community pharmadsts (25%)on communication with physicians (Somer's d asymmetric withcommunication as the dependent variable was — .27, S ^ .001).

The pharmadsts' opportunities for contact with physidans inhospitals promotes a professional relationship. Hospital pharmadstsare more likely to have questioned a physidan's dedsion (76%)than are community pharmadsts (62%) (Yule's O = .32, S :s .01).This contact among hospital pharmacists and physicians does notindicate a distaste for patient counselling. While we found communitypharmacists more likely to counsel patients than their counterpartsin hospitals, 47 per cent of hospital pharmadsts prefer talking aboutailments and therapies with patients over technical and marketingtasks, as compared with only 36 per cent of community pharmacists(Yule's O = .23, S < .05).

In summary, it appears that differences in consulting practicesreflect altemative situations rather than orientations. Communitypharmacists consult more with patients than hospital pharmadsts,but have less contact with physicians. Most importantly, opf>ortunityfor consulting has a significant effect on whether work meetsexpectations, particularly for community practitioners.

Relationship between practice and attitudes Differences in type ofpractice constraints not only the varieties of consulting behaviourspossible (either with patients or physidans), but also influencesattitudes toward increased responsibilities, professional recognition,and the public's esteem. Protecting patients against adverse druginteractions would be enhanced through detailed record keepingof prescriptions for individuals, know as 'patient profiles.' Itwas reasoned that all dedicated pharmacists would advocate theperformance of this task, regardless of location. Yet it is alsopossible to consider professionalism - independent of commercialconstraints - as more likely to be encouraged in hospitals ratherthan community practice. Results showed that the latter hypothesis

2% Amold Birenbaum, Roslyn Bologh and Henry Lesieur

was confirmed. In hospital pharmacy 77 per cent of the respondents,as compared to only 59 per cent of community pharmadsts, wantedthe profession to be legally required to maintain patient profiles(Yule's Q = .40, S < .001).

An appropriate professional environment, one might expect, iswhere expert opinion is taken seriously. Again, the higher rate ofcommunication between hospital pharmadsts and physidans appearsto encourage professional recognition. Hospital pharmadsts are lesslikely (46%) than conmiunity pharmadsts (59%) to believe theyreceive little respect from doctors (Yule's Q = .25, S ^ .05).

Respect, it was hypothesized, was directly related to clinicalresponsibilities. It was found that 49 per cent of hospital pharmadstsfelt they had too many clinical responsibilities, as compared to only24 per cent of community pharmadsts (Yule's Q = .50, S ^ .(X)l).Wherever located, those who felt they have too many clinicalresponsibilities were less likely to dte lack of respect fromphysidans as a problem of the profession (40%), while 60 per centof the respondents who did not mention this problem felt theyreceived too httle respect from doctors (Yule's O = .40, S :£ .001).

Demanding work, characterized by responsibility and involvementin dedsion making, encouraged greater job satisfaction. Those withtoo many clinical responsibilities were more likely to say their workmeets their expectations (59%) than those who did not dte toomany clinical responsibilities as a problem (39%) (Yule's O = .38,S :s .001).

It is possible that the relationship between clinical responsibilitiesand respect from physicians may be an artefact of hospital practicerather than an outcome of performing clinical tasks. Whencontrolling for location, we found that the relationship betweenheavy clinical responsibilities and physician respect still obtained.

Hospital pharmacy includes both clinical and nondinical functions.Performance of technical tasks alone, without consultation withphysicians, is perceived as an insufficient service to receive therespect of physidans. A far greater proportion of hospital pharmacistswho do not practice clinical pharmacy (65%) identified lack ofrespect as a major problem of the profession when compared withthose who practice clinical pharmacy (36%) (Yule's Q = .53,S s .01).

Professional respect was only one problem identified by theseyoung pharmadsts. Lack of recognition from the public wasconsidered an even greater problem fadng the profession, mentionedby 65 per cent of the sample. Differences in perception were found

Reforms in pharmacy education 2S>7

between those practidng clinical pharmacy and others. Of thosewho do not engage in clinical pradce, 72 per cent identified this as amajor problem compared with 59 per cent of those who do practiceclinical pharmacy (Yule's Q = .26, S < .05).

Again, concem for recognition was inversely related to clinicalresponsibilities. Respondents who felt they had too many clinicalresponsibilities were less likely to think that lack of recognition fromthe general public is a major problem of the profession (54%) thanthose who did not perceive themselves as having too many clinicalreponsibilities (68%) (Yule's O = .27, S s .05). In sum, worksetting and opportunities for clinical responsibilities influenceattitudes toward the way the profession of pharmacy is seen byothers and the need to take on more responsibilities.

General value orientation and particular perceptions and attitudesThe general orientation held toward one's profession may existindependent from opportunities to practice according to desiredpreferences. Failure to fulfill those aspirations may eventually resultin departure from the profession or simply retreating from thosegoals. Blocked opportunities may also be perceived as the result of alack of awareness by the public of what pharmacy could accomplishand the presence of impediments in the immediate work settingwhich limit professional achievement.

Respondents who preferred the clinical side of pharmacy, even ifthey do not actually practice it, tend to be more concemed aboutlack of recognition from the general public (71%) than those who donot prefer clinical work to other kinds of responsibilities (58%)(Yule's O = -27, S ^ .05). Community pharmacists who prefertalking with patients about ailments and therapies, an indicator of aclinical orientation, are more likely to cite lack of recognition fromthe public as a problem faced by the profession (71%), as comparedwith those who prefer marketing and technical aspects of pharmacy(58%) (Yule's Q = .27, S < .05).

It was reasoned that pharmadsts with a clinical orientation whowere in the community would be sensitive to and reject an emphasison merchandising. This hypothesis was confirmed: TTiose communitypharmacists who question physidans, an indicator of a clinicalorientation, were more likely to say there is too much emphasis onmerchandising (57%) than those who report never having questioneda physician's prescription (41%) (Yule's Q = .32, S s .05).

Similarly, the attitude towards keeping patient profiles, anotherindicator of a clinical orientation, was inversely related to a positive

298 Arnold Birenbaum, Roslyn Bologh and Henry Lesieur

attitude towards merchandising. Those community pharmadsts whoadvocated that maintaining patient profiles be legally required alsotend to assert that there is too much emphasis on merchandising(58%), as compared with those who did not share this positiveattitude towards patient profiles (47%) (Yule's Q = .32, S ^ .05).

Likewise, among community pharmacists reporting a preferencefor talking with patients about their ailments and treatment, 62 percent said there was too much emphasis on merchandising ascompared with only 45 per cent of those who did not prefer thisaspect of the work (Yule's Q = .33, S ^ .05).

A clinical orientation, like any general value orientation, is basedon prindples. However revealing were the differences in satisfactionbetween preferences and actual practice, those community pharmacistswho insist on having enough time for counselling are less likely tofeel that there is too much emphasis on merchandising (37%), ascompared to those who did not insist on taking the time to counselpatients (56%) (Yule's O = .38, S ^ .05). Prioritizing activities isalso found to account for other perceptions. When insisting on timefor counselling, fewer respondents regard jis a problem competitionbetween local pharmades. Of those community pharmadsts whoinsist on having enough time for counselling, 57 per cent viewcompetition as a major problem compared with 75 per ceiit who donot insist on taking time for patient counselling (Yule's Q — .38,S :£ .05).

Discussion

Young pharmadsts who felt their profession was changing were alsounsatisfied by current work situtions which hmited the application oftheir clinical education. The clinical focus of the curriculum hadconsequences beyond merely changing training and skills; itsensitized these newly graduated pharmadsts to the several divisionsof professional labour, divisions which go beyond conventionaldichotomies such as hospital and community pharmacy. This studyhas identified a number of discrepandes within the field.

First, it cannot be assumed any longer than hospital pharmacyrepresents a unified category, since it was found to includedifferential distribution of opportunity to practice clinical pharmacy.Indeed, the absence of opportunity to engage in cUnical practicemay be more keenly felt by hospital pharmadsts who can observetheir peers doing clinical work, while community pharmadsts, in


contrast, not only do not observe these differences but may as wellhave access to compensatory responsibilities in management andmarketing.

Second, despite the discontinuity between pharmacy educationand practice, those respondents who perceived their work asmeaningful were relatively more satisfied than the respondents whofound their work more limited. Particularly important was theactuzil experience of performing some consulting activity, whetherwith patients or physidans. Even when these activities were notformally or offidally recognized as clinical pharmacy, when theirwork brought them into contact with physidans and the public asexperts, rather than as purveyors of dmgs and sundries, or merely astechnidans, they received respect and recognition.

Third, even among those who did not necessarily practice clinicalpharmacy for want of an opportunity, a preference for clinical workpredicted that respondents perceived a lack of respect fromphysidans and failure on the part of the public to recognize thepharmadst's contribution to the nation's health. They also morestrongly perceived the commerdal side of pharmacy as a roadblockto changing the role of the pharmacist than did the respondents whowere able to engage in some clinical practices.

Fourth, while those with a more clinical orientation are morelikely to cite the business aspects of pharmacy as a problem of theprofession, the relationship between the general value orientationof professionalism and the particular perception of problems iscomplex. Pharmacists in the community who are assertive profession-ally, i.e., insist on making time available to consult with patients,downgrade the difficulties which commercialism engenders. Thepresence of this group may be viewed as a problem or as anopportunity to leam about strategies used to gain access to clinicaltasks. It can be said that individualistic and economically successfulpersons may be less sensitive to the sodal conditions that obstmctprofessionalism than other members of that vocational community.These individuals may constitute yet another division in pharmacy.Altematively, professional assertiveness may result from theseindividuals' perception that they have group support behind them.If the second interpretation is valid, we may see greater collectivismin pharmacy than in the past. Further research is needed to testthese contrasting hypotheses.

300 Amold Birenbaum, Roslyn Bologh and Hem7 Lesieur

Conclusion

A convergence of historical, technologic, economic and social forces- a subject which is beyond the scope of this report - haveencouraged curriculum reforms in pharmacy. Changes in pharmacyeducation have contributed to the rising expectations of youngpharmacists for greater responsibility and autonomy at work. Intheir concrete understanding of the gap between their chnicalorientation and opportunities to engage in that practice, youngpharmacists have become made acutely aware of sodal divisionswithin the profession and the sources of its lack of cohesion. Insofaras this process will encourage demands for change, the educationreceived starting at the university is based on political as well as theclinical sdences. It may well tum out that the new reforms ineducation accellerate reprofessionalization in pharmacy. Encouragedto expand their roles, and thereby perform more clinical services,newly hcensed pharmacists are deepening the existing divisions inthe profession, while moving toward a revision of their place in thehealth care delivery system.

Department of Sociology and AnthropologySt John's University

JamaicaNew York 11439

USA

Note

1 Yule's O is a special case of gamma used for 2 x 2 tables. It, like gamma, is anordinal measure of association and has the same interpretation. The value of Q(which ranges between + 1,0 and - 1) represents the probability that forevery pair of individuals drawn at random, excluding ties, tbe order of the pairswill be the same on each variable. O is calculated according to the formula:O = (ad - bc)/(ad + be) where the letters represent cell frequencies in a2 X 2 table as follows: a = upper left, b = upper right, c = lower left,d = lowerright(Mueller, Schuessler and Costner, 1970:290-292). In ouranalysis, the sign of O is not included in order to avoid confusion. In this case, Qrepresents the probability that for every pair of individuals drawn at random,excluding ties, the order of the pairs will be in the direction discussed in the text.


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reforms in pharmacy education and opportunity to practise clinical pharmacy

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