Thirty-five years have passed since the publication of the first edition of Pharmacotherapy: A Pathophysiologic Approach. During those years we have witnessed dramatic changes in healthcare delivery and advances in the prevention and treatment of many diseases and disorders. Also, new diseases such as COVID-19 and monkeypox have become public health emergencies.
As summarized in the Foreword to the 10th edition, major changes in the pharmacy profession have also occurred during our professional journey. We have seen the emphasis on pharmaceutical care, the change to the entry-level doctor of pharmacy degree, and the growing acceptance of credentials (eg, residency and board certification) for pharmacy specialists. Reimbursement for patient care services (through Medicare provider status or other means) has not advanced as quickly.
As the pharmacy profession promoted patient care services to payers and the public, some fundamental questions became evident and still challenge us today. What services do clinical pharmacists provide to improve patient care? Do pharmacists apply a uniform process of care for a given service? What patient care services do payers, providers, and the public need and want? Should some services be performed by pharmacists with specialized training or advanced credentials?
We didn’t think about those questions in the early days of the clinical pharmacy movement. The term “clinical pharmacy” described the role of the pharmacist in patient care and “clinical pharmacist” was someone who provided those services. Over time, many healthcare professionals and patients came to value the services provided by clinical pharmacists. However, it was difficult to explain to others the services provided by clinical pharmacists, in part because the process of care and its goals were not uniform. Clinical pharmacy services varied between institutions and could entail a general service such as drug information or a specialized service such as nutrition support or pharmacokinetic dosing. Most clinical pharmacists served primarily as consultants to physicians in the acute care setting and were not ultimately responsible to patients for their care. Whatever you called the service that pharmacists provided, hospitals and healthcare systems wanted more, and clinical pharmacy expanded dramatically over the next few decades. When Medicare Part D benefits were implemented in 2006, the term “medication therapy management” (MTM) became popular to describe a new service for pharmacists. However, the confusion continued because pharmacists and pharmacies offered different services labeled as MTM, delivered using different processes of care.
In the last 10 years, the profession has finally begun to address the important questions about the fundamental role of pharmacists. A Task Force of the Patient-Centered Primary Care Collaborative described the integration of comprehensive medication management (CMM) in the patient-centered medical home. The American College of Clinical Pharmacy (ACCP) published Standards of Practice for Clinical Pharmacists and the Joint Commission of Pharmacy Practitioners approved the Pharmacists’ Patient Care Process. These documents described a consistent process for the delivery of pharmacy patient care services. The ACCP Standards of Practice added details to CMM such as the setting (eg, clinical pharmacist working as part of a healthcare team) and qualifications (eg, board certification) of the clinical pharmacist providing CMM. And the 2016 ACPE Standards added new requirements for schools and colleges to teach students about the Pharmacists’ Patient Care Process. The ACCP CMM study results and publications have accelerated the growth and adoption of CMM worldwide.
As the profession has recognized the importance of practice standards and practice consistency, implementation science is being applied to clinical pharmacy service delivery. The CMM in Primary Care Study funded by ACCP was the first large-scale study to apply this relatively new science to the delivery of CMM, further defining the CMM patient care process with the degree of specificity required to ensure consistent clinical and economic outcomes (fidelity). As we look into the near future, we can expect that the application of implementation science will accelerate growth and adoption of CMM worldwide to optimize medication use and patient health.
Although pharmacy education and practice has changed dramatically, the importance of pharmacotherapy knowledge has remained the same. In its 2017 update, ACCP listed in-depth pharmacotherapy knowledge as one of the six competencies necessary to provide CMM in team-based, direct patient care environments. Patient-centered pharmacotherapy knowledge represents 65% of the board certification examination for the Pharmacotherapy Specialty. And Pharmacotherapy (or “Therapeutics” or “Pharmacotherapeutics”) is a major part of the doctor of pharmacy curriculum, usually a series of courses with the most credit hours. Indeed, it is this in-depth knowledge of pharmacotherapy, combined with the clinical experience gained through postgraduate training in direct patient care practice, that allows the pharmacist to be the “medication therapy expert” on the healthcare team and to proactively address medication-related problems. Some have argued that preventing, identifying, and managing medication-related problems should be at the very core of a pharmacist’s professional identity.
Pharmacotherapy: A Pathophysiologic Approach remains as relevant today as it was when originally published 35 years ago. The 12th edition provides students, pharmacists, and other health professionals with the core pharmacotherapy knowledge necessary to prevent, identify, and manage disease and medication-related problems.
Gary C. Yee, PharmD, and Joseph T. DiPiro, PharmD