Pharmacy Vision and Leadership:Revisiting the Fundamentals

William A. Zellmer, B.S., M.P.H.

Key Words: pharmacy vision, pharmacy leadership, pharmacy education,pharmacy history, pharmacy practice, mentorship, pharmacy technicians,clinical specialists, science, change.(Pharmacotherapy 2008;28(12):1437–1442)

Someone said, ‘There is something I haveforgotten.’ There is one thing in the world thatshould not be forgotten. You may forget everythingexcept that one thing, without there being any causefor concern. If you remember everything else butforget that one thing, you will have accomplishednothing. It would be as if a king sent you to avillage on a specific mission. If you went andperformed a hundred other tasks, but neglected toaccomplish the task for which you were sent, itwould be as though you had done nothing. Thehuman being…has come into the world for aspecific purpose and aim. If one does not fulfill thatpurpose, one has done nothing.

Mevlâna Jalâluddin Rumi1

These words of Rumi, the great 13th centurymystic poet of Islam, can be interpreted as amessage about one’s mission in life. Manypharmacists, including myself, feel that our workis not simply a job but a calling. The meaningthat we derive from life, to a substantial degree,comes from our work. We have integrated ourwork with other dimensions of our lives.Although we enjoy the material rewards of ourlabor, a deeper gratification comes from the senseof contributing to an important cause. We feel asense of responsibility for the future of ourprofession, which is linked to a strong belief that

significant changes are needed to secure thatfuture. All of this and more are entwined in oursense of calling. Echoing Rumi, we believe thatpharmacy gives us “a specific purpose and aim”and deep in our hearts, we may fear that fallingshort of fulfilling that purpose is akin toachieving “nothing.”

So it is wise to examine from time to timewhether we remember our specific mission.Being still and listening to that quiet inner voicewill tell us if we have become distracted by “ahundred other tasks” and are neglecting toaccomplish the one task for which we have beensent. It is impossible, however, to achieve acomplex mission without mastery of thefundamentals demanded by the challenge. I willdiscuss these fundamentals as I see them, withthe intent of fostering reflection and, perhaps,recommitment and even redirection.

Relationship Between Vision and Leadership

One of the fundamentals is an understandingof the relationship between vision and leadershipin pharmacy. These are two tightly linkedconcepts. What is the point of leadership if it isnot directed toward some envisaged, sociallydesirable, change?

In the United States, for the past century ormore, leaders in pharmacy practice andeducation have envisaged that pharmacy wouldbecome a health profession that ensures theintegrity of drug therapy. At first, the focus wason the quality of medicinal products themselves.The reforms of the Progressive Era and the movetoward mass production of most medicines haveput this responsibility in the hands of the federalgovernment. Today, pharmacy visionaries have

From the American Society of Health-System Pharmacists,Bethesda, Maryland.

Presented at the Annual Fellows Dinner at the AmericanCollege of Clinical Pharmacy annual meeting, October 13,2007, Denver, Colorado.

Address reprint requests to William A. Zellmer, B.S.,M.P.H., American Society of Health-System Pharmacists,7272 Wisconsin Avenue, Bethesda, MD 20817; e-mail:wzellmer@ashp.org.

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set their sights on the quality of the use ofmedicines. This vision is built on the facts thatthe less-than-optimal use of medicines is a majorpublic health problem and that pharmacy is in abetter position than any other health professionor any agency of government to correct thisproblem.

Leadership is needed to close the immense gapbetween our vision and how most pharmacistspractice their profession. In all sectors ofpractice, most pharmacists still spend most oftheir time on order processing and producthandling functions—functions that could beconducted well with less direct pharmacistengagement through the intelligent design anduse of systems, technology, and technicalworkers.

Imperatives for Leadership

An understanding of the implications of thisgap is another fundamental we must master. Thegap between vision and performance poses twoprofound implications for pharmacy. One has todo with survivability of the profession, and theother has to do with social responsibility. Bothimplications are self-evident. Both are easy toignore because of powerful incentives to preservethe status quo. Not the least of these inertial factorsis the high salaries of dispensing pharmacists.

The survivability imperative tends to bediscounted because traditional pharmacy practiceis still propped up by laws based on the theorythat the knowledge and skills of a pharmacist arenecessary to ensure the safe dispensing of aprescription drug. That theory has been erodedby mail-order pharmacy, and it will be erodedeven further as big corporations continue to co-opt state boards of pharmacy. Most significantly,the theory has been weakened by pharmaciststhemselves, through their insularity from theclients they serve.

The social responsibility imperative is theobligation we have to use our education optimallyin service to society. Addressing preventablemedication use problems is the calling for whichwe have been prepared; to apply our time andeffort to a lower-order function that could beperformed well through other, less expensivemeans is a shameful, immoral squandering ofresources.

There is no mystery about the imperatives forleadership in pharmacy. And yet, we allowourselves to get distracted by a “hundred othertasks.” It is through wise leadership that we will,

in the words of Rumi, not forget the task forwhich we were sent.

Pharmacy’s Strengths

In October 2007, five pharmacists from theUnited States and two from Canada joined 60health care, public health, university, andpharmacy leaders from Mexico to explore lessonslearned in the northern hemisphere that mightassist in the development of hospital-basedclinical pharmacy in Mexico. From a U.S.perspective, this conference served as a reminderabout another fundamental we must master: tobe informed by our own history.

The history, sociology, and culture of Mexicohave resulted in a health care system that isessentially devoid of pharmacy practitioners.There are many pharmacies in Mexico, but theyare not staffed by pharmacists as we define them.There are many hospitals in Mexico, but nearlyall of them function without the benefit of phar-macists. A university-level pharmacy educationexists in Mexico, but most graduates of theseprograms work for the pharmaceutical industry.

The history, sociology, and culture of theUnited States have taken us on a different course.Pharmacy in our country derives strength fromits educational system, as guided by a strong,uniform national standard. We derive strengthfrom the legal requirement that pharmacists mustoversee the distribution of the most potentmedicines. We derive strength from the hospitalaccreditation requirement that the medication-use process must be overseen by pharmacists.We derive strength from the growing demand ofphysicians to include a pharmacist on their team.These strengths did not “just happen.” Theyresulted from visionary leadership in practice andeducation, a commitment to postgraduateresidency training, a philosophy of continuousimprovement, voluntary practice standards, andgood research and communication about thevalue that pharmacists bring to health care.

We should not take our strengths and ourhistory for granted. We should not forget thelessons about the factors that brought us to thispoint in our evolution. These lessons will helpkeep us focused—in the words of Rumi—on ourspecific purpose and aim in this world.

Nature and Pace of Change

Another fundamental we must master toachieve our vision is an awareness of the nature

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and pace of change in the environment in whichwe operate. I remember a period in my life whenI was troubled by a gap in my knowledge of thehistory of science, specifically the history ofgeology. Often, after exploring for the first timesome beautiful spot on the face of the earth andthen reading about how the forces of naturecreated this magnificence, I would wonder whenhumans first began to recognize that the crust ofour planet is in a continuous state of change andwas not created as we see it today. Then I learnedabout the life of James Hutton.2 James Huttonwas a contemporary of David Hume, AdamSmith, and James Watt—intellectual forces in theScottish Enlightenment of the 1700s. Hutton’scuriosity and scientific mind led him to provethat the earth was likely millions of years oldrather than the biblically calculated age of 6000years. Further, Hutton showed that the earth isconstantly being reshaped by myriad everydayforces.

The work of James Hutton opened minds tothe presence of very long cycles of change withina broader sweep of very slow change. During theearth’s evolution, from its origin 4.6 billion yearsago to the present, there have been cycles ofchange—ice ages, for example, and reversals ofthe earth’s magnetic polarity. The pace of thesevery long cycles is not perceptible in the daily lifeof a human, although today’s technology allowsus to track accelerations of slow change such asglobal warming. Long trends and long cycles ofchange are present in human society as well asthe physical world.

Health care and pharmacy function withinbroader societal trends, each unfolding at its ownpace. We mostly focus on the immediate, urgentmanifestations of these trends—our earthquakesand tsunamis—rather than on the underlyingforces themselves—the plate tectonics of ourfield. Our propensity to measure progress interms of a human lifetime tends to make usoblivious to the long trends and patterns thatmay, in fact, seal our fate. So, we must be disci-plined and look dispassionately at pharmacy’slong trends to help us avoid being distracted bythe “hundred other tasks” that Rumi warns usabout.

Pharmacy’s Long Trends

What are the long, broad trends affectingpharmacy’s destiny? At the top of the list, onemight put industrialization, corporatization, andbusiness consolidation. We know the pharmacy

signposts of these trends well:

• The preparation of dosage forms movingfrom individual pharmacists to massproduction by big corporations

• The dispensing of mass-produced medicationscoming under the control of a highlyconsolidated industry, which defines itself asretailing or prescription benefit management

• The pharmacy retailing–pharmacy benefitmanager industrial complex being run byfinancial wizards and manipulators who havea short-term focus on keeping shareholdershappy

• Most pharmacists being employed by theretailing industry, where they are mereinstruments in a corporation’s pursuit ofwealth and where they have lost alldiscretion (and, apparently, desire) todevelop a professional practice built onpersonal caring and competent service.

In 1996, 7 years after the collapse of the ironcurtain, a pharmacy professor in socioeconomicsat Semmelweis University in Budapest discussedwith me the frustrations of privatizing communitypharmacies in Hungary. In the Soviet-dominatedera, pharmacies had been owned and operated bythe state. Now the rules had changed, and thestate wanted to sell each pharmacy to thepharmacists who practiced there. The problemwas that the pharmacists had no interest inbecoming entrepreneurs. The professor theorizedthat those who might have had the ambition tocreate their own professional practice had goneinto other pursuits, such as the pharmaceuticalindustry, which offered better rewards forimagination and initiative.

Something similar has happened in the UnitedStates. The stultifying practice environment ofretail corporations has attracted pharmacists whowant the security and comfort of clear rules,procedures, and routines. Fortunately, there aremany opportunities elsewhere for pharmacistswho are put off by this rigidity. Unfortunately,this has left little substrate to support even themost basic aspects of professionalism such as thepharmacist determining whether the clientknows how to use his or her drug therapy.

Many pharmacists, for too long, have clung tothe dream that this could be changed. Even now,immense effort is being directed into articulatingwhat it means for pharmacists to providemedication therapy management as a service thatis tangential to the mainstream of health caredelivery. Projects of this nature will fail to have

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any significant impact unless the retail drug storecorporations are willing to take three radicalsteps:

• Turn over to their pharmacists a large measureof professional self-determination

• Actively foster the professional socializationof the pharmacists they employ

• Concertedly hire new pharmacists who havethe appropriate psychographic profile andmotivation for professional practice.

This industry is, of course, moving in acompletely different direction. The mind-set ofthe captains of this industry was revealed in astatement by the president of CVS regarding hiscorporation’s merger with Caremark. He said,“[After the merger,] we will be agnostic [about]where the consumer gets [his or her] prescrip-tion filled [within our corporate divisions].”3 Inother words, they are all about increasing thenumber of commodity transactions, and as longas the money flows into their coffers, they don’tcare how their customers get their medicines.

We should certainly stay alert for opportunitiesto collaborate with corporate retailers onprofessionalization projects. But we wouldprobably get a higher yield, in terms of protectingthe public, if we were to lobby for stronger stateboards of pharmacy to oversee the new methodsthese corporations are inventing for distributingprescription medicines. And the yield mostassuredly would be higher in projects thatcontinue to define the role of pharmacists asmembers of interdisciplinary health care teams.

Mentorship

Other long trends are buffeting health care andpharmacy, including the ever-deepeningunderstanding of human biology and diseaseprocesses and the ever-expanding technologicinnovations in diagnosis and treatment of illness.These long trends have fueled specialization inhealth care, which brings us closer to the heartand natural interests of the Fellows of theAmerican College of Clinical Pharmacy (ACCP).

Many of the ACCP Fellows are at the cuttingedge of clinical research and are widely admiredin pharmacy for their dedication to creating newknowledge. Many have pioneered clinicalspecialty practice and hold an honored place inour profession for the ways in which they haveimproved patient care. Most are involved, tosome extent, in pharmacy education.

Pharmacy educators have a profound influenceon the outlook and aspirations of their students.

This gives them immense power to shape thefuture of our profession. I hope that power willbe exercised with mindfulness and wisdom,which will help our profession, in the words ofRumi, to not forget the task for which we weresent.

Mindfulness and wisdom should be applied tothe practice of pharmacy in facilities or programsin which multiple health care workers collaboratefor the care of patients. For the sake of discus-sion, let us imagine that the pharmacy enterprisein these settings is well integrated with the totalcare of patients. Let us imagine further that theamount of work in the pharmacy enterpriserequires that the roles of individual pharmacistsbe differentiated. No single pharmacist doeseverything. Every pharmacist would concentrateor specialize in a set of tasks within the overallpharmacy enterprise.

What I have described commonly occurs in awide range of health care settings, includinghospitals, outpatient clinics, various chronic careprograms, and some group medical practices.Professional pharmacy practice has a strongfoothold in these settings, buttressed by a best-practices and continuous-improvement culture, ateam spirit, solid evidence of cost benefit, andgrowing demand by physicians. Practiceenvironments of this nature deserve a heavyinvestment of time, creativity, and commitmentby our best leaders. These settings are where thepharmacy profession is meeting its two impera-tives of survivability and social responsibility.

There is one aspect of contemporary pharmacyeducation that is disturbingly out of sync withthe needs of the pharmacy enterprise in progres-sive, complex practice environments. Many oftoday’s new graduates seem to have the self-concept of an independent clinical practitioner,uninterested and unconnected to the other vitalcomponents of the pharmacy enterprise. Pharmacycertainly needs more clinical specialists, but thatneed must not blind us to all the other essentialcompetencies required to serve patients well.

Particularly in inpatient hospital pharmacypractice, there is much to be gained through apractice model that integrates all pharmacists andtechnicians into a team that is committed toexcellence in the entire medication-use process.The specific functions within this pharmacy teaminclude general and specialized clinical practice,formulation and implementation of drug-usepolicy, product acquisition and inventory control,product preparation and distribution, sterileproduct compounding, medication-use safety and

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other quality initiatives, and effective implemen-tation of new technology.

The ideal pharmacy team is equipped tointerpret both science and pharmaceuticalmarketing, taking into account the more limitedcapacity that others on the health care team mayhave for such interpretation. Science in thiscontext includes clinical studies, of course, butalso information science; communicationsscience; systems analysis; the administrative,social, and economic sciences; and studies ofdrug stability and compatibility. These areas ofscience cannot be applied effectively to pharma-ceutical care as freestanding, independent fieldsof knowledge. They must be integrated tomaximize the overall value of the pharmacyenterprise to patient care. This level of integra-tion requires sophisticated leadership thatunderstands both operational and clinicalexcellence, inspires team commitment andcooperation, and communicates the value of thepharmacy team.

As new pharmacy graduates enter practice inhealth care settings, our profession will makebetter progress if they come already equippedwith this team-based understanding andphilosophy. We will make better progress if newgraduates understand their role as a componentof a larger whole. We will make better progress ifthey come with an open mind about careeroptions, including a willingness to explore theexciting change-agent opportunities in practicemanagement and leadership. Pharmacists whoare in a position to mentor students and residentscan serve our profession’s long-term future wellby encouraging these perspectives.

Conclusion

In my introduction, I began with a translationof Rumi’s writing to caution us not to forget thetask for which we have been sent. I will closewith a reading from the contemporary poet,David Whyte, who speaks eloquently to manyissues of the human spirit in modern society.This piece, entitled Start Close In,4 connects withthe message of Rumi and gives us a personalformula for mastering the fundamentals of visionand leadership—the fundamentals of producingconstructive change—in pharmacy.

Start close in,don’t take the second stepor the third,start with the first

thingclose in,the step you don’t want to take.

Start withthe groundyou know,the pale groundbeneath your feet,your ownway of startingthe conversation.

Start with your ownquestion,give up on otherpeople’s questions,don’t let themsmother somethingsimple.

To findanother’s voice,followyour own voice,wait untilthat voicebecomes aprivate earlisteningto another.

Start right now,take a small stepyou can call your own,don’t followsomeone else’sheroics, be humbleand focused,start close in,don’t mistakethat otherfor your own.

Start close in,don’t takethe second stepor the third,start with the firstthingclose in,the stepyou don’t want to take.

References1. Helminski K, ed. The Rumi collection—an anthology of

translations of Mevlâna Jalâluddin Rumi. Boston, MA:Shambhala, 2000:1.

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2. Repcheck J. The man who found time—James Hutton and thediscovery of the earth’s antiquity. Cambridge, MA: Perseus, 2003.

3. Day K. CVS, drug benefit manager to merge. Washington Post.

November 2, 2006:A1, A11.4. Whyte D. River flow—new and selected poems, 1984–2007.

Langley, WA: Many Rivers Press, 2007:362–3.

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