L Leemans1, L Willems2, R Kinget 1, N Verbeke1, A Verbruggen1, D Knockaert2, G Laekeman1 1Faculty of Pharmaceutical Sciences, KU Leuven; 2UZ Leuven, Belgium

DOCTOR AND PHARMACIST, HAND IN GLOVE? REPORT AFTER A YEAR OF CLINICAL INTERNSHIP IN BELGIUM

At the dawn of the 21st century, doctors and pharmacists appear to be seeking more and more contact with each other. The main motives appear to be in the area of pharmacotherapy. This paper provides a general review of the history of collaboration between physicians and pharmacists, focusing especially on cooperation with hospital pharmacies. It also describes the clinical internship, during which final-year students in pharmacy are offered 2 months’ training in various hospital departments. In the academic year 1998–9, after a strict selection process, 12 students followed the training and seven departments were explored: endocrinology, g a s t ro e n t e ro l o g y, internal medicine, oncology, paediatrics, pneumology and emerg e n c y medicine. By means of this interdisciplinary method of education, the KU Leuven is striving for a practically oriented training, that a student must study to guarantee adequate provision of care in the 21 st century.

KEY WORDS: Belgium, collaboration, doctors, education, pharmaceutical care, pharmacists

HISTORICAL RELATIONSHIPS to have frequent conversations. The topics discussed Those who believe that collaboration between doctor and were mainly therapeutic matters (usually regarding new pharmacist is a brand new development in the framework drugs and drug interactions), the method of prescription of our profession are wrong. These professions have (both regarding specialties and individually prescribed a p p e a red to be naturally linked to each other for preparations) and repayment stipulations [2]. Practically centuries. The occupation of pharmacist evolved from an all doctors and pharmacists, together with our northern independent business in antiquity to a specialized branch neighbours, discuss prescription conduct between of medicine in the Middle Ages and, subsequently, again themselves in the so-called Pharm a c o t h e r a p e u t i c became an independent profession from 1240. In that year Consultative Groups (Farm a c o t h e r a p e u t i s c h e Emperor Frederick of the Hohenstaufen ordered the clear Overleggroep - FTO) [1,2]. This initiative has a following separation of the preparation and supply of medicines due in Belgium in the so-called IOGA groups (Interactief to a failed poisoning attempt on his life by his court Overleg tussen Geneesheren en Apothekers – (interactive physician. From then on doctors and pharmacists worked discussion between physicians and pharm a c i s t s ) . separately. A gradual change occurred in this during the Unfortunately we have established that these IOGA 15th and 16th centuries. There was often a shortage of initiatives remain small scale and are only welcomed supplies in the average pharmacist’s stock. In some cases enthusiastically in the Province of Antwerp. this led to rather too creative solutions, where the sometimes-shady concoctions occasionally brought the Within the hospital, contact between doctors and population into direct danger. As a consequence of this, pharmacists does not always run smoothly, although we the decision was made that, in future, the doctor would have noticed a trend towards collaboration. The first s u p e rvise the stock and preparations made by the official collaboration between the body of doctors and the pharmacist. This continued until the beginning of the pharmacy began at the UZ Leuven (University Hospital 20th century. Ever since, the pharmacist has again been of Leuven) in 1971 with the foundation of a clinical code: the official inspector of safety for drugs and prescriptions the classification of drugs according to their clinical use, [1]. distinct from the not-yet developed ATC (Anatomical – Therapeutic – Chemical) code. During subsequent years, PRESENT POSITION steps were taken on the initiative of the hospital Doctors and pharmacists again appear to be seeking pharmacists to rationalize the use of drugs in hospitals. contact with each other, albeit tentatively. This time the During that time the government also form u l a t e d motives mainly appear to be for pharmacotherapy. A recommendations in order to arrive at a judicious use of survey carried out by intern supervisors at the KU drugs. The first formulary regarding the use of antibiotics Leuven (Katholieke Universiteit Leuven) showed that the appeared in UZ Leuven in 1975. Gradually a commission majority (58%) of those questioned only sporadically for antibiotics was established in order to observe the contacted the doctor, 16% never did so and 26% claimed use of these products and to formulate guidelines.

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All this encouraged contact between pharm a c i s t s , tradition and fear of losing the monopoly. Doctors and m i c robiologists and clinicians. Over the years, pharmacists have never learnt to talk to each other at a formularies followed for parenteral nutrition and for professional level. Training to be a doctor or a pharmacist c a rdiovascular and gastrointestinal products, which is completely independent of each other. Perhaps this lies encouraged contact with doctors. These contacts were at the foundation of the problem? not limited to the use of drugs. Medical materials also became the subject of numerous working groups in which CLINICAL INTERNSHIP: A CHALLENGE doctors, nursing staff and pharmacists were present. The time now seems right to bring doctors and pharmacists together, at least with regard to training. A The Royal Decree of 23rd March 1991 officially instituted few exchange initiatives started in October 1998 between the Medical Pharmaceutical Committee (MFC), the pre- the two faculties at the KU Leuven: eminent consultative organization for management, doctors, pharmacists and nursing [3]. The MFC’s main • The faculties of Medicine and Pharmacy are duty is to draw up and preserve a therapeutic formulary, implementing a project at an academic level, to as well as to develop guidelines regarding the adequate investigate the value of self-tuition within a course of use (both therapeutically and economically) of communication training. pharmaceutical products. In addition, this Royal Decree • Final year pharmacy students (at least those following describes the activities that should be carried out by the the Healthcare programme) and general practitioners in hospital pharmacy in relative detail, where some clinical, training will be off e red similar pharm a c o t h e r a p e u t i c m u l t i d i s c i p l i n a ry duties are clearly and concisely consultation sessions during which various drug histories suggested for the first time. In short these are as follows: will be scrutinized. The idea is to develop these sessions interactively in the future, where doctors in training and • Distribution of drugs: preparation, delivery, supply and final year pharmacy students will come together. A kind quality control of IOGA project during training! • Multidisciplinary activities through a number of • At the moment a very valuable initiative in our training consultative groups is the clinical internship. In the final year, pharmacy • Clinical activities (!): among others, monitoring drugs students are given the possibility of 2 months’ internship and distribution of information in various hospital departments. This gives them the • Personnel training opportunity to study syndromes more closely and to understand the rationality of the administration of drugs. The Royal Decree of Febru a ry 1997 re g a rding fixed At the same time they learn to communicate with doctors, repayment for the prophylactic use of antibiotics in a conditio sine qua non in the framework of future surgery again offered the opportunity to bring about ph a r macotherapeutic consultation and therapy training. interdisciplinary contacts [4]. At the same time, this Royal Decree actually caused what one can consider to The internship is incorporated in the general medicinal have been the first small steps within clinical pharmacy internship. The total duration of the internship for these – at least according to Anglo-Saxon standards. Currently students amounts to 7 months (5 months in a a hospital pharmacist spends a few hours per day in the community pharmacy and 2 months’ clinical internship surgical department in order to check the prescriptions in the hospital). more closely. This is mainly in order to support nursing s t a ff with the administration of drugs, without In order to give the project a good chance of success the interference from doctor and prescription, as well as to students are only introduced into the hospital in small collect information regarding prophylactic framework numbers and after strict selection. Twelve students implemented. A financial follow-up of this fixed followed an internship during the academic year 1998–99 repayment also takes place in the hospital pharmacy. The and seven departments were explored: endocrinology, reasons for deviation, such as the administration of other g a s t ro e n t e ro l o g y, internal medicine, oncology, p rophylactic frameworks, are investigated. Only paediatrics, pneumology and emergency medicine. From consumption information, not information about a the academic year 1999–2000 the 'Middelheim' general particular patient, is periodically discussed with the hospital in Antwerp will be involved in the project along doctors if possible. with the departments of geriatrics and dermatology in the UZ Leuven. The interns’ home base remains the hospital In Belgium, as in many other European countries, there is pharmacy, where they can ask all kinds of ad hoc not yet any question of an actual clinical pharmacy, as questions and where all kinds of written and computer- has been developed in America and England in particular controlled sources of information can be consulted. After and where pharmacists give pharmacotherapeutic advice an induction day regarding organization of the hospital to doctors at the patient’s bedside [5–7]. It is clearly a p h a rmacy they spend a month accompanying the little early for this and no doubt there is still a long road assistants and supervisors in emergency medicine and the to travel before we reach this goal. Why this reticence department of internal medicine. There they come into still exists between the two professional groups is not contact with extremely diverse pathologies. They see the completely clear. Lack of time for attendance in the case history of the patient, get an idea of the thought nursing departments is certainly a factor for hospital patterns of the doctor when making the differential pharmacists. But presumably everything mainly rests on diagnosis and follow the reasoning of the doctor in his

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choice of treatment. During the following month they The report defines clinical pharmacy as the science that spend time in a more specialized department, where the naturally centres on the solution of clinical patients’ number of pathologies is more limited but where the problems by calling on the clinical sciences. Clinical progress of the illness is followed in great detail. During pharmacy mainly aims at medical and illness-related this internship they are also given the opportunity to p roblems. In other words, clinical pharmacy and attend all kinds of functional measurements (for p h a rmaceutical care have the same basic idea, but example, endoscopy, lung function measurement) and to pharmaceutical care places the whole individual in the take part at doctors’ discussions at which extremely centre (including social and ethical aspects) and does not i n t e resting pharmacotherapeutic cases are often solely consider disorder and pharmacotherapy [11]. presented. Many of the educational topics suggested in this report The students are supervised fairly intensively. A meeting a re already off e red in the pharmacy curriculum of is organized twice per month in the hospital pharmacy students following the healthcare programme at the KU where practical problems can be raised and interesting Leuven. Since 1991 the curriculum has been modernized cases can be discussed. The intern is asked to develop one and the students are taught practical courses, such as of these cases by, on the one hand, following the patient p h y s i o p a t h o l o g y, pharm a c o t h e r a p y, communication during the internship and, on the other, browsing through training, and basic pharmacoepidemiology concepts, literature on the subject (Table 1). In this way the student partially through self-study. Legislation, social law and learns to cope with various sources of information, an ethics had already been included in the curriculum long ideal way for him/her to prepare for life-long learning b e f o re. The introduction of the clinical pharm a c y [1, 8–10]. On the other hand these meetings are an internship is another step in the right direction. invitation for the hospital pharmacists at UZ Leuven to obtain information about the daily use of drugs.

Table 1. Examples of cases developed during the internship.

TRANS-EUROPEAN TRAINING However, the current curriculum is not completely in The European Association for Pharmaceutical Faculties keeping with the knowledge requirements needed to (EAFP) recently published a re p o rt re g a rding the carry out the duties of a clinical pharmacist adequately. implementation of pharmaceutical care in the pharmacy Knowledge of pharmacotherapy concerning antibiotics, curriculum [11]. The increasingly more important place anti-tumour agents and other life-saving pro d u c t s of pharmaceutical care in training is delineated in this p a rticularly appears to be lacking. A basic package in an extremely concrete manner. Clinical pharmacy (knowledge, skill, and proficiency) concerning these areas is one subject, next to pharm a c o e c o n o m i c s , should at least be offered. A number of dimensions could p h a rm a c o e p i d e m i o l o g y, social and administrative subsequently be off e red in more detail in the pharmacy, law and ethics, dispensing, symptomatology, specialization training for hospital pharmacists. If we health promotion and disease prevention (Figure 1). want to present ourselves as drugs consultants to doctors, an in-depth discussion of these pharmacotherapeutic groups must certainly not be omitted [12,13].

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Figure 1. Relation of pharmaceutical care to other fields and activities [11].

CLINICAL PHARMACISTS IN BELGIUM: of manpower and remuneration of the patient-oriented FORECASTING THE FUTURE service then arises. The number of hospital pharmacists One of the objectives of clinical internship is the is usually too low to guarantee a daily round in promotion of pharmacotherapeutic consultation between the departments, let alone time to converse with doctor and pharmacist. As in the USA and various all the patients. Despite the fact that numero u s European Countries, this initiative is supposed to be the p h a rmacoeconomic studies have shown the money- start of a new role for the hospital pharmacist, where he saving effect of clinical pharmacists within a hospital, or she can play an important part in the departments the government still does not seem persuaded to provide themselves in pharmacotherapeutic policy. It appears a larger budget for the implementation of this kind of from recent research in 548 American hospitals that, in clinical-pharmaceutical provision of care [7,8,17,18]. m o re than 95% of the hospitals involved, various supervisory commissions guard drug distribution and use P h a rmacotherapeutic consultation between medical and that, in 80% of cases, the hospital pharmacists pharmacists and doctors appears less than evident. To organize daily consultations themselves during which e n s u re interactive consultation and drug superv i s i o n patients can request information about their dru g s f rom the medical sector, communication skills are [12,14]. Clinical pharmacy is also mainly important in a n e c e s s a ry in addition to well-adapted inform a t i o n hospital environment in the United Kingdom [5,6,15]. technology [15,16,19]. The lack of fee regulation for However, it should be stated that the countries where p h a rmaceutical provision of care is an even gre a t e r clinical pharmacy is flourishing are those with a budget- hindrance to its implementation [13,20,21]. led health service. This means that the hospital has a Nevertheless, initiatives are increasingly being started to limited budget per sector and, consequently, the global promote clinical pharmacy outside the walls of the pharmaceutical budget also has to be spent in a cost- hospital pharm a c y. Between 1995 and 1998 the effective manner. A negative factor in the development of multinational TOM-study (Therapeutic Outcome clinical pharmacy in our country is that only the M e a s u rement), known in Belgium as ASTMAT O M , government and not the hospitals themselves benefit m e a s u red the impact of the intervention of the from the economical use of drugs. In addition, as in the pharmacist on the quality of life and compliance in Netherlands, we can argue that hospital pharmacists are therapy of asthma or COPD patients [22]. The working too ‘expensive’ to be active in the departments in large g roup 'Pharmaceutical Perspectives' of the APB numbers. (Algemene Pharmaceutische Bond – General Pharmaceutical Association) suggests a number of forms, If we were to follow the Anglo-Saxon pattern, the position to be completed by the pharmacist, in order to optimize of the hospital pharmacist should gradually evolve to that contact between doctor, pharmacist and patient [22]. of a ‘healthcare manager,’ where he or she would work In addition to the optimization of interd i s c i p l i n a ry pro-actively as a direct partner of the doctor, with the collaboration, such documents must also confirm patient as the main purpose [16]. Of course, the question the value of pharmaceutical provision of care to society

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