Pharmacy: A Brief History of the Profession

By embarking on a career in pharmacy, you are joining an ancient and honorable profession that deals with the latest, up-to-date technological advances for the benefit of mankind. Today’s status of the profession and those who practice it results from an evolution over thousands of years, with the greatest change for students of the field coming during the past two centuries.

Some aspects of the profession have been constant, unchanged over centuries – the focus on helping patients deal with maladies, the ability to apply contemporary understanding of science and technology to health-related issues, and the ethical mandate to place the patient at the center of all we do as pharmacists. Other facets of the specialty have evolved only over recent years.

The evolution of pharmacy from the perspective of a student

The statement that “What is past is prologue” [1] appears on the base of Robert Aitken’s sculpture “The Future” outside the National Archives Building in Washington, DC. This is to remind us that we should study the past in order to best anticipate and be prepared for the future. A complete and detailed review of the historical evolution of the profession is beyond the scope of this article so interested readers are referred to several other excellent detailed sources. [2-5] The emphasis here will be on identifying selected developments felt to be of particular interest to students.

Apprenticeship
For centuries the exclusive way one could enter the profession was through apprenticeship. Under this system the aspiring pharmacist, most likely known then as an aspiring apothecary, would work side-by-side with the established professional practitioner, learning by observing and doing medication-related activities under the tutelage of the master craftsman or “master.” At some times and in certain locales it was not unusual for the apprentice to even live with the family of the master. An infamous example of an apothecary apprentice was Benedict Arnold, who served in the role for five years before operating a successful pharmacy for twelve years. His infamy came from his traitorous role in the Revolutionary War, fortunately not from any connection with pharmacy.

For a major portion of the twentieth century in order to be eligible to sit for the licensure examination a student pharmacist was required to complete a period of practical experience under a practitioner approved by the state board of pharmacy to serve as a preceptor. In most states part of these hours, usually totaling nearly a year overall, could be completed during the summers between terms of enrollment in classes, with the student being referred to as a “pharmacy extern.” Typically, those same states would also require that a portion of the total hours be completed following graduation, with the term “pharmacy intern” then being used for the recent graduate. A minority of states required that all practical experience requirements for licensure be met following graduation, making it essentially a capstone experience by the pharmacy intern. This emphasis on rounding out the education of the student with a practical experience component can be viewed as a vestige of the apprenticeship system, i.e., learning at the elbow of a seasoned professional.

Today those experiential components of the learning continuum have been moved in the curriculum under an approach that has the students completing all or nearly all of their rotation-based learning as part of degree requirements. The thinking behind this change was two-fold: first, having the experiential learning under the control of the educators should lead to better educational experiences for the students; and second, by using a rotational approach the students can get a variety of experiences in myriad settings rather than only learning from one preceptor in a single locale as usually had been the case. What’s the downside? Now that it’s an educational component students pay tuition for it whereas before the students received pay for their efforts.

Before moving on it is appropriate to take a moment to dwell on terminology. The point was made above that pharmacists used to be referred to as apothecaries. That term is still with us through a national organization known as the American College of Apothecaries, a membership organization for pharmacists who operate their practices in a fashion consistent with the standards of that organization. [6] It should also be noted that in Australia, New Zealand, and the UK, a pharmacy is often referred to as “the chemist.” Finally, in the U.S. one will sometimes still hear the outdated term “druggist.” A druggist was a pharmacist who owned a pharmacy, whereas the people who today would be called “staff pharmacists” at that same establishment were then referred to as “clerks.” So, if you’re reading historical materials about pharmacy, such as, say, old lawsuits against pharmacists for a term paper, note that the clerk is indeed a pharmacist.

Formal Education
The first college to train pharmacists in the U.S. was founded in 1821 as the Philadelphia College of Pharmacy. Impetus for this came from a plan by local physicians to start training pharmacists. Local pharmacy leaders were outraged that physicians would presume to be able to train pharmacists. Hence, the pharmacists were motivated to start their own program. This institution today still bears the same name and is part of the University of the Sciences in Philadelphia. [7]

Boston pharmacists shortly followed (1823) with the second college, the Massachusetts College of Pharmacy, now the Massachusetts College of Pharmacy and Health Sciences. Institutions in New York City, Baltimore, Chicago, and St. Louis followed so that by the end of the Civil War a number of institutions existed, centered primarily in the Northeastern U.S.
The astute reader will notice a pattern in these early schools — they were in urban areas and were private institutions launched by groups of practitioners. The first pharmacy program in a public institution came along at the University of Michigan in the late 1860’s.

The year 1862 had brought enactment of the Morrill Act through which Congress encouraged development of “land grant” universities by giving each state 30,000 acres of public land for each U.S. Senator and Representative from the state under the 1860 census. This land was to be sold to create an endowment to support creation of a university teaching practical courses. Most college-level instruction in the U.S. until that time emphasized the classical fields of law, theology, and perhaps natural history. A number of schools of pharmacy in the U.S. are at these land-grant institutions.

Now we need to fast-forward to the era of World War II. Many of the independent colleges of pharmacy had become affiliated with universities over the years. Those that had not done so faced perilous financial times during the war because of being heavily dependent on tuition revenue for operations. Pharmacy students were overwhelmingly male at that time and when most became soldiers and went off to fight the war the schools fell on hard times.

At the same time, academic health centers began to emerge at U.S. universities as clusters of schools of the health professions assembled with a university hospital operated for the dual purposes of providing patient care and educating future professionals. Many of these operations included colleges of pharmacy.

Evolution of the Pharmacy Curriculum
To examine the pattern of pharmacy curricula over the past century we begin with an approach under which colleges of pharmacy offered the academic degree Graduate in Pharmacy (Ph.G.). For an additional year of study the student would be awarded the degree Pharmaceutical Chemist (Ph.C.) and even further study could earn the student the degree Doctor of Pharmacy (Phar.D.).

By the 1940’s this approach had been given more uniformity with the move with the four year baccalaureate degree as the norm, frequently abbreviated B.Sc. After World War II a group under the auspices of the American Council on Education, a national organization of higher education specialists, studied the situation in pharmacy and recommended that the profession adopt a uniform six year curriculum for entry into practice. Many schools were unwilling to make the jump from a four-year program to one of six years duration so they compromised with a five year professional degree, the Bachelor of Science in Pharmacy (B.S.Pharm.). [8] Only a few schools on the west coast of the country adopted the shift to a six year curriculum at that time.

It deserves emphasis that the configuration of two years of pre-professional work followed by four years of professional study was adopted not to allocate additional time for the professional coursework but to assure an adequate time for pharmacists to get a grounding in general education before commencing professional coursework. When the colleges moved from the four year curriculum to the five year curriculum they exhibited creativity in how it would be structured. The most common approach was a 2+3 configuration but some schools adopted a 1+4 structure while others used a 0+5 approach with students admitted to the pharmacy degree program directly out of high school. By the late 1990’s all this was moot because the profession had moved to a six year Doctor of Pharmacy (Pharm.D.) degree as a standard, although some schools continued to admit high school applicants directly to the professional curriculum, a so-called 0-6 program. It can be argued that moving the experiential component from externship/internship into the curriculum left the total time to qualify to sit for the licensure examination unaffected – 5+1 with the B.S.Pharm. programs versus 6 years with the Pharm.D. degree.

During this same timeframe the focus of the pharmacy curriculum was shifting. Originally heavily rooted in chemistry, the pharmacy curriculum of the early 1900’s prepared a pharmacist not only to prepare and dispense medications but also to do what today we would call clinical chemistry or medical technology, e.g., urinalysis, etc. The chemical focus gradually transferred over to a biological focus during the 1960’s with increasing emphasis on pharmacology. Then during the 1970’s a clinical focus began to emerge, moving the emphasis from the product to the patient. [9]
As the hallmark of the pharmacy curriculum became a focus on patient care it was realized that no part of the pharmacy curriculum included patient contact. This was in stark contrast to nearly all other training programs for health professionals. The colleges moved to incorporate this modification this as well.

In the 1990’s a new philosophy of pharmacy practice was advanced by Helper and Strand – pharmaceutical care. The touchstone of this approach was that the pharmacist should accept responsibility for assisting patients to obtain the very best outcomes from their use of medications. [10] This was in response to a number of reports that indicated that pharmacists were doing a relatively admirable job of distributing medications – things – but not performing so well in distributing information about how to best use them and assisting patients with getting the best results. [11] This concept was embraced by the faculty and carried into their interactions with students.

One final point related to pharmacy education is the importance of accreditation. Institutions of higher education are accredited by a number of regional accrediting agencies that have jurisdiction within geographic subdivisions of the country. Professional degree programs in pharmacy are accredited by the Accreditation Council for Pharmacy Education (ACPE) based in Chicago, IL. [12] These agencies publish standards for either the institution as a whole (regional agencies) or the degree program in particular (specialty agencies). They periodically send visitation teams to campus to review institutions and programs to assure the standards are being met. During such visits they typically meet with groups to students to collect their views.

Accreditation is critical because state laws require that an applicant for the licensure examination be a graduate of an ACPE-accredited degree program designed to train pharmacists for entry into practice, a so-called “entry-level degree program” or “first professional degree program.” Students considering enrolling at an institution to complete a Pharm.D. degree program should carefully review its accreditation status. And remember, as with the somewhat controversial U.S. News & World Report rankings, it is the Pharm.D. degree program being rated, not the school.

Licensure
One of the earmarks of an occupation that is regarded as a profession is a licensure requirement for those engaged in practice. In the U.S. such licensure has existed for pharmacists for nearly a century and a half, with some early but very different approaches preceding that by an additional half century.

The pharmacy graduate must apply to the board of pharmacy in a particular state to take the licensure examination. That agency, composed primarily, but not exclusively, of pharmacy practitioners has been delegated authority by the state legislature to license pharmacists, establish standards for their practice, and administer enforcement and discipline programs.
The licensure examination typically is composed of two parts, both administered by the National Association of Boards of Pharmacy. The first, the North American Pharmacist Licensure Examination™, known colloquially as NAPLEX®, is designed to assess whether the licensure applicant possesses the minimum competence to be admitted to practice. The second part, the Multistate Pharmacy Jurisprudence Examination® or MPJE®, uses questions on federal law as well as on state-specific statutes and regulations to assess the licensure candidate’s knowledge in those areas. The examinations are now administered by computer. [13]

Once licensed the pharmacist has a professional, ethical and legal obligation to maintain competence to practice. The vast majority of states have in place a continuing education requirement for renewal of licensure, typically fifteen contact hours of education per year. Some states have adopted specific requirements such as a certain amount of time devoted to a pharmacy law update each year or periodic updates on certain disease states, e.g, HIV/AIDS.

A somewhat related process that is associated with establishing one’s professional competence is specialty certification. While this is not administered by a governmental agency like the licensure examination, board certification has come to pharmacy just as it has assumed a major role in medicine and other health professions. By taking an examination created by a national voluntary agency a pharmacist can obtain external validation and documentation of professional expertise. The primary vehicle for this is the Board of Pharmaceutical Specialties. [14]

Organizations
Early organizations for pharmacists were the guilds of Europe where members of an occupation or profession would gather to address common issues and organize training of apprentices. Local organizations in the country during the first half of the 19th century were primarily focused on educational issues as addressed above. In the U.S. the first national organization for pharmacists was the American Pharmaceutical (now Pharmacists) Association, launched in 1852 in Philadelphia. APhA was and is the “umbrella” organization for American pharmacy where all pharmacist can come together regardless of specialty area of practice.
Over the years a number of specialized organizations have also evolved in pharmacy, focusing on locus of practice, e.g., American Society of Hospital (now Health-System) Pharmacists, professional specialization, e.g., American Society for Pharmacy Law, or category of patients served, e.g., American College of Veterinary Pharmacists.

A look ahead for the future of the profession and the role of the pharmacist
What does the future look like for this esteemed profession whose practitioners are very highly regarded by individual patients and the public collectively? The future is limited only by the imaginations and abilities of those entering and leading the profession.
Change is a certainty – will you be positioned to capitalize on opportunities as they emerge and evolve? Perhaps this is best summed up through a quotation attributed to Charles Darwin:

 “It is not the strongest of the species that survive, nor the most intelligent that survives, but the one most responsive to change.”

Charles Darwin

Do pharmacists have knowledge and abilities to provide services valued by others? Can their services have a positive impact on others? Are they accessible so people can avail themselves of these services? Can pharmacists discern emerging trends and opportunities to advance the profession and themselves? One need only look at the tremendous growth that occurred in the nursing home or long-term care industry in this country during the 1970’s and 1980’s as a result of creation of the Medicare and Medicaid programs in 1966. Astute pharmacists identified this as a professional opportunity, thereby creating the field known as consultant pharmacy to serve patients and residents in long-term care facilities of a variety of types – skilled nursing facilities, intermediate care facility, residential care facilities, etc.

Pharmacy school can provide you with an excellent grounding, a springboard you can use to launch a successful, satisfying, fulfilling and rewarding career. It’s up to you to identify the opportunities to apply your skills, knowledge and abilities.

References
[1] Shakespeare, W. The Tempest, Act 2, Scene 1.
[2] Sonnedecker G. (ed.), Kremers and Urdang’s History of Pharmacy (4th ed.), Philadelphia, PA: J.B. Lippincott Company (1976).
[3] Higby GJ. From compounding to caring: An abridged history of American pharmacy, in Knowlton CH, Penna, RP (eds.) Pharmaceutical Care. New York, NY: Chapman & Hall (1996), pp. 18-45.
[4] Higby GJ. Evolution of pharmacy, in Troy DB (ed.) Remington: The Science and Practice of Pharmacy (21st ed.), Philadelphia, PA: Lippincott Williams & Wilkins (2006), pp. 7-19.
[5] Posey LM. Development of pharmacy in history as a healing profession, in Posey LM (ed.) Pharmacy: An introduction to the profession, Washington, DC: American Pharmacists Association (2003), pp. 8-18.
[6] More information available at http://www.americancollegeofapothecaries.com/
[7] See http://www.usp.edu/aboutUSP.
[8] For more information about this degree designation see Fink III JL. Viewpoint – A matter of degree: Let’s get it right. Drug Topics, 2007(March 5);151:64.
[9] For example, see Fink III JL. A student’s opinion – The patient or the product. J Am Pharm Assoc. 1969;NS9:140.
[10] Hepler CD, Strand, LM. Opportunities and responsibilities in pharmaceutical care. Am J Pharm Educ 1990;53:7S-15S.
[11] Millis JS et al., Pharmacist for the future: The report of the Study Commission on Pharmacy. Ann Arbor, MI: Health Administration Press (1975).
[12] More information available at www.acpe-accredit.org.
[13] More information available at www.nabp.net.
[14] More information available at www.bpsweb.org.