Encircling Gloom: The Realities of Pharm D in India

Introduction

The launch of PharmD (Doctor of Pharmacy) program in India can be marked as a notable development in pharmacy education and practice (May 10, 2008, by the Ministry of Health and Family Welfare and The Pharmacy Council of India). It is a six-year integrated pharmacy doctoral program, pursued after completing 10+2 or a D. Pharm (Diploma in Pharmacy). It comprises five years of academic training, followed by a one-year internship. The goal of this professional doctorate program is to produce highly qualified clinical pharmacists capable of working in interdisciplinary healthcare teams, effectively managing pharmaceutical therapy, contributing to drug research and development, and engaging in pharmacy education.

The inclusion of Pharm D professionals is expected to reduce the workload of physicians, who currently serve as the sole managers of drug therapy in the Indian healthcare setting. More precisely, the Pharm D graduates are expected to actively participate in ward rounds and meetings, prevent medication errors, assess prescriptions, manage drug to drug interactions, monitor and report adverse drug reactions, play an active role in the selection of chemotherapeutic agents, provide patient medication counseling, and coordinate with community health services. As Pharm D is primarily a patient-centered curriculum, patients are expected to benefit the most from the services provided by these professionals. Patients can receive detailed information about their diseases, drugs, and necessary lifestyle modifications. Additionally, clinical pharmacy services would minimize the workload of physicians in the Indian healthcare system.^1-3

Since the 1960s, deliberations have been underway to make pharmacist training more patient-centric. The definitions of roles played by pharmacists, as outlined by organizations like the FIP (International Pharmacy Federation) and the ACCP (American College of Clinical Pharmacy), formed the foundation for these discussions. The core competencies of clinical pharmacists (CP) have been identified in various documents reviewed by the ACCP, the ACPE (Accreditation Council of Pharmacy Education) and the ASHP (American Society of Health-System Pharmacists). According to ACCP, the pharmacy profession encompasses personnel trained in the rational use of medications, extending beyond supplying and dispensing medicines.⁴ The need for patient counselling -beyond the scope of clinical consultation - has been strongly recognized as a means to bridge the asymmetry in knowledge of the patients and the clinicians. To address this issue, government authorities, pharmacists, and academicians proposed training programs, introducing new patient counseling methods in pharmacy curricula, and utilizing modern techniques and social media.^5,6 Further, some initiatives have introduced dedicated courses for pharmacists, such as patient counselling course offered by the Pharmacy Council of Maharashtra. The necessity to leverage clinical pharmacists' potential for improving healthcare outcomes has been increasingly acknowledged.⁷

Steps toward the active engagement of pharmacists in clinical care are evident not only in the developed Western nations, but also in developing countries. In Sudan, for example, clinical pharmacy has recently emerged as a specialty, requiring postgraduate training. Initiatives such as the University of Khartoum's master's program have facilitated this evolution. The Sudanese government has acknowledged the need to enhance pharmaceutical services and include clinical pharmacy in strategic plans. Challenges faced by clinical pharmacists in Sudan include overcoming educational barriers, collaborating with academics, healthcare professionals, and managers.⁸

Materials & Methods 

A cross-sectional study using a structured questionnaire was conducted involving 100 PharmD graduates and 30 hospital administrators. Respondent led sampling method was used, by which PharmD graduates referred their colleagues as subjects for participation in the study. A pilot study was undertaken by the researchers to design and validate the tool. Assuming an 80% prevalence rate of PharmD graduates being involved in direct patient care, and applying 95% confidence interval, the estimated sample size was calculated to be 97. Accordingly, 100 PharmD graduates were included in the study, out of which 30 hospital administrators who had employed PharmD graduates in their hospitals were identified and approached to obtain their perceptions on the prospects and challenges of employing PharmD professionals in hospital settings. This data was intended to complement the responses obtained from the PharmD graduates. The study was conducted after receiving approval from the Institutional Ethics Committee.

Statistical Analysis

Data were collected using a structured questionnaire which was mailed electronically via Outlook forms. The questionnaire, based on a 3-point Likert scale, included demographic details and other variables related to the current roles and future prospects of PharmD graduates in India, along with the challenges faced by the hospital administrators in employing them. Responses were categorized as follows: scores above 70% were considered ‘good’, scores between 50% to 69% as ‘moderate’, and scores below 50% as ‘poor’. The data were analyzed using SPSS. Cross-tabulations between demographical variables and study variables were computed, and the Chi-square test was performed to assess significant associations between categorical variables.

Discussion

A review of literature revealed several noteworthy parallels with the present study. An exploratory study conducted in Sudan in 2017 aimed to investigate the various roles of clinical pharmacists and found that diagnosing drug-related issues (100%, n=51), providing drugs related information to other medical personnel (96%, n=47), and educating patients about their medications were the most frequently performed responsibilities.8 Similarly, our study conducted in India highlights that the most prominent roles played by PharmD professionals in hospitals include therapeutic counseling of patients (73%, n=100 ) designing treatment protocol in collaboration with physicians (63%, n=100), and monitoring the use of narcotics (79%, n=100), (Table 2).

Hani Naseef et al., conducted a cross-sectional study in Palestine to assess the degree acceptance and awareness of clinical pharmacy among healthcare professionals. According to the findings, 259 respondents (83.8%) agreed that clinical pharmacists can provide pharmacological therapy management, dosage modifications, and drug-related information to both patients and medical professionals. A total of 263 respondents (85.1%) concurred that clinical chemists are adequately trained in patient counseling. This indicates that a majority of the participants firmly concur that clinical pharmacists possess the necessary education to provide patient counseling. According to 278 participants (90.0%), a clinical pharmacist in the clinical ward team improves the quality of patient care in a hospital setting. Notably, 75.4% of the 233 respondents disagreed with the notion that the involvement of clinical pharmacist compromises doctor's autonomy and independence.⁹ 

In the present study, a similar pattern was observed. The majority of hospital administrators (93%, n=30) believed that PharmD graduates enhance the quality of healthcare delivery, reduce medication errors, thereby enhancing the therapeutic value of the drugs used (93.3%, n=30). Furthermore, 63.3% (n=30) acknowledged that PharmD professionals contribute significantly beyond traditional pharmacy roles and not confined to working within the four walls of the pharmacy. Interestingly, while only 47% (n=30) of administrators disagreed with the idea that PharmD graduates reduce physician’s autonomy, and 27% stayed neutral, a significant 86.6% (n=30) disagreed with the statement that Pharm D professionals are a threat to the other pharmacy personnel (Table 3).

Venkataraman et al., conducted a study to explore the perceptions of healthcare practitioners (HCPs) in India regarding the Pharm D program and the services provided by clinical pharmacists (CPs). A cross-sectional survey using a 10-item questionnaire-based was administered to HCPs from the medical, nursing, pharmacy, and academic fields at a tertiary care teaching hospital in Karnataka, southern India. A total of 130 participants took part in the study. Among them, 91.54% (n=119) agreed that CPs can provide appropriate therapies for better patient care, while 92.31% (n=120) agreed that patient counseling by CPs can enhance medication adherence. Additionally, 82.31% (n=107) supported the inclusion of CPs in the multidisciplinary healthcare team.10 In our study, 93.3% of hospital administrators (n=30) acknowledged that CPs enhance the quality of healthcare delivery, 86.6% (n=30, Table 3.2) expressed a positive opinion regarding patient counseling by CPs, and 63% (n=30) opined that the role of CPs extends beyond medication supply (Table 3).

A study conducted in India in 2014 demonstrated that clinical pharmacists can play a significant role in the detection, prevention, and reporting of adverse drug reactions (ADRs). They may also provide recommendations to physicians regarding alternate drug therapies for individual patients.11 The present study further concludes that a majority of the CPs, 70% and 73%, respectively, (n=100, Table 2) are presently involved in ADR monitoring and providing therapeutic counseling to patients in collaboration with physicians.

A literature Review conducted in the United States highlights that the presence of CPs in emergency departments (ED) significantly enhances the efficiency of pharmacy services. Emergency physicians readily utilize and value the support of CPs in providing continuous care, 24 hours a day, 7 days a week, throughout the year. According to the review, ED Physicians have stated that the presence of CPs helps reduce the turnaround time in delivering appropriate care, thereby improving the overall quality of care.12 Similarly, in the present study, 93% of hospital administrators (n=30, Table 3) acknowledged that the presence of CPs in hospitals contributes to enhancing the quality of patient care.

Conclusion

 A significant proportion of PharmD professionals are actively involved in various aspects of medication management within hospitals. They contribute toward drug usage recording, auditing, and therapeutic counseling of patients in conjunction with treating physicians. While some Pharm Ds perceive teaching as a promising career path, opportunities in government organizations remain limited, with teaching roles currently confined to private facilities. A small percentage view research as a promising career path; however, most Pharm Ds lack the necessary opportunities to utilize their hard-earned doctoral training in research. Hospital administrators are primarily concerned about the management approaches and institutional policies that are not conducive to employing Pharm Ds. Nevertheless, the majority do not perceive appointment of Pharm Ds as a threat to physician's autonomy. According to the findings, a resounding majority of the administrators believe that hiring clinical pharmacists improves the quality of healthcare delivery. Despite this, they often cite constraints and limitations for employing them. Sixteen years after the program’s introduction in India, Pharm D professionals are still struggling to secure a significant role in the healthcare sector that aligns with the level of their doctoral research degree.

Strengths and limitation of the study

To evaluate the current situation and future prospects of PharmD graduates working in hospitals, the study surveyed both hospital administrators and PharmD graduates. Including perspectives of both groups provides a strong foundation for the study's conclusions. In future studies, PharmD teaching institutions can also be included to gather their views on the evolution of the course.

Conflict of Interest

There is no conflict of interest from any author present at any phase of the study.