Don't Be an Interchangeable Part

WHAT DOES IT MEAN TO BE A PROFESSIONAL?

A profession is said to arise when any occupation or trade transforms itself through “the development of formal qualifications based upon education, apprenticeship, and examinations, the emergence of regulatory bodies with powers to admit and discipline members, and some degree of monopoly rights.”¹

Following Wikipedia’s outline of the term, professionalism confers a state of greater-than-average influence in the industry, prestige, and semiautonomy. The concept of a profession was created to acknowledge and manage a set of human capital and skills that are both advanced and unique, in which the benefactors of the profession’s practice are particularly susceptible to dependency because of lack of knowledge and skills required of the practice. A profession is usually manifest with client-centric relationships, each being rela- tively distinct in both circumstance and context. Relationships between professionals and their clients often become sacrosanct and have led to protections under the law, such as attorney—client privilege and physician–patient privilege.

INTERCHANGEABLE PARTS AND ASSEMBLY LINES

Interchangeable parts were first popularized in the United States in the late 18th century when Eli Whitney (yes, the guy with the cotton gin) signed a contract to mass-produce guns for America’s defense. Standardized parts could be mass-produced, and as long as all those parts fit together to make a functional gun, the cost and the time to make those guns were greatly reduced. This allowed manufacturers to hire less skilled labor to assemble the parts rather than rely on craftsmen to produce each gun one by one.

The same strategy should also work well for health care services, right? Just teach aspiring students only the requisite portions of anatomy and mechanisms of drug action that are required to work within a pre-engineered system of patient evaluation, prescribing, monitoring, and follow-up, and place special emphasis on eliminating variation. That would do away with the need to teach providers skills beyond the systems as designed because no variances would be expected, no special patient cases would exist, and the need for patient context and uniqueness of circumstance, or patient receptivity to environment, would be obviated, as would historical interaction and provider rapport. Oh, and make sure all the providers fit nicely into this system so they can be mixed and matched into any community, culture, disease state, or geography and easily placed, removed, or replaced without affecting the system.

This was Dr. Atul Gwande’s 2012 Cheesecake Factory vision of health care.² What matters is the meal, prepared exactly the same way for the customer with the same ingredients, regardless of the location or staffing. It is an entrepreneur’s dream come true: no need for chefs, only cooks who follow a recipe. The individual cook does not matter. Hire, fire, place, replace, eliminate. In health care terms, just have robots do the surgery instead of artisans. The art of medicine fades.

Yet most of health care delivery requires doing something with and not to a patient, especially given that the need for managing chronic disease grows as the main driver of morbidity and health care utilization. Unlike in most surgical practices, such as Gwande’s, clinicians in primary care practices trade in trusted, often long-standing relationships between patients and physicians for the expression of effectiveness and value. Five years after his promotion of mass production in surgical procedures, Gawande acknowledged as much when he published a rebuttal of sorts to himself in the follow-up article “The Heroism of Incremental Care.” I highly recommend reading it, as the article has so many instructive parallels to what could foretell the future of pharmacy practice and the optimization of medication use, including deprescribing and avoiding medication chaos.³

The subtitle of his article says it all: “[The US health care system devotes] vast resources to intensive, one-off procedures, while starving the kind of steady, intimate care that often helps people more.”

Yes, intimate, relationship-based, and steady care that takes into consideration the entire patient journey over time is at odds with moment-in-time, on-off procedures.

“‘It is the relationship,’ they would say. I began to understand this only after I noticed that doctors, the front desk staff, and the nurses knew almost every patient who came through the door by name.”

ALWAYS BE A PROFESSIONAL: YOUR JOB DEPENDS ON IT

Pharmacists should ask themselves what they enjoy most about their pharmacy practices. Is it the conveyor-belt, mundane activities that the cook can cover or that the advanced practice pharmacy technician can handle? Or is it that conversation with a neighbor about their concerns, health goals, losses, and wins? Do you take the opportunity to materially participate in their health trajectory? Do you enjoy exercising professional judgment when the company’s legal team passes the red-flag alert on to you to determine the best course of action, or do you dread it as a time killer that destroys workflow? Being a professional at all times means that your activities require not only unique skills but also patient-specific goodwill, knowledge, and trust that are essential to well-managed, well-organized care delivery. Professionals do what mass production cannot.

ARE YOU A COOK OR A CHEF?

Does it matter whether you are in the pharmacy when a patient drops off a prescription? Or when they have a question? Or can anyone in the pharmacy do that in your absence? Can any phar- macist or technician replace you without affecting the pharmacy, just like Whitney’s interchangeable parts? Or are you a chef whom the customer has chosen based on your palate, style, and ability to provide you with an experience rather than a meal?

With thousands of pharmacists being laid off and many more entering the profession with daunting levels of student debt, making yourself indispensable is more important than ever. Somebody besides you has to be hurt if they are looking to cut staff members. Who suffers if you are replaced? Local care team members? Other pharmacy team members? Patients? What about patient outcomes?

WE NEED TO CHANGE THE EXPECTATIONS OF PHARMACY PRACTICE

Ultimately, we are all on this ship together, and it will either crash on the rocks or weather the storm to live for another half-century of prosperity. We all need to be professionals, every day, with every encounter. We need to keep the profession of pharmacy intact, and to do so, it cannot comprise one pharmacy here or one pharmacy there that does things differently. It has to be thousands of pharmacies and tens of thousands of pharmacists who reprofessionalize our practice.

Why? Because exceptionally low consumer expectations of pharmacy are retarding our ability to evolve, and those expectations will not change without a demonstration of indispensable professional activities, activities that would otherwise be impossible to provide if using interchangeable parts. The craft beer market took off about a decade ago. Yet craft beer has existed longer than mass-produced beer but had never flourished until recently. What changed? Critical mass was achieved, and most consumers had access to craft beer, and thus the consumer marketplace changed its palate. That resulted in a change in consumer expectations of what the beer drinking experience was. Can we do the same in pharmacy?

Now is the time reconnect with local, national, and state professional pharmacy associations. You need them, and they need you. The old wars are nearly decided, and we are barely hanging on, so now we fight for new opportunities. We need a pharmacy revolution to happen soon. Consumer expectations will not change without it.

Troy Trygstad, PharmD, PhD, MBA, is vice president of pharmacy programs for Community Care of North Carolina. He also serves on the board of the American Pharmacists Association Foundation and the Pharmacy Quality Alliance.

REFERENCES

• Bullock A, Trombley A. The New Fontana Dictionary of Modern Thought. 3rd ed. London, England: Harper-Collins; 2000.
• Gawande A. Big med. New Yorker website. newyorker.com/magazine/2012/08/13/ big-med. Published August 6, 2012. Accessed September 30, 2019.
• Gawande A. The heroism of incremental care. New Yorker website. newyorker.com/ magazine/2017/01/23/the-heroism-of-incremental-care. Published January 23, 2017. Accessed September 30, 2019.