This chapter has suggested the existence of two identities for pharmacists which relate to the physical objects which are medicines – the maker of medicines and the dispenser and supplier of medicines.
The first of these can be divided into the ‘traditional medicines maker’ and the ‘contemporary medicines maker’. The traditional medicine makers – the pharmacists who compounded constituent ingredients, by hand, in the dispensary before supplying them to clients, have been viewed retrospectively as ‘craftspeople’, defined by their role as compounders of medicines, by Birenbaum.57 In terms of empirical research of pharmacists’ role orientations, Quinney’s scale originally included ‘compounding’ as a task which pharmacist could express their orientation towards. As noted in section 2.3.3, nowadays, medicines tend to be made in factories, Birenbaum viewed the loss of pharmacists’ compounding role as a threat to their professional status.57 Sociological theory on the professions claims that occupations have a specialist area of work which claim and which others cannot undertake.46 Birenbaum follows ideas such as this in arguing that pharmacists have lost their niche area of work. By losing their compounding function, Birenbaum was concerned that they had lost their professional status. Birenbaum
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suggested that pharmacists should move forward and ‘re-professionalise’ by embracing clinical roles and redefining pharmacy as a clinical profession.57
While the issue of the pharmacist as a maker of medicines has been absent from much of the pharmacy practice research literature, the empirical studies that followed Quinney73, (e.g.75,78 reviewed in section 2.7.2) make no mention of it. However, as data generated for this study have shown, the identity of the traditional pharmacist as a maker of medicines still exists, albeit mainly in the memories of study participants. This somewhat unexpected finding prompted me to search specifically for more recent literature which might address the issue of
extemporaneous dispensing. This search revealed that the subject has in fact received attention in recent years, both from within the pharmacy profession, in terms of an ‘improve versus abandon’ debate127 and from sociologists studying pharmacy education.127-129 Harding and Taylor in particular have paid attention to this topic. Unlike Birenbaum, they do not assume that the role is entirely a thing of the past, but suggest a number of potential benefits of pharmacists continuing to formulate medicines today, three of which in particular match with findings from this study. Firstly, Harding and Taylor claim that patients could benefit from:
the receipt of a bespoke medicinal product, which has been hand-crafted by a specialist “just for me”, and not mass-produced by a faceless industry.’130
Pharmacists in this study (in section 5.2.3) also thought that pharmacy users had appreciated the individualised service they received when medicines were prepared especially for them in the past. The ‘personal service’ aspect of traditional pharmacy where medicines could be made, is interesting considering that government pharmacy policy has emphasised that pharmacists must provide ‘patient centred care’.23,28
Secondly, Harding and Taylor perceive benefits to the pharmacists’ own sense of identity, in terms of a connection to not just knowledge about the constituent ingredients that make up a medicine, but direct experience of working with these to formulate medicines. They argued in 1999 that continuing to carry out extemporaneous dispensing was an opportunity to consolidate pharmacy’s identity, as extemporaneous dispensing is a ‘physical manifestation of the
pharmacist’s skills and training’.130 They conducted research with pharmacy students and staff on a university course teaching extemporaneous dispensing and their papers on this published in 2004 and 2005 showed that pharmacy students appreciated being taught extemporaneous dispensing and enjoyed the extemporaneous dispensing practical classes. One student commented that:
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Teaching staff also felt that the way that the skills required for extemporaneous dispensing are applied was ‘a creative process and as such akin to an art’.129 Formulation was further
described as an art that involved ‘experience and just feeling, rather than firm science’.128,129 The ideas conveyed here seem to link to two areas of focus of the power theorists’ views about professionals having esoteric knowledge and a sense of mystification (described in section 2.5.2.2).46,50,131 A pharmacy technician in this study described the traditional pharmacist as ‘conjuring up’ (section 5.2.3) medicines in the back of the shop - the word conjure means ‘to bring as if by magic’ which relates to the idea of mystique and esoteric knowledge.131 Other data presented suggest that pharmacists’ work traditionally had an element of mystery, probably more so than is associated with handing the client a box of pre-packed tablets.
Thirdly, as well as being associated with a sense of mystery, or esoteric knowledge, which is by nature intangible, Harding and Taylor have also argued that the fact that medicines are tangible, material objects, could contribute to a more ‘solid’ identity for pharmacists and that
extemporaneous dispensing is ‘a potent symbol of the pharmacist’s status and value to the community’.130 They argue for the value of retaining ‘the practice of formulating and manufacturing’ which they describe as being at the ‘very heart of pharmacists’
identity...encapsulated by the archetypal symbol of pharmacy – the pestle and mortar – an iconic image...’ 129 The data presented in section 5.2.2 show that the pharmacist as a maker of goods was indeed a clear, easily recognisable identity, for several participants in this study.
Harding and Taylor also argue that the more tangible benefits of cost-savings for the NHS and time-saving or convenience for patients would result, as a product made within a pharmacy could be more cost-effective for the national health service.130
Data presented in section 5.2.4 also highlighted that medicines are still routinely made in hospitals, in aseptic dispensing areas. While this type of work has received little attention within the research literature, one article, published in 2004, claimed that even though pharmacists would be unlikely to physically carry out much aseptic dispensing themselves in practice, it was beneficial to invest time in thorough teaching about aseptic dispensing procedures at university. This, it was argued, should ensure that pharmacists would enter practice with a high level of understanding of the principles of this type of work, which would help them to supervise it from a position of authority.132 A similar argument could be made with respect to extemporaneous dispensing and pharmacists’ ability to judge the quality of pre-made medicinal products that they handle in practice – that even if they are not called upon to make medicines, having experience and understanding of their makeup could be beneficial.
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In terms of pharmacists as suppliers of pre-made medicinal products, in a similar way to the traditional compounding role, the idea of the pharmacist as dispenser or supplier of medicines is rarely discussed in any detail in the contemporary policy literature. As noted (in section 2.3.6), government and professional policy direction has been for pharmacists to move towards supervising dispensing, while support staff undertake the actual physical tasks. When the government does mention pharmacists in relation to the supply of medicines, it is with reference to them as managers of the process, especially in hospital pharmacy.
Hornosty’s work, published in Canada at the start of the 1990s, conveyed concern amongst pharmacists that their profession was still seen by the public as that of the ‘pill counter’ and bottle ‘labeller’.78 Later in the same decade, Varnish (in a UK publication) wrote that technology was ‘rapidly making the tablet counter redundant’.133 This was with reference to ‘original pack dispensing’ and computer generated labels, reducing the counting and label writing/typing tasks. Today, in the UK, computer generated labels are common practice within pharmacy, dispensing robots have been installed in some hospital pharmacies, and some medicines can be ordered over the internet, and participants in this study associated pharmacists with such technology. However, pharmacists do still undertake dispensing work, particularly in the community sector, and the image of the pharmacist as a supplier of medicines and even as a ‘pill’ counter was still relevant for participants in this study.
Pharmacists’ function as suppliers of medicines is still appreciated, and this chapter identified four attributes of supply work which were valued – being quick, being accurate, being willing and being reliable. Of these, being accurate was the most important. For a prescription to be
dispensed accurately means that the products supplied match what is written on their label, which in turn matches what was prescribed (written on the prescription). The potential consequences of this not being done accurately could be tragic, for example in an extreme case, where a lethal dose of a medicine could be supplied, taken by the recipient and kill them. The accuracy check itself does not take long, does not require knowledge, just an ability to read the prescription and medicines’ labels so can be considered small but very significant. Indeed, interviewees in this study evoked both the vital importance of accuracy when medicines are being dispensed and also the responsibility entailed in doing so. Overall, pharmacists were seen as people who worked with a high degree of accuracy, however, there was some expression by pharmacists of a fear of the potential consequences of making a mistake that may overshadow their work.
Analysis of the empirical data generated for this study revealed five negative issues in relation to pharmacists’ identity as suppliers in terms of it being seen as boring, wasteful of pharmacists’ skills, technical in nature which therefore means it can be undertaken by machines, making the
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pharmacist replaceable and also potentially lowering their professional status, and also tends to take place out of sight, meaning pharmacists are often hidden from view. Lay clients and doctors seem to ‘accept’ the pharmacist as a dispenser ‘neutrally’, whereas pharmacists and community nurses expressed more concern and frustration with what they saw as pharmacists being stuck with work that was wasteful of resources (which is not beneficial to society)
replaceable/not esoteric (bad for professional status) boring to do (bad for the individual) and in terms of wider image - seemed uninteresting to others, had low status and low visibility (bad for the profession). A nurse in section 5.3.4 referred to pharmacists in general as ‘nerdy’, an adjective which describes the characteristics of a nerd, that is, a type of person defined by the dictionary as:
An insignificant, foolish, or socially inept person; a person who is boringly conventional or studious [also] who pursues an unfashionable or highly technical interest with obsessive or exclusive dedication. 124
The low visibility of pharmacists was also perceived by participants in this study to extend to pharmacist’s lack of coverage in the media. This has been noted by a previous study of pharmacists in the media undertaken in the USA.104
This chapter has explored the concept of pharmacists as makers and suppliers of medicines. Next, chapter six presents the ideas of pharmacists as scientists and medicines advisors.
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