Clinical pharmacology and therapeutics in a changing world

New drugs have contributed significantly to the economic impact of new developments in health care. Traditionally Clinical Pharmacologists have been very active in this area through involvement with the British National Formulary, the Drug & Therapeutics Bulletin, and Prescribers Journal. More recently the introduction of the new National Institute for Clinical Excellence (NICE) in England and Wales[1], and the Scottish Intercollegiate Guidelines Network (SIGN) in Scotland have been put in place to address these issues. Senior Clinical Pharmacologists are making major contributions to the promotion of clinical excellence and the development of guidelines through their active involvement in all these initiatives, and in addition contribute extensively to postgraduate and undergraduate medical teaching.

Clinical Pharmacologists also contribute substantially to the development of new medicines and to the world-leading success of UK pharmacology, as judged by its place in impact tables[2], and to the pre-eminent place of the UK pharmaceutical industry. According to these criteria it might be expected that Clinical Pharmacology & Therapeutics as a specialty would be thriving within the United Kingdom. However as a small specialty, clinical pharmacology and therapeutics is very sensitive to modest changes in numbers, and to the participation of senior Clinical Pharmacologists in National activities. Over recent years there have also been changes in University curricula and a loss of individual pharmacology and clinical pharmacology departments as they have been merged into larger groups. A survey of academics with responsibility for teaching and training in clinical pharmacology and therapeutics conducted in 1996[3] revealed that 90% of respondents thought that recruitment for training posts was more difficult than 5–10 years earlier[4].

Clinical Pharmacology & Therapeutics in the UK is therefore not in robust good health. The ABPI has recognized a shortage of Clinical Pharmacologists to meet the demands of industry and with the NHS Executive has funded training posts to try and meet this need. The wider needs of the NHS and academia also require active consideration.

The United Kingdom experience appears to be echoed in the United States. Thus the theme of Robert Vestal’s Presidential address to the 99th annual meeting of the American Society of Clinical Pharmacology & Therapeutics—‘The clinical pharmacologist: An endangered species?’[5]. He presented data indicating that the number of programmes and training posts in clinical pharmacology and therapeutics in the United States had peaked in the 1970s and early 1980s, had experienced a resurgence in the early 1990s, but had again begun to fall. The declining interest in clinical pharmacology training among medical graduates saps the discipline’s health and vitality which depends on a continuing influx of new people and new ideas. Vestal suggested five critical issues for the speciality in the United States: recognition of the discipline (by an intensive public relations programme and involvement of related healthcare organizations); enhancement of professional status (by promoting the role and leadership opportunities in decision making); improvement of training (by identifying and developing career opportunities, recruitment, educational programmes and funding sources); unification of the discipline (by bringing together stakeholder organizations with overlapping goals and missions); and promotion of membership of the academic organization (by meeting the academic and research needs of members and nonmembers).

In the United Kingdom clinical pharmacology and therapeutics has a strong academic base but a suboptimal age structure[3]. The shortage of young clinical pharmacologists is reflected in experience at the Clinical Pharmacology Section of the British Pharmacological Society. From 61 oral and poster presentations in 1975, presentations increased to 258 in 1985. After this peak, the number of presentations at the Clinical Pharmacology Section has fallen to 71 in 1998 (meetings in December 1997 and April 1998). While this change has a number of causes, it highlights current concerns.

Clinical pharmacologists in the United Kingdom have seen their fortunes ebb and flow over that last four decades: from the time when it was suggested that every district general hospital should have a member of the speciality on its staff and when academic departments were blossoming, through a time of entrenchment into the present era. Changes in the National Health Service and in University departmental structure stimulated the Royal College of Physicians of London to set up a Working Party to consider and advise on the future development of clinical pharmacology and therapeutics in the United Kingdom. The Working Party has now reported[6].

The Working Party had wide representation from academia, the health service, licensing authorities, industry and other professions including pharmacy and nursing and was given clear terms of reference:

1. To advise on the development of clinical pharmacology and therapeutics so as to enhance the health of the population and meet the needs of government and industry.

2. To review education and training requirements and the provision of expertise for universities, the National Health Service (NHS), pharmaceutical and other industries with particular regard to future manpower requirements and career structures.

The Working Party report includes within its first chapter a table of the strengths and weaknesses of clinical pharmacology and therapeutics. These are reproduced in Table 1. There follow chapters dealing in turn with the speciality within the health service, universities and the pharmaceutical industry, its advisory role for government and its relationship with other disciplines both in medicine and in associated professions. A particularly important chapter is that on training.

Table 1.

Strengths and weaknesses of clinical pharmacology and therapeutics in the UK over the past 30 years.

Overall the report is positive. It outlines the progress of clinical pharmacology and therapeutics over the past 40 years and emphasizes its major contribution to healthcare. As might be expected, the report makes recommendations that have important implications for all active clinical pharmacologists, wherever they are based. It also has important messages for other groups, particularly health service managers and universities.

The report stresses the need for a co-ordinated approach to recruitment and training within the health service and universities. What it does not do is to indicate exactly how this should be achieved. However, for the foreseeable future, clinical pharmacologists will be able to use this report as a reference document to stress the need for such strategies and to facilitate their development and implementation.

A second important theme of the report is the need to improve training opportunities. Changes within the structure of postgraduate medical training has resulted in a potential lack of flexibility. To comply with European Union policy, from 1997 training in clinical pharmacology and therapeutics in the United Kingdom has been limited to individuals with an allocated training number in an approved training programme. Only after completion of the necessary period of training and the award of certificates by the Specialist Training Authority is the individual eligible to apply for consultant appointments in the national health service and elsewhere in Europe.

The present training programmes tend to reduce the opportunities for clinical pharmacologists to develop links and to gain experience in a range of specialities, traditional strengths of the discipline. The report welcomes the Specialist Training Authority’s approval of the principle of ‘triple certification’ (clinical pharmacology and therapeutics plus general internal medicine plus another medical speciality) although this necessitates a longer period than the current five year programme for clinical pharmacology and therapeutics plus general internal medicine. The Working Party advocates development of more formal links with a range of specialities and their endorsement by postgraduate deans. With the continuing development of new drugs in many therapeutic areas, there are clear opportunities for combined training with many specialities including anaesthetics, nephrology, neurology and psychiatry as well as more obvious candidates such as cardiology. For this recommendation to be successful, such posts need to be proposed within localities in the United Kingdom.

In support of expansion of consultant grade opportunities, the report emphasizes the favourable influence clinical pharmacologists can have on prescribing within both primary and secondary care. A strongly worded section recommends joint appointments (between health authorities and hospitals) of clinical pharmacologists who would have a significant role in providing prescribing advise that is appropriate and cost-effective.

In order to fuel the expansion in clinical pharmacologists manpower planning is essential. An important development acknowledged and applauded by the report is the initiative between the Association of the British Pharmaceutical Industry and the NHS Executive to jointly fund training positions[7]. An increased part of trained clinical pharmacologists would help to remedy the current shortage of such specialists in industry. Joint appointments between academia and industry at consultant level would encourage young physicians to join the pharmaceutical industry and are encouraged by the report.

The report also comments on educational issues and includes within it a firm endorsement of the undergraduate clinical pharmacology and therapeutics curriculum developed by the Clinical Section of the British Pharmacological Society and recently published in this Journal[8]. The importance of this document is that it should encourage basic pharmacologists to consider producing a similar strategy for medical students in training, and places a responsibility on universities to facilitate delivery of teaching together with appropriate resources. The report recognizes the importance of clinical pharmacology and therapeutics in the teaching of medicine. To facilitate this, universities will need to address the manpower pressures on departments of clinical pharmacology and therapeutics.

Clinical pharmacologists also have an important role in delivering postgraduate education. The report recommends a departure from current industry-funded and commercially driven education towards education based on local priorities. More formal links with regional specialist advisers and postgraduate deans are needed to facilitate the development of such clinical pharmacologist-led programmes.

On both sides of the Atlantic, clinical pharmacology and therapeutics is under threat. British and American clinical pharmacologists must respond to the challenge in a manner tailored to their own circumstances. In the United Kingdom, clinical pharmacologists can take encouragement from the Report of the Working Group of the Royal College of Physicians of London. However, the report will have a significant impact only if its recommendations are adopted. This will require the advocacy and energy of all clinical pharmacologists, particularly the speciality’s senior members who must use their influence to ensure the continued development of clinical pharmacology, locally, nationally and internationally.