Clinical pharmacology: a declaration of intent

‘When I use a word’, Humpty Dumpty said …, ‘it means just what I choose it to mean – neither more nor less’. (Lewis Carroll: Through the Looking Glass and What Alice Found There).

In this issue we publish a ‘manifesto for clinical pharmacology’ as a personal view of Jeff Aronson (a clinical pharmacologist with a considerable knowledge of words, but no Humpty Dumpty in any other regard) [1]. Much of his manifesto (i.e. a declaration of intentions) consists of definitions, both of a clinical pharmacologist and of clinical pharmacology. These form the basis for his call for action for the dissemination of clinical pharmacology expertise. He emphasizes, surely rightly so, the clinical nature of our discipline, but aspects of his argument will be controversial.

One such issue is the relation between ‘clinical’ and ‘medical’. It is the author's strong belief, not universally shared by the editors of BJCP, that ‘one cannot be a fully fledged clinical pharmacologist unless equipped to practice clinical medicine, i.e. medically qualified’, albeit not necessarily ‘… implementing the knowledge in clinical practice’. He suggests that non-clinically qualified clinical pharmacologists could be described as (say) applied pharmacologists, in order to recognize their contribution while maintaining the distinction between clinician and non-clinician. We disagree, but feel that the opinion is an important one to debate. To kick this off, we revisit the complementary but distinct contributions, acknowledged in the ‘manifesto’, of medically and non-medically qualified leaders in pharmacology and clinical pharmacology now and in the past.

Pharmacology exploded in the nineteenth century, as a result of interactions between synthetic organic chemists in the German dye industry and academic bioscientists such as Bucheim and Schmiedeberg [2]. During the 20^th century many ‘basic’ pharmacologists were clinically qualified (from undergraduate medical student days, in but one department: Burn, Walker, Paton, Blaschko, Bulbring, Vaughan Williams and Rang). Some outstandingly distinguished pharmacologists and medicinal chemists (notably George Hitchings and Gertrude Elion) of this era, without whom there would have been few new drugs to study, were not medically qualified, but equally several of the great 20^th century drug hunters, including James Black, were medically qualified. The subject has evolved; with the rise of molecular biology new drugs are now often biologicals rather than organic small molecules, and clinically qualified basic pharmacologists are now exceptional but by no means redundant.

Clinical pharmacology was named in the 20^th century (probably by Harry Gold in Cornell) although its origins in materia medica and therapeutics are much earlier. The first laboratory of clinical pharmacology was set up by Bernard Brodie at the invitation of James Shannon who had left Squibb to head the NIH in 1949. This department was the training ground of the first generation of North American clinical pharmacologists. This heroic group, which included Udenfriend, Axelrod, Burns, Sjoerdsma, Oates and Melmon, among many others, comprised both medically and non-medically qualified people. Similar diversity was also a feature of founding academic departments of clinical pharmacology in Europe in Sweden and the UK [3] and more recently elsewhere in the world, including Australia, Japan, China and India. Medical, scientific or other allied professional qualifications (e.g. in pharmacy or nursing) vary between countries and in our view are less important in defining the essence of a clinical pharmacologist than is a personal professional focus on therapeutic drugs in a broad (i.e. not restricted to a single therapeutic area) clinical context. Consequently BJCP, an international journal, will continue to consider, on their merits alone, papers on ‘all aspects of drug action in man’, irrespective of the professional qualifications and professional designations of authors. In the editorial board of the Journal we attach priority to clinical pharmacology (the subject), rather than the clinical pharmacologist (the person).

Where we strongly agree with the Aronson manifesto is in the importance of ensuring a supply of clinical pharmacological expertise to meet the needs of patients and of pharmaceutical companies as well as of academia. It is here surely that his declaration of intent should be extended into political action, the ultimate success or failure of which will depend importantly on appropriate provision of undergraduate and postgraduate education in pharmacology, prescribing and therapeutics. To pre-specify the prior training of the persons holding this expertise is, in our opinion, counterproductive, as it is almost certainly held by a group of experts rather than by an individual.

In this issue of the Journal we also publish an important paper that addresses the teaching of clinical pharmacology and therapeutics in UK medical schools [4], and will, we hope, inform this aspect of the debate. Since 1993 the General Medical Council's guidance on undergraduate medical education in the UK has emphasized integration of CPT teaching within the medical curriculum during a period when the number of senior clinical pharmacologists has declined progressively in contrast to numbers of consultants in organ based disciplines, which have increased steadily. Most medical schools do not assess the performance of their graduates as prescribers, and there is little evidence that the diverse teaching methods employed are suitable for the development of prescribing skills. This is one place where barricades do surely need to be manned!

Lewis Carroll's Humpty Dumpty was a philologist, but the nursery rhyme on which his character was based may have referred to a gun that was deployed by the Royalists during the English Civil War, but dramatically self-destructed on first use (‘all the King's horses and all the King's men couldn't put Humpty Dumpty together again.’). Optimal use of therapeutic drugs, new drug discovery and drug development are critical to human progress: clinical pharmacology, the science that underpins them, is too important to be allowed to follow the Humpty Dumpty example by imploding after a brief moment of glory. The inscriptions on tombstones documenting infant and maternal mortality before antibiotics attest this. The predictable resurgence of antibiotic-resistant microbe-related deaths is a chilling reminder that progress is not inevitable, and that to be effective clinical pharmacology must remain a broad church. Evolutionary biologists are as welcome and as necessary as physiologists, chemists or molecular biologists, whether or not medically, nursing or pharmacy qualified.

We hope that the Aronson manifesto will concentrate minds on defining what actions are needed to secure a healthy future for our subject. In this regard it is worth re-iterating Colin Dollery's 2006 proposals for the way ahead [3]:

• develop experimental medicine;

• employ medically qualified clinical pharmacologists in service delivery;

• re-integrate pharmacology in centres of excellence with clinical pharmacologists providing the clinical arm;

• revive clinical pharmacology teaching;

• develop personalized medicine (in its broad sense of individualizing therapy by methods that may or may not include genomic technology);

• get rid of unnecessary bureaucracy (especially in training academic physicians).

Debate will continue long after the delegates at World Pharma have savoured a last Carlsberg and returned to their departments. We anticipate rapid progress and will welcome timely correspondence to inform political action in the UK and elsewhere in the world.

Competing interests

There are no competing interests to declare.