The Daniel K. Inouye College of Pharmacy Scripts

Abstract

The Daniel K. Inouye College of Pharmacy is the newest professional school to be established in the State of Hawai‘i. The College is based at the University of Hawai‘i at Hilo, but faculty and students are located and practice on every major island. The mission of the College is to serve the entire Pacific Region. Having reached a respectable level of maturity over the past few years, we are now pleased to announce a partnership that has been established with the Hawai‘i Journal of Medicine & Public Health. With Dr. Carolyn Ma serving as column editor and coordinator, our main objective is for faculty and affiliates of the College to provide communications of contemporary interest in the field of professional pharmacy. Since academic pharmacy is new to the State, this inaugural article (Part 1) describes a brief history of the profession leading up to the founding of the Daniel K. Inouye College of Pharmacy. An article describing the mission, vision, and infrastructure of the College, as well as some objectives and accomplishments will follow this inaugural column. The pharmacist is an integral member of the health care team with unique expertise in pharmaceutical care. The topics we present should be of broad interest to the readership of this journal but, additionally, any suggestions for specialized topics in our realm of expertise are welcome.

Introduction

The Hawai‘i Journal of Medicine & Public Health and the Daniel K. Inouye College of Pharmacy (DKICP), University of Hawai‘i at Hilo, have established a partnership that will enable faculty and affiliates of the College to submit articles describing contemporary issues of pharmacy education and practice. We hope these articles will be of broad interest to the readership of the Journal. We welcome any suggestions for topics falling within the realm of our expertise.

The first class of student pharmacists at the DKICP was accepted in 2007; full professional accreditation was earned in 2011. Realizing that academic pharmacy is relatively new for the State of Hawai‘i, this inaugural article will focus on the practice of pharmacy from a historical perspective. Part 1 leads us to the point of creating the DKICP, which is the only pharmacy program in the entire Pacific Region. In Part 2 of the inaugural article, various aspects of the College itself will be described, and we will provide a glimpse of articles to be submitted for ensuing issues.

The Discipline of Pharmacy: A Historical Perspective

Some of the first signs of pharmacy as a profession can be traced to Baghdad ca. 750 AD. The collective Arab civilization is credited with educating students of pharmacy, establishing hospital pharmacies, and creating accountability though governmental inspections. In Palermo, ca. 1240 AD, under the rule of King Frederick II, the disciplines of medicine and pharmacy were separated. Pharmacy became an independent branch of public welfare service with the implementation of various regulations: The number of pharmacies was limited; fixed prices of remedies were set; pharmaceutical practice required official supervision; bribes were prohibited; use of a prescribed formulary (fixed formula for a certain drug) was made compulsory. Over time, similar standards and responsibilities were implemented in other urban centers throughout Italy, Spain, and France.

Another important milestone was the establishment of the first pharmacopeia (Florence, 1498). In effect, standards were set for the identification and preparation of drugs. The public was provided with greater protection from adulterated drugs, and prescribers as well as consumers could have greater assurance of uniformity and quality of products. Over 100 years later, in 1607, the first English Apothecaries Guild was established in London. Under the rule of King James I, the special skill and knowledge of the apothecary was recognized. Apprenticeships, examinations, and inspections were established; the special skill of preparing drugs was entrusted to the apothecary, rather than the grocer, spicer, doctor, etc.

The profession continued to grow throughout Europe over the next century. Official pharmacopoeias were produced in major European cities, organized activities and a periodical literature were implemented, prolonged apprenticeships were required, as well as examinations to assess competency. The Guilds were eventually replaced by professional societies. Even today, the practice of pharmacy in Europe is more tightly regulated than in the United States. For example, on the European continent, the number of pharmacies is limited, there are no 24-hour stores, ownership is limited, and there are no large chains of community pharmacies.

Pharmacy in the United States

During the colonial period of the United States, pharmacy was basically practiced by anyone who wanted to set up a shop. The success of the business was strictly determined by the market. Patent medicines were a major source of profit. Although a few well-trained genuine European apothecaries set up professional shops in cities, in general, the field was characterized by pandemonium. There was no regulation of the “profession.” No formal educational requirements were in place. The number of drugstores was growing, wholesalers were dispensing to the public, and physician dispensaries were gradually phasing out. As a result, there was even greater dependence on ill-trained druggists and self-declared apothecaries for medication compounding.

One of the first signs of progress was documented in 1816. In the State of Louisiana, one apothecary and four physicians and surgeons were entrusted with the examination of other health professionals. L.J. Dufilho became the first licensed pharmacy professional in the state. The sale of poisons was restricted and the sale of deteriorated drugs was banned. Shortly thereafter, in 1818, an examination for licensure was instituted in South Carolina. Candidates were tested on the definition of chemistry and pharmacy, and preparations involving substances such as mercurous chloride, tartar emetic, ipecac preparations, laudanum, arsenic, and plasters.

In essence, no controls were in place for the practice of pharmacy and early attempts at legislation failed due to the general attitude of laissez faire. Both educated and self-declared uneducated pharmacists were opposed to regulation. Merchants, wholesalers, and apothecaries drifted in and out of professions at will. Some drugs were adulterated, deteriorated, and dangerous. Outcomes were unreliable, differed from store-to-store, and it was generally not clear what was being dispensed. With pharmacies cutting corners, providing unreliable drugs with unreliable outcomes, the public was not being well-served.

As a result, in 1820, the dean of medicine at the University of Pennsylvania published a report in a local newspaper describing the poor quality of drugs. Physicians had just organized (nationally) the first pharmacopeia (USP), without any input from pharmacy. Following a university board action, the medical school gained authority to award a Master of Pharmacy degree to any student who completed the required number of lectures. It was further agreed they would award the degree to pharmacists if they determined the pharmacist met the standard. As might be expected, this led to some acrimony, and four days later, pharmacists created a committee and it was decided to start a college to regulate, educate, and control some of the problems in the profession.

Philadelphia College of Pharmacy

In 1821 the first college of pharmacy was established in the United States, the Philadelphia College of Pharmacy (PCP). Although this was a major step in the history of pharmacy education, PCP was not really an educational institution by modern day standards. It was still believed that pharmacy was an art that could be learned through the apprenticeship system. However, some important steps were taken for regulating the practice of pharmacy. A formulary was published, sale of adulterated drugs led to being expelled, a dispute resolution committee was created, and guidance was provided, especially for producing patent medicines, a very large business at the time.

Largely driven by pressure from the medical profession, other early colleges were founded such as the Massachusetts College of Pharmacy (1823), the College of Pharmacy of the City of New York (1829), and the Maryland College of Pharmacy (1840). In addition, the New York Pharmaceutical Literary Society (1851) was founded by extremely well-qualified German pharmacists to train and examine apprentices.

The Father of Pharmacy and the American Pharmacists Association

As is often the case, adversity is required for the implementation of change. In the mid-1800s, a pharmacist discovered a container labeled calcium carbonate was actually calcium sulfate (pharmacists were trained to test chemicals and drugs). This was reported to the NY College of Pharmacy (later to become part of Columbia University), and it was discovered other contaminated drugs were being imported from England and passing port inspection. Port Inspectors were political appointees who were not educated to detect contaminated drugs. Since physicians owned stores and practices of pharmacy, the NY College of Medicine got involved with the issue. The American Medical Association (AMA) proposed standards for the ports, but since pharmacists were trained to test drugs, the problem was referred to the NY College of Pharmacy. In turn, other colleges of pharmacy were invited to participate in resolving the problem. As a result, a letter was received from William Procter, a professor at PCP, who wanted to broaden the scope of the meeting and form a national pharmacy organization.

Procter, later dubbed as the Father of Pharmacy, owned a pharmacy in Philadelphia. Moreover, he was an administrator and teacher at PCP, published over 550 research papers, wrote the first pharmacy textbook, and served as editor of the first pharmacy journal in the United States, the American Journal of Pharmacy. He felt strongly that only graduates of a pharmacy school should practice in the profession. Receiving a diploma involved three evening lectures per week, with no laboratories, for two 6-month sessions. Botany was emphasized. But unlike European practice, he supported a free-market system, where competition would regulate the number of practicing pharmacists, not the government. With a growing population, he did not support limiting the number of pharmacies. He believed European immigrants had and would continue to elevate the standards of the profession, and competition and reputation would be self-limiting. Importantly, however, according to Procter, everyone involved in the practice of pharmacy would be accountable to the law and regulation.

As a result of Procter's vision, 20 pharmacists founded the American Pharmaceutical Association (now named the American Pharmacists Association, APhA) in 1852, and he became the corresponding secretary (now called CEO). Today the organization represents more than 62,000 practicing pharmacists, pharmaceutical scientists, student pharmacists, pharmacy technicians, and others interested in advancing the profession. In the beginning, the elected officers wrote a constitution mandating members to abide by a code of ethics. This eliminated the promulgation of sham medicines, promoted pharmacy education in science and practice, provided regulations to prevent adulteration and contaminated products, regulated apprenticeships, limited drug sales to qualified pharmacists, and provided punishment for improper conduct.

The Evolution of Pharmacy Education and Regulation

During the period of 1870–1900, many more colleges of pharmacy were created, several associated with universities, in part due to the Morrill Land-Grant Act of 1862. In addition to the tenets established by the APhA, states began to introduce legislation to protect community pharmacists and the health of the public. Nonetheless, training in the profession was still integrally linked to the apprenticeship. But again, change was inspired by one individual, Albert Prescott, a physician-chemist, who was Dean of Pharmacy at the University of Michigan (1876). The Michigan program ignored the apprenticeship requirement of all other schools, and opened admission to fulltime day students, rather than as an add-on to employment. The approach was shunned by APhA and opposed by the leading program of the time, PCP. In due course, however, the approach pioneered by Prescott was adopted by other programs, and he became president of the APhA in 1900.

Concurrently, starting in 1870, John Maisch, APhA committee chairman, was charged with creating a model state law to provide some guidance. The goal was to define practice, examinations, and established a Board of Pharmacy in every state. With opposition from various factions such as “saddlebag” doctors and “prescribing” pharmacists, Maisch mailed the “model” law to various state governors, but without APhA endorsement. The situation changed by 1900, when the proposal was revised and sent openly to each state. Finally, about 25 years after the start, approximately 35 states adopted laws specifically related to pharmacy and the sale of adulterated drugs and poisons. If adulterated drugs were knowingly dispensed, fines and imprisonment could result.

The National Association of Boards of Pharmacy (NABP), an organization that currently manages standardized tests that are part of the professional licensing process (such as the Multistate Pharmacy Jurisprudence Examination and NAPLEX), was formed by 16 states at an APhA meeting in 1904. Creation of the NABP was critical for promoting cooperation and uniformity between various states, enhancing reciprocity, resolving conflicts between state standards, and promoting uniformity of licensing requirements. NABP member boards now include all states. The Hawai‘i State Board of Pharmacy, serves mainly to protect consumers against unfair practices. The three main areas of responsibility include legislative, adjudicatory, and executive decisions. The Board reviews statutes and amendments on upcoming senate and house bills, holds public hearings, and serves as resource for legislators. Duties related to adjudicatory review involve review and approval of settlement agreements negotiated by the Regulated Industries Complaints Office (RICO) to discipline licensed pharmacists who fail to follow the legal and professional standards of practice. Lastly, executive decisions assure that appropriate licensing of persons who seek to enter the profession meet the legal competency standards as well as permitting of pharmacies within state and out-of-state.¹

Thus, as described above, there has been a continuous progression in the profession over the millennia. Over the last century educational programs have evolved from the two-year PhG (Graduate in Pharmacy) (1907), to the three-year PhC (Pharmaceutical Chemist) (1925), to the four-year BS in Pharmacy (1932), to the five-year BS in Pharmacy (1960), and finally, to the six-year PharmD (Doctor of Pharmacy). As mandated by current accreditation standards, the only degree leading to professional licensure is the PharmD.

According to the Accreditation Council for Pharmacy Education (ACPE),² there are currently 133 pharmacy programs with accreditation status. However, prior to 2004, no program had ever been launched in the State of Hawai‘i.

The Fiasco of Private Pharmacy Education in Hawai‘i^3–5

As evidenced by the rapid proliferation of pharmacy programs throughout the United States,⁶ over the past 20 years or so, the number of students interested in pursuing the profession of pharmacy has exceeded the number of places available in established programs. With no pharmacy education whatsoever in the State of Hawai‘i, this led to the creation of a bogus program in Kapolei given the name Hawai‘i College of Pharmacy. In the fall of 2004, the program opened with an inaugural class of 240 students. Approval had not been obtained from the ACPE. Although an application was retrospectively submitted, it was denied, presumably due to poor planning and infrastructure, as well as excessive class size. Nonetheless, the founders of the program, Denise Criswell and David Monroe, wrongfully collected nearly $7 million in student tuition. In the spring of 2005, the dean of the program (H.A. Hasan) resigned and some faculty members were fired. By summer, it was clear a successful application could not be submitted to the ACPE, and the dean of the pharmacy program at the University of South Nevada disavowed being associated with the program in Hawai‘i, which was run through Nevada-based Pacific Educational Services. In addition to pharmacy, this organization had also boasted plans for opening dental and nursing programs in Hawai‘i.

The end of the fiasco became clear in July 2005 when the enrolled students were informed that only the top 100 could go onto the second year of the program while the others would need to repeat the first year and, of course, continue paying tuition. By this time, the Hawai‘i Department of Commerce & Consumer Affairs, Office of Consumer Protection had assigned workers to investigate the program, leading to freezing assets for unfair and deceptive business practices. Within a month, the Hawai‘i College of Pharmacy used this as a reason for closing the program with roughly $6 million from student tuition having supposedly “disappeared.”

A Time for Excellence in Hawai‘i's Pharmacy Education

Surprisingly, the defunct Hawai‘i College of Pharmacy had little or no bearing on the building of the University of Hawai‘i College of Pharmacy. Discussions and planning with the profession's state leaders were ongoing since the late 1990s. Receiving pre-candidate status from the ACPE is absolutely essential prior to enrolling a class of student pharmacists, but one of the first obligatory steps is the appointment of a qualified dean. A search commenced in 2005. In essence, the Hawai‘i College of Pharmacy did everything wrong. For anyone with experience in academic pharmacy, it was perfectly clear the program had absolutely no chance for success.

When the Founding Dean of the UH College of Pharmacy was appointed in 2006, over 25 years of experience gained at Top-10 pharmacy programs came to the table. Ambitious goals were set to create a college that not only would meet all of the standards for full professional accreditation, but to strive to achieve a position among the Top-25 programs in the country. Although the program has yet to reach its tenth anniversary, progress has been strong, many milestones have been crossed, and the unit has become an integral part of the community and University as a whole.⁷

Conflict of Interest

None of the authors identify a conflict of interest.