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From mortar and pestle to prescription bottles: rationalization of pharmacy Kyra King

In his book, The McDonaldization of Society, George Ritzer relates the progress of society to that of the restaurant industry. Ritzer coined the term “McDonaldization” in this text and defines it as the process by which principles of fast food restaurants have come to dominate virtually every aspect of society. To specify, Ritzer gives four dimensions in which Medialization has affected society. The first of these dimensions is efficiency which is defined as the use of the optimum method of reaching a goal. The next dimension, calculability, explains the quantitative aspects of production. Predictability, the third dimension, discusses the guarantee that products and services will be equivalent over time and in different places. Lastly, control highlights the increase in organization that allows for more function in society.

Origins of Pharmacy

Egyptian and Mesopotamian medical practices, beginning around 3,000 BCE, were much more pharmaceutically sophisticated. In these cultures, specific individuals specialized in the preparation and sale of medications, similarly to the trends in pharmacy that are seen today. Yet, the difference between then and pharmacy now is that there was little to no separation between medical physicians and pharmacists, especially as these civilizations began to decline. Over the next 1,000 years, modern medical professions were founded by Greek civilization. Similarly to the predated forms of pharmacy, the majority of Greek medicines were curated from plants. Theophrastus (circa 370-285 BCE), one of Aristotle’s students, completed the first major of plants in the western hemisphere by combining the knowledge of scholars, physicians, and farmers.

Pharmacy became its own occupation in 1240 AD when King Frederick II officially separated the job from the medical professions when public apothecaries began to become popular in Europe. From then on, pharmacists worked closely with physicians in guilds that were often also made up of spicers and grocers. Later, In 1792, the first United States apothecary was opened by Christopher Marshall in Philadelphia, Pennsylvania. Apothecaries existed before guidelines and regulations were created for pharmacists. During this time, there was no specialized education required, most apothecaries learned through apprenticeships or had a typical college degree.

First discoveries and Improvements

In the year 1640, cinchona bark was imported into Europe and caused a major reconsideration in what pharmacists at the time thought they knew. Cinchona bark was used to cure the symptoms but could not rid the symptoms of any similar diseases. This occurrence changed the belief that all illnesses could be cured by applying medications that have opposite qualities. The new knowledge brought about by this finding displaced the beliefs that lasted in the profession for almost 1500 years.

FIRST DISCOVERIES AND IMPROVEMENTS

As the community debated the new findings, pharmacists throughout Europe moved out from the complex guilds that were made up of professionals from multiple fields to form their own groups and organizations. While this allowed for the separation of professions, it removed pharmacists from the system of training, restrictions and regulations that was upheld by the previous guilds. The lack of control in the occupation caused conflict among competing pharmacists and a lack of predictability in the field. These conflicts would eventually be solved by government intervention, implementing regulations on education and practice and forming the pharmacy professions that focused on creating and distributing medications and drugs.

Control in Education and Regulation

While medicines became more and more complex, turning away from natural herbs and spices towards extracted chemicals and compounds, the new system of education and regulation allowed new findings to be published in textbooks so that advancements could be widespread across the occupation. The increase in control of education and production allowed for the pharmacy profession to become more predictable for patients and professionals in connected occupations. To improve the public’s view of the occupation, pharmacists applied strict requirements for appropriate education and licensure the restrictions on the locations and amounts of apothecaries in one area restricted success in the career. By the 1800s, the use of credentials and the findings of pharmacists was able to improve the reputation and reliability of pharmacists.

Yet, as these professionals became more accepted as practitioners of medicine, lower-level professionals like druggists, those who created and sold drugs for pharmacists, took over the pharmaceutical field, effectively blurring the lines between the health professions again. It was during this time that the British colonized the United States, causing the United States’ healthcare field to grow and define itself differently from the way it did in Europe. Yet, in North America, apothecaries were typically ran by a physician and their apprentice or by an apothecary hired by the physician causing, again, a blending of the two professions, pharmacy and medicine, with practitioners prescribing and compounding their own medication. In the years surrounding the war of 1812, the importance of pharmacy was beginning to be recognized as the United States began to separate from the United Kingdom. During this time, the first hospitals employed apprentices as apothecaries instead of having the physicians fulfill their own prescriptions. This was the first instance of physicians and pharmacists beginning to separate in the United States.

Systems of standards, like the United States Pharmacopeia, and societies, like the American Pharmaceutical Association (APhA), were created to avoid variation and streamline the processes by which pharmacists produced, prescribed and distributed drugs to their patients . The start of this control is seen in the late nineteenth century when the APhA increased public protection by publishing a model pharmacy act. At this time, physicians were concerned that a lack of legislature could result in the misuse of potent drugs by pharmacists. Due to this, the rivaling profession petitioned state legislatures for laws that would govern pharmacy. There was resistance by pharmacists who took negatively to government and physician control over their profession with fear that these outsiders would gain control over pharmacy practice through governmental control. Despite this push back, pharmacy only became more and more regulated over time with today’s standard education for a licensed pharmacist being a four-year degree from a professional pharmacy school.

The Effects of Technology

A form of technology that has been introduced in chain pharmacies is computer programs that prompt pharmacists to input specific patient or drug information. These programs store the data on the types of drugs and the quantities they are used in, giving the chain pharmacies information on the medications they need to have in supply and how much will be needed. This allows the companies to be able to calculate the correct number of medications they need to purchase so that they can maximize profits by not buying so much that they have excess or running out of products because they did not buy enough. This provides improvement in two of Ritzer’s dimensions, calculability and predictability as patients are allowed to be confident in the fact that their pharmacy won’t run out of the drugs needed to fill their prescriptions.

Efficiency in chain stores

Chain pharmacy stores have also become more efficient over time as well. Counter prescribing, drive through lines, and the addition of convenience stores in pharmacies has allowed for pharmacies to become more and more efficient for both the pharmacists and the patients. By providing drive through lines, pharmacies limit the amount of time needed for a patient to be in the pharmacy in order to receive their prescriptions. This provides efficiency for the pharmacists as less time is needed to be spent with individual patients and more time can be spent with work like filling prescriptions. This also benefits the patients as they can pick up their prescriptions without needing to leave their cars, effectively eliminating the time it takes to park, walk into the store, and walk back to their cars. Many chain drug stores have added items of convenience, like groceries, in order to increase efficiency for themselves and their customers. Through providing grocery items, pharmacies increase efficiency for their customers by allowing them to complete two errands in one stop. This gives patients more reason to choose chain stores to get their prescriptions from, increasing the amount of revenue made by the chain pharmacies and therefore increasing their own efficiency. Counter prescribed medicines, more commonly known today as over-the-counter- medications, provides efficiency for pharmacists by allowing them to distribute medications without the need for a physicians prescription. This is also more efficient for the patients because it allows them to get the medication they need without needing to go to their physician first.

Irrationalities

Similarly to rationalization, Ritzer separates irrationality into dimensions, including inefficiency, disenchantment, homogenization, and dehumanization. This can be seen in pharmacy as changes are made is used to adjust tasks so that the job can be performed in the optimal manner. With the increase in rationalization comes advancements in pharmacy that continue to push the occupation towards profit and speed. In an attempt to rationalize pharmacy to its full extent, advancements in technology and communication have caused irrationalities that are fueled by a disconnect between patients and pharmacists and pharmacists and their own careers.

Dehumanization

In order to increase the efficiency of pharmacy, large companies have shifted away from in-person consultations, phone calls and other forms of communication to automated messages. For example, when a patient calls a chain pharmacy, they are met with a prerecorded message that will list a series of options and questions so that the patient can express the nature of their phone call. In many cases, these phone calls do not result in speaking to an actual pharmacist and may even point the caller towards a website to complete their desired task.

Dehumanization

The lack of personal connections in this field is starkly different from the relationships that are able to be formed in a comparable field like primary care physicians. The advancement in pharmacy technology and communications is a clear example of dehumanization. As the occupation works to be more efficient, it loses a personalized touch with its clients and begins to be overrun by technology.

Disenchantment

Furthermore, pharmacists also take issue with the lack of personhood that the industry has developed as a result of rationalization. On her blog, The Blonde Pharmacist, Beth Lofgren explains why she left her position as a pharmacist with the following statement:

“JOB HAD BECOME SOMETHING VERY COMPUTER-DRIVEN, AND [SHE] HAD LOST THE ABILITY TO BE A FREE-THINKER DUE TO CHECKING THE BOXES. HEALTH CARE HAS PROGRESSED IN SO MANY WAYS, BUT ALONG THE WAY IT HAS BECOME TOO RELIANT ON TECHNOLOGY”

conclusion

Rationalization has greatly contributed to the advancements in pharmacy and has allowed it to reach achievements that could not have occurred without improvements in technology. Patients can access their prescriptions with ease through fast ordering, communication, and pick up formats that are only made possible by technological advancements. The benefits of these improvements even reach the pharmacists themselves. They are able to assist more patients at a greater speed than they were able to before as their tasks are lessened by technology. However, these improvements decrease the number of interactions between pharmacists and their patients and also distance pharmacists from the job they prepared for with their education. In addition to this, the trend of increasingly advanced technology has caused a disconnect between pharmacists and their patients as prescriptions are still typically written by physicians and sent automatically to the pharmacists. This leaves very little reason for a patient to interact with a pharmacist outside of a conversation though a drive through window. To combat the irrationalities that come with rationalization, pharmacy would need to begin finding ways to make pharmacist-to-patient connections just as optimal as technology like the automatic refill. Through bridging the gap between pharmacists and patients, the occupation would effectively re-enchant and re-humanize its work and move itself away from retail and back towards patient care where the professionals in this field desire to be.

Citations

Apfel, Adam, et al. “Pharmacy's New Era--in the Home.” McKinsey & Company, 6 Dec. 2021, https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/pharmacys-new-era-in-the-home.

Barker, Alex. “Pharmacy’s Mass Exodus: Why So Many Pharmacists Want to Leave the Profession.” The Happy PharmD, 2 Mar. 2020, https://thehappypharmd.com/mass-exodus-why-pharmacists-want-to-leave-the-profession/.

“Becoming a Pharmacist & History of Pharmacy.” Pharmacy for Me, 25 Sept. 2017, https://pharmacyforme.org/learn-about-pharmacy/history-of-pharmacy/.

Berger, Karen. “Why Did You Become a Pharmacist?” Drug Topics, 19 Mar. 2020, https://www.drugtopics.com/view/why-did-you-become-pharmacist.

Center for Drug Evaluation and Research. “Understanding over-the-Counter Medicines.” U.S. Food and Drug Administration, FDA, https://www.fda.gov/drugs/buying-using-medicine-safely/understanding-over-counter-medicines.

"George Ritzer and the McDonaldization of Society: Definition and Principles." Study.com, 31 January 2013, study.com/academy/lesson/george-ritzer-and-mcdonaldization-of-society-definition-and-principles.html

Gregory J. Higby, Benjamin Y. Urick, Chapter 1 - History of pharmacy, Editor: Adeboye Adejare, Remington (Twenty-third Edition), Academic Press, 2021, Pages 3-22, ISBN 9780128200070, https://doi.org/10.1016/B978-0-12-820007-0.00001-5.

Tan, Stewart K, and George J Elliot. “Pharmacist Consultations in General Practice Clinics: The Pharmacists in Practice Study (PIPS).” Research in Social & Administrative Pharmacy : RSAP, U.S. National Library of Medicine, https://pubmed.ncbi.nlm.nih.gov/24095088/.

“The Fascinating History of Pharmacists: Before the White Coat.” Dr. James, 10 Nov. 2019, https://www.dr-james.com/blogs/news/the-fascinating-history-of-pharmacists-before-the-white-coat.

The “McDonaldization” of Society. 20 Feb. 2021, https://socialsci.libretexts.org/@go/page/8111.

“The Pharmaceutical Manufacturing Process - Steps, Tools and Considerations.” Thomas https://www.thomasnet.com/articles/chemicals/the-pharmaceutical-manufacturing-process-steps-tools-and-considerations/.

Lofgren, Beth. “It Has Been 4 Years since I Pressed Submit on the Keyboard.” The Blonde Pharmacist, 15 Mar. 2021, http://www.theblondepharmacist.com/blog/category/Career+Change. Accessed 2 Mar. 2022.

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Toklu, Hale Zerrin, and Azhar Hussain. “The changing face of pharmacy practice and the need for a new model of pharmacy education.” Journal of young pharmacists: JYP vol. 5,2 (2013): 38-40. doi:10.1016/j.jyp.2012.09.001

Photo Attributions

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