CIMA Lecture SeriesCIMA Lecture SeriesPharmacy Practice in Pharmacy Practice in Japan and Thailand: Japan and Thailand:

Experiences as a Experiences as a Visiting ProfessorVisiting Professor

Sara D. Brouse, Pharm.D., BCPS, AQ Sara D. Brouse, Pharm.D., BCPS, AQ CardiologyCardiology

Associate Professor of Pharmacy PracticeAssociate Professor of Pharmacy Practice

Advanced Practice Pharmacist—Advanced Practice Pharmacist—Cardiology/Critical CareCardiology/Critical Care

May 5, 2010May 5, 2010

ObjectivesDiscuss TTUHSC SOP exchange agreementsDescribe the government healthcare systems

in Japan and ThailandCompare/contrast pharmacy education

systems between the US, Japan, & Thailand

State of US Pharmacy Practice

1977 – First US policy adopted supporting single, doctorate degree in pharmacy by pharmacy organization

1995 – deadline for drafting plan for conversion to 6-year PharmD degree

2000 – deadline for conversion to 6-year PharmD degree or loss of accreditation

By 2010, most states passed legislation allowing collaborative practice agreements, immunization by pharmacists

AACP COMMISSION TO IMPLEMENT CHANGE IN PHARMACEUTICAL EDUCATIONA Position Paper ENTRY-LEVEL EDUCATION IN PHARMACY: A COMMITMENT TO CHANGEAvailable at: http://www.aacp.org/resources/historicaldocuments/Documents/COMMISSPOSPAPER3.pdf. Accessed April 4, 2010.

TTUHSC SOP Exchange AgreementsFaculty exchange program

Kobe Gakuin University School of Pharmacy, Kobe, Japan 2002 to present

Keio University School of Pharmacy, Tokyo, Japan (formerly Kyoritsu University of Pharmacy) 2004 to present

Khon Kaen University School of Pharmacy, Khon Kaen, Thailand 2009 to present

TTUHSC SOP Exchange AgreementsFaculty exchange

Visiting Professor6 week experienceTeach elective courseParticipate in scholarly

activitiesVisiting Teaching Professor

1-2 week experienceTeach core content within

particular curricular area, ie cardiovascular module

BS program: translator

Masters programs: no translator

TTUHSC SOP Exchange AgreementsFaculty exchange

Visiting Professors to Texas Tech SOP1-2 week experienceArrange shadowing

experiences Faculty teaching models

for problem based learning, active learning, experiential training

TTUHSC SOP Exchange Agreements

Student/Resident exchange programKeio University School of

Pharmacy, Tokyo, Japan 11 students from Keio to Texas

Tech (2006-present) Masters in clinical pharmacy

candidates 2 students from Texas Tech to

Keio (2009-present) Doctor of pharmacy candidates

TTUHSC SOP Exchange AgreementsStudent/Resident

exchange programKhon Kaen University

School of Pharmacy, Khon Kaen, Thailand 2 students from Khon Kaen

to Texas Tech (2009 to present)

1 pharmacy resident from Khon Kaen to Texas Tech (2009)

JAPANJAPAN

JAPAN: State of HealthcareSocialized medical model

Universal healthcare provided to citizensPhysician-dominated practice model

All other healthcare disciplines subordinatePharmacists not allowed to touch patients

Cannot administer medications/immunizations or perform diagnostic testing (BP, blood glucose)

Patients kept sheltered from diagnosisLack of patient counseling by pharmacists

about medications

JAPAN: State of Pharmacy Practice

Hospital length of stay: 28 daysSome hospital pharmacies dispense 2 week

supply of meds Patients self-administer medications other

than intravenousMany hospitals have nurses mix all IV

medications on hospital ward30-40 pharmacists for 1000-bed hospitalNo pharmacy techniciansCost and safety burden

JAPAN: State of Pharmacy PracticePMDA = pharmaceutical manufacturing drug

administrationSimilar to FDAApproves medications for use in JapanCoordinates safety monitoring

Medical focus on prescription drugsLittle emphasis on herbal remedies

JAPAN: State of Pharmacy Practice

Until recently, physicians dispensed medications directly from offices

After law change, now physicians required to transmit prescriptions to a pharmacyAdditional safety checkElectronic means (fax, email)More than 1 medication per “prescription”No refills allowed

Expanded scope of “pharmacies” from convenience stores to true full-service pharmacies

JAPAN: State of Pharmacy PracticeTypes of outpatient pharmacies

Community pharmacy Similar to community pharmacies in US Dispense prescription and non-prescription

medications Licensed pharmacist

Drugstore Not required to have a pharmacist on staff Non-prescription medications Health and beauty products

JAPAN: State of Pharmacy EducationMinistry of EducationUntil 2006, pharmacy was 4-year degree program

(4 years post-high school)Bachelor’s degree in pharmacyBridge to graduate school in pharmaceutical sciences No therapeutics courses No practical experiential training experiences ~200-250 students/class

Post-2006, mandatory 6-year6-year bachelor’s degreeAlso available Ph.D. in pharmacyDid not approve “Pharm.D.” in Japan

JAPAN: State of Pharmacy Education post-20066-year bachelor’s program

Addition of 6 months experiential training 3 months hospital pharmacy practice 3 months community pharmacy practice

Provision of “therapeutics” portion of curriculum Application of pharmacology

Expansion of “clinical” faculty to bridge gap between science and practice

Expansion of practice-based curriculum Problem-based learning courses

JAPAN: My ExperiencesKobe Gakuin

UniversityVisiting Professor, 6

weeks (2004)Taught 1 credit hour

elective course for bachelor’s of pharmacy students

Translators for each lecture

JAPAN: My ExperiencesKobe Gakuin University

Gave formal faculty seminar on “Evolution of Pharmacy Practice in the US”

Collaborated on 4 papers related to development of pharmacy practiceExperiential training,

preceptor development, community pharmacy practice in US, collaborative practice agreements

JAPAN: My ExperiencesKyoritsu University of

Pharmacy / Keio University School of PharmacyVisiting Teaching Professor,

(2005-10)Taught cardiology subjects

within Masters of Clinical Pharmacy degree program

English lectures provided to Masters of Clinical Pharmacy Students

Therapeutic case focus

JAPAN: My ExperiencesInternational

Conferences on Experiential TrainingInvited twice to

speak on relevant experiential training topicsPreceptor

developmentContinuous

professional development

JAPAN: InsightsSimilar issues exist

Development of quality experiential training sites to meet demand Mentoring model at practice site

ChallengesMindset traditionally against interprofessional

collaborationFew role models for students / new pharmacistsNo pharmacy residency programsSurplus of pharmacists for practice-based

positions >10,000 graduates/year

Larvae

THAILAND: State of HealthcareSocialized medicineBoth government and

private healthcare availableGovernment healthcare

inexpensive, so many select based on priceGovernment hospitals

& clinics at capacityHospitalization $1/dayStrict medication

formulary

THAILAND: THAILAND: State of HealthcareNational Drug Formulary

5 classes of medications Classes 1 & 2: general medicines Classes 3 & 4: high-cost or high toxicity risk meds

Only available in large urban hospitals Class 5: new medications

Defines drugs by generic name Individual hospitals choose brand name

manufacturer or “local made” generic equivalentIf patients use non-national formulary

medication, must pay out-of-pocket for drug cost

THAILAND: Khon Kaen UniversityGovernment Hospitals

Belief in using natural elements for healingOpen hallways, pharmacy waiting area,

wards, ICU & ward windowsFresh water bowls with fresh flowers in middle

of ICUCeiling fans circulate air throughout units and

bring in fresh air from outsideLack of air conditioning in government

hospitalsHolistic medicine unit for Thai massage,

“Tiger Balm” applications, herbal compresses

THAILAND: State of HealthcareHolistic Health Care

UnitAlternative medicine

units on hospital wardTherapeutic “Thai”

massageFacial spaFoot spa & massageHerbal compress

techniques

Oil massage & aromatherapy“Tiger Balm”

applicationsTraditional Thai knowledge

THAILAND Wat Pho Temple1st site for “Thai massage”Massage school still exists on temple property

THAILAND: State of Healthcare

All medications ‘over the counter’Antibiotics, opiates,

dermBrand name products &

“local made” products available before brand is off-patentRegulated by Thai FDA

for bioequivalencyProducts still can vary

by company

Pharmacists play key role in recommending drug therapies based on symptoms

THAILAND: Khon Kaen UniversityCommunity Pharmacy

Faculty of Pharmaceutical Sciences run 2 campus community pharmacies Training of students to learn the

clinical aspects & management of community pharmacies

Carry products from reputable companies

Offer counseling and front-line provider of health-care to patients Logbook record of controlled

substances

THAILAND: Khon Kaen University

6-year Pharmacy degree program starting 2009Doctor of Pharmacy

(Pharm.D.) from 2009 Students enroll in either

“Thai” program or “English” program

175 students/class Previously 5-year

Bachelor’s degree Masters --Clinical

Pharmacy Masters--Pharmaceuticals Masters--Pharmacy

Management

THAILAND: State of Pharmacy Practice

Thai pharmacy degree programs and practice modeled after US pharmacy modelPharmacology and therapeuticsClinical application of medications for disease

treatmentClerkship rotations for students (~ 9 months)

Many faculty trained in US for PharmD, residencies, & fellowships

Pharmacists enjoy high level of clinical practice as providers (esp community pharmacy)

No prescriptive privileges in hospitals but round with physicians & make recommendations

THAILAND: Khon Kaen UniversityCenter for Research and Development in

Herbal Health Products (CRD-HHP)To increase herb and herbal health product

research to support commercial development Quality, efficacy, safety of herbals

To support research endeavors of masters degree students

To develop herbal patents

THAILAND: Khon Kaen UniversityCenter for Research and

Development in Herbal Health Products (CRD-HHP)Rice bran creamCitronella grass creamTurmeric lotionAloe vera lotionGlycerin soapGel nanotechnology

products of Kaempferia parviflora

Daily Compounding ListSodium fluorideWhite vaselinePEG 400Phenytoin sodiumSodium thiosulfateGanciclovirEucalyptus oilRose oilMCT oil

THAILAND: Khon Kaen UniversityCentral Lab

Faculty of Pharmaceutical Sciences run a central lab to support the university teaching hospital Laboratory analysis & interpretation Drug levels in biological samples (therapeutic drug

monitoring, or TDM) Theophylline, Vancomycin, Aminoglycosides,

Phenobarbital Drug levels in biological samples (analysis)

Paracetamol, salicylate, diazepam Metal level analysis Toxic level analysis

Gastric and urine samples

THAILAND: My Experiences

Khon Kaen UniversityLectured to “English

program” Doctor of Pharmacy students Cardiovascular

pharmacology & therapeutics

Toured university (government) hospital

Toured campus community pharmacies

THAILAND: InsightsSimilar issues exist

Control of hospital-acquired pathogens in hospitals

Cost-containment of expensive inpatient medications through formulary process

Similar practice models for pharmacistsChallenges

Overcrowding amongst public facilities due to lack of resources

Purity/efficacy concerns with certain available drug products

ConclusionsSimilar issues exist amongst the US, Japan, &

Thailand regardingRegulation of government healthcare & cost

containmentEducation of pharmacy students

Future collaboration globally amongst healthcare providers can provide insight into how others solved similar issues successfully

Exchange collaborations are win-win opportunities for both institutions

Questions?