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It’s time research got a new image

Rachel Airley believes pharmacy research needs an image make-over if it is ever going to be about more than just proving that pharmacists have a role

By Rachel Airley

Rachel Airley believes pharmacy research needs an image make-over if it is ever going to be about more than just proving that pharmacists have a role

Science needs a makeover within pharmacy practice research. For too long it has been assumed to be the territory of industrial and academic pharmacists. Patient-facing sectors are given a peripheral awareness of it, but limited opportunity to design or lead research studies that will directly feed into their practice. In community pharmacy especially, what is described as research is often little more than audit dressed up as research, where data are used for comparison against cookie cutter standards rather than for the generation of new ideas and ideals.

Although translational research, which forms a continuum of studies that take therapeutic advance from the laboratory to clinical validation and practice, is a staple part of the career progression of our medical colleagues, the same cannot be said for pharmacists. Instead, we have created a young discipline, pharmacy practice research.

I am going to be brave and question the tendency of practice research advocates, valued and respected academic colleagues and all, who talk in terms of carrying out practice research specifically to prove that we pharmacists have a role and add value to the health service.

Devil’s advocate

Playing devil’s advocate, should we not be asking why pharmacy needs to devote its research expertise to defending our turf as a profession, when no analogous “medical practice” or “nursing practice” research exists? We might say these professions choose instead to concentrate on research that is less about protecting their profession, and more about advancing health care, which speaks for itself.

Perhaps it is time to question the pharmacy practice research movement and ask ourselves whether research carried out to prove the value of the researcher is inherently biased and self-interested. Surely, research is about creating and applying new knowledge, whereas public relations and lobbying are important but separate issues. The two skill sets may meet in scenarios where quality research becomes citable, but the PR itself is not the hypothesis by which the research should be driven.

I wonder what exactly pharmacy research is all about and why it is currently so under-cited and has such a narrow audience compared with biomedical research. Currently, the field seems to be dominated by social science disciplines and methodology, but just when did the core pharmaceutical sciences that innovate, nurture and contextualise the practice of pharmacy, such as clinical pharmacology, clinical pharmaceutics and clinical trial design, stop or even fail to start being “pharmacy practice”?

Conversely, should not fields as diverse as pharmacoeconomics, social pharmacy, health psychology, pharmacy education and pharmacoepidemiology each be celebrated as an integral and vital part of a continuum of pharmacy research, rather than sanitised of their associations with the underpinning bench science and placed under the umbrella of what we have come to know, perhaps erroneously, as pharmacy practice research?

Why, for example, should the potential of some of our brightest health service researchers, social scientists and educational theorists be assigned to a discipline that, to the outside, risks being viewed, rather like the man-made beaches in Barcelona, as a construct justified into existence by the need to impress the tourists?

Somewhere along the way, it seems we have learnt to accept a schism between the “hard” pharmaceutical science that we associate with big words, test tubes, titrations and industrial pharmacists; and the “soft” science of “practice research”, which involves even bigger words, interviews and questionnaires. Of course, both descriptions are misconceptions — rigorous scientific technique and fully validated analytical instruments show obvious differences in formating but are of equal necessity to carry out social pharmacy research. Likewise, much of the pharmaceutical science research taking place these days is more likely to involve high-throughput “labs on chips” and bioinformatic software than test tubes. It is these misconceptions, in my view, that have led to a pharmacy research base so disconnected, so polarised and so confined to territorial zoning that we need a whole network of Belisha beacons just to summon up the courage to cross over.

To properly reunite all areas of pharmacy research with our clinical practice, we need to make an assault on this schism. For this reason, I have come up with the term “translational pharmacy research”, which is as much of an appreciation of our own professional research portfolio as a way to increase awareness of the importance of the whole of our research base among patient-facing pharmacists.

Translational pharmacy

In comparison with translational science, translational pharmacy:

• Takes advantage of the fact that our profession is the health profession that encompasses all aspects of medicines research and clinical application
• Focuses on collaborative work between pharmacists involved in research in all disciplines
• Has an additional layer dealing with medicines optimisation, whereas
translational science culminates in the evidence-based application of medicines, translational pharmacy uses the expertise
of patient facing pharmacists to research
the best way of using medicines in the individual patients or patient populations they care for
• Is a cyclical process that includes the three main arms of the pharmacy disciplines: (1) disease pathology, pharmacology, medicinal chemistry; (2) formulation and clinical  development; and (3) the social, health services, clinical pharmacy and practice research which define the objectives of medicines optimisation that will be the common theme running the length of the translational pharmacy continuum

 

Conveyed

­So what exactly can be conveyed by the term “translational pharmacy” research? Well, we can model it on translational science or medicine,1 the stage of therapeutic advance which works out how to take data obtained at the laboratory bench into the clinic. Translational science is the bridge between basic and applied research. The first stage, T1, is proof-of-concept, first-in-man studies. Subsequent stages, T2 and T3, take a treatment through phase II and III studies, following up to outcome and evaluating the impact first on the patient and then on clinical practice. The final stage, T4, is where pharmacoepidemiological studies will examine the benefit of the treatment to society as a whole. This is the stage where clinical guidelines are put into place. But this is not the end of the story. Pharmacists potentially add another stage, because once medicines are cemented into clinical practice they require pharmacists to pick up any problems and optimise their use according to the realities of clinical practice and our patients. If we can just keep our finger over the word “optimisation” for another paragraph or so, it is this word and its splicing onto our reason for being — medicines — that is buzzing through the profession at the moment.

Medicines optimisation will be what turns medicines management, which is primarily focused on the medicines, into roles that are focused on the nuances, individual therapeutic challenges and confounding factors that we come across in patients taking the medicines. Such roles make pharmacists an essential part of the healthcare team. To make this transformation, patient-facing pharmacists, not pharmacists marooned in industry and academia, will be needed for their experience and their clinical knowledge. It is only by fitting scientific advance, in situ, to pharmacy practice, that we can develop medicines optimisation roles that work, are credible, and, most of all, have evidential support that will sell it to commissioning bodies.

I have always said that it is the role of industrial and academic pharmacy research to provide the foundation, a blueprint in fact, for potential new advances in the therapeutic management of patients by pharmacists. But to become a reality, only pharmacists directly involved in clinical practice can refine and implement those advances. So instead of translational research being a linear process, it can be cyclical; a model for this is proposed in Figure 1. Pharmacists can make this happen, because our expertise and professional input at all stages, from basic through the translational stages to medicines optimisation, means we can work together and continually improve outcomes for our patients.

When I was working on my PhD at the Paterson Institute for Cancer Research in Manchester, I shared an office and collaborated closely with senior registrars in radiation oncology who were engaged in MD projects as part of their career development.  This is a standard career progression pathway for hospital doctors wanting to specialise and involved them carrying out biomedical laboratory research using biopsy and resected material from their own patients. The reason this approach works so well is that they can then work towards feeding back their findings into their area of practice. They understand where their clinical practice has come from- not from books or guidelines, but from their own experience. They have the credibility to carry out their role because they helped to develop it and, what is more, no one will dispute their place in these roles as they were there from the beginning.  

Maybe this is our problem. Almost every professional advance we have made over the past two decades that I have been qualified has meant tearing it away from the very people who, like the doctors I worked with on my PhD, were in there right at the beginning — prescribing, public health, medicines review, the list goes on. So by far the biggest justification for bringing pharmacy research into pharmacies is that to get that bite at the cherry we need to be in at the beginning too. Although it is the job of academic and industrial pharmacist researchers to point the way to new advances with the earlier stages of translational pharmacy research, it is the job of patient-facing pharmacists to develop them as uniquely pharmaceutical roles.

Reference

1    Woolf SH. The meaning of translational research and why it matters. JAMA 2008;299:211–3.


Rachel Airley, PhD, MRPharmS, is senior lecturer in pharmacology at the University of Huddersfield (email r.airley@hud.ac.uk)

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Citation: The Pharmaceutical JournalURI: 11119427

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