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Arnold Birenbaum, Roslyn Bologh and Henry Lesieur Reforms in pharmacy education and opportunity to practise clinical pharmacy

Abstract The impact on 357 newly licensed pharmacists, graduates of two colleges, of efforts to tum pharmacy into a clinical profession, was examined by way of a self-administered questionnaire. Perceptions and expectations about work, differences in consulting practices, relationships between practice and attitudes, and the presence or absence of an identifiable general value orientation (which could account for spedfic perceptions and attitudes), were examined. Results indicated that hospital practice was more likely to be associated with clinical pharmacy and clinical pharmacy practice was more likely to meet the expectations of recently graduated pharmacists. In addition, 52 per cent of the community-based pharmacists were found to engage in patient counseling, as compared with 39 per cent of hospital-based pharmacists. Newly licensed pharmacists are deepening the existing divisions in the profession, while moving toward a revision of their place in the health care delivery system.

Introduction

Traditional sodological analyses of the professions rarely have considered how, under what conditions, and with what consequences, an established profession seeks to change its position within a single industry. In the structural-functional perspective (Goode, 1960; Greenwood, 1966; Parsons, 1968) an occupation becomes a profession when granted autonomy and receives recognition from sodety for possessing a technical knowledge-base, demonstrating effective performance, developing a lengthy and superior education, and espousing ethical commitments to the common good. This list of attributes does not take into account that new technology can take functions away from established professional practitioners, new Sociology of Health & Illness Vol. 9 No. 3 1987 ISSN 0141-9889

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market and organizational structures may delegate tasks to lesser trained occupations, and other occupations may try to encroach on a profession by increasuig educational requirements and adopting a code of ethics. Fadng these threats, leaders of an established profession may advocate reforms in education to permit reprofessionalization. An altemative approach (but within the same tradition) is suggested by Wilensky (1964), in which reprofessionalization is designated a social and poUtical process. Herein some professions (with particular attributes) actively take on the task of getting greater sodetal recognition, usually tiu^ough developing comprehensive educational programmes which are connected with universities, national organizations to represent the interests of the occupation, and codes of ethics. It can be said that educational reforms may be achieved more rapidly than changes in professional practice. Reprofessionalization movements within an occupation are usually led by university based elites capable of taking risks to bring about the future desired legal support and sodal recognition. What happens when non-elites responding to the initiatives of elites - attempt to take on new responsibihties? And what kinds of responses do they receive intemal to the profession and from other professions with which a division of labour is shared? This paper examines the impact on newly licensed pharmadsts of efforts to tum pharmacy into a clinical profession. Advocates of reprofessionalization define this new role as: . . . the application of pharmaceutical service emphasizing integration and coordination of the patient's total drug regimen, using all available means to achieve maximum effectiveness and safety of drug therapy in the context of the patient's total environment (Provost, 1971). Despite this clear definition of a complex task, this author went on to assert that in the future pharmacy would no longer need this label, or any other, provided that the profession '. . . embraces the opportunity to offer services . . . only temporarily, distinguished from other parts of pharmacy' (Provost, 1971). In other words, in the future all pharmadsts, including those in the community, would be professionally engaged in clinical practice. Clearly, there is a movement within this profession to gain more authority in health care settings. Professionalization in pharmacy has been characterized as incomplete because of ongoing and sometimes incompatible business and service orientations, the lack of exclusive control over the social object which is its reason for

288 Amold Birenbaum, Roslyn Bologh and Henry Lesieur

existence (i.e., the drug), and failure to achieve widespread recognition as a knowledge-based field (Denzin, 1972). The historical source for the movement toward clinical pharmacy in the United States came from efforts to make structural changes in the management and delivery of medications to hospitalised patients. Citing the high rates of errors committed by nurses in dispensing, hospital pharmadsts designed and evaluated 'unit dose' systems to assure accuracy in the administration of drugs to patients (Philip H. Greth, et al., 1965; Black and Tester, 1964). Conditions outside of hospital practice reforms, including the end of compounding of most prescription drugs, automated dispensing, the increased competition in retail pharmades from discount chain stores, more salaried employment for pharmadsts in hospitals and nursing homes, along with increasing utilization of pharmacy technidans and assistants, has raised the spectre of reduced economic opportunities in the future without a new direction for pharmacy (Birenbaum, 1982). In the early 1970s the colleges of pharmacy, whose faculty would also be threatened by reduced enrollment, commissioned an investigation of how they could best prepare pharmadsts for their future role in health care. Encouraged by the widely acclaimed Millis Report on the need for reform in pharmacy education, many colleges of pharmacy revised their curriculum to refiect a new emphasis on the drug advisory activities of pharmadsts in hospitals and in the community. By the middle of the past decade, colleges of pharmacy began to stress that their graduates would be performing clinical frinctions in relation to patients and physidans, since pharmadsts were experts in drug information. In essence, function would follow education reform. Newly educated pharmacists have been employed in various settings for a number of years. Currently, however, clinical practice in pharmacy takes place in relatively few hospitals, mainly those with a tradition for innovative health care services. Conducted in 1978, a national sample survey of pharmaceutical services at 815 acute care hospitals suggests that clinical services are most cost effective at large hospitals (Stolar, 1979). Based on projections from the sample, only 150 hospital pharmades in the United States provided a comprehensive clinical service programme in 1978. Most of these hospitals were large (over 400 beds) and are located in New England or on the Padfic coast. (Although information was not provided, it is likely that these hospitals are affiliated wdth medical schools).


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The most recent studies of levels of satisfaction among hospital pharmacists indicate that the professional sodalization experience may not be able to withstand the situational constraints of hospital practice, with little opportxmity to act as dinidans. Johnson, Hammel and Heinen (1977) compared the responses of Midwestem hospital pharmacists to professional managerial and nonprofessional workers surveyed nationally on working conditions and job satisfaction. There was '. . . an overall pattem of less satisfaction among hospital pharmacists than among workers included in the Michigan surveys' (Johnson, Hammel, and Heinen, 1977: 241). SpedficaUy, pharmadsts were least satisfied with the lack of opportunity for advancement, staffing practices, employer's polides and practices, and compensation practices. Interestingly, those who got to practice clinical pharmacy were far more satisfied than staff pharmadsts. This pattem of dissatisfaction was also noted in a study of Israeli pharmacists (Shuval and Gilbert, 1978), wherein cynidsm was found to be consistent with the subjects' reduction of expectations of rewards from future practice. In another survey of recent graduates of eight American colleges of pharmacy, respondents were found to be strongly committed to their work but often expressed less feeling of accomplishment at work compared to a 1973 national sample survey of workers (Curtis, Hammel and Johnson, 1978:1516). Furthermore, when institutional and hospital pharmadsts were compared with community pharmacists, no differences in satisfaction were found. However, one exception to this overall result was that practitioners in ethical pharmades where no sundries are sold - reported higher levels of satisfaction than pharmadsts in other settings. Impressionistic evidence provided by a veteran pharmacy educator also suggests that there is widespread disillusionment among pharmacy graduates who '. . . are full of idealism when they leave the campus in search of jobs. But in a year or so their attitude changes. Most of them will sell anything to make a quick buck' (Siegelman, 1978: 5). How does it come to be that professionzdism is impractical in community pharmacy? Are there some conditions under which idealism is maintained? Under what conditions does hospital pharmacy encourage or discourage feelings of accomplishment? These issues are not merely spedfic to pharmacy practice. General concem over the discontinuity between education anc practice is found among many educational spedalists in the field o health care. A work group on the education of the healtl

290 Amold Birenbaum, Roslyn Boiogh and Henry Lesieur

professions and the nation's health, made up of a cross-section of leaders in that field, noted that there is little research on how sodalization of providers affects their productivity (Magraw, et al., 1978). In the profession of pharmacy, it would be necessary, first, to determine how much of the education of recent graduates is utilized in their work, particularly in the Chnical areas, before investigating their effects on the health of individuals or groups. In line with the more realizable recommendation of the work group to identify the '. . . contributions of education and practice to professional behaviour and their effect on health services. . .' (Magraw, et al., 1978: 540), this report examines the discrepandes and continuities in pharmacy practice. There is some evidence that context can make a difference: Continuity between education and practice is encouraged in some environments and discouraged in others. Opportunities to engage in clinical practice, such as consulting with patients and physidans, was viewed more favourably by younger than older pharmadsts, but effectiveness in performance varied very httle by age (Watkins and Norwood, 1977)i Moreover, the settings found in community pharmacy can encourage or discourage consulting behaviour. Significantly higher consultant behaviour scores were found among respondents employed in service-oriented than discount pharmadsts (Watkins and Norwood, 1978). When environment was held constant, however, no significant differences in consulting behaviour were found between older and younger pharmadsts. Respondents who had information used it in the service of the patient. Pharmadsts of all ages, when knowledgeable, advised patients about potential difficulties with prescriptions. Patient consultation was not followed by physidan consultation, however, when pharmadsts were aware of potential problems. Watkins and Norwood also found a significant difference in consulting behaviour between pharmadsts located in a serviceoriented and discount pharmades. Pharmadsts practidng in the service-oriented locations were more likely to advise physidans about potential problems than their equally knowledgeable counterparts in the discount stores (1978). It is important to collect data on discontinuities between education and practice in order to detennine not only what settings encourage the practice of clinical pharmacy, but what strategies are employed by newly employed pharmadsts to accompl^h this objective. Moreover, recent graduates constitute an appropriate sample because they are less likely to have become cynical about

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professionalism than more veteran pharmadsts. Finally, sampling from recent graduates makes possible the inclusion of a variety of vocational experiences and reactions to them by respondents. Method The only two pharmacy colleges in New York City were interested in finding out more about the experiences of their recent graduates since they implemented curriculum reform. Hardly Eastem 'establishment' universities, Amold and Marie Schwartz College of Pharmacy (Long Island University) and the College of Pharmacy and Allied Health of St. John's University provide the bulk of the new recruits to hospital and community pharmacy in much of the metropolitan area made up of lower New York State, northem New Jersey and southem Connecticut. All 1975 through 1979 graduates inclusive received a mailed self-administered questionnaire withfixedaltemative answers. Discussion with pharmacy faculty led to the development of a prestested instrument. The questions were designed to elicit attitudes and perceptions about the profession of pharmacy, opportunities to utilize skills acquired through undergraduate education, and whether, after several years of employment, the clinical emphasis of their education was reflected in their occupational orientation. The response rate was thirty per cent, with some respondents now located not only in the Northeast but all sections of the United States. The results reported below were based on 357 completed questionnaires. The respondents appear representative of newly licensed pharmadsts. Neither college could be considered as a locus for the generation of new practices in clinical pharmacy. Both lacked close contact with medical school teaching hospitals where many of the service innovations recently reported in pharmacy joumals take place. Increasingly, colleges of pharmacy were admitting and graduating more women, as the traditional barriers to entry to this profession by women were lowered. Unlike other technical support occupations, pharmacy's commercial avenues to success made it a highly desired vocation for men while long hours in retail owner/ operated establishments in the community made it unattractive to women. With opportunities shifting toward salaried employment and away from entreprenurial endeavours, these trends toward feminization should continue. Results were analyzed to determine (1) the recently employed


pharmadsts' perceptions of their profession and expectations about work, (2) whether there were differences in consulting practices, (3) the relationship between practice and attitudes, and (4) whether there was an identifiable general value orientation which accounted for particular perceptions and attitudes. Results Perceptions of the profession of pharmacy and work expectations Many respondents (43%) viewed the profession of pharmacy as changing, mainly as a result of the new clinical directions imdertaken. Others (36%) found it hard to judge whether pharmacy was changing because of structural divisions in the profession, including distinctions between community and hospital pharmacy, university affiliated innovators and others, and because of sharply perceived generational differences. In addition, 21 per cent felt the profession was not changing. The lack of consensus found above in the tripartite distribution of responses is related to the widely shared view that lack of cohesion among pharmadsts is the most serious problem of the profession. Eighty-two per cent of the respondents saw fragmentation as weakening their profession. Despite a substantial minority's recognition that pharmacy was becoming more clinical, more than half the sample (54%) did not feel their current work met their expectations. Most were disappointed primarily because 'my knowledge goes far beyondfillingprescriptions.' Only seven per cent mentioned not being well paid as a source of dissatisfaction. Moreover, of the 37 per cent of the respondents who were satisfied with their current work situation, half claimed that their work was clinical in nature and the other half said they were using their knowledge to fill prescriptions. Thus, no more than 19 per cent of this sample of recent graduates of colleges of pharmacy which now follow a revised curriculimi, saw themselves as clinical pharmadsts. When asked if they were utilizing their training, 67 per cent did indicate positively that their work dep>ended on what they leamed. While not naming their work activities clinical pharmacy, many respondents mentioned that they used their knowledge of how dmgs work, eduated nurses and doctors in pharmacology, interviewed patients to acquire drug histories and explained to patients how to use medications properly, what the side effects of these dmgs are


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and the potential interactions of these drugs v^th other medications. Exposure to a new education and new practices helped some of the respondents maintain their 'new breed' image. A large majority of respondents saw themselves as different from older pharmadsts, who they claimed held different expectations from recent graduates of five year programmes. In the main, they attributed the differences mostly to the older pharmadsts holding a concept of the field as a business rather than a profession (43%). In addition, they mentioned that young pharmadsts could maintain their professional orientation because they were better trained in pharmacology and clinical practices. However, 25 per cent held to the view that doing the same job and experiendng the same problems and stresses reduced the differences between the younger and older practitioners. Doing more clinical work made respondents feel more professional than their more experienced colleagues, yet they still did not feel that their work fully met their expectations. In response to a question as to whether, given their training and knowledge, there were some further contributions that they could make, 62 per cent responded affirmatively. And almost all respondents who saw themselves underutilized thought they could do more advising of doctors and nurses about drugs, have more direct contact with patients, and assist physidans in selecting the correct medications for patients; a small number (9%) indicated that they could educate youth about the harmful effects of drug abuse. Clinical training was eclipsed by the routine aspects of their employment. Respondents complained about extensive paper work, mere counting of pills and labelling containers ('SpUl, fill, lick and stick.'). Further complaints centered on their lack of authority and responsibility, which limited the use of their knowledge. These sources of dissatisfaction were mentioned by 89 per cent of the sample. It is reasonable to expect that different organizational settings would or would not promote work satisfaction. We hypothesized that expectations regarding work would be more likely met in hospital rather than community pharmades. Differences were statistically significant when the two settings were compared. Of the hospital pharmacists, 52 per cent reported their work as meeting expectations as compared with 41 per cent of the community pharmacists (Yule's O = 22, S < .05).^ Reflecting the influence of the educational stress on clinical work, the opportunity to practice clinical pharmacy should discriminate between those who find the work meeting expectations and those


who do not, regardless of hospital or clinical setting. This hypothesis was confirmed: Of all pharmadsts who reported practidng clinical pharmacy, which included slightly more than half the respondents, the majority said that the work was meeting their expectations (58%), in contrast with only 33 per cent of those who reported not practidng clinical pharmacy (Yule's O = 47, S ^ .001). Furthermore, hospital pharmadsts are much more likely to report doing clinical work (70%) than are community pharmadsts (42%) (Yule's O = .47, S ^ .001). In sum, hospital practice is more likely to be assodated with clinical pharmacy and clinical pharmacy is more likely to meet the expectations of recently graduated pharmacists. Differences in pharmacists' consulting practices There are several components to clinical pharmacy, with hospital and community locations encouraging different consulting practices. When counselling patients is considered part of clinical practice, 52 per cent of the community-based pharmadsts were found more likely to engage in this practice, as compared with 39 per cent of the hospital-based pharmadsts (Yule's Q = .25, S ^ .05). Counselling patients is a satisfying activity, with 55 per cent of the respondents who engage in this practice feeling that their work meets their expectations as compared to 39 per cent who do not counsel feeling the same way (Yule's O = .32, S ^ .01). Counselling refiects not only greater responsibility at work, often a source of satisfaction, but greater control over how one performs at work, which also provides a sense of autonomy. Those who report having enough time to consult with patients are more likely to say that the job meets their expectations (59%) than respondents who claim they have no time to perform this clinical task (42%) (Yule's O = .34, S < .01). Performing the tasks of clinical phcirmacy (e.g. counselling patients), even without formal recognition of these functions as part of one's job description, encourages work satisfaction, independent of location. When organizational setting was held constant, hospital pharmadsts who practiced clinical pharmacy were more satisfied than their peers who did not; and similar results were obtained among their community-based colleagues. Counselling patients was a more important source of job satisfaction among community than hospital pharmadsts. Indeed, the relationship between counselling patients and job satisfaction among the latter was not statistically significant, whereas it was


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among the former group. Community pharmadsts who counsel patients were far more likely to say their work meets their expectations (54%), as compared to those who do not counsel (27%) (Yule's O = .52, S < .001). Satisfaction among hospital pharmadsts may be based on working closely with physicians. Using questionnaire items about relations with physidans, including whether the respondent ever questioned a physidan's dedsion on a prescription, we developed a three point index of pharmacist-doctor communication. Hospial pharmadsts (51%) had much higher scores than community pharmadsts (25%) on communication with physicians (Somer's d asymmetric with communication as the dependent variable was — .27, S ^ .001). The pharmadsts' opportunities for contact with physidans in hospitals promotes a professional relationship. Hospital pharmadsts are more likely to have questioned a physidan's dedsion (76%) than are community pharmadsts (62%) (Yule's O = .32, S :s .01). This contact among hospital pharmacists and physicians does not indicate a distaste for patient counselling. While we found community pharmacists more likely to counsel patients than their counterparts in hospitals, 47 per cent of hospital pharmadsts prefer talking about ailments and therapies with patients over technical and marketing tasks, as compared with only 36 per cent of community pharmacists (Yule's O = .23, S < .05). In summary, it appears that differences in consulting practices reflect altemative situations rather than orientations. Community pharmacists consult more with patients than hospital pharmadsts, but have less contact with physicians. Most importantly, opf>ortunity for consulting has a significant effect on whether work meets expectations, particularly for community practitioners. Relationship between practice and attitudes Differences in type of practice constraints not only the varieties of consulting behaviours possible (either with patients or physidans), but also influences attitudes toward increased responsibilities, professional recognition, and the public's esteem. Protecting patients against adverse drug interactions would be enhanced through detailed record keeping of prescriptions for individuals, know as 'patient profiles.' It was reasoned that all dedicated pharmacists would advocate the performance of this task, regardless of location. Yet it is also possible to consider professionalism - independent of commercial constraints - as more likely to be encouraged in hospitals rather than community practice. Results showed that the latter hypothesis

2% Amold Birenbaum, Roslyn Bologh and Henry Lesieur

was confirmed. In hospital pharmacy 77 per cent of the respondents, as compared to only 59 per cent of community pharmadsts, wanted the profession to be legally required to maintain patient profiles (Yule's Q = .40, S < .001). An appropriate professional environment, one might expect, is where expert opinion is taken seriously. Again, the higher rate of communication between hospital pharmadsts and physidans appears to encourage professional recognition. Hospital pharmadsts are less likely (46%) than conmiunity pharmadsts (59%) to believe they receive little respect from doctors (Yule's Q = .25, S ^ .05). Respect, it was hypothesized, was directly related to clinical responsibilities. It was found that 49 per cent of hospital pharmadsts felt they had too many clinical responsibilities, as compared to only 24 per cent of community pharmadsts (Yule's Q = .50, S ^ .(X)l). Wherever located, those who felt they have too many clinical responsibilities were less likely to dte lack of respect from physidans as a problem of the profession (40%), while 60 per cent of the respondents who did not mention this problem felt they received too httle respect from doctors (Yule's O = .40, S :£ .001). Demanding work, characterized by responsibility and involvement in dedsion making, encouraged greater job satisfaction. Those with too many clinical responsibilities were more likely to say their work meets their expectations (59%) than those who did not dte too many clinical responsibilities as a problem (39%) (Yule's O = .38, S :s .001). It is possible that the relationship between clinical responsibilities and respect from physicians may be an artefact of hospital practice rather than an outcome of performing clinical tasks. When controlling for location, we found that the relationship between heavy clinical responsibilities and physician respect still obtained. Hospital pharmacy includes both clinical and nondinical functions. Performance of technical tasks alone, without consultation with physicians, is perceived as an insufficient service to receive the respect of physidans. A far greater proportion of hospital pharmacists who do not practice clinical pharmacy (65%) identified lack of respect as a major problem of the profession when compared with those who practice clinical pharmacy (36%) (Yule's Q = .53, S s .01). Professional respect was only one problem identified by these young pharmadsts. Lack of recognition from the public was considered an even greater problem fadng the profession, mentioned by 65 per cent of the sample. Differences in perception were found

Reforms in pharmacy education 2S>7

between those practidng clinical pharmacy and others. Of those who do not engage in clinical pradce, 72 per cent identified this as a major problem compared with 59 per cent of those who do practice clinical pharmacy (Yule's Q = .26, S < .05). Again, concem for recognition was inversely related to clinical responsibilities. Respondents who felt they had too many clinical responsibilities were less likely to think that lack of recognition from the general public is a major problem of the profession (54%) than those who did not perceive themselves as having too many clinical reponsibilities (68%) (Yule's O = .27, S s .05). In sum, work setting and opportunities for clinical responsibilities influence attitudes toward the way the profession of pharmacy is seen by others and the need to take on more responsibilities. General value orientation and particular perceptions and attitudes The general orientation held toward one's profession may exist independent from opportunities to practice according to desired preferences. Failure to fulfill those aspirations may eventually result in departure from the profession or simply retreating from those goals. Blocked opportunities may also be perceived as the result of a lack of awareness by the public of what pharmacy could accomplish and the presence of impediments in the immediate work setting which limit professional achievement. Respondents who preferred the clinical side of pharmacy, even if they do not actually practice it, tend to be more concemed about lack of recognition from the general public (71%) than those who do not prefer clinical work to other kinds of responsibilities (58%) (Yule's O = -27, S ^ .05). Community pharmacists who prefer talking with patients about ailments and therapies, an indicator of a clinical orientation, are more likely to cite lack of recognition from the public as a problem faced by the profession (71%), as compared with those who prefer marketing and technical aspects of pharmacy (58%) (Yule's Q = .27, S < .05). It was reasoned that pharmadsts with a clinical orientation who were in the community would be sensitive to and reject an emphasis on merchandising. This hypothesis was confirmed: TTiose community pharmacists who question physidans, an indicator of a clinical orientation, were more likely to say there is too much emphasis on merchandising (57%) than those who report never having questioned a physician's prescription (41%) (Yule's Q = .32, S s .05). Similarly, the attitude towards keeping patient profiles, another indicator of a clinical orientation, was inversely related to a positive

298 Arnold Birenbaum, Roslyn Bologh and Henry Lesieur

attitude towards merchandising. Those community pharmadsts who advocated that maintaining patient profiles be legally required also tend to assert that there is too much emphasis on merchandising (58%), as compared with those who did not share this positive attitude towards patient profiles (47%) (Yule's Q = .32, S ^ .05). Likewise, among community pharmacists reporting a preference for talking with patients about their ailments and treatment, 62 per cent said there was too much emphasis on merchandising as compared with only 45 per cent of those who did not prefer this aspect of the work (Yule's Q = .33, S ^ .05). A clinical orientation, like any general value orientation, is based on prindples. However revealing were the differences in satisfaction between preferences and actual practice, those community pharmacists who insist on having enough time for counselling are less likely to feel that there is too much emphasis on merchandising (37%), as compared to those who did not insist on taking the time to counsel patients (56%) (Yule's O = .38, S ^ .05). Prioritizing activities is also found to account for other perceptions. When insisting on time for counselling, fewer respondents regard jis a problem competition between local pharmades. Of those community pharmadsts who insist on having enough time for counselling, 57 per cent view competition as a major problem compared with 75 per ceiit who do not insist on taking time for patient counselling (Yule's Q — .38, S :£ .05). Discussion Young pharmadsts who felt their profession was changing were also unsatisfied by current work situtions which hmited the application of their clinical education. The clinical focus of the curriculum had consequences beyond merely changing training and skills; it sensitized these newly graduated pharmadsts to the several divisions of professional labour, divisions which go beyond conventional dichotomies such as hospital and community pharmacy. This study has identified a number of discrepandes within the field. First, it cannot be assumed any longer than hospital pharmacy represents a unified category, since it was found to include differential distribution of opportunity to practice clinical pharmacy. Indeed, the absence of opportunity to engage in cUnical practice may be more keenly felt by hospital pharmadsts who can observe their peers doing clinical work, while community pharmadsts, in


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contrast, not only do not observe these differences but may as well have access to compensatory responsibilities in management and marketing. Second, despite the discontinuity between pharmacy education and practice, those respondents who perceived their work as meaningful were relatively more satisfied than the respondents who found their work more limited. Particularly important was the actuzil experience of performing some consulting activity, whether with patients or physidans. Even when these activities were not formally or offidally recognized as clinical pharmacy, when their work brought them into contact with physidans and the public as experts, rather than as purveyors of dmgs and sundries, or merely as technidans, they received respect and recognition. Third, even among those who did not necessarily practice clinical pharmacy for want of an opportunity, a preference for clinical work predicted that respondents perceived a lack of respect from physidans and failure on the part of the public to recognize the pharmadst's contribution to the nation's health. They also more strongly perceived the commerdal side of pharmacy as a roadblock to changing the role of the pharmacist than did the respondents who were able to engage in some clinical practices. Fourth, while those with a more clinical orientation are more likely to cite the business aspects of pharmacy as a problem of the profession, the relationship between the general value orientation of professionalism and the particular perception of problems is complex. Pharmacists in the community who are assertive professionally, i.e., insist on making time available to consult with patients, downgrade the difficulties which commercialism engenders. The presence of this group may be viewed as a problem or as an opportunity to leam about strategies used to gain access to clinical tasks. It can be said that individualistic and economically successful persons may be less sensitive to the sodal conditions that obstmct professionalism than other members of that vocational community. These individuals may constitute yet another division in pharmacy. Altematively, professional assertiveness may result from these individuals' perception that they have group support behind them. If the second interpretation is valid, we may see greater collectivism in pharmacy than in the past. Further research is needed to test these contrasting hypotheses.

300 Amold Birenbaum, Roslyn Bologh and Hem7 Lesieur

Conclusion

A convergence of historical, technologic, economic and social forces - a subject which is beyond the scope of this report - have encouraged curriculum reforms in pharmacy. Changes in pharmacy education have contributed to the rising expectations of young pharmacists for greater responsibility and autonomy at work. In their concrete understanding of the gap between their chnical orientation and opportunities to engage in that practice, young pharmacists have become made acutely aware of sodal divisions within the profession and the sources of its lack of cohesion. Insofar as this process will encourage demands for change, the education received starting at the university is based on political as well as the clinical sdences. It may well tum out that the new reforms in education accellerate reprofessionalization in pharmacy. Encouraged to expand their roles, and thereby perform more clinical services, newly hcensed pharmacists are deepening the existing divisions in the profession, while moving toward a revision of their place in the health care delivery system. Department of Sociology and Anthropology St John's University Jamaica New York 11439 USA Note 1 Yule's O is a special case of gamma used for 2 x 2 tables. It, like gamma, is an ordinal measure of association and has the same interpretation. The value of Q (which ranges between + 1,0 and - 1) represents the probability that for every pair of individuals drawn at random, excluding ties, tbe order of the pairs will be the same on each variable. O is calculated according to the formula: O = (ad - bc)/(ad + be) where the letters represent cell frequencies in a 2 X 2 table as follows: a = upper left, b = upperright,c = lower left, d = lowerright(Mueller, Schuessler and Costner, 1970:290-292). In our analysis, the sign of O is not included in order to avoid confusion. In this case, Q represents the probability that for every pair of individuals drawn at random, excluding ties, the order of the pairs will be in the direction discussed in the text.

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