EVOLUTION OF CLINICAL PHARMACOLOGY: A STEP TOWARDS SAFE AND RATIONAL PRESCRIBING OF DRUGS

Abstract

Clinical Pharmacology is defined as the scientific
study of the actions and use of drugs in human
beings, their efficacy and safety being the centre of
interest. Basically, it teaches us how effective and
safe a particular drug is in humans and how does the
body handle and respond to it.
Clinical Pharmacology is concerned with the
scientific use of drugs for rational (ethical, effective,
economic and safe) treatment of patients.
Purkinje1, in 1829, wrote that normally we
should simply think of making use of animals but the
most reliable results may be obtained only by
experimenting on one's own body, provided the
experimenter performs the experiment with adequate
care. Believing this concept he studied the effects of
digitalis, camphor and belladonna on himself. A
primitive concept of clinical pharmacology was
founded in the minds of scientists concerned with
patient care.
Sir Malcolm Lader, famous psychiatrist,
stressed upon his students to always taste a drug at
least, before prescribing it, so that the prescribing
doctor may realize the experience that patient goes
through.
European regional office of World Health
Organization ( WHO), in 1977, reported that there
was a growing concern of governments, health
authorities and general public that, drugs were not
used in medicine as efficiently and safely as they
should be 2. This report called for an action by the
European community to look for the reasons of the
reported concern. It was revealed that optimum use of
drugs required the same expertise level as was
demanded for the diagnosis of disease.
The European community collectively
decided to adopt optimum use of ethical, effective,
safe and economic drugs in the treatment of patients.
Soon after the implementation of this decision,
benefits were experienced in the form of gradual
reduction in morbidity and mortality. This approach
encouraged the developed nations to work further and
look into the ultimate mechanism, which governs
optimum use of drugs in the treatment of patients.
The knowledge of the scientific use of drugs in
humans, in health and disease, was r ecognized as
Clinical Pharmacology and application of this applied
science as rational prescribing was therefore,
established as an academic discipline in medical
schools and some universities, i.e. University of
London3 and was also recommended to be an
essential element in the provision of health care in
Europe.
A sound knowledge of drugs and their
optimum use enables a physician to give a moment's
thought to consider before prescribing, whether drug
treatment is really necessary, because, certain
diseases are self-limiting and drug intervention can
safely be avoided by careful observation of the
patient during his illness. How ever, when life of the
patient seems at risk and demands urgent drug
intervention, it becomes the responsibility of the
attending doctor to select safe, effective, economic
and convenient drug/s .
It is worth mentioning that drug treatment is
not free from complications and one should not get
trapped in the wrong belief of, a pill for each ill.
These iatrogenic diseases are usually difficult to
identify and may go undiagnosed, with fatal out come
at times.
The practice of clinical pharmacology was
meant to improve upon prescribing habits of
clinicians in their day to day practice. Later on it took
the shape of an academic discipline, as a full fledged
subject to be taught in the medical institutions and in
some universities in Europe. Clinical Pharmacology
and Therapeutics is not only taught but is considered
to be of sufficient importance to be classed and
examined in as a separate subject in final year
MBBS.
The concept of Clinical Pharmacology, its
prospects and role in improving patient care in
Pakistan was first published in 1977, for creating
awareness amongst the medical professionals 4.
The role of Clinical Pharmacology in undergraduate medical education was published in l980 in
order to motivate young students to take up this
subject for their profession in future 5.
Nierenberg published consensus for a core
curriculum in Clinical Pharmacology for medical
students, in 1906 6.
A workshop held in Perth, Australia, on
December 6' 19917, endorsed the core curriculum in
Clinical Pharmacology developed by Nierenberg6. It
was recommended in the same workshop that a
manual in Clinical Pharmacology should be written
for students to learn the subject with interest.
J Ayub Me d Coll Abbottabad 2007; 19(1) 2
College of Physicians & Surgeons of
Pakistan approved postgraduate degree in Clinical
Pharmacology in 1994.
Twelve years have passed since the approval
of post-graduate qualification in Clinical
Pharmacology but it seems as if no one has either
joined the course or has not been able to qualify. This
may be inferred that introduction of Clinical
Pharmacology and as a consequence r ational drug
therapy has been put in abeyance at the graduate and
post-graduate levels for so long.
It is of concern that the concept of Clinical
Pharmacology has not been taken in the correct sense
in Pakistan. The general physicians seem skeptical as
to what will happen to their future status after
introduction of this specialty in the country, whereas
specialist physicians consider it an extra task of
learning about the drugs, which they claim to know
already. On the other hand teachers of basic
Pharmacology stay in the basic sciences departments
mostly. They usually refrain to conduct trials on
human subjects for the reason, that they do not retain
confidence to handle human subjects and manage
drug trials.
The drugs and treatment scenario demands a
collective effort as was done by the European
community. They changed their prescribing habits by
scientific research to a rational approach and named
it '˜Clinical Pharmacology'. Developed nations did
not stop at improving the prescribing habits only but
went on towards post-graduate specializations
through continued research in the subject.
A similar line of action is recommended to
achieve rational therapy in Pakistan. All it needs is a
collective effort and harmony of thought.
A reasonable approach to introduce the same
is based on the recommended curriculum by the
College of Physicians and Surgeons Pakistan in
19948, to motivate the young under-graduate medical
students in their pre- clinical years to learn the basic
principles of phenomena occurring in the living body
as a result of administration of drugs, such as
absorption through the mucous membranes,
distribution in various compartments of the body,
metabolism of drugs and even various ingredients of
food, etc., their utilization for different useful
purposes, elimination of the waste products which is
of no use to the body, will ultimately motivate the
young student to find an answer to the above
mentioned and learn how to make use of these
phenomena for correcting any abnormal condition in
the human body on the same lines. This Knowledge
may be provided as a pre-requisite for training in
Clinical Pharmacology in the form of a core
curriculum / syllabus
Initially, teaching may begin with the basic
knowledge of Pharmacology such as mechanisms of
actions of drugs (pharmacodynamics) and
mechanisms by which the body deals with the
administered drug/s (pharmacokinetics). The student
should start learning basic and preliminary,
interesting, non-invasive, easy to perform and clearly
under-stood practical skills in their practical classes
and apply the knowledge and the skill thus gained, to
clinical situations before taking up the responsibility
of patient care.
All it needs, is more emphasis to attain
knowledge in order to justify as to why, how and
when a drug should be used, if at all. Once the
student is able to justify a decision of treatment or no
treatment, he is considered to have learnt Clinical
Pharmacology and hence rational prescribing.
In compliance with the recommendations of
Perth workshop, an attempt has been made to design
a manual for under-graduate medical students , in our
institute.
It is recommended that other institutions in
the country also adopt similar policy. It is further
suggested that approval of teaching of Clinical
Pharmacology to the under-graduate students by the
Pakistan Medical & Dental Council, as recommended
and approved by the College of Physicians &
Surgeons Pakistan, will facilitate and give
momentum to teaching of rational therapy.