CIMA Lecture Series Pharmacy Practice in Japan and Thailand: Experiences as a Visiting Professor

1. CIMA Lecture SeriesPharmacy Practice in Japan and Thailand: Experiences as a Visiting Professor Sara D. Brouse, Pharm.D., BCPS, AQ Cardiology Associate Professor of Pharmacy Practice Advanced Practice Pharmacist—Cardiology/Critical Care May 5, 2010

2. Objectives • Discuss TTUHSC SOP exchange agreements • Describe the government healthcare systems in Japan and Thailand • Compare/contrast pharmacy education systems between the US, Japan, & Thailand

3. 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 EDUCATION A Position Paper ENTRY-LEVEL EDUCATION IN PHARMACY: A COMMITMENT TO CHANGE Available at: http://www.aacp.org/resources/historicaldocuments/Documents/COMMISSPOSPAPER3.pdf. Accessed April 4, 2010.

4. TTUHSC SOP Exchange Agreements • Faculty 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 • KhonKaen University School of Pharmacy, KhonKaen, Thailand • 2009 to present

5. TTUHSC SOP Exchange Agreements • Faculty exchange • Visiting Professor • 6 week experience • Teach elective course • Participate in scholarly activities • Visiting Teaching Professor • 1-2 week experience • Teach core content within particular curricular area, ie cardiovascular module • BS program: translator • Masters programs: no translator

6. TTUHSC SOP Exchange Agreements • Faculty exchange • Visiting Professors to Texas Tech SOP • 1-2 week experience • Arrange shadowing experiences • Faculty teaching models for problem based learning, active learning, experiential training

7. TTUHSC SOP Exchange Agreements • Student/Resident exchange program • Keio 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

8. TTUHSC SOP Exchange Agreements • Student/Resident exchange program • Khon 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)

9. JAPAN

10. JAPAN:State of Healthcare • Socialized medical model • Universal healthcare provided to citizens • Physician-dominated practice model • All other healthcare disciplines subordinate • Pharmacists not allowed to touch patients • Cannot administer medications/immunizations or perform diagnostic testing (BP, blood glucose) • Patients kept sheltered from diagnosis • Lack of patient counseling by pharmacists about medications

11. JAPAN: State of Pharmacy Practice • Hospital length of stay: 28 days • Some hospital pharmacies dispense 2 week supply of meds • Patients self-administer medications other than intravenous • Many hospitals have nurses mix all IV medications on hospital ward • 30-40 pharmacists for 1000-bed hospital • No pharmacy technicians • Cost and safety burden

12. JAPAN:State of Pharmacy Practice • PMDA = pharmaceutical manufacturing drug administration • Similar to FDA • Approves medications for use in Japan • Coordinates safety monitoring • Medical focus on prescription drugs • Little emphasis on herbal remedies

13. JAPAN:State of Pharmacy Practice • Until recently, physicians dispensed medications directly from offices • After law change, now physicians required to transmit prescriptions to a pharmacy • Additional safety check • Electronic means (fax, email) • More than 1 medication per “prescription” • No refills allowed • Expanded scope of “pharmacies” from convenience stores to true full-service pharmacies

14. JAPAN:State of Pharmacy Practice • Types 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

15. JAPAN:State of Pharmacy Education • Ministry of Education • Until 2006, pharmacy was 4-year degree program (4 years post-high school) • Bachelor’s degree in pharmacy • Bridge to graduate school in pharmaceutical sciences • No therapeutics courses • No practical experiential training experiences • ~200-250 students/class • Post-2006, mandatory 6-year bachelor’s degree • Also available Ph.D. in pharmacy • Did not approve “Pharm.D.” in Japan

16. JAPAN:State of Pharmacy Education post-2006 • 6-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

17. JAPAN:My Experiences • Kobe Gakuin University • Visiting Professor, 6 weeks (2004) • Taught 1 credit hour elective course for bachelor’s of pharmacy students • Translators for each lecture

18. JAPAN:My Experiences • Kobe Gakuin University • Gave formal faculty seminar on “Evolution of Pharmacy Practice in the US” • Collaborated on 4 papers related to development of pharmacy practice • Experiential training, preceptor development, community pharmacy practice in US, collaborative practice agreements

19. JAPAN:My Experiences • Kyoritsu University of Pharmacy / Keio University School of Pharmacy • Visiting 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

20. JAPAN:My Experiences • International Conferences on Experiential Training • Invited twice to speak on relevant experiential training topics • Preceptor development • Continuous professional development

21. JAPAN:Insights • Similar issues exist • Development of quality experiential training sites to meet demand • Mentoring model at practice site • Challenges • Mindset traditionally against interprofessional collaboration • Few role models for students / new pharmacists • No pharmacy residency programs • Surplus of pharmacists for practice-based positions • >10,000 graduates/year

22. THAILAND Larvae

23. THAILAND:State of Healthcare • Socialized medicine • Both government and private healthcare available • Government healthcare inexpensive, so many select based on price • Government hospitals & clinics at capacity • Hospitalization $1/day • Strict medication formulary

24. THAILAND: State of Healthcare • National 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 equivalent • If patients use non-national formulary medication, must pay out-of-pocket for drug cost

25. THAILAND:KhonKaen University • Government Hospitals • Belief in using natural elements for healing • Open hallways, pharmacy waiting area, wards, ICU & ward windows • Fresh water bowls with fresh flowers in middle of ICU • Ceiling fans circulate air throughout units and bring in fresh air from outside • Lack of air conditioning in government hospitals • Holistic medicine unit for Thai massage, “Tiger Balm” applications, herbal compresses

26. THAILAND:State of Healthcare • Holistic Health Care Unit • Alternative medicine units on hospital ward • Therapeutic “Thai” massage • Facial spa • Foot spa & massage • Herbal compress techniques • Oil massage & aromatherapy • “Tiger Balm” applications • Traditional Thai knowledge

27. THAILAND Wat Pho Temple • 1st site for “Thai massage” • Massage school still exists on temple property

28. THAILAND:State of Healthcare • All medications ‘over the counter’ • Antibiotics, opiates, derm • Brand name products & “local made” products available before brand is off-patent • Regulated by Thai FDA for bioequivalency • Products still can vary by company • Pharmacists play keyrole in recommending drug therapies based on symptoms

29. THAILAND:KhonKaen University • Community 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

30. THAILAND:KhonKaen University • 6-year Pharmacy degree program starting 2009 • Doctor 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

31. THAILAND:State of Pharmacy Practice • Thai pharmacy degree programs and practice modeled after US pharmacy model • Pharmacology and therapeutics • Clinical application of medications for disease treatment • Clerkship 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

32. THAILAND:KhonKaen University • Center 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

33. THAILAND:KhonKaen University • Center for Research and Development in Herbal Health Products (CRD-HHP) • Rice bran cream • Citronella grass cream • Turmeric lotion • Aloe vera lotion • Glycerin soap • Gel nanotechnology products of Kaempferia parviflora

34. Daily Compounding List • Sodium fluoride • White vaseline • PEG 400 • Phenytoin sodium • Sodium thiosulfate • Ganciclovir • Eucalyptus oil • Rose oil • MCT oil

35. THAILAND:KhonKaen University • Central 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

36. THAILAND:My Experiences • Khon Kaen University • Lectured to “English program” Doctor of Pharmacy students • Cardiovascular pharmacology & therapeutics • Toured university (government) hospital • Toured campus community pharmacies

37. THAILAND:Insights • Similar issues exist • Control of hospital-acquired pathogens in hospitals • Cost-containment of expensive inpatient medications through formulary process • Similar practice models for pharmacists • Challenges • Overcrowding amongst public facilities due to lack of resources • Purity/efficacy concerns with certain available drug products

38. Conclusions • Similar issues exist amongst the US, Japan, & Thailand regarding • Regulation of government healthcare & cost containment • Education 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

39. Questions?