The Hebrew word for pharmacist, rokeah
, implies that the person providing
medications mixed them himself. For many decades, however, most drugs have come
as a ready-made product, manufactured in a factory in pill, cream, capsule or
liquid form and distributed and sold by a private or public health fund
Those who work in hospitals remain largely behind the scenes
and are unknown to patients.
Yet licensed pharmacists are highly trained
professionals who – given the shortage of physicians and nurses, not only in
Israel and many other countries – should be utilized for more than filling
prescriptions and persuading customers to buy cosmetics, unproven homeopathic
preparations and even wallets over the counter.
Little known to the
layman is clinical pharmacy, a health specialty in which pharmacists – usually
with a doctoral degree – provide patient care that optimizes the use of
medication and prevents disease and promotes good health. Clinical pharmacists,
who often work with doctors and other professionals, care for patients in all
healthcare settings, but the clinical pharmacy movement initially started inside
hospitals and community clinics.
In countries where clinical pharmacists
are given maximum authority, they may prescribe and administer drugs, prevent
medication errors, provide drug information, counsel patients, review drug use
and document professional services. They also have extensive knowledge about the
synthesis, chemistry and preparation of drugs and their effects on patients.
Among their functions are to use the most effective treatment for each type of
patient, minimize the risk of treatment-induced adverse events and ensure
patient’s adherence to the drug regimen.
The New York Times editorialized
last week that in the US, pharmacists are “remarkably underutilized, given their
education, training and closeness to the community... After an initial diagnosis
is made by a doctor, federal pharmacists manage the care of patients when
medications are the primary treatment, as is very often the case.”
chief pharmacist of the US Public Health Service argued that pharmacists should
be able to start, stop or adjust medications, order and interpret laboratory
tests and coordinate follow-up care. But various state and federal laws make it
hard for pharmacists in private practice to perform such services without a
doctor’s supervision, even though patients often like dealing with a pharmacist,
especially for routine matters.
One clinical pharmacist who will surely
have an impact on Israel’s pharmaceutical sector and bring a breath of fresh air
to the system is Dr.
Eyal Schwartzberg, the new director of the Health
Ministry’s pharmaceutical division. Schwartzberg replaced Batya Haran, who
served in the post for four decades.
He went to the UK to attend
university along with his Israeli-born wife, who studied law.
initially thought of going into medicine,” said Schwartzberg in an interview
with The Jerusalem Post in his office in Jerusalem’s Talpiot quarter (most
Jerusalem staffers will soon move to a large, high-rise headquarters in the
Romema quarter). “But I encountered pharmacists in their white coats and thought
that could be a fun profession.”
So in 1996, he earned his bachelor’s
degree in pharmacy at Cardiff University in Wales and his master of science
degree in evidence-based pharmacotherapy at Aston University in Birmingham.
After returning to Israel, he looked for a job and spent some time at the Taro
pharmaceutical company. But as a clinical pharmacist, he sought a hospital post
and wrote to most of the country’s medical centers.
“They said they
needed dispensing pharmacists. But I had a vision of doing more,” he
Finally, he found Hillel Yaffe Medical Center in Hadera –
convenient, as his family lived in a moshav near Hod Hasharon. He spent more
than 13 years there and gained a reputation as an innovator. At the same time,
he earned his doctorate in health system management at Ben- Gurion University of
the Negev in Beersheba, and continues to lecture once a week on clinical
pharmacy practice at BGU’s School of Pharmacy.
For the past decade,
Schwartzberg was director of laboratories and pharmaceutical services at Hillel
Yaffe and added to his experience in clinical pharmacology, risk management and
in the promotion of quality and excellence. At present, only about eight to a
dozen new clinical pharmacists with doctorates are produced by the Hebrew
University each year.
“We hope BGU’s school will graduate clinical
pharmacists for the community as well,” he said.
ONE OF his major
accomplishments was bringing to the hospital a robot that dispenses drugs for
patients in six in-patient departments. In most Israeli hospitals, the
distribution of medications has been the same for decades, said
“The nursing team prepare the correct medicines and
distribute them to patients in accordance with either a handwritten or
computerized prescription doctors give their in-patients. This is very
time-consuming and could potentially lead to mistakes in the administering of
medicine. The great advantage of the robot is its ability to intercept problems
with medications and prevent them before they happen.”
The new robot was
manufactured by the Sinteco company in Italy, said Schwartzberg.
are other companies in the US and Switzerland, but we decided on this one.
Introduced about a year ago in the Hadera hospital, it cost about $1 million and
was purchased through Sarel, the government’s purchasing company for medical
technologies. The robot is regarded as very effective in reducing medical errors
significantly, and apparently, more robots will follow in other
Medical errors cause many preventable deaths around the
When patients receive the wrong medication, or the wrong dose of
the correct drug, tragedies can occur.
Not all prescription errors are
critical, but they often do cause harm.
Frequently, the prescribing
doctor is to blame because of careless handwriting that forces hospital nurses
or pharmacists to guess what he has written.
Pills reach the hospital
pharmacy in large packages with bar codes, with individual pills in plastic
blister packets. But once the blisters are cut apart, they are separated from
the bar codes, and – when pharmacists distribute them – lose their
The robot is better able to keep track of medications and
eliminate identification errors; it also picks up drugs whose expiry dates have
passed. It also reduces the burden on hard-pressed nurses in the wards, whose
handling of medications is now much simpler, thus minimizing potential
“This robot is currently receiving the patient’s demographic
It knows the patient’s age, and where they are staying at
It knows all about the patients’ background as long as
their department is defined. The robot can also interface with other hospital
systems, such as the lab system, and receive lab results that might affect the
administration of drugs and information about the patients’ sensitivities. It
all goes into the robot’s system, and it can perform a clinical examination
based on the patient’s situation.”
Yet Schwartzberg said it would take
many years for “robot pharmacists” to replace people at their
“Human intervention will always be necessary. On a major scale, I
can’t see a situation in which humans are completely replaced, not to mention
the fact that modern medicine is only becoming more and more
But the sophisticated new system cross-checks a patient’s
medical data with the doctor’s prescription and doesn’t distribute the drugs
unless they match. Doctors use digital prescriptions that eliminate the problem
of unreadable handwriting.
Patients’ medications handled by the robot are
sent to the relevant department. The robot, he continues, brought down errors
and nearerrors by a significant degree.
The chief of pharmaceuticals
believes that the ministry has to computerize all hospital prescriptions, like
what has occurred in the health funds, and integrate them fully with medical
records. Ministry director-general Prof. Ronni Gamzu, said Schwartzberg, is
promoting the establishment of a national drug catalogue that would contain all
relevant data about medications.
THE MINISTRY’s chief pharmacist worries
about the problem of “drug compliance,” which he prefers to call “adherence” so
it doesn’t imply that doctors are dictating to patients.
“There are many
reasons for refusal to buy prescribed medications or to take them after
Perhaps the doctor’s explanation was not convincing. Some
people can’t afford the copayments for buying them. If patients don’t understand
the importance of taking the medications, pharmacists must explain it. But in
the first place, doctors have to be more aware of their patients’
Non-adherence is not a matter of age; the young, middle aged
and the elderly all do it. There may be language and cultural barriers. If it’s
a chronic condition and drug-taking regimen is complicated, this also
Also, physicians might not instruct patients how
to take medicines.
For example, there are dozens of medications whose
effects change if taken with grapefruit juice, or even after eating grapefruit.
Even some pharmacists don’t know – but they must check to make sure. And
individuals must also raise their awareness and responsibility for their health,
Schwartzberg has just set up a “pharmaco-vigilance unit” in his
division to ensure safety when drug formulas are changed somewhat.
headed by Dr. Dorit Nahlieli Dil, who is an expert in adverse drug reactions. We
have started small, but I’m sure that in a year, the unit will have very high
standards and expand,” he said.
The best-known recent case (before
Schwartzberg arrived) involves Eltroxin, the widely consumed drug for
hypothyroidism whose formula was changed without the ministry informing
patients, some of whom claimed to suffer from moderate or severe side effects
until the ministry issued a statement.
“The ministry learned from
mistakes in the Eltroxin case. The drug is registered in 30 countries, so it is
not just Israel’s problem. Changes are made frequently, and the process is very
dynamic. The ministry now understands that it has to be better connected to the
public and give information in real time.”
As to complaints that many
drug companies pack only 30 pills in a packet rather than 31, when months have
an additional day, Schwartzberg said the ministry is determined to ensure the
companies do not leave patients short.
It is ministry and health fund
policy to encourage the use of cheaper generics, he continued, but not at all
costs, and physicians and patients must be informed when they are not as good as
the originals, he promised. In addition, the ministry has already, through its
Jerusalem Institute for Standardization and Control of Pharmaceuticals (ISCP),
reduced red tape and now approves new medications within a year of application
instead of the previous three years. His division takes into account the views
of the US Food and Drug Administration and the CE of Europe, but “not everything
they approve is safe, so we also consult with our own
Schwartzberg worries that international pharmaceutical
companies are developing fewer drugs that don’t promise to be
The cost of research and clinical trials is such that
they prefer surer things like lifestyle drugs and those for common diseases, and
are devoting less effort to new antibiotics or “orphan drugs” for conditions
that affect small numbers of patients.
He encourages doctors and laymen
to contact to his division in Jerusalem if they have complaints about side
effects, improper advertising of prescription drugs and other relevant
Schwartzberg’s appointment has raised hopes in the
“He is a knowledgeable pharmacist and an impressive
administrator, he has proven this by his exceptional achievements at Hillel
Yaffe and his work on the academic staff of BGU,” said Howard Rice, a
pharmaceutical consultant and former head of the Israel Pharmacists’
“I am grateful that someone of his caliber, foresight and
ability has taken the helm. He realizes that the added value that the
pharmacist, if used correctly and remunerated accordingly, can bring to the
Israeli public is a lowering of deaths and illness, and will save a great deal
of money for the benefit of the public.”
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