Clinical pharmacology: A new specialty

Abstract

I n the past, the efficacy of many drugs was limited and the toxicity was frequently unknown or substantial. Hence, Sir William Osler was a therapeutic nihilist and Oliver Wendell Holmes believed that the entire pharmacopoeia could be discarded. Another view, related to those of Osler and Holmes, holds that pharmacology itself is an unnecessary discipline in medical schools because physicians in the traditional clinical specialties can teach medical students whatever they need to know about drugs and drug therapy. These views are now outdated and inadequate for patient care and student education. Clinical pharmacology merits recognition as a clinical specialty because clinical pharmacology satisfies the four criteria that we believe are necessary for any field to merit specialty status: (1) a large and sufficiently well defined body of knowledge; (2) direct applicability of that knowledge and expertise to patient care; (3) a clearly developed training program to produce practitioners; and (4) a firm research base which will continue to grow and expand. A substantial body of clinically relevant, fundamental information on therapeutics and toxicology has accumulated in the last 20 years. Through the use of the tools and principles of clinical pharmacology (e.g., prospective, randomized, controlled trials; pharmacokinetics; pharmacogenetics), we can now make more precise statements about the proper treatment of many patients. Moreover, the development in recent years of many therapeutically effective or curative drugs (e.g., cimetidine, L-dopa, antibiotics, propranolol) has revolutionized treatment of several previously untreatable or inadequately treated diseases. The fund of knowledge in clinical pharmacology has increased so much that books on therapeutics (e.g., Drug Treatment by Avery (1980) or Clinical Pharmacology by Melmon and Morelli (1978)) rival in size standard textbooks of medicine. Approximately one third of the questions on the Internal Medicine Board examination covers material in the domain of clinical pharmacology [l]. A clearly defined clinical role for clinical pharmacologists has emerged in recent years. Certain types of patients and clinical problems (for example, patients with adverse drug reactions or patients who are poisoned or overdosed) are best handled by physicians who bill for their services as clinical pharmacology consultants [2]. Another important contribution made by the clinical pharmacologist is the application of pharmacokinetics for more rational and effective use of drugs [2,3]. The importance of dosing regimens, the plasma target concentration strategy and the rational use of drug levels have become apparent [2,3]. Other roles of clinical pharmacologists in the hospital include participation in drug utilization review audits, selection of drugs for formularies and consultation for Poison Control Centers [2,3]. Teaching and training in clinical pharmacology have become better defined in recent years [4]. The National Institutes of Health support training in clinical pharmacology and treat clinical pharmacology as a scientific discipline. The role of clinical pharmacologists in training medical students, house-staff, fellows and postgraduate physicians has been recongized in recent years [a]. Certain topics, including pharmacokinetics, drug reactions and interactions, clinical toxicology, clinical trials and statistics relevant to clinical trials, may be taught effectively by clinical pharmacologists who can illustrate general principles directly from experience with patients. In some medical schools, senior medical students take courses in therapeutics offered by clinical pharmacologists, and residents rotate through clinical pharmacology services. The importance of even greater curricular emphasis on clinical pharmacology has been repeatedly emphasized [5]. We and others believe that medical education at all levels needs to focus on clinical pharmacology to remedy the widely perceived deficiencies in physician prescribing [5]. High-quality, original research is now an important component of many academic clinical pharmacology units. Progress in therapeutics has been extremely rapid both in terms of development of effective new drugs and rational use of drugs currently available. During their