1. CIMA Lecture Series Pharmacy 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 Khon Kaen University School of Pharmacy, Khon Kaen, 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 6-year 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. 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: 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: Khon Kaen 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 1 st 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 key role in recommending drug therapies based on symptoms

29. THAILAND: Khon Kaen 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: Khon Kaen 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: Khon Kaen 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: Khon Kaen 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: Khon Kaen 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?