Pharmacists: emperors of entropy

The bench contains many prescriptions awaiting dispensing. Outside the dispensary, a group of patients wait, individuals displaying varying degrees of patience. Your head is down and you are working as fast as you can, yet you feel patients’ eyes boring into you. Every minute, to you, seems like five minutes to them.

“How much longer?” demands one patient. “It’s only tablets!”

What, precisely, is it that patients want from pharmacists? Also, what is the connection with entropy: the tendency of order to change into disorder over time?

What patients want from pharmacists is the same as what they want from other experts and professionals. Sometimes people break, wear out or otherwise cannot, alone, cope with their situation. They are victims of circumstance and need outside help from specialist rescuers. The nature of that rescue varies. Examples are a lawyer advising using knowledge of statutes, a drain unblocker inserting a long brush – or a pharmacist giving medicines.

In all those interventions we expect a particular group to offer a particular solution. Their credibility to undertake a particular rescue is buttressed by society’s expectations: the lawyer is expected to give legal assistance and not to unblock drains, for example. The fact that, for their medicines, patients know to go to pharmacists might seem simple and obvious but is not inevitable. It is also not inevitable that it will continue. Others, including apothecaries, booksellers, chemists, doctors, herbalists, industrialists, lay people, quacks and sovereigns have, over history, jostled to profit from medicines. Today’s situation, where in Britain pharmacists seem the automatic first port of call, is connected with complex social, political and economic forces.

What, then, are patients gaining, which predisposes them to visit a pharmacist? At root, patients expect and receive a particular type of knowledge-based healing using medicines as tools.¹

Some of pharmacists’ knowledge is “technical”, written within books and so on; “anyone”, potentially, can access it. Other knowledge, however, is “indeterminate”; this can only be learned by experience. Pharmacists learn some at the “counter-side”; doctors have long capitalised upon their knowledge acquired at the bedside. An example of pharmacists’ counter-side knowledge is how to react, sensitively, to individual patients, who are “unpredictable” human beings with unique combinations of backgrounds, circumstances and expectations. An example is recommending a medicine for constipation. The pharmacist may possess “little” pharmacological knowledge (although exceeding that of the patient) but has interacted with many individuals of varying age, class, gender, and vulnerability. Vulnerability may range from clients wishing to lose weight to those suffering from colonic cancer. The pharmacist will have learned, from patients’ reactions, a reassuring and credible counter-side manner, including the precisely correct dose of sympathy that the sick expect. The difficulty for pharmacists is that increases in technical knowledge increase effectiveness, but then, “anyone” can access that knowledge. To help achieve the highest status, there needs to be an optimal balance between technical knowledge and indeterminate knowledge, which is associated with mystery and confers a different sort of status. Priests are the extreme example of an occupation having indeterminate knowledge, which is unknowable, in principle, by the laity. Sociologists speak of the indeterminacy/technicality (I/T) ratio.² The patient who is upset, because tablets have taken so long to dispense, would be less likely to complain, were the pharmacist’s I/T ratio higher.

Knowledge conversion

However, this knowledge has to be converted into an outcome desired by the patient. How does this occur? Just as a surgeon, with surgical knowledge, cuts, how does the pharmacist, with pharmaceutical knowledge, act? I suggest that the pharmacist, with pharmaceutical knowledge, puts. That little verb embraces “advises”, “clinically governs”, “counsels”, “dispenses”, “formulates”, “hands over a medicine to the patient”, “maximises concordance”, pharmaceutically cares”, “responds to symptoms” – or whatever jargon is today’s fashion. “Puts” still also includes “supplies” – that politically incorrect verb. If the pharmacist did not put the corporeal thing of a medicine into a situation where it was of value to a client, pharmacy, as we know it, would disappear. Medicines remain pharmacists’ raison d’être. Without medicines, pharmacists would lose their cultural backbone. Pharmacists would become a purposeless, floppy mass that could easily gurgle down the plug hole.

Pharmacists, then, put medicines where they can benefit clients. Clients go to healers when clients fear that they cannot control their futures; they seem too uncertain. The healers restore order to their clients’ futures, which then become more certain. That is worth waiting for – but not for too long. The patient who grumbles about a tardy pharmacist has judged the anticipated increase in order was not worth the wait. That patient would be less likely to complain about the length of wait to a surgeon, who projects a higher I/T ratio.

It bears repeating that patients go to healers to obtain more certain, more ordered futures. That is an extraordinary anticipation. In the non-human universe, disorder – or entropy – tends to increase over the passage of time. For example, a cup drops, hits the floor, and then smashes into many disordered fragments – you know the film is running backwards if the many fragments fuse into one. Galaxies spread apart as their earlier order fades. However, the competent professional reduces disorder in clients’ lives and so reverses the arrow of the otherwise ubiquitous “law of entropy”.
Pharmacists achieve this with medicines and proud publicity. An illustration is a pharmacologically active ointment changing a disfiguring skin condition to the desired norm. However, Max Factor make-up was used to camouflage war-induced injuries. Pharmacists also sell other aesthetic image enhancers, such as various cosmetics, deodorants, perfumes and hair dyes. Many pharmacists consider those artefacts professionally less important than medicines; this journal seldom features perfumes, for example. However, many community pharmacists display image enhancers prominently. Perhaps those pharmacists have intuitively got it right because image enhancers also “reverse entropy” by serving clients’ hopes and dreams of returning to desired “norms”, such as glamour and the unwrinkled skin and vigour of youth.

The direction of the “arrow” of entropy in this sociological account of the pharmacists’ world is in collision with its direction in a dominant paradigm of contemporary physics. This metaphorical article conflates languages of natural and social science and could be considered to do some violence to both. However, I suggest that this article is more than a hollow play on words. Although clients may not realise it, this account outlines outcomes that clients seek: that extraordinary, entropy-reversing power contained within pharmacists’ artefacts. Clients do seek those artefacts. Pharmacists made them more potent by tailoring for individuals, and then put those artefacts into the possession of their clients. Clients can then take away those portable, powerful artefacts.

While pharmacists remain connected with those medicines and other artefacts, their clients will know where to return and pharmacists’ future may be more certain.

References