Zen and the art of achieving excellence in pharmacy practice

Helping pharmacists achieve excellence, proclaims the Royal Pharmaceutical Society’s letterhead and website homepage. Excellence is an aspiration and rallying cry that I suspect greatly interests every practising pharmacist; they do, indeed, strive to achieve excellence.

So, let us examine “excellence” and endeavour to understand what it means. I emphasise that I do not claim to achieve excellence in my practice. I am just struggling to do my best, as are other pharmacists. But here is my take on excellence.

Let us start with some practical illustrations. Imagine that you are a locum in two pharmacies over two days. In the first, excellence is not achieved; in the second it is. Each is at an opposing pole: diabolical to excellent; those extremes aid comparison.

EVERYTHING GOES WRONG

The first day dawns. The computer crashes. The patients are grumpy. A patient presents with 13 items and expects them in 10 minutes.

“They are only tablets. Can you be quick? I’m parked on double yellow lines.”

Your staff are sullen. One looks as if she is chewing on a pickle. Pandemonium reigns. There are so many prescriptions that you are stressed out, barely functioning. You are expected to take no lunch hour. Some medicines are new to you but you lack time to look them up. You make one dispensing error. You chase halfway across the city to correct it.

“Who do I complain to?” asks the patient.

You understand that a no-blame culture is reputed to be imminent; however, that patient’s solicitor probably still favours a culture that blames you. You spend the rest of the day rattled with nerves.

On the second day, you travel to another pharmacy. There the patients are appreciative.

“You give such good service,” says one.

The staff are cheerful and supportive. The prescriptions arrive in a rhythm that is neither too fast nor too slow. You detect one forgery. You pick up and correct two dispensing errors made by assistants; they accept correction gratefully. You field one prescribing error.

“What would we do without you?” says the doctor.

You have seen every medicine before. You handle, effectively, every situation. Others had, metaphorically, patted you on the back. You feel good about yourself, at home. You know that you had achieved excellence.

Most pharmacists would prefer the second to the first day. They are, after all, hedonists and not masochists.

To the ancient Greeks, the word aretê meant both excellence and (high) quality and was considered a virtue in a personal life. Similarly, if possible, a virtuous pharmacist, today, suffering the first environment will choose to migrate to the second.

That does not demand lofty, professional ideals. In migrating, a pharmacist is just behaving like an amoeba. That organism, floating in an environment at pH 7, will flow away from a drop of sulphuric acid towards a location of more neutral pH.

I have borrowed that analogy from Robert Persig, chemist, philosopher and author famed for his best selling ‘Zen and the art of motorcycle maintenance’. 1 But it is another insight of Persig, as amateur technologist — maintainer of motorcycles — that matters even more for pharmacists as professional technologists of medicines.

Persig links the philosophical, navel-gazing notion of excellence that is in the mind, with high quality of actual artifacts in the physical world. This is pertinent for achieving excellence by practising pharmacists: pharmacists’ raison d’être is high quality in the artefacts of medicines.

Persig argues that the skilled mechanic perceives a deep, inner, kinaesthetic feeling for the elasticity and softness of materials and a deep respect for their vulnerabilities. For example, the mechanic knows when a nut is sufficiently tight. If tightened more, the thread will break. Even I, as a DIY fixer of door handles on to wood, using metal screws, have felt that softness. Twist the screwdriver too strongly and the screw will tear the wood and the screw will rotate uselessly and remain loose. But there is a moment when the wood fights back and I know the bond has maximum strength. I feel it in my wrist and in my mind, while the screwdriver handle is not imagined but here, absolutely here, in my hand. There is a sort of smooth change and your mind comes to rest precisely when the work is exactly right.

I suggest that excellence in the practice of pharmacy is similar. Consider the commonest activity of pharmacists: dispensing. In the dispensary, medicines are safely stored, each under the correct conditions, so that (high) quality is maintained. You know that all manner of safe working systems are in place. Examples are the “first in, first out” convention, high-risk medicines such as oral hypoglycaemics being stored in a separate location, and double checks. There are staff who are trained, motivated, know their limitations and work together with the pharmacist as a team. The pharmacist possesses academic credentials, practical skill and experience, knows much about medicines and wants to know more.

Now, all the checks have been made, all the questions asked. The patient, if required, has been counselled, not too little and not too much. All aspects, great and small have been taken into account; a myriad of patient-specific factors have been allowed for. Any intuitive niggles of doubt have been laid to rest. A profound feeling of the intrinsic sacredness of the task prevails — for patients trust the pharmacist and can seldom tell whether medicines are right or wrong. The material from the shelf has been labelled, checked, bagged, handed out and so on. The medicine, during that process changes, as do the pharmacist’s thoughts. They change together in a progression of smooth, even changes until the pharmacist’s mind is in harmony, at rest, at peace, at the exact instant that the medicine is safe, right, and excellent. The individual pharmacist knows when excellence has been achieved.

A word akin to the word “excellence” is the simpler word “good”. Moreover, the old English roots for “good” and “God” appear to be identical. Some pharmacists connect “God” with ethics. This article does not develop that connection, instead noting it and “bracketing it off”, to use sociologists’ jargon.

DOING NOTHING SPECIAL

Excellence for pharmacists can be achieved by doing nothing special. They are just dispensing, just managing medicines and so on. Similarly, an angler might be just fishing, an ornithologist just bird watching or the Buddha just sitting. All are immersed, engrossed, as one, for example, the duality between the angler and the fish disappears.

I suggest that, with these thoughts in mind, you reflect on your practice. Remember that striving for excellence motivates you; striving for perfection is demoralising. Sometimes, things will seem bad. For example, a “heartsink” patient presents and criticises your service. However, occasionally, you will feel that your service was good, very good — or even excellent. Your patients may, or may not, recognise that. However, you are your harshest judge and know that things are, occasionally, absolutely right.

Feel that glorious moment intellectually — and in your heart and gut. Feel the pleasure and feel the pride.

REFERENCES

1. Persig RM. Zen and the art of motorcycle maintenance. London: Vintage; 1999 (original, 1974).