1973–1994: Herfindal

The Division of Clinical Pharmacy was established within the School of Pharmacy in early 1973. Prior to that time, clinical instruction was provided through the Department of Pharmacy under the chairship of Sidney Riegelman. Donald Sorby, vice chair of the department, had the additional responsibility of being director of pharmaceutical services for UCSF Medical Center, and so was intimately involved in the early development of the clinical instructional programs. Eric Owyang, the chief pharmacist of the medical center, provided leadership of the department.

In 1971, Robert Miller, who directed the Ninth-floor Project, was appointed director of pharmaceutical services. When Sorby left for the University of Washington, Robert Day was appointed vice chair for clinical instruction. Subsequently, Miller took a position outside the University. The clinical group showed increasing signs of growing pains.

Division of Clinical Pharmacy forms

Dean Jere Goyan, Riegelman, and Day, in consultation with some faculty members, concluded that another organizational structure was needed for clinical pharmacy and pharmaceutical services. It was decided that a separate division should be established with the chair of the division reporting directly to the dean. Under the academic rules of the University, a school could establish a division without Academic Senate approval, whereas forming a department would require a lengthy approval process. (The division did not become a department until 1996.) After faculty and campus consultation, Goyan appointed Toby Herfindal as chair of the new Division of Clinical Pharmacy.

In addition, Donald Beste was recruited from Yale New Haven Hospital to become director of pharmacy at UCSF Medical Center with the additional title of assistant dean in the School of Pharmacy. Dean Goyan’s expectations were that Beste and Herfindal, with input from Day, would jointly manage the overall clinical pharmacy program on the Parnassus campus, given that the clinical faculty had service responsibilities in addition to their academic duties.

Herfindal and Beste undertook a detailed study of the clinical services and the teaching program which resulted in a major reorganization on July 1, 1973. A team concept was developed in which compatible services and teaching responsibilities were assigned to and shared by all team members. A critical component of the organization was that all clinical staff members have structured and accountable service and teaching responsibilities.

In support of this organizational change, the UCSF Medical Center (hospital and clinics) agreed to fund nine full-time clinical faculty positions in return for equivalent in-patient care services. Herfindal and Beste were charged with ensuring that the medical center received a fair return in clinical services. At the same time, the School of Pharmacy wanted assurances that there was adequate person-power to support the teaching program. The medical center provided funding for five pharmacy residents, and the division provided support for an additional five. This arrangement greatly increased the number of clinical faculty members and residents in the division. In addition, federal capitation grants helped fund the initial expansion.

The Ambulatory Care Center (ACC) opened in 1973, and clinical pharmacy services quickly expanded to most floors of the hospital and the new center. The unit-dose distribution system was centralized, and on most floors the drug distribution role was minimized in favor of more clinical involvement. Clinical pharmacy offices on each floor of the new ACC provided a base of operation and a physical presence for the clinical pharmacist, residents, and students.

Antimicrobial Stewardship Program improves patient care and safety

The origins of the Antimicrobial Stewardship Program involved Steven Barriere, who developed both the infectious diseases pharmacist role and a restricted antimicrobial program at UCSF Medical Center. Upon his departure in the mid-1980s, B. Joseph Guglielmo assumed the role of infectious diseases pharmacist and oversight of the restricted antimicrobial program. Over the years, the restricted antimicrobial program evolved into a full-scale Antimicrobial Stewardship Program with use of an antimicrobial order sheet, annual review of antimicrobial susceptibility patterns, and 24/7 pager coverage. Lastly, the infectious diseases second-year specialty residency was created in the mid-1980s and is now the most continuously offered one in the United States.

Space secured

Providing adequate space for the growing faculty and administration of the division was a challenge on a campus already stretched to the limit. Initially, the division office was located on the ninth floor of the Medical Sciences building, and the faculty was temporarily located to houses acquired by the University on Third Avenue. By 1974, the campus provided space on the first floor of the old clinics building that had been vacated with the opening of the new Ambulatory Care Center. In addition, funding for renovation was made available from the University. Room C-152 became the division office, the Drug Information Analysis Service (DIAS) was located next door, and office space for the faculty was made available.

1982–1986: Value of clinical pharmacy services scientifically proven

Since the beginning of the Ninth-floor Project, there had been a great deal of pressure to prove the clinical and economic benefit of clinical pharmacy services. In 1982, the team of Herfindal, Linda Bernstein, and Donald Kishi undertook studies to quantify and evaluate some of the roles that had emerged at UCSF, specifically in the orthopedic, vascular, and cardiothoracic services. Prescribing patterns of physicians on services with clinical pharmacists were monitored and compared with patterns on similar units without clinical pharmacy services. The results demonstrated significant reduction in orthopedic post-operative antibiotic prophylaxis when the clinical pharmacist was present. There was also an overall reduction in drug cost and a reduction (although statistically non-significant) in length of stay.

In 1984, the American Society of Hospital Pharmacy Research and Education Foundation bestowed the Research Award for Outstanding Contribution to the Literature of Research in Hospital Pharmacy to the team for the orthopedic study published in the American Journal of Hospital Pharmacy (40:1945–1951, 1983). In 1985, the Cardiothoracic and Vascular Surgery studies were published in Drug Intelligence and Clinical Pharmacy (19, 440–444, 1985). In 1986, Michael Winter, Herfindal, and Bernstein published a paper in the American Journal of Hospital Pharmacy (43, 2178–2184, 1986) on the impact of the UCSF Pharmacokinetic Consult Service.

Off-campus electives supplement the on-campus experience

San Francisco General Hospital Medical Center and the San Francisco Veterans Administration hospital were critical to the growth of the elective programs. Other hospitals, including San Francisco Kaiser Permanente, Palo Alto Veterans Affairs Medical Center, St. Joseph’s, Alta Bates, Good Samaritan, Mary’s Help, and Stanford were clinical sites for pharmacy students. Other sites included a pharmacy at Ross Valley Clinic in Greenbrae run by the innovative Paul Lofholm, the Co-op Pharmacy in Berkeley, the South of Market Clinic, the Sunset Mental Health Day Treatment Center, and the Haight-Ashbury Heroin Detoxification Clinic. Most of these sites had UCSF graduates willing to become volunteer preceptors.

Jacqueline O’Leary started an outpatient clinical pharmacy service in the pediatric clinic in the old clinics building in 1968. In addition, a clinical pharmacy service was established in the Comprehensive Medical Clinic as part of a multidisciplinary teaching approach involving medical, nursing, dental, and pharmacy students. Division of Clinical Pharmacy faculty members served as preceptors and consultants.

In 1974, Theodore Tong was selected to participate in teaching and research in the Drug Detoxification Unit at San Francisco General Hospital (SFGH). Later Robert Levin, Ronald Conte, and Betty Dong became the core clinical pharmacy faculty at SFGH. Tong later became the director of the Bay Area Poison Control Center.

Division leadership changes

During the formative years of the division’s life, Mary Anne Koda-Kimble served as vice chair, with overall responsibility for educational affairs. Later, in 1983, Michael Winter was appointed that role after Dean Goyan asked Koda-Kimble to lead the Office of Student Affairs. Kishi was vice chair for clinical services with responsibility for the residency program.

1979: Poison Control Center provides valuable services

The San Francisco Bay Area Poison Control Center was established in February 1979 under the direction of Theodore Tong at the San Francisco General Hospital Medical Center (SFGHMC) through collaboration among the UCSF School of Pharmacy, UCSF School of Medicine, and the San Francisco Department of Public Health. Its four poison-related goals were to:

1. Be a resource for information.
2. Reduce the number of poisonings.
3. Educate physicians and other health care professionals.
4. Act as a site for research and data collection.

The center had a full-time staff of nurses and pharmacists who could call on experts, including emergency unit physicians and UCSF faculty at SFGHMC.

A financial crisis in 1980 was averted by an infusion of funding from the San Francisco Department of Public Health, but it was the beginning of funding difficulties for California Poison Centers. In 1986, 11 California hospitals administered completely independent poison control centers; in 1987 the number was reduced to seven. Thomas Kearney followed Tong as director of the Bay Area Poison Control Center in 1989.

By 1992, funding for poison control centers was critically low, despite the fact that the centers saved thousands of dollars in emergency room costs. The National Health Foundation recommended consolidating the centers under one management, and the current California Poison Control system was established at UCSF under Stuart Heard, who accepted the role of executive director of the program.

Firsts

The young clinical faculty was responsible for a number of firsts in the emerging discipline of clinical pharmacy:

1. First regular drug information column in an international pharmacy journal (Joseph Hirschmann)
2. First regular drug therapy column in a national pharmacy journal (Joseph Hirschmann and Toby Herfindal)
3. First two clinical pharmacy textbooks (Toby Herfindal and Joseph Hirschmann; Brian Katcher, Mary Anne Koda-Kimble, Theodore Tong, and Lloyd Young)
4. First textbook on clinical pharmacokinetics (Michael Winter)
5. First Clinical Pharmacokinetics Consulting Service Center (Michael Winter)

In 1977, California Assembly Bill 717 (AB 717) was passed, providing prescriptive authority to pharmacists—but only to those pharmacists involved with pilot projects in an organized health care setting. UCSF and USC were selected to participate. The UCSF Anticoagulation Clinic served as one of the study sites; it was under the guidance of Steven Kayser. The project resulted in increased efficiencies and delegation of authority from physicians to pharmacists.

Legislation was passed in 1981 allowing all pharmacists practicing in California-licensed acute and intermediate health care facilities to provide drug therapy management, pursuant to a prescriber’s order. Pharmacists were authorized to adjust drug dosage, order laboratory tests, perform physical assessments, and administer drugs.

The law later expanded twice. In 1983, pharmacists were further authorized to initiate drug therapy. Subsequently, Guglielmo worked with medical center administration to initiate drug therapy at UCSF Medical Center including anticoagulation, thyroid, and other specialty clinics. Guglielmo and Kishi evaluated this increase in the role of pharmacists. (See Pharmacist-managed drug therapy in California hospitals.)

By 1994, the types of practice sites covered by the authorization had expanded to include clinics and systems licensed as health care plans (e.g., managed care organizations). The site- and practice-specific protocols ranged from pharmacist-managed nutritional support in the inpatient setting to antihypertensive drug management in the outpatient setting.

AB 717 was the beginning of the recognition by California policy makers of the expanded role that pharmacists could play in providing direct clinical services to patients. This recognition culminated in the passing of Senate Bill 493 (SB 493) in 2014. Signed into law by Governor Jerry Brown, it granted pharmacists in all practice settings expanded authorities, including drug administration and ordering and interpreting tests for the purpose of monitoring drug therapy.

1975–1993: Collaboration with UC San Diego

As the curriculum became more clinical, it became obvious that the San Francisco area could not provide all the experiential courses necessary to graduate more than 120 students each year. At the time, the nine campuses of the University of California had five medical centers, five medical schools, and one school of pharmacy, and there were no plans to add another pharmacy school. In 1973, Dean Jere Goyan began a dialogue with the new dean of the UC San Diego (UCSD) Medical School, Jack Moxley, to discuss possible collaborative relationships. Moxley was intent on making medical education at UCSD more interdisciplinary, a goal that aligned well with the UCSF teaching philosophy. The possible range of options included: developing a new pharmacy school (a hard sell, given fiscal limitations); offering the last two years in San Diego (eventually ruled out because of cost and lack of adequate faculty); and the final option, to have as many as 20 UCSF pharmacy students complete their fourth year in San Diego.

During the next two years, many School leaders traveled to San Diego to meet with UCSD campus and medical center leadership to work out the details. In 1975, David Adler accepted the position of vice chair of the division and agreed to move to San Diego to coordinate the program. The initial arrangement called for the School to jointly fund the UCSD Hospital Pharmacy Residency Program; the director of pharmacy and the hospital administrator agreed to provide teaching resources and space to support the program. Adler quickly established sufficient student rotations to satisfy the UCSF curriculum committee, and the first six students arrived in September of 1975 to begin their final year of the PharmD program.

Adler also established a clinical practice in anticoagulation with the UCSD Veterans Administration Division of Hematology. In 1977, Tony Manoguerra and Robert Ignoffo were recruited from the University of Minnesota. Manoguerra became director of the San Diego Poison Control Service. Robert Weibert had experience in ambulatory care, and he established an anticoagulation clinic at UCSD. As clinical resources became available, the number of students in the San Diego program grew from eight to 12 to 20.

Beste left the program in 1982 to take a hospital pharmacy position in Saudi Arabia. Herfindal took on the additional position of director of pharmaceutical services for the UCSF Medical Center.

Additional faculty hires during this period include

Who	Area of responsibility or expertise
Peter Ambrose	program director of the Advanced Pharmacy Practice Experience program in Los Angeles and Orange County
Fran Aweeka	Drug Research Unit, kidney transplant
Robin Corelli	cost containment
Stuart Heard	director of pharmacy at SFGH then later inaugural executive director of CPCS
Thomas Kearney	managing director of the San Francisco Bay Area Regional Poison Center at SFGH, which evolved into the California Poison Control System
B. Joseph Guglielmo	cardiothoracic and vascular surgery, critical care, infectious diseases
Kathryn Phillips	health economics and health services research
Ronald Ruggiero	outpatient pharmacy, women’s health
Marilyn Stebbins	Mercy/Catholic Health managed care contract in Sacramento, managed care and medical group pharmacy utilization
Linda Hart	director of the Drug Information Analysis Service

1982–1985: Refugee Pharmacist Training Program

In 1982, Adler received a grant from the Social Security Administration Refugee Resettlement Program to train refugee pharmacists from Vietnam. The goal was to prepare them to pass pharmacy licensure examinations in the United States. Faculty members from UCSF and UCSD trained 110 Vietnamese pharmacists, and 95 percent eventually were able to pass the exams in California and elsewhere.

In 1985, Adler obtained support from the federally funded Area Health Education Center to re-train community pharmacists in many aspects of clinical practice. He also established a fellowship in ambulatory care, facilitated by a UCSF grant from the U.S. Department of Health and Human Services (HHS).

1998–2002: Giving birth to a new school of pharmacy at UCSD

The success of the UCSF Pharmacy Program in San Diego and the growth of biotechnology in San Diego renewed interest in developing a school of pharmacy at UCSD. In 1988, the UCSD Master Plan called for a second health sciences school—a school of pharmacy. By 1996, a planning committee was established under the chairship of Palmer Taylor, UCSD School of Medicine. Adler was asked to serve on the committee, and he lent his expertise to the planning process.

It took another four years to clear University hurdles, and the UC Board of Regents approved the new school in 2000. The charter class of 60 students matriculated in 2002. Taylor (first dean), Adler (professor and associate dean for academic affairs), and Manoguerra (professor and associate dean for student affairs) led the new UCSD Skaggs School of Pharmacy. By any measure, the UCSF-San Diego program was a success, and although UCSF no longer sends students to San Diego, the new school was created as envisioned by Deans Moxley and Goyan almost 30 years before.

Satellite programs expand experiential sites available to pharmacy students

The UC Irvine satellite program was added in 1980. Sam Shimomura agreed to move to Orange County to coordinate the program. Working with the directors of pharmacy departments at UC Irvine Medical Center, UCLA Medical Center, and Long Beach Memorial Hospital, he identified both clinical sites and preceptors. Building on Adler’s experience in San Diego, in short order Shimomura was able to provide sites for 17 to 20 students for a full academic year.

Shimomura established an educational program—similar to the one at UCSF-UCSD—to retrain refugee pharmacists from Vietnam. Funded entirely by tuition from the students, the program prepared over 300 Vietnamese pharmacists to pass the pharmacy licensure examinations in the United States, with an 80 percent completion rate.

In 1996, Shimomura accepted a position at Western University College of Pharmacy. Robin Corelli and Peter Ambrose were appointed to the program in Southern California.

In 1985, Barbara Sauer began a similar program using the UC Davis Medical Center in Sacramento as the main clinical site.

Drug Research Unit

The Drug Research Unit for the School of Pharmacy was established around 1983 by John Gambertoglio, who had been doing research since the mid-70s with transplant surgeons and nephrologists and with Leslie Benet from the School.

In 1983 or 1984, this research space was comprised of a small office and very small lab on the 11th floor of the Medical Sciences building on Parnassus. Gambertoglio and Guglielmo staffed the laboratory while doing antibiotic pharmacokinetic (PK) studies; Gambertoglio also studied kidney transplant drugs. Francesca Aweeka worked with Gambertoglio, first as a resident and then as a fellow.

In about 1987, they moved the unit to the Laundry Storage building at the back of the Parnassus campus, occupying about 3,500 square feet. There, the laboratory was further developed and expanded to include clinical research space so that study subjects could have a place to undergo PK sampling.

The laboratory moved to San Francisco General Hospital Medical Center around 1995 and was officially named. Originally called the Drug Research Unit at the General (DRUG); the name was shortened to the Drug Research Unit (DRU). Gambertoglio was director of the DRU until his death in 2001, although from 1999 to 2001 or so, Gambertoglio and Aweeka shared duties as co-directors. The clinical science of this, the biomedical arm of the department, evolved from antivirals to malaria and tuberculosis.

Gambertoglio is the first and only tenure track faculty member with PharmD in the history of the School.

1990: Mount Zion integration offers new experiential education opportunities

In 1990, UCSF and Mount Zion Hospital signed an integration agreement. Under the agreement, the pharmacy department at Mount Zion became affiliated with the UCSF Medical Center Department of Pharmaceutical Services. Herfindal had general oversight of the department including serving on the Mount Zion Pharmacy and Therapeutics Committee. An oncology satellite was soon established and became a pharmacy student rotation.

1993–1994: Herfindal and other key leaders depart

In 1993, Toby Herfindal, founding chair of the Division of Clinical Pharmacy, took a one-year leave of absence to explore the application of clinical pharmacy principles in the private sector (Access Biotechnology). He officially retired in 1994 to pursue this goal. Bret Brodowy, Michael Cunningham, and Kevin Rodondi, who were key leaders within the UCSF Medical Center’s Department of Pharmaceutical Services, joined Toby.

Pictures from the Herfindal Years

Next: 1993–1998: Koda-Kimble

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Image credits: Kaz Tsuruta for Peter Ambrose

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