David Adler: Expanding and enhancing pharmacy education and practice

It was fortuitous that David Adler, PharmD ’70, began his studies at the UCSF School of Pharmacy in the fall of 1966, precisely when UCSF Medical Center’s Ninth Floor Project went into action. That project’s unprecedented placement of pharmacists on a UCSF hospital ward—providing their drug expertise directly to physicians, nurses, and patients—pioneered a radically new clinical role.

Indeed, in the half-century since, Adler, a former School faculty member and now faculty member and associate dean of academic affairs at the UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, has played leading roles in expanding and enhancing clinical pharmacy education and practice at UCSF, in California, and beyond.

Those vital roles alone would have readily earned him recognition as the 2016 Distinguished Alumnus of the Year by the Pharmacy Alumni Association. The annual honor is bestowed on a School graduate “who has made outstanding contributions to the profession of pharmacy, to society, and/or to UCSF.” Adler’s many contributions have included:

• Establishing the School’s first satellite program, which provided advanced pharmacy practice experiences (APPEs), then called clerkships, as well as proof that the then-new model of clinical pharmacy education would work beyond the UCSF campus
• Creating some of the first chronic disease and ambulatory clinics in which pharmacists played a leading role, collaborating with physicians to manage outpatients’ medications, and training students and residents to export the practice model nationally
• Advocating for expanded scope of practice for state pharmacists working under protocol with physicians, including as a past president of the California Society of Health-System Pharmacists
• Helping to plan and implement the second pharmacy school in the UC system

Yet concurrent with those achievements, Adler also pursued notable social activism and volunteer work, including spearheading one of the School’s finest public service efforts: the creation of a UCSF weekend program that enabled more than 100 disenfranchised Vietnamese refugee pharmacists to regain their professional livelihoods.

Elisabeth Fall

Gathered at the 2016 Alumni Weekend afternoon program are Robert Day, PharmD ’58; David Adler, PharmD ’70; and Dean B. Joseph Guglielmo, PharmD.

Education of a clinical pharmacist: The Haight and the Ninth Floor

As a pharmacy student, Adler’s path was initially shaped less by the Ninth Floor Project and more by San Francisco’s so-called Summer of Love.

“We were still very much involved in the traditional pharmacy curriculum,” he recalls. That meant coursework in drug compounding and dispensing labs, and, in Adler’s case, summers in the lab of Sidney Riegelman, PhD, researching the pharmacokinetics of the diabetes drug tolbutamide in dogs.

Meanwhile, Haight-Ashbury and Golden Gate Park, just down the hill from the School, were ground zero not only for the ’60s cultural revolution but also for a new wave of recreational drug problems and the health needs of the era’s flower children. As a second-year student, Adler joined others helping to organize medications donated to the neighborhood’s newly founded Haight-Ashbury Free Medical Clinic.

This led to Adler’s first clinical experiences: “Sometimes it was making sure we could get a medication for patients, and other times, perhaps, it was participating in the talk down of someone that was having a bad trip.”

That experience led, in turn, to Adler’s first role as a pharmacy educator. He began a student-run drug education committee that visited schools, from elementary through community colleges. The effort won the 1969 American Pharmacists Association (APhA) Public Education Award for the UCSF chapter of the APhA Academy of Student Pharmacists.

“It was to make sure that young people knew what the risks were in reality,” he says. “Not to use fear tactics, but to talk about drugs in a way to help understand them and recognize that they could create problems.”

Bob Levin Collection

Doors of the Haight-Ashbury Free Medical Clinic, 1972

While still studying pharmacology fundamentals, Adler began to realize “my passion really was in dealing with people and more clinically relevant issues.” Adler’s shift was matched by burgeoning curricular changes. By his fourth year, the School began for the first time to offer education experiences in hospital wards and clinics, including pairing pharmacy and medical students in an ambulatory comprehensive care clinic.

Proving clinical pharmacy could ‘fly’ in other locales

Upon graduation, Adler was one of just five UCSF Medical Center pharmacy residents in one of the first such programs. Upon completion, he became a School faculty member and was among “the core clinical faculty responsible for implementing major curricular changes,” wrote Eric “Toby” Herfindal, PharmD ’65, MPH, faculty member emeritus and chair of the School’s then-nascent Division of Clinical Pharmacy, in his letter supporting Adler’s Distinguished Alumnus nomination.

As the School’s curriculum became more clinical in the 1970s, “it became obvious the San Francisco area could not provide all the experiential courses necessary to graduate [the expanded class size of] 120 students each year,” Herfindal recalls.

In 1972, Dean Jere Goyan, PhD, began discussions with UC San Diego Medical School leadership that eventually led to the School’s first satellite experiential program. UCSF gained a site for up to 20 of its fourth-year students to complete their clinical training, while UCSD “got a collaborative interprofessional education program,” says Adler, “and the realization that their medical students could depend on pharmacists to provide them with drug information.”

In fact, the new program’s significance went well beyond the needed outlet for fourth-year student clerkship (now called APPE) placements. As Adler recalls: “Jere was getting pushback from other pharmacy school deans who came to visit [the Ninth Floor Project]: ‘This isn’t going to fly elsewhere.’ And, ‘If it’s so great, out of five [UC] campuses that have schools of medicine and medical centers, why is UC San Francisco the only one that has this kind of a clinical [pharmacy] program? Why isn’t it elsewhere?’ So part of that impetus was to demonstrate that it was capable of being done elsewhere.”

In 1975, Adler relocated and successfully founded and coordinated the new program, which, in ensuing years, expanded in faculty, residency positions, and clerkship sites. This led to the School’s five satellite programs today, and helped spread the concepts and practice of clinical pharmacy statewide.

UCSF School of Pharmacy

David Adler and Toby Herfindal, 1985

Collaborating to manage chronic diseases—and spreading the model

In San Diego, Adler continued pioneering in pharmacy practice and education models. He began a clinical practice in anticoagulation therapy, working closely with renowned hematologist Samuel Rapaport, MD, and other physicians in the local Veterans Administration.

“That’s one of the first examples of the collaboration between pharmacy and medicine for the management of chronic disease,” Adler recalls. Warfarin, the primary drug of the day for preventing blood clots (and still the most widely used) requires especially careful management, given its narrow therapeutic index (the ratio between toxic and therapeutic doses) and its potential for interactions with many medications and foods that can increase or reduce its effects, yielding dangerous bleeding or inadequate “blood thinning.”

Back then, medical residents “just weren’t paying enough attention to all the details … and particularly to patient adherence,” Adler recalls.

This collaborative care model was expanded to University Hospital, now UC San Diego Medical Center, with Adler recruiting Robert Weibert, PharmD ’70, to establish and lead the anticoagulation clinic there, which became pharmacist managed. Both clinics also became sites for student training.

That model, in which pharmacists manage chronic disease outpatient treatments in collaboration with physicians, was soon extended to clinics specializing in HIV/AIDS, hypertension, organ transplants, and beyond.

In the early 1980s, Adler and colleagues, along with the University of Washington, developed and hosted the American Society of Health-System Pharmacists (ASHP) anticoagulation traineeship program, which spread the model nationally through its graduates.

For example, Pamela Schweitzer, PharmD ’87, 2015 Distinguished Alumnus, did postgraduate training with the ASHP program in San Diego, before moving to rural South Dakota to work in the Indian Health Service.

“I used skills learned in the course to help develop anticoagulation monitoring programs and clinics in settings that had not yet been exposed to clinical pharmacy,” recalls Schweitzer, now a rear admiral, assistant surgeon general, and the chief pharmacy officer in the U.S. Public Health Service. “On occasion, I reached out to Dr. Adler for assistance and his thoughts on different approaches.”

Along with faculty colleagues James Gates, PharmD ’58 and Lawrence Strom III PharmD ’61, and as president of the California Society of Health-System Pharmacists in 1983, Adler’s advocacy helped achieve further legal leeway for the collaborative model’s growth via expanded scope of practice for pharmacists. In the early 1980s, several new state laws authorized pharmacists working under protocol with physicians in hospitals and clinics to further manage drug therapies: This includes ordering lab tests, adjusting dosing, administering, and even initiating medications. More recently, state law similarly expanded the potential scope of practice by community pharmacists with the 2013 passage of SB 493.

Coming to the aid of refugee pharmacists

One of the highlights of Adler’s career—and of the School’s history of public service—came somewhat out of left field: In late 1983, he was introduced to Dr. Dong To, the former dean of the University of Saigon School of Pharmacy, who was working as a researcher in a UCSD lab.

“He was looking for opportunities and options for his former students,” Adler recalls. “He had all these people [pharmacy graduates] who had been able to escape and seek asylum in this country in the wake of the fall of Saigon in ’75. They had a real survival network and knew where everybody was.”

From Dr. To, Adler learned of the plight of these refugee pharmacists. Despite rigorous training in chemistry, biology, and lab techniques, many were unemployed or stuck working menial jobs, unable to practice their profession.

With communications cut off by their homeland’s new regime, the refugees could not produce the official certification of their educational and professional status required by the state Board of Pharmacy and necessary to sit for the Foreign Pharmacy Graduate Equivalency Exam (FPGEE) of the National Association of Boards of Pharmacy.

As School historian, faculty member emeritus, and Adler colleague Robert Day, PharmD ’58, recalls, “Early in 1984, an agitated David called and told me that, even if it was hopeless, he had to try to help them out of this deplorable situation.

“What followed was an effort so massive and complex … fraught with dead ends,” wrote Day in his letter supporting Adler’s Distinguished Alumnus nomination. “It is impossible to estimate the hours he devoted to this effort,” alongside administrative, teaching, and practice responsibilities. “He didn’t do it alone … but he was the primary and central driving force.”

Concurrent with tackling bureaucratic barriers, Adler and Day set about preparing members of Dr. To’s network to pass the FPGEE, should they be allowed to take it. Working with local government, the duo successfully gained federal funding for refugee retraining (which typically targeted far more rudimentary occupations) to assemble a UCSF pharmacy-review program.

The program took place on Friday nights and Saturdays over a year and a half. Basic science and clinical faculty members flew in from UCSF to teach the 110 students, some of whom slept overnight in their cars to attend.

Meanwhile, project associate Elvira Richardson travelled to the Library of Congress to pore over a journal that listed graduates of the University of Saigon. Combined with an affidavit from former Dean To vouching for its accuracy, this listing passed graduate-certification muster, allowing the program graduates to sit for the foreign pharmacy equivalency exam. State legislation was then fostered and passed, allowing the Board of Pharmacy to accept passing scores on the FPGEE and the TOEFL test of college-level English proficiency as qualification for its licensing exam.

In the end, 95 percent of the program’s students passed all their exams and were able to practice again.

“We are expressing our undying admiration and gratitude for his tireless efforts … that made it possible for more than 100 of us to reenter our profession of pharmacy,” reads a letter in support of Adler’s alumnus honor that was personally signed by 64 of the program’s graduates. “Due mainly to his efforts on our behalf, we were able to alter the course of our lives and that of our families.”

And Day adds, “Hundreds of other Vietnamese pharmacists who could not be accommodated in the initial [UCSF program] utilized the methods and paths that Adler had cleared and were also able to regain their practices.”

From establishing a satellite to building a school: UCSD Skaggs

The demonstrated success of the Adler-led School program in San Diego, combined with growth in the region’s biotechnology industry, eventually led UCSD leaders to propose the development of a second pharmacy school in the UC system as part of their 1988 campus master plan.

Through the 1990s, Adler played vital roles in a complex undertaking that required detailed needs assessment and planning, and then approvals from numerous parties and levels of the UCSD campus and UC System, as well as the state legislature, which funds new academic buildings.

“David was instrumental in securing this support in the community and with educational colleagues,” recalls Palmer Taylor, PhD, UCSD Skaggs founding dean emeritus. “The paperwork and number of presentations were virtually incalculable and lasted some three years, but through David’s leadership in many areas … UCSD was successful in building a small school of pharmacy with an entering class of 24 in 2002.”

UCSD Skaggs School of Pharmacy and Pharmaceutical Sciences has since grown to include 240 PharmD students as well as 30 pharmacy residents.

Communications, UC San Diego Health

David Adler visited with UC San Diego PharmD graduates at a party in 2014.

As a UCSD administrator and faculty member, Adler continues to advance pharmacy education. In recent years, he chaired a joint UCSD/UCSF committee that worked with stakeholders to change rules that had required California pharmacy graduates to pursue an additional 900 internship hours before they could sit for their state licensing exams.

Essentially, state law had credited as internship hours only 600 of the 1500 hours of experiential learning that California pharmacy students undertake in their introductory pharmacy practice experiences (IPPEs) and advanced pharmacy practice experiences (APPEs)—hours required by the national Accreditation Council for Pharmacy Education (ACPE).

The additional interning hours “were a duplication of what students were getting, in higher quality, in school,” says Adler, noting that additional hours could also conflict with students’ participation in research projects. “It was taking away from their academic curriculum, and in a potentially less meaningful way, in that those hours were not controlled, whereas the IPPEs and APPEs have specific objectives and preceptors who are overseeing them.”

The sought-after changes took effect via state law SB 590. Students graduating from ACPE-accredited schools of pharmacy after January 1, 2016 are deemed to have satisfied the required hours of practice experience to sit for their California licensing exam.

As last year’s Distinguished Alumnus Schweitzer aptly concluded about this year’s, “David Adler has dedicated his entire career to making a difference in the profession and he has touched more lives than he ever realized.”

More

• History of the Department of Clinical Pharmacy: 1965–1972: Ninth Floor Project
• History of the Department of Bioengineering and Therapeutic Sciences: 1967–1978: The Riegelman Chairship
• New law could expand role of pharmacists as health care providers