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Clinical Pharmacology & Therapeutics (CPT)

What does a career in Clinical Pharmacology & Therapeutics Involve? Clinical pharmacologists employed within the NHS usually combine their specialty with work as a general physician. About half of their time involves the supervision of acute medical admissions, managing medical inpatients and running outpatient clinics. These individuals will normally have another clinical specialty interest (for example cardiovascular risk management, toxicology) and will take a particular interest in prescribing issues on behalf of their employing NHS body. The mission of the specialty is to improve the care of patients by promoting safe and effective use of medicines and to evaluate and introduce new therapies. Therefore, clinical pharmacologists will often make wider contributions to the NHS clinical service (Table 1). At a local level this may involve leading the drug and therapeutics committee, developing and maintaining a drug formulary, assessing new products, creating prescribing guidelines, reviewing medication incidents and promoting evidence-based therapeutics. Some consultants may play a leading role in a medicines information service for local prescribers, usually with the support of a clinical pharmacist. At a national level, consultants in clinical pharmacology and therapeutics occupy many positions within key bodies such as the National Institute for Clinical Excellence (NICE), the Medicines and Healthcare Products Regulatory Agency (MHRA), the Committee on Safety of Medicines (CSM), the Joint Formulary Committee overseeing publication of the British National Formulary, and adverse drug reaction monitoring (pharmacovigilance) schemes. The National Poisons Information Service (NPIS) is run almost exclusively by NHS clinical pharmacologists. The work programme of a consultant in CPT varies greatly, depending on the job setting. At the time of the last College Census, approximately two-thirds of consultants held academic appointments within universities. While having a service commitment, many of these individuals will have a strong research emphasis in their work that will contribute to knowledge about drug actions and their clinical usage. They will also play an important role in the planning and delivery of undergraduate teaching in therapeutics. Other clinical pharmacologists at consultant level are employed by the pharmaceutical industry and are involved in the development of new drugs and early clinical trials in patients. Some also hold joint appointments with academic units or trusts, a trend that may grow in the future.
Table 1. Roles of the clinical pharmacologist NHS University
Physician (general internal medicine or specialty) Poisons information services Formulary development Prescribing adviser (trusts, health authorities) Ethics committee Drug and therapeutics committees Adverse event reporting Basic research Clinical research Pharmacovigilance Pharmacoeconomics Teaching

Pharmaceutical Industry
Drug Development Clinical trials Phase I and II Phase III

National activities
Drug Regulation - MHRA - EMEA Joint Formulary Committee - BNF - BNFc Health Technology Assessment - NICE - SMC National Prescribing Centre

How do I become a clinical pharmacologist? Applicants for medical specialist training in CPT will have satisfactorily completed and obtained the competencies of the Foundation training programme (obtaining a certificate of completion of Foundation training or equivalent). Before entering Specialty training in CPT you will have satisfactorily attained the competencies (or equivalent) of general internal medicine (GIM) (Acute) to level one in approved posts. This will include at least 12 months experience of the unselected acute medical take during core training or other post foundation training by the time of entering Specialty training in CPT. These competencies will be demonstrated by satisfactory completion including assessments of the Acute Medicine level 1 curriculum. The subsequent 4 year training curriculum will be delivered in a University and/or teaching hospital NHS-based department of clinical pharmacology, supervised by one or more trainers who are at least consultants or senior lecturers in seniority, and supported by an independent educational supervisor trained in CPT and of similar seniority. The key components of training are Undertaking and interpreting early phase studies of drug action in humans. Using pharmacokinetic principles to optimise drug administration and drug effect. Using drugs rationally and cost-effectively Evaluating critically literature relevant to CPT including basic pharmacology, toxicology and phase I, II, III and IV clinical trials and meta-analysis. Designing clinical trials, including phase 3 studies, and contribute to their execution and dissemination. Select prospectively appropriate statistical methods for planned experiments (including clinical trials), perform such analyses, and interpret the resulting statistical output. Understanding the influences that determine the pattern of use of medicines in populations. Anticipating, detecting, managing, reporting and analysing adverse drug reactions (ADR). Advising on cases of overdose or poisoning, and to manage such cases as are relevant to their clinical speciality (e.g. children for paediatrician How family friendly is the job? CPT has traditionally been one of the more male-dominated specialties but this is changing. A significant number of younger consultants are female and some work parttime. The new training curriculum explicitly recognises the potential for part-time training. What are the best aspects of the job? A career in CPT has a number of advantages. First, it is never dull. The constant change in the development and use of medicines in the NHS always creates new challenges. Second, there is the potential to make a difference. Clinical pharmacologists are often at the apex of new developments in therapeutics, either by creating them through their research or implementing them in the clinical service. They also play a major role in promoting patient safety and effective use of drugs at a population level thus making a significant

contribution to the public health. Third, it is extremely varied. The range of activities of a clinical pharmacologist extend from patient bedside to laboratory research, clinical research trial to regulatory agency, and student lecture to international conference hall. Few consultants would describe their working life as repetitive. Fourth, it is yours to create. No two clinical pharmacologists in the UK have the same career pathway. The flexibility to create your own interests and develop them to their full potential is probably greater in CPT than any other career. The revolution in molecular genetics is set to transform therapeutics in the next century leading to the discovery of many hitherto unknown target sites and the design of specific drugs created to interact with them. Doctors can expect new, highly specific drugs to progressively replace the blunter pharmacological approaches of past decades. The next generation of clinical pharmacologists will be leaders in responding to these changes. What are the worst aspects of the job? There are two main disadvantages of a career in CPT. First, it is always providing new challenges and opportunities. If you like stability and predictability in your work pattern then CPT is probably not an ideal career. Second, working across the clinical-researchteaching spectrum means that you are regularly judged and appraised in various different quantifiable domains of activity. If you tend to be nervous about being judged by your peers and dont like receiving rejections (research grants, papers, new ideas) then CPT is probably not for you. What personal attributes would make someone suited to clinical pharmacology? The primary attributes for a career in clinical pharmacology are enthusiasm to develop drugs, monitor their effects, apply them to clinical situations for benefit, and ensure that your peers use them safely and appropriately. Clinical pharmacologists need to adapt to multiple challenges, from designing trials for assessing new drugs to dealing with ethical dilemmas and the legal aspects of drug regulation. Clinical pharmacologists are generally active and energetic individuals who enjoy being challenged and prefer to find answers to questions themselves rather than wait to be told. Being good at communicating both by the spoken and written word is a particular advantage. Is it stressful? The kind of work patterns described above tend to produce multiple deadlines which some would find stressful. Consultants in CPT will normally be juggling several commitments and are generally good at multitasking. If you see this approach to life as stressful rather than challenging then CPT is probably not the career for you. Are the hours antisocial? The overall work commitment of a clinical pharmacologist is considerable but most consultants are able to control that commitment to suit their own lifestyle. Although clinical aspects of the job can only be undertaken at a hospital site, the advance of technology means that many of the other activities can often be undertaken at a time and location of your choosing. Is it competitive? Entry to the specialty is perhaps not as competitive as in the past. For a number of reasons, CPT has not been as visible as it used to be. Most good candidates who are intent on

pursuing a career in CPT can expect to find a training post. Similarly, the breadth of the training means that all trainees can expect to find a job in either the NHS or a UK University. The Pharmaceutical Industry continues to be short of well-trained specialists in CPT and is another destination for some CPT trainees. Life as an established consultant is full of competition for research funding and publications. What is the salary like? Clinical pharmacologists do not do private practice and are remunerated on a standard 10 programmed activity consultant contract. Most in Scotland, in addition, are paid 2 extraprogrammed activities in recognition of the flexibility of their commitment to clinical workload, research and teaching. The nature of their expertise means that it is possible to earn further money by acting as consultants/advisers to the pharmaceutical industry. Where can I obtain further information? If you want to learn more about a possible career in clinical pharmacology you should first make contact with a local department. There are clinical pharmacologists working in all of the Scottish medical schools. They will be able to talk to you about their own perspectives on CPT and work interests as well as put you in contact with others. Alternatively, you can contact the Clinical Section of the British Pharmacological Society (www.bps.ac.uk), which is the Specialist Society for UK clinical pharmacologists. A further detailed description of the Specialty can be found within the publication Consultant Physicians: Working for Patients produced by the Royal College of Physicians (http://www.rcplondon.ac.uk/pubs/books/CPWP/).

Simon Maxwell s.maxwell@ed.ac.uk