As I approach the end of my career, a question that keeps occurring to me is, “was it worth the one and only life I chose to devote to it?” I would like to say my immediate response is an unequivocal yes. But honestly, it’s not so clearcut. That being the case, I decided that a review of my career was in order.
I had intended this review to be a straightforward chronological narrative using my CV as the source document. But once I began, it quickly became clear that to explain what I did and why I did it would necessarily include the key people and events that inspired, assisted or influenced my career. That made it significantly more involved than I had originally intended. So, buckle up, this will take a while.
Since this is something of an informal cost-benefit analysis, we should begin with a quick overview of costs. Over the past 45 years, I have spent an estimated 80,000 hours sitting at a desk, much like I am now, willing myself to create something meaningful from a blank screen. When I wasn’t doing that, I was standing in front of students or colleagues telling them what I know, or more accurately, what I think I know . . . probably.
Beyond the direct costs in time, energy, and physical/emotional wear and tear, we must also consider the indirect costs. What costs did my family incur because of my career choices? Those are real costs that must be weighed against any benefits I incurred or achievements I may have accomplished. Then there are the opportunity costs. What alternative life, career, and achievements did I forego because of the choices I made to dedicate myself to this one? In a cost-benefit analysis, it is often the opportunity costs that turn out to be the most decisive factors, i.e., what you didn’t do but might have done. I am told that question is the one that most haunts people toward the end of their lives. They regret not so much what they did, as what they didn’t do but coulda, woulda, shoulda done.
To review the life and career I did choose, we need to rewind the clock to my younger years. In the personal effects my siblings and I found in my parents’ house after the death of my father was a letter from his sister, Anna. Aunt Anna was both perceptive and always more than willing to share her opinion about anything and everything. The letter followed a visit we had made to her home in Wichita some weeks before when I was about 8 years old. In it she offered her analysis of the personality of each of the Rupp children.
After describing the gregarious and extroverted personalities of my two brothers, she wrote, “Michael is quiet and aloof. He keeps his own counsel like his grandfather, John.” This perspective was further reinforced by the nuns who taught me at St. Joseph elementary school in Scott City, Kansas. Although I don’t recall any of them saying it to me, my mother insisted they called me their “little professor.” Apparently, I was projecting a certain vibe even then.
Whatever the case, I remember being a thoughtful and reflective child who took his studies seriously and was rewarded for it with the recognition and approval of my teachers and, especially, my mother. Being the middle child of seven and otherwise invisible in our family, I think the early recognition and approval I received from my academic achievements was pivotal in the direction my life would take. I was actually good at school, and people noticed. I liked that.
In sixth grade, my father abruptly pulled me and two younger siblings out of St. Joseph because of a minor dispute with the nuns that escalated, as disputes with my father often did. In the middle of the school year, we were extracted from our little Eden and dropped into the town’s public school. On my very first day I clearly recall thinking “Oh my God, they’re barbarians!”
It was immediately clear that I was well ahead of my class in almost every subject. That wasn’t because I was smarter than everyone, but because public schools tend to teach to the middle, if not the bottom of the class. But instead of being admired for my academic acumen, I was now being ridiculed for it. This was evident one day when I was called upon by the teacher to answer a question in class. In response, I stood next to my desk and recited the answer while holding my hands behind my back. Although this was standard operating procedure at St. Joseph, it came off as nerdy and brown nosing to my new classmates who responded with a mixture of amusement and disdain. I think even the teacher thought it was funny. That day I vowed to fit in and join the barbarians. A few days later, I met a kid named Bill on the playground. Bill became my barbarian mentor. It was 1965.
Bill was fun, funny, and did not give a shit. He did as little as possible to get grades that would keep him out of too much trouble at home, and that was it. Otherwise, he was there for the party. Consequences? Fuck the consequences! Bill was also fearless when it came to mind-altering substances. He would swallow, inhale, snort or huff anything he thought would get him high, absolutely anything.
It would take an entire book to recount the adventures and misadventures we had during the subsequent years of middle school and high school, besides which some of it was technically (or not so technically) illegal. Suffice it to say, Bill taught me how to relax, have fun, and be bad without feeling bad about it. And while he was almost always the instigator of our shenanigans, I was usually an enthusiastic participant. I will readily admit that it was delightfully liberating for a parochial school kid who was wired more than a little too tight.
Due to my changes in attitude, middle school and high school were fun, and I look back on those days fondly. I cruised to acceptable grades with little effort while learning very little. I played sports and lettered in wrestling and football, which gave me credibility with the jocks. I partied enough to have hippie cred and still pulled good enough grades to have nerd cred. I dated some cute girls and generally led the life of a popular kid – not prom king popular, but well inside the cool kids’ club.
Looking back, had I not been pulled out of Catholic school and met Bill when I did, I believe those years and my subsequent life would have been very different. He was probably the best friend I ever had outside of my brothers. The thing that eventually killed my relationship with Bill was his girlfriend, Lynette. Ironically, Lynette had been a classmate at St. Joseph, and while I won’t say she was a tight ass, I’m pretty sure if you gave her a piece of coal she could produce a diamond. According to Lynette, I was a bad influence on Bill. That’s right, it was me who was a bad influence on him. Anyone who knew us knew that was like saying Anthony Bourdain was a bad influence on Hannibal Lector.
Being the child of a doting but domineering mother, Bill was someone who readily accepted direction from women. Lynette recognized this and exploited it by monopolizing his time and eventually forbidding him to hang out with me and his other friends. Bill was whipped enough to go along. I still miss him and resent her. That said, given his previous trajectory she may have also saved his life, so who knows.
Upon graduation from high school, I didn’t really have much of a plan other than getting out of the house and away from Scott City, Kansas. I didn’t know what I wanted but I knew what I didn’t want. Even at the tender age of 18, I had done every hot, hard, dangerous, dirty, soul-crushing job that a young man could do in a small, rural community. I had seen what the hard life does to a person and decided it was not a goal for me. Education seemed my only way out. It was 1972.
My parents couldn’t help with college, so aside from $100 a month from my grandparents, it was all on me via full-time summer work and part-time work during the academic year. I ultimately decided to attend Wichita State University, primarily because tuition was affordable and my sister and her husband were willing to rent me their basement cheap. It really was as simple as that; I initially went to WSU because it was convenient and affordable. I don’t know if that really counts as a choice. If so, it was certainly a constrained one. It turned out, however, to be an important one.
My first semester at WSU was a wakeup call. I had confidently loaded up my schedule with biology and chemistry because I figured I would ultimately do something in the health sciences. What I badly underestimated was how little foundation I had in either area. Due to a combination of inadequate instruction in high school and having never really applied myself since elementary school, I knew next to nothing. I got a 2.5 GPA that semester and I scrambled to get that. It would be the last time I received anything less than 3.0 in my academic career.
It was during the first semester of my sophomore year at WSU that I noticed a beautiful girl in my English 102 class. Her name was Valerie and she would come to play the single most pivotal role of any individual or event in my subsequent life and career. I was coming off a recent breakup with a long-time girlfriend and decided to take the opportunity to get to know this smart, funny, beautiful girl better. One afternoon, we convinced our teacher, Mrs. Hudson, to have class outside. While sitting on the grass, Valerie asked me where I was from.
Here I must interject that since leaving my hometown and coming to the big city, I had become uncomfortable talking about where I was from. No one in Wichita had ever heard of Scott City. In my immaturity, I was ashamed to be from a little nowhere spot in the road out west.
I replied “it’s a little town in Western Kansas. You wouldn’t know it.”
“Try me,” she said, “maybe I do.”
“Really, you won’t know it,” I said. “Nobody here has ever heard of it.”
“Oh, come on,” she said. “Give me a chance at least.”
“You’ll just laugh,” I said.
“No, I won’t. I promise,” she said.
Finally, I relented, “okay, it’s called Scott City.”
And she DID laugh, and not just a little, she laughed a lot. Feeling wounded, I said “see, I knew you wouldn’t know it.”
“No, no, that’s not it” she said, “I know it well! I’ve been there often. I’ve spent entire summers in Scott City.”
You can call it coincidence, fate, destiny, providence, or blind dumb luck. Whatever else it was, it was serendipity. It turned out that her father had been raised in Scott City and her grandparents and great aunt still lived there . . . on College Street, the same street where I had been raised. Unbelievable.
As we began dating, it became clear to me that I needed to up my game, aspiration-wise. She was no dirt farmer’s daughter. Her father was a well-known political consultant in Wichita, her grandfather was an affluent rancher and community leader for whom the federal building in Scott City would later be named, and her brother eventually became governor. In contrast, my father was a mailman who was known among the female population of the town for “delivering more than just the mail.” If she and I were to have a future, I needed a plan for what I was going to do with my life. That’s when the next serendipitous event occurred.
During the fall of my junior year, Val and I visited Scott City. During the trip we visited her great aunt, Eva, who also lived on College Street. During our chat, she asked “so what do you plan to do with your education?” I admitted that I wasn’t sure, but I felt it would probably be something in the health sciences. She gave that a little thought then said, “well, the pharmacist here in town makes a good living and he doesn’t seem to work very hard.”
Honestly, I had never even considered pharmacy. While being a legal drug dealer had a certain ironic appeal (it was the early 70s, after all), everything I knew about pharmacy had been learned on a soda fountain stool at Rexall Drugs on Main Street. Upon returning to Wichita, I investigated the idea and found I had already completed all the prerequisites except physics which I could take during the spring semester. Almost on a lark, I applied to one school, the University of Kansas, and was astonished to be accepted. I guess I was going to be a pharmacist!
When I arrived at KU the following fall, my cavalier outlook had changed. I recognized it as an opportunity for a better life than I had dared to dream of as a poor kid growing up in a little farming town in Western Kansas. I resolved not to blow it. Don’t get me wrong, I had fun at KU, especially when Val joined me after we got married between semesters. But with an opportunity for a better life and now the responsibility of a family, my perspective had changed. My grades reflected my new commitment, and I was inducted into the Rho Chi Honor Society which only accepted the top 20% of the class. I was later elected president of our chapter, Alpha Rho, but I think that was mostly because all the other members were too smart to want the job.
It’s important to note here that during the late 1970s, the profession of pharmacy was undergoing dramatic change, fueled by what was called the “clinical movement” which began in the California schools in the mid-1960s. I bought in completely to the vision of the pharmacist as a true clinician, i.e., a provider of health care services, not just a supplier of health care products. Toward that end, I decided to pursue a job in hospital pharmacy where I figured such an opportunity might be possible. As it turned out, the only positions that fit my interest were in Kansas City, on the Missouri side.
After several interviews, I was provisionally offered a job at Truman Medical Center (TMC) in downtown Kansas City, MO, but the job was contingent on becoming licensed in Missouri. At that time, Missouri required someone who had not taken the Missouri licensure exam, or practiced as a pharmacist for at least one year, to complete a year of internship before becoming eligible for licensure. Since I had already applied to take the Kansas licensure exam in Lawrence in June, that meant I would be driving to St. Louis to take the Missouri licensure exam in July. I decided to do just that and passed both exams. We moved from Lawrence to Prairie Village, KS, and I commuted from there to TMC every day. It was 1978.
TMC was simultaneously a hell hole and a great learning experience, both professionally and personally. It was – and continues to be – an inner city, poorly funded, indigent care teaching facility. It served a primarily black population of patients, and most of the staff were also black. It was at TMC that I learned what it is to be poor and black in urban America. It was an epiphany for a kid who had grown up in a place where there was only one black family in the entire county, and they seemed as white as me . . . because they had to be, of course.
I spent two years at TMC and I learned a lot. By the time I left, I considered myself a very capable hospital pharmacist, but I still didn’t feel that I was practicing the clinical pharmacy I had been told about in school. I think that was one reason I left, I just wanted something more challenging. That said, the rotating shift work, the long commute, and the constant insecurity of working for an employer that was perpetually on the verge of insolvency also convinced me to move on. Following one particularly difficult day, I came home and told Val, “I want to move. Where do you want to go?” Val’s parents had once lived in New Mexico, and she thought that sounded like a nice place to live. “Fine,” I said. It was 1980.
The following day, I went to the public library and found a directory of hospitals in the United States. I copied the address of every hospital in New Mexico with over 100 beds, thinking that most of them would have an in-house pharmacy. I then sent a letter of introduction and CV to each one explaining that I was interested in relocating and asking if they had a position available. It was pure cold-call marketing but, surprisingly, it worked. I received three positive responses, two of which were in Gallup: McKinley General Hospital and Gallup Indian Medical Center, the latter being part of the Indian Health Service (HIS), an agency within the U.S. Public Health Service (PHS).
The administrator for McKinley paid to fly me out for an interview. She was a nice lady named Gigi, and I told her in advance that I would also interview at GIMC while I was there. She assured me she was fine with that, but I still felt guilty when I eventually took the GIMC position. As it happened, however, I was later able to pay her back by filling in temporarily when her pharmacist abruptly left.
Whereas the McKinley position was a one-man show in a small community hospital, GIMC offered an entire pharmacy staff within a regional medical center. And with only one notable exception whose name shall not be mentioned, they all seemed eager to teach me what I did not know, which turned out to be a lot. They were excellent clinicians and very encouraging. At the same time, they made it clear there was a standard I would be required to reach and, despite thinking myself a very capable pharmacist, it quickly became clear I would have to up my clinical game significantly just to fit in.
It should be noted here that this was a golden era in IHS pharmacy, which was widely recognized at the time to be one of the most innovative and progressive practice settings in the country. IHS pharmacists were walking proud, talking loud, and there was a palpable sense of camaraderie and shared purpose. We were all commissioned officers in the U.S. Public Health Service, so I guess you would call it an esprit de corps, something I had not experienced before nor have I since.
More unusual still is that this spirit went beyond the pharmacy to the medical and nursing staff. To be sure, we had our disagreements, but they were usually collegial and for the purpose of achieving our common goal of better patient care. It was the one and only time in my life I experienced being part of a true health care team and it felt good. Moreover, it extended beyond work hours as many of us hung out and played together, too. On any given weekend, diverse groups of hospital staff would be heading west to the Grand Canyon, or north to Telluride, or east to Santa Fe, Chama or Taos.
My 28 months at GIMC was perhaps the most personally and professionally rewarding time of my life. The pharmacists I worked with were the best I’ve ever known, and they influenced much of what I would later do in academia. They especially helped me recognize the importance of the pharmacist’s role as a fearless patient advocate for at-risk patients, and the critical role that patient information plays in improving pharmacists’ clinical decisions. During that time, we also had our first child, Ashley, who was born at GIMC. As Val would later quip, “we knew she was the right one, she was the only white one,” which was absolutely true.
I think I could have spent my entire career in the IHS, albeit probably not in Gallup. So, why didn’t I? Once again, fate intervened . . . or in this case, politics. In the early 1980s, Ronald Reagan had blown the federal budget on defense spending. To make up for it, he decided to take an axe to all non-defense spending and that included closing 8 PHS hospitals and some 27 outpatient clinics, mostly on the coasts. Although they were not IHS facilities, their personnel were commissioned corps and most had seniority over those of us in IHS which was a comparably young service at the time. As a result, senior officers had “bumping rights” into IHS during the reduction in force that followed.
The chief pharmacy officer for the Navajo Area at the time was Gene Smith, a good friend with whom I fished and hunted. When he informed me that I might lose my job, I felt like it was TMC all over again. At the same time, it occurred to me that it might be a blessing in disguise. I had been talking with Gene about the idea of graduate school for some time. In fact, it was he who had originally put the idea in my head. The dream of pursuing a graduate degree and eventually coming back to conduct research that demonstrated the value of what we were doing in IHS was appealing. While I enjoyed my job and the impact I made on individual patients, the prospect of conducting research and demonstration projects that would influence the practice of pharmacy on a macro scale was exhilarating. Later in my career I was asked by a former IHS colleague why I left. “I never did,” I replied. I still feel that way.
I recall being very conflicted about my decision to return to school. I had a good (albeit tenuous) job in a stable profession, Val and I had good friends, and we had a new baby. Was I really going to risk it all on something I didn’t even know if I could do in a place I’d never seen a thousand miles from any family? I felt that it was maybe more than a little self-indulgent.
One evening I shared my doubts with Val. “Grad school will be tough on both of us,” I said. “We won’t have much money and I’m not even completely sure I can do it or what I will do with the degree when I’m done. It will also take at least 4 years, so by the time I’m done I’ll be 32 years old.”
Val responded, “How old will you be in 4 years if you don’t do it?” That settled it and demonstrates how trusting and supportive she has always been of my career aspirations and choices.
Having completed a 2-year tour of duty as a commissioned officer, I was eligible for veterans’ benefits when I resigned from the PHS as a first lieutenant. And while the educational benefits for veterans at that time were nowhere near as generous as those during Vietnam, they helped significantly. In return for my contribution of $2,800, the PHS contributed $5,600 toward my graduate education. That may not sound like a lot now, but at the time it made a difference.
There were only a few PhD programs in the country that were widely recognized for training researchers in the areas that interested me. Three were in the Midwest; University of Minnesota, Purdue and Ohio State. I applied to each of them and was accepted at all three. I eventually decided to go to (The) Ohio State University because of one man: Dev S. Pathak. It was 1982.
Dev Pathak was a whirling dervish of energy and ideas who bore a resemblance to the actor, Omar Sharif. He may also be the most competitive person I have ever known. Whether it was golf, racquetball, ping pong, poker or tiddlywinks, he wanted to win and usually did. He was also an excellent salesman. As the head of the Department of Pharmaceutical Administration, I had initially called him to thank him for his offer and to tell him I had narrowed it down to Minnesota or Purdue. Instead, we spoke for over an hour at the end of which he had convinced me to go to OSU. I never regretted it. Dev Pathak became the single most influential person in my intellectual life and the only person I have ever considered to be a true mentor. To this day, he remains my aspiration and role model as an academic.
Dev and I disagreed and argued – in a civil but vigorous way – about almost everything to do with pharmacy. Dev was not a pharmacist. He came from a business background, especially marketing, and that was his perspective. I came from a clinical background and that was mine. Dev was a pragmatist. I was – and remain – an idealist. That set the stage for a lot of disagreements about where the profession of pharmacy should go and how to get there. That having been said, on important matters of truth, justice, and how one should live one’s life, Dev and I were very much of like mind.
The first term paper I wrote for Dev came back filled with critical comments and corrections with a grade of B. Taking it personally and believing myself to be an excellent writer (I was not), I was not happy. After allowing me to vent to him for a while, Dev leaned back in his chair, smiled, and said, “Michael, you are like a wild horse. You have a lot of potential, but that’s all right now, just potential. It’s my job to break you to the bridle and the saddle.” He never broke me, but he did train me.
It was Dev who convinced me that for any clinical model to be successful, it must be grounded by a sustainable business model. Just being a good clinician was not enough, unless you were practicing in a completely artificial and subsidized setting – like the IHS, for example. That meant that pharmacists must demonstrate and quantify the value they add to the drug product via their cognitive services. Furthermore, they must develop methods by which they and their organizations can be compensated for those services. I decided that was how I could best contribute to advancing clinical pharmacy.
Dev was quick witted, but he was also a deep thinker. When I think of the term “a beautiful mind,” I think of him. It was Dev who introduced me to philosophy, initially via the works of Bertrand Russell and, through him, to the rest of Western philosophy of which I would become an avid student. It was Dev’s opinion that someone who held the degree Doctor of Philosophy should know something about philosophy – what a concept! As I was slowly but surely losing my belief in all things supernatural at the time, philosophy provided a source of consolation, comfort and direction that eventually replaced religion entirely.
My 4 ½ years at OSU are something of a blur to me now, probably because of the frenetic pace. I took a full load of courses that included the core of OSU’s MBA and MHA programs, supplemented by economics, epidemiology, policy analysis, research methods and lots of statistics. My graduate stipend of $6,000 per year required 20 hours per week as a teaching and research assistant, so I was typically at the university at least 60 hours each week just to keep my head above water. To top it off, during the final 2 years, I worked in an independent community pharmacy at night and on weekends to help make ends meet.
But as rough as it was for me, I think it was worse for Val who felt isolated in Columbus carrying for Ashley and eventually, Erica, who was born at the OSU Medical Center. We only had one car and that was usually with me, so she and the kids were stranded at home most of the time. To her credit, she never let on how unhappy she was in Columbus until much later. I still feel guilty about that.
In December 1986, I received my PhD in Pharmaceutical Administration. I subsequently interviewed and was offered a position at the University of Utah and Purdue University. I chose Purdue, largely because of their pharmacy practice department chair, Robert K Chalmers, who became my greatest advocate there. It was 1987.
At Purdue, I discovered very quickly that although I would be given a lot of latitude to pursue my interests, I would not be given much direction or support beyond encouragement from Bob Chalmers. Bob hired talented people and expected them to learn the job and do it. That suited me just fine, and I soon began what eventually became dual streams of scholarly activity that continue to represent what I consider to be the core of my career: improving medication safety and developing documentation and compensation mechanisms for pharmacists’ cognitive services.
Inspired by my IHS roots, I quickly conducted a pilot study of prescribing errors and pharmacist interventions in nine community pharmacies in Indiana. The objectives of this study were threefold: Describe the incidence and nature of prescribing errors that occur in community practice; Assess the impact of pharmacists’ prospective drug use review activities related to identifying and resolving those errors, thereby providing a rational basis for economic valuation and compensation, and; Demonstrate the need for a larger multicenter study.
Following publication of the Indiana study,1,2 I submitted a proposal to the APhA Foundation for a multicenter study of prescribing errors and pharmacists’ interventions in the community practice setting. Due in large part to the behind-the-scenes lobbying by Bob with the Foundation’s board, the proposal was funded and the study was completed in 1990. To my knowledge, it continues to be the largest study of its kind ever conducted in the community practice setting. It resulted in multiple peer-reviewed articles, abstracts and presentations that kick-started my career and national reputation.3-13
The methods we developed to systematically document and evaluate prescribing problems and pharmacists’ interventions were later adopted and used by other investigators in the U.S., Canada, Great Britain, South Africa, Australia and New Zealand. The codes we developed subsequently fueled a parallel stream of activity; the development of electronic data interchange (EDI) standards for documenting and billing for pharmacists’ professional activities, something I felt would be essential for the development of efficient payment systems.
To rigorously study pharmacists’ prescription screening and intervention activities, it was necessary to create standardized coding systems that would facilitate accurate documentation and subsequent quantitative analysis of what were essentially qualitative data. As the recognized need for and value of pharmacists’ professional services grew, so too did support for creating systematic methods to document and bill for these clinical services. Beginning in 1992, this stream of activity became my primary focus and resulted in numerous articles, manuals, book chapters, CE programs, and invited presentations to state, national and international pharmacy and health care organizations.14-26
Particularly important during this period was my work with the National Council for Prescription Drug Programs (NCPDP), whose telecommunication standards are used in the electronic transmission of over 5 billion prescription claims each year in the ambulatory care setting. As a founding co-chair of the Professional Pharmacy Services Technical Work Group, I helped to lead the development and adoption of a national telecommunication standard for the routine documentation and transmission of clinical and billing data related to the delivery of professional pharmacy services.15,16
Since its adoption as a recognized standard of the NCPDP in 1994, this coding system has been used in numerous prescription drug benefit plans to alert pharmacists to possible medication use problems, and to allow for efficient and systematic payment to pharmacists for their patient care services, assuming those services are recognized by patients’ insurance benefit plans. The problem is, they generally were not recognized in benefit plans and still aren’t, so my “build it and they will come” strategy never really materialized. Disappointing.
At about the same time, I was also a member of the APhA workgroup that developed the Pharmacy Practice Activity Classification (PPAC). Released in 1996, the PPAC was intended to serve as a systematic classification of pharmacists’ professional activities. Essentially, the PPAC represents the foundation for a theory of pharmacy practice in the form of a hierarchical taxonomy for classifying virtually everything pharmacists do in their professional role. Regrettably, aside from a modest update a few years later, not much has subsequently been done with it.
In early 2002, the NCPA joined with APhA, ASCP, ACCP, ASHP and NACDS to develop the X12 Pharmacy Advisory Panel. The Panel was created to advance professional pharmacy services billing via the X12N 837 standard, and to provide oversight and maintenance of the HIPAA-compliant X12N 837 Health Care Claim: Pharmacy Professional Services Companion Guide that had been released by NCPA in 2001. The Guide contained the EDI transaction segments and data elements that are relevant to pharmacy professional services as billed using the X12N 837 claim, the electronic version of the CMS-1500 claim that physicians and other primary health providers use. I was a member of the X12 Pharmacy Advisory Panel and served as the chair of the X12N 837 Companion Guide Maintenance Committee.
The common thread woven through all these activities was to standardize how pharmacists document their professional services, thereby eliminating an important barrier to creating systematic payment systems for pharmaceutical care. To what extent that has occurred is still unclear to me even now. Another disappointment.
In 1992, I was promoted to Associate Professor and granted tenure. In 1996, I was promoted to full professor. At that time, I was told it was the fastest that any faculty member had attained the rank of full professor in the Department of Pharmacy Practice at Purdue. I don’t know if that is true, but it sounded nice.
So by 1997, I was a tenured full professor at a major university. My career was on cruise control, and I had a stable of excellent graduate students to assist me in keeping it there. One of them would later become a long-term colleague and collaborator in medication quality and safety studies, Terri Warholak.
Terri had been a pharmacy student at Purdue in the early 1990s. After hearing me and others speak highly of the IHS, she joined following her graduation and quickly became a rising star. Seeing her a few years later at an APhA meeting, I asked if she planned to stay in the IHS her entire career. If not, I suggested she should consider coming back to graduate school where she could pursue a PhD and conduct the type of research that our clinical careers in IHS had inspired. Within a year, she had done just that, and we have been close colleagues ever since.
In the late 1990s, I also began a collaboration with Dennis McCallian, and his model community practice in West Lafayette, the Family PharmaCare Center. This relationship resulted in the creation of a suite of innovative community pharmacy-based disease state management programs and payment models.27-31 Val also played an important role in the creation of Family PharmaCare and its programs by creating virtually all the marketing materials that were used.
In 1999, I decided to leave Purdue for Midwestern University in Glendale, Arizona. My reasons were both personal and professional, but a big part of it was due to changes in leadership in the Department of Pharmacy Practice and the resulting de-emphasis of graduate (i.e., PhD) training. Purdue had recently implemented a PharmD program and all the emphasis and resources were being channeled to professional students to the detriment, I felt, of the graduate program. A lesser but relevant reason for the move was that I was simply tired of living in Indiana and wanted to move back west and closer to family. Three of my graduate students chose to stay at Purdue. Terri moved with me to Arizona and completed her PhD there.
How I came to work at Midwestern University in Glendale, Arizona is its own story. At the time, I was being recruited by the University of Arizona in Tucson. I interviewed but decided it was just Purdue in Arizona, and it didn’t really offer the change I was looking for. Specifically, I was looking for a university that recognized that the future of pharmacy is in the ambulatory care setting, including independent and chain community pharmacy. Moreover, that’s where I felt the need for people like me was greatest. On the morning after my UA interview and before my flight out of Phoenix, I had breakfast with an executive for Fry’s, a division of Kroger in Arizona. He listened to my analysis of the job in Tucson then said, “You know, there’s a new school opening in Glendale that sounds like it might be more like what you’re looking for.”
When I returned home, I contacted the recently appointed dean for the new school, David Slatkin, and gave him a cold-call pitch: “You don’t know me,” I said, “but I’ve heard what you’re trying to do in Glendale, and I think I can help.”
We agreed to meet at the upcoming APhA meeting. It was there that I convinced him to create a position for me that was not on the pro forma for the new school. As Dev Pathak used to tell me, “You have to give people an opportunity to say no. Sometimes they’ll surprise you and say yes.”
At Midwestern, I continued my work with Terri and another former graduate student, Michelle Chui, toward improving the quality and safety of medication use, especially using computer-assisted DUR applications and databases that still failed to live up to their marketing hype.32-35 I would return to this issue years later and was disappointed to find that these software applications and databases were still falling short of their potential. Making matters worse, through my expert witness work I discovered that many pharmacists are totally reliant on these flawed automated DUR systems to alert them to possible medication problems, especially in community practice. Michelle Chui has continued to do very good work in this area. Indeed, Terri and Michelle have both done brilliantly in their careers and I am proud to have played a small role.
At Purdue, teaching was not given a high priority or even particularly valued. In fact, I was told point blank by colleagues to stay out of the classroom if I wanted to get promoted and tenured. They encouraged me to devote my energy to developing my research and working with PhD students who could contribute to it. I listened.
Although I have always been effective in one-on-one or small groups, large classroom teaching is a different skill which is much more like performance art, and I did not begin to develop that skill until I got to Midwestern. I still don’t consider myself a great classroom teacher, but I have definitely improved and I credit the many great teachers I have known during my years at MWU for that.
Besides disease management programs, another innovation at Family PharmaCare was the creation of the very first accredited community pharmacy residency program in the country. Within a couple years of my move to Midwestern, Dennis McCallian sold Family PharmaCare to a former resident and accepted a position we had created for him at MWU. We subsequently created an educational program called CommuniRes to train community pharmacy residency directors and preceptors. The APhA funded our grant proposal to package the program and take it on the road. Due in part to the CommuniRes training program, the number of community pharmacy residencies in the U.S. grew from one to over 50 during the next 5 years.36
In the early 2000s, electronic prescribing was only slowly and tentatively being implemented in community pharmacy. To accelerate adoption, there was interest among the chains, network providers, and systems vendors to support research and demonstration projects to accelerate adoption. Initially, this involved studies to demonstrate the impact of e-prescribing on improved pharmacist efficiency and productivity.37-39 Eventually, the central focus of this research became one of improving implementation and assessing the impact of e-prescribing on patient safety, especially when combined with computer-assisted DUR. Much of this later work was done with quality assurance staff at Surescripts, the network administrator for e-prescribing in the community setting.40-45
At about this same time, I was approached by a large professional services administrative organization (PSAO) to conduct a cost-of-dispensing (COD) study of their members. The PSAO negotiated third-party prescription contracts for its members and needed a better sense of how they were distributed with respect to their internal operating costs to dispense prescriptions. To this day I don’t know how they got my name since this was not my area of expertise, or even an interest. However, I was generally familiar with the cost accounting methods used and decided to accept the contract. How hard could it be, right? Pro tip: Never say “no,” always say “yes, and . . .”
While conducting the study in the traditional way (i.e., developing a data collection survey, mailing it out, following up multiple times, inputting data, analyzing data, etc.), the idea occurred to me to create an online software application that would automate the entire process and deliver instant customized financial reports to individual users. My inspiration was TurboTax, and I used a similar approach in designing a guided online interview to collect data paired with an analytical algorithm to produce an instant report that would detail what their internal COD costs were and how those costs were distributed. Were their personnel costs too high? Were they paying too much rent or carrying too much inventory in comparison to other similar pharmacies? That was the hook to users, but the real attraction to me was that each user’s data would be included in a database that I could quickly tap for group analyses.
I worked with a couple software developers and spent an embarrassing amount of time and money before I finally found one capable of doing the work. Ironically, it turned out to be my nephew, Mitch, who did a great job at a family discount price. I named the application PharmAccount and trademarked the name and symbol I created which was a mortar and pestle with a calculator keyboard. It was pretty slick and the application worked great.46 I subsequently used it to conduct a number of large COD analyses, both in the U.S. and Canada. Since these were proprietary works, there were no external publications.
Ultimately, however, I mothballed the website (www.pharmaccount.com) for two reasons. First, a couple of specialty accounting firms eventually decided to expand into the small but lucrative area of conducting pharmacy COD studies, especially for state Medicaid programs. In doing so, they slowly pushed independent entrepreneurs like me out. Second, the PharmAccount software application had been developed using a coding language that was quickly becoming obsolete and not supported on newer servers. Updating it would cost more time, money and effort than I was willing to spend on a shrinking market. Still, I’m proud of what PharmAccount was while it was active and I continue to consider it a successful venture. It was just not the home run I had hoped it would be.
By 2010, I felt I had drifted further from my original interests than I had intended, so I took a 6-month sabbatical to rededicate myself to medication quality and safety. As part of that experience, I spent a couple weeks in New Zealand. The remainder of the time was spent embedded in various medication quality and safety agencies and organizations here in the U.S., including the FDA.
When I returned from sabbatical, I felt recharged and refocused. In collaboration with colleagues at Midwestern and elsewhere, we addressed continuing problems with computer-assisted DUR platforms,47 issues with quality-sensitive data segments and elements in e-prescribing,48 creating and implementing continuous quality assurance programs,49-52 and advocating for the inclusion of diagnosis or clinical indication on all prescription orders to improve pharmacists’ clinical decision-making during prospective DUR and patient counseling.53-55
Besides my main streams of activity there have also been several side areas in which I may have been able to at least raise awareness and perhaps make modest contributions. In the mid-1990s, I was one of the first to examine the pharmacist’s role in medical assistance in dying.56-58 I returned to this important issue later with a more unequivocal argument in support of what I believe should be a basic human right in a compassionate society.59
Beginning in 2016, I was inspired by a quirky little book called Premature Factulation written by Philip Hansten (he of drug interaction fame) with whom I subsequently became friends. While difficult to pigeonhole, the book is essentially a primer on rational reasoning using Western philosophy with special attention to the essays of Michel Montaigne, who Phil especially reveres.
Before reading Phil’s book, it had never occurred to me to write professionally about a topic that I considered to be just an enjoyable pastime. But thus inspired, I subsequently wrote and published several peer-reviewed articles to demonstrate the applicability of philosophy to pharmacy education. 60-62 The articles were so enjoyable to write that I almost felt guilty doing it on university time. And while I genuinely believe in their message, I wonder what impact they can have on pharmacy curricula that are much more about training pharmacists than educating them. My message was probably more relevant to graduate students who want to know than professional students who want to do.
Throughout my life, people have often asked me if I enjoy my career. I have always reflexively said yes. But if I’m being truthful, I’m not sure I really meant it. Someone once asked Hemingway if he enjoyed writing. “No one enjoys writing,” he said, “they enjoy having written.” I think that’s what it’s like for me.
Thoughts and ideas are elusive things. Trying to pin them down is like trying to capture smoke. I find satisfaction in being able to capture and then clearly and succinctly articulate a thought or idea that I want to communicate to others. I have always prided myself on being someone who doesn’t just do things, but rather someone who gets things done. I derive satisfaction from the things I have accomplished in my career, but not so much the process of accomplishing them. I guess that’s why they call it work.
So, why retire now? The bottom line is that I have lost the enthusiasm I once had for the job, including the accomplishments that once brought me satisfaction. Increasingly, I feel it is a disservice to students and colleagues to continue doing something that my heart is no longer in, especially when it is at the expense of a younger and more enthusiastic successor whose place I am occupying. It’s an ethical dilemma that I wish more of our very senior elected representatives would recognize. You need to know when it’s time to walk away.
So, while I’ve left a few things on the cutting room floor, that’s basically the story of my professional career in a nutshell. And we return to the question with which we began: was it worthy of a life? Was it worthy of my life? Well, it paid the mortgage and put food on the table, so that’s something. And I think I did make contributions, however modest, to the issues I raised and the topics I addressed.
But did the life I used up by choosing the career I did generate any meaningful or lasting achievements? Was it a good use of a life? Honestly, I don’t know, and maybe at the end of the day it’s not my place to say.
With that, I will just end with this . . . In early 2000, soon after I left Purdue, I heard that Bob Chalmers had been diagnosed with a very aggressive form of breast cancer and the prognosis was grim. After sitting on the news for a few weeks, I sent him the following letter:
Dear Bob,
I have struggled with this letter more than any I have ever written. For a while I was even able to convince myself not to write at all – that anything I sent would only run the risk of making things worse. Naturally, that was just the self-deception of a coward who was afraid to face a difficult situation. Having finally struggled past my own fears, I will speak from the heart in the sincere hope that what I say may provide some comfort.
I don’t pretend to know why we are here. I think all of us wrestle with that question over the course of our lives. For myself, I seem to be no closer to an answer than when I first began considering the question. And it really is THE question, isn’t it? What is our role? What piece of the final puzzle does each of us represent? If we are only to come and go, why is it important that we were here at all?
Since learning of your illness, I have had the opportunity to think about these questions from a somewhat different perspective, i.e., that of an objective observer who is contemplating the purpose of another’s life, rather than his own. That new perspective has led me to, if not an epiphany, at least a somewhat different understanding which I would like to share with you.
It seems to me that understanding the meaningfulness of our lives is somewhat analogous to Einstein’s Theory of Relativity (stick with me here, okay?). Using Einstein’s metaphor of a person on a moving train, each of us perceives our lives to be relatively stationary. That is, from our perspective we are unable to appreciate the dynamic motion – the sense of direction and purpose – that an observer sees as our train speeds by. I think it is for this reason that each of us is unable to fully define the meaning and purpose of his or her life. Instead, a complete picture is only possible when we include the perspectives of others who are not standing on our train.
As one of the many who has been privileged to witness the Chalmers Express as it hurtled through life, I can tell you there are few people I have known whose positive influence has been felt by more people than you. Speaking strictly for myself, the support you demonstrated for my interest in pharmacy practice-related research during the early parts of my career was pivotal in the direction I have taken since. As I recall, you asked me two questions. The first was “Is there funding for this research?” My response was “Not right now. Someday, maybe.” Your second question was, “Will what you want to do make a difference?” My answer was, “Yes, I think so.” I have tried to focus on projects that will make a difference ever since.
Thank you for your guidance, support, and encouragement over the years. While I may not have said it often enough, I have appreciated it deeply. Speaking on behalf of Valerie, Ashley, Erica and myself, our thoughts and prayers are with you and Elizabeth. Take care, and may God bless.
Mike
Bob died later that year. Afterward, I heard from colleagues at Purdue that Bob appreciated my letter so much that he walked it around and showed it to others in the college. That made me feel good. Looking back now, it also makes me think I may have been on to something.
References
1. Rupp MT, Schondelmeyer SW, Wilson GT and Krause JE. “Documenting prescribing errors and pharmacist interventions in community pharmacy practice” Am Pharm 1988;NS28:30-37.
2. Rupp MT. “Evaluation of prescribing errors and pharmacist interventions in community practice: An estimate of ‘value added'” Am Pharm 1988;NS28:22-26.
3. Rupp MT, DeYoung M and Schondelmeyer SW. “Prescribing problems and pharmacist interventions in community practice” Medical Care 1992;30:926-940.
4. Rupp MT. “The value of community pharmacists’ interventions to correct prescribing errors” Annals of Pharmacotherapy 1992;26:1580-1584.
5. Rupp MT. “Screening for prescribing errors” Am Pharm 1991;NS31:71-79.
6. Rupp MT and DeYoung M. “Reactive pharmacist interventions: Results from a spontaneous reporting program” J Pharmacoepi 1991;2:35-49.
7. Rupp MT. “Pharmacist interventions in community practice: The Ohio experience” Ohio Pharmacist 1992;41:12-15.
8. Rupp MT. “Pharmacist interventions in community practice: The Indiana experience” Indiana Pharmacist 1993;74:6-8.
9. Rupp MT. “Value of Community Pharmacists’ Intervention to Correct Prescribing Errors” Illinois Pharmacist 1993;June:14-17.
10. “Documentation and Evaluation of Prescribing Errors in Community Pharmacy Externship Sites,” AACP Annual Meeting, August 3, 1988, Chicago, IL.
11. “Pharmacists’ Resolution of Prescribing Errors in Community Practice: An Estimate of’ Value Added’,” APhA Annual Meeting, April 10, 1989, Anaheim, CA.
12. “Community Pharmacists’ Interventions: Analysis of Spontaneous Reports,” 1990 Midwest Pharmacy Administration Conference, August 25, 1990, Cincinnati, OH.
13. Blank JW, McCallian DJ, and Rupp MT. “OBRA ’90 – The Challenge to Pharmacy: Drug Use Review and Patient Counseling,” videotape and workbook, November 1992.
14. Rupp MT. “Strategies for reimbursement” Am Pharm 1992;NS32:79-86.
15. Rupp MT. “Standardizing Documentation for Filing Pharmaceutical Care Claims” Am Pharm 1995; NS35:26-30.
16. Rupp MT. “An EDI Standard for Professional Pharmacy Services,” Council Connection, Journal of the NCPDP, Jan/Feb, 16-20, (1995).
17. Rupp MT. Pharmacist Care Claim Form User’s Manual: a guide to pharmacist care compensation. published by NARD, 1995.
18. Rupp MT. “Compensation for Pharmaceutical Care” in Pharmaceutical Care, Calvin H. Knowlton and Richard P. Penna, Ed. Chapman & Hall, 1995.
19. Rupp MT. “Compensation for Professional Service in the Delivery of Pharmaceutical Care,” videotape and live national broadcast on the PharmEdNet, July 14, 1994.
20. Rupp MT. “Managed Care Schemes in the U.S.” in proceedings of a Working Group Meeting on Getting Paid for Patient-Focused Services sponsored by the Canadian Pharmaceutical Association, November 18-19, 1994, Toronto, Ontario.
21. Rupp MT. “Documenting, Billing and Reimbursement for Pharmaceutical Care Services” in Remington: The Science and Practice of Pharmacy, 21th Edition, Lippincott Williams & Wilkins, 2006.
22. Rupp MT. Paying Pharmacists to Meet Patients’ Needs: the American Experience, proceedings of the Conference on Pharmaceutical Remuneration held at the Royal Pharmaceutical Society of Great Britain, London, December 2, 1993.
23. Rupp MT and Kreling DH. Alternative Payment Methods: Value and Payment of Pharmacy Services, prepared for the National Association of Chain Drug Stores, Alexandria, VA, October 1992, 38 pages.
24. “The Pharmacy Services Benefit: It’s More Than Prescription Drugs,” Ontario Pharmacists Association Meeting “Managed Care Revolution: Pharmacists Do Make A Difference,” September 20, 1995, Toronto, Ontario.
25. “Getting Paid for Professional Services: The Family PharmaCare Experience,” College of Pharmacists of Puerto Rico Annual Meeting, September 16, 1994, Dorado, PR.
26. “Designing Pharmaceutical Payment Systems,” Royal Pharmaceutical Society of Great Britain, December 2, 1993, London, England.
27. McCallian DJ, Carlstedt BC and Rupp MT. “Caring for Asthma Patients in a Community Pharmacy” Am Pharm 1994;NS34:64-73.
28. McCallian DJ, Carlstedt BC and Rupp MT. “Developing Pharmaceutical Care Plans for Desired Outcomes.” J Am Pharm Assoc 1996; NS36:270-9.
29. Rupp MT. “Delivering Pharmaceutical Care for Improved Outcomes.” J Res Pharm Econ 1997;8(1):133-46.
30. Rupp MT and Kreling DH. “The Impact of Pharmaceutical Care on Patient Outcomes.” Drug Benefit Trends 1997;9:35-37.
31. Rupp MT. Communicating Pharmacist Care to Managed Care, published by NCPA, 1997.
32. Rupp MT. “Establishing realistic performance standards for community pharmacists’ drug-use-review activities in managed care” Am J Health Syst Pharm 1999; 56:566-7.
33. Chui M and Rupp MT. “Evaluation of Online Prospective DUR Programs in Community Pharmacy Practice” J Manag Care Pharm 2000;6:27-32.
34. Warholak-Juarez T, Rupp MT, Salazar T and Foster S. “The Effect of Patient Information on the Quality of Pharmacists’ Drug Use Review Decisions” J Am Pharm Assoc 2000;40:500-8.
35. Chrischilles E, Fulda TR, Byrns PJ, Winkler SC, Rupp MT, Chui MA. “The Role of Pharmacy Computer Systems in Preventing Medication Errors” J Am Pharm Assoc 2002;42:439-48.
36. Rupp MT “Program Planning for a Community Pharmacy Residency Support Service” J Am Pharm Assoc 2002;42:646-51
37. Rupp MT “The Impact of E-Prescribing on Staff Productivity in Community Pharmacy – Part 1” Computer Talk 2005;25(3):15-22.
38. Rupp MT “The Impact of E-Prescribing on Staff Productivity in Community Pharmacy – Part 2” Computer Talk 2005;25(4):14-17
39. Rupp MT and Warholak TL. “Evaluation of e-prescribing in chain community pharmacy: Best-practice recommendations” J Am Pharm Assoc 2008;48:364-370.
40. Dhavle AA, Rupp MT. “Towards Creating the Perfect Electronic Prescription.” J Am Med Inform Assoc 2015 Apr;22(e1):e7-e12.
41. Dhavle AA, Corley ST, Rupp MT et al. “Evaluation of a User Guidance Reminder to Improve the Quality of Electronic Prescription Messages.” Appl Clin Informatics 2014;5:699-707.
42. Dhavle AA, Rupp MT, Sow M et al. “A Continuous Quality Improvement Initiative for Electronic Prescribing in Ambulatory Care.” Am J Med Quality 2015 Nov-Dec;30(6):598-600.
43. Dhavle AA, Ward-Charlerie S, Rupp MT, et al. “Evaluating the Implementation of RxNorm in ambulatory electronic prescriptions.” J Am Med Inform Assoc 2015;0:1-9.
44. Dhavle AA, Ward-Charlerie S, Rupp MT, et al. “Analysis of National Drug Code Identifiers in Ambulatory E-Prescribing.” J Manag Care Spec Pharm 2015;21(11):1025-31.
45. Dhavle AA, Yang Y, Rupp MT, et al. “Analysis of Clinician Notes in Electronic Prescriptions in Ambulatory Practice.” JAMA Intern Med, 2016;176(4):463-70.
46. Rupp MT. “Analyzing the Costs to Deliver Medication Therapy Management Services” J Am Pharm Assoc 2011;51:e19-e27.
47. Reynolds JL and Rupp MT. “Improving Clinical Decision Support in Pharmacy: Toward the Perfect DUR Alert.” J Manag Care Spec Pharm, 2017;23:38-43.
48. Yang Y, Ward-Charlerie S, Dhavle AA, Rupp MT, Green J. “Quality and Variability of Patient Directions in Electronic Prescriptions in the Ambulatory Care Setting.” J Manag Care Spec Pharm, 2018;24:691-99.
49. Chinthammit C, Rupp MT, Armstrong EP, Modisett T, Snead R, Warholak TL. “Evaluation of a guided continuous quality improvement program in community pharmacies.” J Pharm Policy and Practice, 2017;10(26):1-8.
50. Rupp MT. “Assessing the Quality of Care in Pharmacy: Remembering Donabedian.” J Manag Care Spec Pharm, 2018;24:354-56.
51. Rupp MT. “Assessing the Quality of Pharmacy Care: It’s Not About Adherence.” J Manag Care Spec Pharm, 2018;24(4):354-56.
52. Rupp MT. “10 Ways to Improve Medication Safety in Community Pharmacies.” J Am Pharm Assoc, 2019;59:474-478.
53. Loera C, Olsen J, So A, Murata J, Murcko A, Rupp M, Warholak T. “Prescriber and pharmacist attitudes toward inclusion of diagnosis or clinical indication on prescription orders.” J Am Pharm Assoc, 2021; (61) e284 – e288.
54. Rupp MT, Warholak TL, Murcko AC. “Indication or diagnosis should be required on prescriptions.” J Manag Care Spec Pharm, 2021;27(8):1136-9.
55. Rupp MT, Warholak T, Murcko AC, Axon DR. “Stakeholder views on requiring diagnosis or clinical indication on e-prescriptions.” J Manag Care Spec Pharm, 2024;30(4):305-12.
56. Rupp MT and Isenhower HL. “Pharmacists’ attitudes toward physician-assisted suicide” Am J Hosp Pharm 1994;51:69-74.
57. Rupp MT. “Physician-assisted suicide: Issues for pharmacists” Am J Health Sys Pharm 1995; 52:1455-60.
58. Rupp MT. “Issues for Pharmacists in Assisted Patient Death” J Pharm Care Pain & Symptom Control 1995; 3:43-53.
59. Rupp MT. “Dying Better.” J Am Pharm Assoc, 2018;58:250-252.
60. Rupp MT. “Of Philosophers and Pharmacists.” Am J Health-Syst Pharm, 2016;73:1278-80.
61. Rupp MT. “The case for philosophy in pharmacy education.” Am J Health-Syst Pharm, 2017;74:1192-5.
62. Rupp MT. “Encouraging Students to Challenge Assumptions.” Am J Pharm Educ, 2019;83:727-728.