Opportunities for a career in clinical pharmacologyBMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7084.2 (Published 22 March 1997) Cite this as: BMJ 1997;314:S2-7084
- Nigel Baber, Clinical pharmacology department,
- Morris J Brown, professor of clinical pharmacology,
- David Webb, professor of clinical pharmacology
Nigel Baber, Morris J Brown, and David Webb set out the pros and cons
Clinical pharmacology or, more precisely, clinical pharmacology and therapeutics is a relatively young specialty concerned with the understanding of drug action in man, and with the practice of rational prescribing.
Clinical pharmacology was born out of pharmacology - drug action in animals and in in vitro systems and out of the explosion in the number of new drugs which were emerging about 20 years ago.
Three developments in particular have enabled the specialty to flourish and a fourth is responsible for current excitement.
Firstly, the recognition that clinical studies must be properly designed, executed, and analysed in order to be certain that observed drug effects are real and not due to chance, bias, or a placebo effect. In particular, the randomised, placebo controlled, or positive controlled double blind trial of sufficient size and power has been a mainstay of clinical pharmacology.
Secondly, the development of sensitive and specific assays of biological fluids by chromatography, and more recently by mass spectrometry, has enabled the detection of small quantities of parent drug and metabolises to be determined. This has enabled the subspecialty of pharmacokinetics - the study of the absorption, distribution, metabolism, and excretion of drugs to emerge.
Thirdly, the development of techniques to measure dynamic responses to drugs has allowed clinical pharmacologists to better define the dose effect or response relationship and to understand the mechanism of action of many important drugs. Some drugs can be used as tools or probes to understand physiological and pathophysiological processes, even if the drug itself never becomes a prescription medicine.
The fourth and most recent development is the interaction of molecular genetics and studies on the human genome with drug response and drug development. As we move into the era where every gene and, in theory, every drug target is known, there is a challenge to, and demand for, clinical pharmacologists who are able to marry up disease with the right genes and drugs.
Therapeutics has also advanced dramatically over the past 20 years. Firstly, the assessment of safety and tolerability of drugs has been systematised, again through the randomised controlled clinical trial, but also through spontaneous adverse event reporting and postmarketing surveillance. Pharmaceutical companies and regulatory authorities maintain comprehensive data bases on adverse events. Secondly, there have been tremendous advances in our understanding of mechanisms of drugs - drug interactions, largely through knowledge of the routes of metabolism of drugs, and how these are genetically controlled. Thirdly, the emphasis on evidence based medicine, and the meta-analyses of trials have helped to define the therapeutic and economic value of a drug in populations.
Not just academic
It may seem from this account that clinical pharmacology is predominantly an academic subject. Virtually all British medical schools have departments of clinical pharmacology. Most of the professors of pharmacology as well as the small number of clinical pharmacologists in health service posts are responsible for clinical pharmacology firms and outpatient clinics. But clinical pharmacologists also work in the pharmaceutical industry (including contract research organisations) and in the regulatory authorities (the Medicines Control Agency).
You need curiosity
What sort of physicians, then, would want a career in clinical pharmacology, what are the opportunities, and what do they actually do? Probably the single most important attribute is a curiosity about how drugs work, about the understanding of why some patients respond while others do not. But the discipline is broad, embracing such disparate skills as molecular biology and pharmacoeconomics. Many young doctors who will become clinical pharmacologists will have shown some interest in drug action and usage by taking an intercalated BSc (or equivalent) in the subject. Clinical pharmacologists are usually practical hands on people. They like to design, conduct, and analyse experiments themselves.
Advantages and disadvantages of a career in clinical pharmacology
Wide choice of careers in academic, health service, industry, or regulatory authorities
Broad range of skills can be catered for
Opportunity to be at the forefront of new drug discovery and its application in man
Combines intellectual approach to applied physiology with practical, experimental skills
Allows contact with many other disciplines ranging from basic research, organ based specialties, and marketing departments of industry
Possibility for dual certification or even triple
Two flourishing societies that represent academic and industry interests.
Relatively few hospital based posts available outside teaching centres
Opportunities exist in the three main areas mentioned - academia, industry, and the regulatory authorities. We do not expect many new NHS posts in pure clinical pharmacology to be created, but specialists in an organ based specialty who are also certified in clinical pharmacology are likely to be increasingly sought after by trusts wanting some clinical pharmacology skills. The majority of physicians start their careers in clinical pharmacology in a teaching hospital, where the classical tract of work is undertaken - patient care, research, and teaching. Departments of clinical pharmacology have rotational general medical takes as do other medical firms and outpatients which reflect the interest of the firm.
Clinical pharmacologists play a major role in the hospital drugs committee, the ethics committee, and may run a service or offer advice on overdoses and poisonings. Trainees would be expected to learn clinical trial methodology, basic pharmacokinetics, and to advise on drug interactions. The research undertaken - leading to an MD or PhD - will depend on the departmental interest, but is likely to be linked to an organ based specialty. Those aspiring to a career in academic medicine are particularly encouraged to seek three year fellowships from the Medical Research Council or charities for work which may include a high proportion of non-clinical laboratory techniques.
In the post-Calman era, it is most likely that clinical pharmacologists will acquire dual certification, linking clinical pharmacology to either general medi- cine or one of the organ based specialties. This can make for a very attractive career, as the individual will acquire the combined skills of understanding drug action and its application in the chosen subject. One particular specialty that lends itself to the skills of clinical pharmacology is cardiovascular medicine. Many of Britain's academic cardiovascular physicians are clinical pharmacologists. Despite initial pessimism that Calman would stop this trend, it is now clear that dual certification in cardiology in clinical pharmacology is feasible. Finally, senior clinical pharmacologists in academia may be asked to serve on the Committee on Safety of Medicines to advise the Medicines Control Agency on drug applications.
More doctors needed in industry
Clinical pharmacologists in the pharmaceutical industry usually take up these posts after they have acquired an MRCP (or equivalent) and have some experience of academic clinical pharmacology or a disease specialty. At present there is a dearth of appropriately trained individuals, and most major companies offer attractive career opportunities and training. The main responsibilities in industry are to work with the research scientists in the selection of potential new drugs to test in man, and in the design and execution of phase I clinical studies.
The role of the clinical pharmacologist in the pharmaceutical industry needs to be distinguished from that of the clinical research physician and medical adviser (see Career Focus, 31 August 1996). The clinical research physician is concerned with the organisation and interpretation of large scale phase IIb and III trials, to confirm the dose range, comparative efficacy, and relative safety of new drugs. The stress of the job is on management of trials, usually in several countries, and has a larger administrative component to it than the work in clinical pharmacology. Medical advisers work with the commercial departments to provide the medical viewpoint into the marketing strategy and ensure that product literature and promotional material are accurate and acceptable to the company.
The two major differences between clinical pharmacologists and other industry physicians are their close collaboration with research scientists and toxicologists and their direct responsibility for volunteers or patients in phase I/IIa trials. Many companies encourage their clinical pharmacologists to take up honorary clinical appointments and this is frequently possible in the hospital where the company's clinical pharmacology unit is situated.
The close ties between academic and industrial clinical pharmacology have been strengthened recently by the establishment of up to 20 joint training posts between the two groups. In response to the need to increase the number of clinical pharmacologists in training who could choose a career in academia, the NHS, or in industry several of the major British based pharmaceutical industries have through the Association of the British Pharmaceutical Industry linked with academic departments of clinical pharmacology in jointly funded five year training posts, which will lead to certification in clinical pharmacology and either general internal medicine or a specialty.
Physicians working for the regulatory authorities in Britain require a sound knowledge of clinical pharmacology and therapeutics in order to assess the quality of drug applications for licensing. These are governmental positions and deal with all aspects of new drug development, from pharmacology and toxicology, to assessment of safety, efficacy, and pharmacoeconomic value from clinical trials. A second major division is concerned with pharmacovigilance of registered and commercially available drugs so that an up to date safety database can be maintained and interrogated.
British Pharmacology Society, Clinical Section,16 Angel Gate, City Road, London EC1V 2PT (tel 0171 417 0111/2/3)
The Association of the British Pharmaceutical Industry, Dr Richard Tiner, medical director, 12 Whitehall, London SW1A 2DY (tel 0171 747 1404).