Misunderstandings and missed opportunities are part of life's drama. But when they involve drugs and chronic diseases such as hypertension, diabetes or HIV, they can cut short the performance years early. Yet precisely because the stress on organs and body systems is an insidious subplot, it does not always command the same attention or urgency as a heart attack or stroke. Clinical pharmacist Betty Dong begs to differ, and since finding her voice three decades ago as a UCSF pharmacy student, she has put astute drug management -- and the prevention of health emergencies -- at the center stage of good practice.

"I have always liked patient care," says Dong, who joined the pharmacy faculty in 1973. "You get to know people well, and you have opportunities to track and change the course of a disease." In service to that goal, Dong has expanded what was once a drug refill clinic into several referral clinics at San Francisco General Hospital's Family Health Center, including those for hypertension, anticoagulation, HIV and diabetes.

"I educated myself, developed protocols and lobbied everyone on behalf of these clinics," says Dong. The work paid off. And in tribute to her years of listening to and observing patients -- skills that have taught Dong the difference between the truly recalcitrant and the merely confused -- she now sees many of the most difficult cases. "Patients can often get confused about their medications, even those who are in and out of hospitals all the time," she explains. Language and cultural differences, and the sheer volume of medications being consumed -- 10 to 15 for a single person is not uncommon -- contribute to the problem. Simple devices can also become anything but simple in the wrong hands. "I recently saw a long-standing asthma patient who still did not understand when to use the different inhalers and how to use them correctly."

Some patients, of course, understand all too well, but choose not to comply. Dong saves her most "forceful voice" for them, but only after spending the time to identify and cull out a subgroup of patients she was among the first to recognize. These are the discretionary patients, who use their discretion -- and not the physician's or pharmacist's instructions -- when taking their medications. "They are not willful. They truly believe they are being compliant simply by taking the drug when they think they need to. They just don't realize the importance of taking the drug at certain times and consistently, even if it may be inconvenient."

Value of prevention

Toiling as she does in the health care trenches where untreated conditions can explode into expensive emergencies, Dong knows the value of prevention and the pressure to stretch every treatment dollar. So, as an expert in the treatment of hypothyroidism (thyroid deficiency), Dong was a logical choice in the late 1980s to conduct a drug company-sponsored efficacy study. The study was designed to compare a brand- name thyroid drug with its generic equivalents. When Dong found that the less expensive generic equivalents were as effective as the more expensive brand name drug, she was initially prevented from publishing her results because of a clause in the drug corporation's contract.

Years of legal wrangling, bad blood and big headlines -- which ended when the controversial results were finally published in 1997 -- left their mark on the Sacramento, California native. "I was not a happy person for almost seven years. I was very naive about the situation; I believed that people would act honorably." That they did not always do so has made her wiser -- and even more appreciative of the strong support from her UCSF colleagues. Dong has made new friends among the pharmaceutical companies as well.

For her students, though, it is Dong's expertise as a pharmacist on multidisciplinary teams -- she was one of the first pharmacists to participate in what was a radical experiment 30 years ago -- that counts. "Students know that pharmacists earned their place on these teams [with nurse practitioners, physicians, and social workers] because of their drug knowledge -- and because they were not afraid to speak up." Now that the pharmacy curriculum has changed, bringing the new crop of students into patient care settings earlier in their academic careers, Dong sees a marked improvement in the students' quality, experience and confidence. "Most are a lot more forthcoming than they used to be. And because they have seen more patients, they are more likely to incorporate patient care aspects into their drug care recommendations." They are also more likely to learn what herbal supplements patients may be taking, an important part of an individual's drug history that physicians often forget to obtain.

The increasing sophistication comes at a time when pharmacists in a variety of settings are being asked to help manage the complicated drug regimens of HIV patients. Dong's response: apply for a grant that would determine if the training of community pharmacists in HIV drug management improves the quality of care. The proposed study is a logical offshoot of the 12-year-old National HIV/AIDS Clinicians' Consultation Center based at SFGH, in which the irrepressible Dong also participates. The 24-hour telephone consulting service is staffed by pharmacists, physicians and nurse practitioners. "Doctors and other health care providers from all over the country call us for advice." With an average of 25 calls per day, some lasting as long as 40 minutes, Dong has no doubt that the information is desperately needed.

In the meantime, Dong continues to surprise her patients, some of whom profess mild alarm that she is "just a pharmacist." Indeed, it is this kind of professional discrimination, far more than any based simply on gender, that Dong continues to battle. "I never take it personally. I'm confident I have something important to offer."