We Are Here For You

Accessibility: (of a person, especially one in a position of authority) friendly and easy to talk to; approachable.
Why are pharmacists the most trusted professionals?
Why do people call us with most of their medication questions?
Why do we get yelled at more than any other professional? 
Why are we held to a different standard than other professionals?
Why do people think we hold all the cards when it comes to their healthcare?

Accessibility. We are the most accessible healthcare profession available. We are the most accessible point of contact for all healthcare questions/concerns/complaints. People can't call their insurance companies and get immediate feedback. Pharmacies provide that. Even though we have nothing to do with the issue you are having, you can immediately vent to us. Your insurance company is locked away somewhere but I am here, face-to-face with you and your ire. Someone commented, a doctor I think, who was a little off base, on yesterday's post with this witticism: How many prompts does it take to talk to a pharmacist? Now, had he phrased his question better, I could have granted him a single point. However, the answer to his question is, simply, one. Press "0" on most any pharmacy menu and you'll get someone to answer the phone. The fun part about pharmacy is this: Ask to speak to a pharmacist. I can guarantee you will speak to a pharmacist. Period. Now, let me try that at a doctor's office.
Press 1 if you are another doctor
Press 2 if you'd like to make an appt.
Press 3 for prior authorization
Press 4 for billing
Press 5 if you are a patient needing a refill
Press 6 for questions for a nurse
Fine. Pharmacy menus can be long too and we have to have ads for flu shots. I won't argue that and I have to call other pharmacies too, but who waits? Press the button. And when I call a doctor and ask to speak to a doctor, will I ever get a doctor? (Not including ER doctors who just saw a patient. They're usually pretty good when it comes to talking to us.) No. I get a receptionist; perhaps a nurse. Someone will call me back. Who? A receptionist; perhaps a nurse. A doctor? Never. At any given hour of business (usually 9-9, unlike doctors) a pharmacist will be available to speak to someone about his medication. A pharmacist may even answer the phone herself! We can't hide behind a wall of receptionists and nurses who screen calls and take messages and who make our calls for us. 
I ask you to read those first two questions again. 
We are accessible. We are here for our customers. We are available. You can call my phone number and speak to me directly. All you have to say is "May I speak to the pharmacist please?" Seriously. It is that simple. I think I'm going to try that with the doctor's offices I call tomorrow. "May I speak to Dr. Zoffis, please?" 

Calling Doctors...

What is easier? Making 2 phone calls or making 3 of them? I always thought 2 was fewer than 3 and therefore simpler. Why do some doctors' offices require the pharmacy call them for prescriptions? The way it is supposed to work is the patient visits the doctor. The doctor prescribes something. Someone at the office either writes it, faxes it, electronically sends it, phones it, or teleports it over to the pharmacy. The pharmacy then fills it. I can't spend all day tracking down prescriptions for patients because doctors won't call pharmacies. If the patient calls the doctor then the doctor calls us, that is 2 calls. If the patient calls the doctor, then calls us, then we call the doctor, that is 3 calls. What reasons have I been given by the offices?
1. You're long distance and you work for a big corporation. They can afford the bill. (I guess no one near you uses an independent then, huh?)
2. We always have to wait on hold for such a long time with pharmacies. (Fantastic. I guess you never heard of this thing called voicemail. Revolutionary concept, this. You call. You talk. It records. Done!)
3. We only have one person who can call in prescriptions here. (And I only have one person who can take prescriptions here. That doesn't stop the other dozens of offices from calling me all day.)

It was an especially awesome and frustrating Saturday when this unfolded at 9:15 am:
Impatient Patient: My doctor wants you to call him at home.
Me: WTF? Why?
IP: I just called his cell phone and talked to him. He wants to prescribe me something but you have to call him. He said you have to call him at home right now because he's leaving.
Me: Wouldn't it have saved time if he would have just hung up with you and called me? He could have left a voicemail by now and I could be working on it. I am going to do over 400 prescriptions today, by myself. I don't have time to track down your doctor immediately. (I take the number from him...)
IP: <less than 3 minutes later> Did you call yet? I have his cell number.
Me: <I call the cell number. It was incorrect. I call the house number I was originally given. The doctor's wife answers and gets all bitchy with me because she is put out that I am calling. She gives me his correct cell number and I get his damn voicemail.>  Listen, if your husband is going to request people call him, take it up with him. I'm just doing what he told me to do. I'm not happy about it either because his lazy, self-important ass could have called me at 9:15 and this would have been over. Instead, I have to make multiple calls and track him down on a Saturday and waste 2 & 1/2 hours of my time for one lousy prescription. <Doctor finally called back...at 11:45. After I got 6 more phone calls from IP>

It's all in the Planning

I like to plan my day. I like to know when I am going to do certain things. I like to be able to tell people when they can expect me. Many pharmacies employ some type of timing system when it comes to filling prescriptions. They either use little clocks on their computers for each order, times on patients' bags, or stopwatches clipped to baskets, to keep track of when something is due for pickup. How do we arrive at these times, you ask? Simple-we ask people questions:
When do you want to come back for this?
Did you want to wait or come back for this?
When would you like to pick this up?
Usually this conversation ensues...(it has many forms)
Me: Will you be waiting or did you want to come back?
Every Single Customer Ever: Well, how long will it take?
Me: Our wait time is about 20 minutes right now.
ESCE: Hmmm. I'll probably come back.
Me: What time did you want to come back?
ESCE: You said about 20 minutes? I'll be back in 15-20 minutes.
Me: So I should say you're waiting?
ESCE: No. I can't wait that long. I'll be back then.
This one isn't too bad. It usually ends with a head shake and a 20 minute wait time on it.

The ones I really love are these:
Me: Okay. And when did you want to come in for it?
Phone Customer: This afternoon some time.
Me: Ok. I'll put an hour on it an we'll see you after then.
PC: But if I'm not there, it'll be tomorrow some time.
Me: So I should put tomorrow instead?
PC: Well, if not today or tomorrow, then it'll be some time on Saturday.
Me: Great. Thanks for helping me plan my day and prioritize. When everyone else's orders get behind, I'll blame you.

The times are there so we know when to expect you. If you're going to tell me Saturday, I expect to not see you before Saturday. It's like a date. If we are going to make reservations for dinner for Friday at 7pm, we are not going to tell the maitre d' "Unless we decide 8:17 works better. Maybe we'll just wait until Saturday instead. Even better, how about we just show up unannounced at around 5:29?"
Worse yet are these:
Drive-Thru Guy: Here to pick up a prescription.
Me: Ok. What's the name and date of birth?
DTG: Here you go.
Me: I don't have anything ready for you. When did we tell you it would be ready?
DTG: I told them I would be back after 7:30 tonight. I dropped it off this morning.
Me: I see. Here it is. You dropped it off at 11:34 this morning. You told us you'd be here after 7:30 tonight. It is currently 12:17pm. It's not quite ready yet.
DTG: Why the hell not?
Me: Um. Do you own a watch? Perhaps have a sundial on your dashboard? Some means of telling time? I know in my world that I can't confuse 43 minutes with 8 hours on my worst days but you seriously have to get a grasp on this thing called "time". I bet you order your pizzas from the parking lot and walk in 10 seconds later expecting those 30 minutes to have magically melted away like my brain from this conversation.

Ask the Question

I have always been a believer in asking the question that you want answered. What do you ask of someone when you want to know the time? What do you ask of someone when you want to know about their allergies or if they need counseled?

Time Guy: Do you know what time it is?
Me: No.
TG: But you're wearing a watch.
Me: I am. And it has the time on it.
TG: What does it say?
Me: It doesn't talk.
TG: Can you tell me what time it is?
Me: I can.
TG: Will you?
Me: No.
TG: Why not?
Me: I'd have to look at my watch first.
TG: Can you look at it?
Me: I can. But I don't want to. I know what it looks like.
TG: Sir, what time is it?
Me: Time for the next question...

Any Tech: Do you have any drug allergies?
Funny Customer: Well, weed makes me a little funny?
AT: Um...
FC: Oh, and Ecstasy makes me really thirsty.
AT: Um...
FC: Meth makes my teeth fall out.
AT: Any allergies to any medications?
FC: Oh. No. I guess those were side effects, not actual allergies anyway.

Any Tech: Any questions today?
Every Customer: What are the winning lottery numbers?
AT: Um, for the pharmacist?
EC: Is she single?
AT: Um, do you have any questions for the pharmacist regarding your prescriptions today?
EC: That's better.

I also like the people who walk up and say "Can I ask you a question?" Hmmm. Didn't give me a lot of choice on that one. My answers have ranged from:
"Besides that one?" to "You just did." (said as I walk away).

If McDonald's was like your Pharmacy

People always act as if pharmacies are fast food joints. We do have drive-thrus. We also have a dollar menu (okay, it's more of a free, $4, $10 menu but you get the gist). To help people understand the differences, however subtle, I have written the following guide:   If Mcdonald's was my Pharmacy...

-You would need to visit a doctor to make sure you need the meal you are here to purchase.

-Your doctor would write you a prescription for the exact meal and quantities you need today (no ordering a la carte or upsizing without prior authorization).

-Your order, after being entered into the touchscreen, would generate individual receipts (read:labels) for each item on your order (fries, apple pie, quarter pounder, Coke). This is provided, of course, that he can read the doctor's directions. Even though the doctor only had to circle a picture of the sandwich he wanted, he managed to circle two pictures (one from the dollar menu and one from the regular menu). Now she will have to call the doctor for clarification. 

-One person would then take these receipts (labels) to fill your order. He would pour a pile of fries on a tray and count them to get you the prescribed amount. He would use a graduated cylinder to pour you the correct volume of your beverage and count out the ice cubes for each cup. The quarter pounder would be weighed out on a scale or balance to ensure accuracy. Each of these would then have its own receipt (label) attached to it.

-The manager would receive the tray from the filling station. She would scan the receipt to bring up an image of the food product you ordered and make sure it matches what is in her hand. She would check the order, one item at a time, to make sure it exactly matches what the doctor ordered (wouldn't want to forget an order of hash browns first thing in the morning) and to make sure they can all be eaten at the same time (no interactions). She would also check to make sure you didn't forge any refills on the Coke or change the small fry to a large fry--you know, to prevent abuse. Then your history would pop up on the screen. She could see if you always get this order or if your doctor changed something since your last visit. She would also check your medical history to make sure you are healthy enough to receive today's meal. (Heart problems?-No Big Mac for you. Diabetes?-No Diet Coke. High Cholesterol?-No fries with that!) She would also check with other chains to make sure you are not getting these meals prescribed by another doctor and using two different fast food chains for the same thing. She wouldn't want you to accidentally overdose on cheeseburgers because they're called something else at Burger King and you didn't tell her you just filled an order there. If you are healthy enough, your food moves down the line. If not, we have to call your doctor to ask why he prescribed this particular meal for you. In some cases, he may tell us you need the large fries and a milkshake, but she will tell him it needs prior authorization through your insurance. Once he calls for the prior authorization and the insurance calls him back (usually 24-72 hours later--long wait for lunch!) either to approve the large fries or change the prescription to apple slices, your order will move on.

-Now your order proceeds to checkout. We give you a cash total. It's the first of the month/year and your insurance has changed but you didn't provide it immediately. The cashier takes the new information and hands it off to someone else for correction and an update to your file. She hands the tray back to the checkout person who tells you the new copay, collects the copay from you, then smiles and says "Have a nice day!".

-Refills on beverages will not be authorized without a new order from your physician.

-Medicaid patients will have copays and the formulary will only include items on the $4 and $10 menus board. This means no milkshakes, no medium or large sized portions, and no sundaes. 

-All the while, every person involved in your order in the back- the person cooking, dropping a basket of fries, wrapping the sandwiches, pouring drinks, waiting on drive-thru-is also answering the phone that is ringing off the hook. At this McDonald's, doctors are phoning/faxing/electronically sending in orders for other hungry diners. There are hungry diners sitting at home calling in orders they want to pick up later or checking to see if their doctor called in their orders yet, or calling for our hours. The manager is also out administering espresso shots to those who have prescriptions for caffeine because she is required to do so. She is also walking out to help people find the bathroom, the condiments, the napkins, the trash can, and a place to sit all in the name of good customer service. (She's not allowed to just point to the stand behind the customers and say "everything is right there.")

-Drive-Thrus. Remember, drive-thrus are about convenience, not speed! What takes so long, then? It can actually take longer because managers are required to do counseling if someone asks and if they ask at the drive-thru the wait can seem interminable. When this happens, the manager patiently, expertly demonstrates how to open a straw, insert it into the "X" cut into the plastic lid, and use it to deliver himself a mouthful of ice cold beverage. He then demonstrates how to properly open a packet of ketchup and apply it to your burger as well as the proper method to dip fries into it. Next, he'll answer a question about the appropriate number of bites to take for this particular sandwich and how much mastication is required for each bite. 

-When the fries look different, the patient may be confused. It is up to the manager to patiently explain that this is McDonald's, not Wendy's, so there is not skin on the fries here. He will also have to explain why the wrapper looks different (different burger joints use different wrappers) or why they may have changed colors (the new Christmas cups are in at McDonald's).

Everybody got it? Please remember this the next time you visit either of our establishments and maybe it will change your perception.   

The Golden Rule of Pharmacy

We were always taught to obey the Golden Rule-treat others as you would have them treat you. Great for kids, bad for business.  The Pharmacy Interpretation should be-Treat others the way they want to be treated. Business books agree with this, and I adopted it in my pharmacies without realizing how relevant it truly was. In fact, I was practicing it before I read its witticisms.
We all deal with the same customers every day. I have worked inner-city, affluent suburb, blue-collar, college, and every other town in which there is a pharmacy. In every one of these, the customers are the same: quiet ones who cause no problems; loud, boisterous ones who want you to know they are there; dedicated ones who love their pharmacy staff; fickle ones looking for an excuse to leave you; and the whimsies-those who shop wherever they happen to be at the moment they decide they need a refill.
I am truly focused only on the ones who make our life hell at work. Why do people find it necessary to yell and argue with pharmacy staff? I am very good at conflict resolution and solving problems. I often find that most perceived problems are misunderstandings that we have not been allowed to explain. At my most recent store, I was warned of a number of customers who cause problems every time they call or visit. My staff always find it necessary to tell me so-and-so is on the phone, or here, and that he always causes a problem. Why do my staff feel threatened or intimidated by these people? Because this is the situation the customers have fostered and the staff have felt powerless to change it. (To that I say, Thank You Corporate 1-800 Customer Service Calls! Thank You for making my staff feel powerless to stop abuse from customers.)
ATypical (True) Interaction: Lady complains that she had to wait for something until the next day and was gracious enough to bring it in the night before to give us plenty of time to work on it. (Nice, but her doctor put a Do Not Dispense date on it until the next day so she wasn't exactly trying to help us.) She arrived earlier than we told her it would be ready and she complained. I was already warned of her history so I was prepared. She kindly explained how she went out of her way to bring it in early, how we're her only pharmacy, but she's considering changing after this, blah, blah, blah. I offered her an apology and a $5 Gift Card for the inconvenience of having to wait an extra 10 minutes-though she was early. She ignored that and told me how, every time the other 3 pharmacies she uses make a mistake, they give her something without her even asking. How they buy her off just to shut her up, apparently. Not backing down, I apologized again. Now, 19 minutes into this conversation I had had enough. I interrupted her and asked "What do you want?" Taken aback, she said "Excuse me?" I told her "Listen. You have had me on the phone for 20 minutes now. I offered an apology and $5. You are not happy with that. In my experience there are only 2 types of people who call 1-800 numbers:         1.) Those who like a place and want it to improve and found something a little off during a recent visit.  2.) Those who want something.  This is you. Now. What. Do. You. Want? She told me she wanted a gift card. I told her I already offered that and she could pick up with her next refill, but not to yell at me or my staff again.  She has been back a number of times and no longer strikes fear in the hearts of my staff.  All it took was someone to stand up to her and call her out on her attitude.

Grouchy Guy refused to give my tech his wife's date of birth. He threw the Rx at her and told to fill it, he'd be around. I paged him back to the pharmacy and asked him why he was so mean. He said my job was just to fill it and he walked away. I shouted back to him to come back here, stuck out my arm with his script and said "Here. Take this. We're not filling this for you. There are plenty of pharmacies around and I don't need your business if you're going to treat my staff that way." Dumbfounded, he took it back and left. The funny follow-up is that his wife brought it back later and ignored the issue from earlier. Her husband has been back a few times and is always a model customer. Why did it take all of that to arrive at an amicable situation?

Why do we let customers abuse us? I love my technicians, for without them, I am nothing. At all of my stores, I have taken it upon myself to run interference between them and problem customers. My reasoning is simple and I have told many techs and customers this: They have a job to do. They don't get paid enough to get yelled at by you. Neither do I, but I can refuse to fill your prescription if I choose.  The only person who can yell at my techs is me.  I don't understand why other pharmacists won't stand up for their techs and themselves in these situations. We are still a profession. Doctors can discharge patients with a letter if they don't want them anymore. We have to do it face-to-face. What other profession gets yelled at as much as we do? What other profession rewards customers with the opportunity to call a 1-800 number for feedback that could impact that professional's career?
I elect to take a stand. I have a job to do. It does not involve getting yelled at for things that are way beyond my control. If you want to treat me that way, expect me to think that's how you prefer to be handled and I'll give it right back.

I believe...

This is the post where I lay it all out there.  It is titled "I Believe...A Cynical Pharmacist's Manifesto".

I Believe...

• in no more 3-day holdover supplies for patients.  You knew your bottle was getting empty. Learn some responsibility. If you filled a 30-day supply more than 30 days ago, too bad. Your car tells you when it's almost out of gas and you listen. Your bottle says "only 1 tablet left" so listen. 
• the State Board of Pharmacy should serve their pharmacists, not the public. They should not be out to get us, but should listen to our input.
• if you ever use more than one transfer coupon, you give up all right to sue if an error is made. Period.
• retail pharmacies need to get rid of 1-800 customer service numbers.  If I can't complain about a bad doctor or horrible patients, they can't complain about me and impact my bonus for doing my job.
• we need 1-800 customer service numbers to complain about doctors and patients.
• if doctors expect us to do their jobs (fax refill requests, look up profiles, run narcotic usage reports, remind patients of their appointments) then I should be able to bill the office and get paid as their employee.
• if doctors are going to tell patients how much something costs in my pharmacy, they should pay the difference every time they are wrong.
• if the FDA is truly worried about Acetaminophen toxicity and overdose, they would immediately stop all production of combination OTC products. (not change the packaging on Children's and Infant's Tylenol.)
• if look-alike, sound-alike names are so error-prone, the FDA would NOT allow generic names to be so similar, differentiated only by salt form (metoprolol, anyone?). They also would come to some agreement on the stupid letters: CD, LA, SR, XL, ER. (How am I supposed to fill this Rx, again "Buproprion 150mg 1qd"?  or Bupropion XR 150mg? 
• Pharmacy is way under-represented in our legislature. We cannot have a health care conversation without pharmacy.  The AMA and PBMs carry more weight than we do and dictate what we do. This should not be so. 
• the 6-month exclusivity on new generics is OK, as long as we call it what it really is: Patent Extension. The brand company owns the generic that gets those rights (i.e. Actos) and they don't even change the tablets.  It saves customers money, but it's a lie.
• the "customer is always right" is a terrible philosophy in pharmacy.  It would be akin to arguing a diagnosis with your doctor.
• awesome technicians make pharmacists awesome. Without them, we are nothing.
• manufacturer copay coupons are misprinted lies! They are more work for my techs, and misleading for customers who will immediately yell at us, not the manufacturer.
• with a new diet pill on the horizon, that trying to lose weight by taking a pill is like trying to get pregnant by just watching porn.
• in pharmacists as immunizers. But I also believe in at-will participation.
• if my Medicaid customer comes to my drive-thru with a better car, or to my counter on an iPhone, smokes, or appears to have more money than I do, she should be arrested, forced to hand over those possessions, and immediately removed from the welfare rolls, along with anyone who shares her blood.
• all Medicaid prescriptions should have copays. 
• the children are our future.  Teach them well and let them lead the way.

Predictive Refill Programs

I have never been a fan of the predictive refill programs that have taken over our profession.  Correction: The original concept was nice, but we have, as always, let the programs run away from us and now have to fight to get it right.  My problems are these: No one is happy even if they voluntarily enroll in the program and no one program is perfect.

If we call patients to tell them their refills are ready, they are bothered because they are not out of medication yet.  If we do not call a patient, they are bothered because they ran out and no one told them they were going to run out.

I believe the best fix for these programs is to employ the early refill narcotic patients as mentors.  These patients know the exact hour we can fill each of their narcotic prescriptions and usually call us daily and hourly for weeks up to the due date.  If we could simply embed a narcotic taker with a blood pressure taker, then everyone would know precisely when to pick up their prescriptions.  In fact, I would be willing to bet that the diabetics would become even more compliant with their own daily regimens and actually take/use their medications correctly.

No longer would we have to suffer the ignoramus who comes to our counter after 6pm on Friday and complains that his bottles of insulin are empty and he's been without it for 3 days and he's going to die if we don't just give him Lantus and Humalog right now.  Sorry.  If you're willing to bet your life on the first 3 days, I'm willing to bet your life over the weekend.  Let me introduce you to Mr. Percocets.  He's always prompt when his medication runs out.  He's your new flatmate until you can learn to accept personal responsibility for your own health and wellness.

The other issue with these programs is the amount of work involved. I actually believe we had fewer customer complaints prior to implementing these programs.  Under the early refill system, we fill prescriptions we're not even sure they're still taking.  Not only that, but the entire concept is based on strict patient compliance.  It assumes they are taking the medication exactly as prescribed, not missing doses, and keeping appointments.  We all know what happens next: Our computer calls the patient on days 3, 5, 7, 9, 11 (or according to some patients, never) and they don't come in for it.  On the 13th day, per insurance regulations, we put the medication back in stock.  Now we have to label this bottle with a lot # and expiration date because the State Board says we can't dump it back in the stock bottle and then we have to hope we can use it in the next 90 days (Ohio's law).  Then, on day 14 (or mere hours after we pulled the bag, reversed the claim, and returned it to stock) the patient comes in and wants to know why it isn't ready and why they have to wait another 20 minutes when it should have been done last week.  This is usually followed with "I got a call that said I had until yesterday to pick it up. Why isn't it done?"  I guess you ignored the first 4 phone calls you got, huh?  Now we have to put them back in line, pushing back the other people whose prescriptions we should be filling, and do everything for them a second time.  This one person made us do triple work, but we only get paid once.  Never mind the other costs that go into filling the script.  How is this more efficient?

What about the automatic doctor refill requests? Wasn't that part of the original plan too? The refills would pop into our system early, see the patient was out of refills, fax the doctor, the doctor would get back to us, the refill would be filled, the patient would come in having no idea all the work that went on behind the scenes, and walk out, happy and ignorant as a clam. Brilliant! Except it never works that way. The patient wanted it somewhere else, switched to mail order, hasn't been to the doctor in over two years so they deny the refill, then the patient's phone number is disconnected.

(Full disclosure: The only reason I have to favor the refill system is for out-of-stock or special order drugs.  I don't have to keep these items in stock or I get at least a day's notice I need to order extra of something just for you.)

It's become a stupid, busywork generating system that promised to save us time but seems to only create  more work. We even have to dedicate 1-2 tech hours a day solely on dealing with these old refills. I understand the need to generate more prescriptions as much as any pharmacist today, however, how much time are we really saving?