Wonky Labels

Nothing good comes after: "I wish to register a complaint. I need to speak to the manager".

Label Lady: Do you have new people working down there?
CP: Not really.
LL: Is that dashing manager there today?
CP: Nope. You're stuck with me. How may I help?
LL: My labels were all wrong.
CP: Sorry?
LL: They were on all weird. I save them and take them off and put them on other bottles and couldn't get these off and they ripped and they came out of the bag all weird and stuck together and I need to put them on another shelf up high where any kids who come in my house can't reach them and now they won't fit and I can't keep the labels to call in the refills and my system is all screwed up and...
CP: Breathe! Are the labels on the correct bottles?
LL: Yes.
CP: But you peel them off and put them on smaller bottles?
LL: Yes.
CP: So we labeled the giant stock bottles?
LL: Yes. But that other wonderful pharmacist has always taken of me. He always labels them perfectly and I have never had a problem in all my years coming there when he is working and carefully labels all my bottles. They come right off. I don't know what I'm going to do now. My whole system won't work.
CP: Ma'am, I can pretty much guarantee that he never personally labeled 93.2% of your bottles over the last many years you have been coming here.
LL: I've been coming there since we owned our house right across the street. Do you have interns there?
CP: Yes. We love having students.
LL: That must be it.
CP: Of course. Well they do have to learn somewhere. We can't teach them everything about the profession in little rotations. Surprisingly, this is the first time in my career that any patient has ever complained about how their labels were placed on their bottle.
LL: (laughing) Really?
CP: Yes. And that wasn't a compliment. Seriously. I am guessing what happened is that we normally tape the stock bottle before placing our labels. This way they will peel right off if we return them to stock. Since you always get these, or since we have students, this step may have been missed.
LL: I keep a folder of them and they ripped. What do I do now?
CP: Ask for smaller bottles?
LL: But I'll need like 10 of them for each medication. Can't you just put a note in my file about how I like them labeled?
CP: Sure. With over 500 prescriptions filled each day and over a dozen employees on the payroll, I'm sure we will always see the note about how you like each bottle labeled. As long as you get the right drug in the right bottle with the right label and there are no other issues, I am happy. How about you just call us ahead of time and we will see if we can accommodate your request with each refill?
LL: Well that awesome manager always takes of me.
CP: Yes. We like him too. From now on, call to ask if he is working when you need your refill. This way, we can guarantee that he will personally enter, fill, count, label, check, and bag each of your prescriptions.
LL: You can do that?
CP: No. But he'll get a kick out of that phone call.

Cutters

I know people suffer from terrible maladies. Cutting is a serious disorder that needs immediate attention.  After all, cutting is a true cry for attention.
Pharmacy is being overrun by cutters. With the new prescriptions being issued on full sheets of paper, people find them too bulky and cumbersome to simply fold. They feel an urge to cut.
The problem is prescribers prefer to put multiple prescriptions on one sheet. This is acceptable, as long as each has its own heading and signature.
But patients like to cut them.
And never at the obvious separation of the two; below the signature. The always cut the page directly in half. Why?
When the law requires for a prescription to be valid, the address and phone number of the prescriber on each prescription, lopping it off renders in invalid. Simple.
Despite repeated warnings to patients to not tamper with a legal document, we have habitual offenders. We need to stop coddling these patients. I know many out there will say something like "You're supposed to care for your patients", or "why can't you just call the prescriber", or "You're just a bitch!".

Right. How about the simpler alternative: The patient doesn't cut their prescriptions? Simple. It is the mollycoddling of patients and doing everything for them that brought our profession down to the dregs of healthcare. I understand no one likes to hear "no". Too bad.
When I explain to them, like a naughty puppy that they did something bad, they stare down. They stare at the counter with the look of shame of a child who got in trouble.
"Why did you cut your sister's hair?"
"I don't know."
"She made me do it."
"Nuh-uh!"

Yet they continue to do it. Why? Because we allow it. Just like everything else. No one can take advantage of you unless you allow it to happen. Is this petty? No.

Commissions

Businesses that pay based on commission annoy the crap out of me. I hate the feeling of being hounded/followed/watched/spied upon while trying to buy furniture or a car. I know how to shop. I know how to ask for help when I need it. Get away from me. I see you hiding behind the faux fern.

That being said, I think the next evolution in corporate pharmacy should come from paying bonuses on commission. They want us to push vaccinations and perform MTMs. I say pay us on commission. The more we do, the higher percentage we get. The more expensive the medicine, the higher our bonus. For the longest time, I was the only pharmacist who administered immunizations and pushed Zostavax in my area.

Corporations advertise the hell out of our services. Today, everyone offers the same services. The ads are on TV, radio, online, on the front door, on our phone answering system, on each cash register, in each aisle, our bags, and name badges and giant buttons on our smocks. What makes corporate think we can do a better job?

If you want me to do what our marketing department, which has a budget bigger than I do, cannot do then pay me. Simple. I will work harder to promote and score the big ticket items if there is some healthy competition to push me. Hell, get the patients in on it as well. Have them rush to the pharmacy and shout "Who wants to shoot me?!" Then they can watch us fight for the right to give the shots.

If we take this one step further, we could fight over who gets to fill the most expensive medications during the day.

Since we have already sold our souls to corporate, let's get rid of the rest of our dignity.

Secret Shoppers

Who came up with this idea? It's like getting your best friend to hit on your girlfriend to check her loyalty...or his. In this case it's not about trust. It's about being able to keep an eye on you from a remote location: to let them know Big Brother is always watching.
For those unfamiliar, here is the gist of the program: Regular people, or actual employees of a company, visit a company's stores and pretend to shop. They make some observations then send a report to corporate. Some of them actually buy things, but they are testing you.
They ask questions.
They check on your wait times.
They check to see if you walk out and put products in their hands.
They check to see if you ask them questions.
They check to see if your smock is clean.
They check to see if your name badge is on it.
I think they get close enough for breath checks.

The problem I have with this is not that I have to assist my patients. I developed that habit a long time ago in a galaxy far, far away known as my internship. It's the mark of a great pharmacist.
My problem with this culture of fear is that I am wasting my time not doing my job.

There are patients who walk directly to my counter and ask where something is. It is immediately behind them. It is in a shiny box with neon lights and a speaker that announces its presence. Rather than point it out to them, I must walk around and put in in their hands.
And here is what will happen: I will rush to finish your prescription. I will walk away from it. I will come back to it and forget where I was. Then I may miss something.

I try to provide "excellent patient service" when companies want "customer service". I think these types of programs have lead to a "factory of fear" mentality. Instead of being allowed to do our jobs, we live in fear of "THEM"; "They-who-shall-not-be-named"; "The Corporations".

I find it rather ironic that the companies put in place workflow designs and computer systems to prevent errors, but continue to open their pharmacies and pharmacists to more and more distractions.

Why You're in Line So Long

I'm popular. It's all about pop-u-lar. It's not about aptitude, it's the way you're viewed. So it's very shrewd to be very very popular, like me.
Being popular comes with side effects though. Since everyone wants a piece of me, you have to wait your turn. Whether it's asking a question, phoning in a prescription, or needing to be counseled, others are seeking my wisdom as well. You must be patient. There is only one of me. It's like going to the Vatican and hoping to high-five the pope.

But today is not about me. It's about my pharmacy. Many people understand having to wait to talk to the pharmacist. What they don't understand is #WhyItTakesSoLongToPickUpYourPrescription at the pharmacy. People wait in lines for seats at popular restaurants. They even wait weeks for reservations. Why? Because they are popular...and very good. So are we.

Every patient is entitled to the same treatment: you have the right to ask questions of the pharmacist. If you do this at the drive-thru or in line, it may take longer. But what else is to blame?

CP: May I help you?

The Patient In Front Of You:
I'm picking up for myself and I don't have my Fan Club Rewards Card so can you look it up so I can get my free pack of gum and I have to write a check but don't have a pen and didn't fill any of this out while I was in line so can I borrow yours and I need to buy these extra couple items which may or may not go on my Flex Spend Card so you'll have to let me know so I know how much the check is for but I also want to pay cash for the magazine I was reading in line and I have new insurance you need to bill but I don't have the card and it should be under one of my kids but I don't know which one it was and can you check to see if I also have anything for my husband, my goat, my neighbour, or my first grade teacher and no, I don't know any of their dates of birth but can you look them up or can I borrow your phone to call them because they come here all the time and asked me to check and those would be separate transactions because I'm not paying for their stuff too and I know the one thing needs mixed so can I ask the pharmacist a question while he's mixing it because they changed my medication and I'm not sure if I'm supposed to take both or just stop the one and start the other and I think I forgot to have something else refilled and of course I don't have the bottle with me but can you just look it up for me and refill it and maybe I'll wait for it or come back in a few minutes if it's no trouble and I think I need the pink one too while you're filling the white one for my heart or stomach or whatever it is but I know for sure that I just filled it last month because I just ran out, unless that was the one from last year and I think it stars with a "Q" or a "B" but it's not the blue one and my doctor took me off that other one so can you cancel the refills on that because I had horrible dreams with that one that my mouth stopped working one day and could you imagine how difficult that would be for me if that happened?

CP: I'm trying.

Abbreviations

It is beyond time to do away with Latin and shorthand when it comes to prescription writing. Hand-written prescriptions are the worst since many prescribers drop periods and cross random letters with such careless disregard that we cannot decipher q.i.d. from q.d. from b.i.d. from t.i.d., let alone the abbreviations unique to the prescriber himself. It's also difficult when prescribers make a 4 look like a 6 which sometimes looks like an 8. With e-scripts, it is easier to read, but typing out the frequency is much safer and leaves no question.

Let's petition to have all shorthand removed from prescription orders.
No more abbreviations. There is no standard among healthcare professionals.
In veterinary medicine, S.I.D. means "once a day".
It does not exist anywhere else and this can confuse pharmacists who are not used to seeing it. (It may also be misread.)

One I have been seeing too much of lately is "SX". I learned it as "Symptoms". Some prescribers use it to mean "Surgery" and it can also mean "Sex", though I'm not sure why that needs abbreviated...
It's a little strange to see a prescription that reads "begin 3 days prior to SX" and question whether the patient can anticipate symptoms or sex or is having surgery.

No more Roman Numerals. Many prescribers never figured out any number beyond X=Ten anyway which results in prescriptions for 40 looking like this: XXXX. Wrong.
In some states, quantities on controls must be written numerically AND spelled. We have many prescribers who like to write it like this: X (10). So not compliant with the law. While X is indeed a letter, it is not a spelling of "TEN".

I realize we are in a transition period between full electronic prescribing and handwritten orders. I realize many prescribers are old school and have been prescribing this way for decades. It doesn't make it right. It doesn't mean it's safe. With the volume of prescriptions we see today, this is probably the easiest step we can take to ensure safety and accuracy in patients' prescriptions.

I tell my patients to look at their handwritten orders before they leave the office. If they can't read them, what are the odds I can?

Then there are the abbreviations that look okay until read aloud.

The Long and Winding Road

K.eep
I.t
S.imple
S.tupid

There are companies that do workflow studies. They observe your operations and note where you can save time, money, energy, and aggravation.
I try to do this myself. Yesterday's example is how NOT to save time.

We faxed a prior auth request to a prescriber.
A couple hours later I get this voicemail.

Random Office Lady: We received a fax for a prior auth from you. The name got cut off but I have the date of birth. Can you refax it to us so we can read the name. It looks like it was a problem on your end. But the name got cut off and we can't read it. Here's our phone number in case you have any questions.

She did not tell me her name. She did not tell me the office name. Only a date of birth and their phone number. That is less information than she received on my fax.

CP: Here's a question for you. Why the hell couldn't you have pressed the option for "Speak to Pharmacist"? or "Prescriber's Office"? Simple. Ask for the pharmacist, get the name, write the name on the paper, start the prior auth process. If you need another copy, ASK for it while you have me on the phone. Perhaps I should leave a voicemail with just the patient's name. You already called my phone number.

That's like the out-of-town office that used to have their ROL call us. We'd answer and they'd hurriedly say "doctor has a prescription and you need to call him back". They didn't want to pay for long distance. YOU ALREADY HAVE ME ON THE PHONE!

The New Answer

Ruminating as I do, I developed a few ideas that should be presented to all 50 State Boards of Pharmacy and all professional organizations, national and state.
The first I shall present today. Pharmacies need to be removed from businesses where the pharmacy is not responsible for at least 50% of the business. It cannot be a loss leader. It cannot occupy space as a  department in a big box retailer. If we are going to reestablish ourselves as a serious profession, we have to take ourselves seriously. It's like the food court in a mall. You move from Chinese to Dairy Queen to Indian to McDonald's to Pretzels to Cookies. In a big retail store you move from Automotive to Gardening to Pharmacy to Baby Clothes to Electronics. I believe we should move to smaller-sized pharmacies. Stand-alone stores, if you will.
I know, "where will we put them? how will this work? is it feasible? what about robberies?". I get it. That's not the point. Logistics can be worked out later. Pharmacies need to be more independent. The big chains offer somewhat acceptable business models. The other locations, including grocery stores and discount clubs, have no business in pharmacy. We, as a profession, need to dictate how our profession is sold to the public. The only way around the 50% or grocery/club exclusion is if they agree to establish pharmacies according to the business model laid out below.
All hospitals that are built or being renovated in any way must have a separate outpatient pharmacy attached if they currently do not provide one. All of those doctor parks, where multiple offices are squished into a big building or spread over a large area, must include a pharmacy or two on property.

Pharmacies have no business being in retail business. What if we set them up like doctors' offices? We would have a receptionist sitting behind a glass window who greets you. She is your only access point to the pharmacy. She asks you to fill out forms to verify all your information is correct. You sign a permission slip allowing us to bill your insurance and "treat" you today. You will also sign that, should any issues with billing occur, you will be notified/paged/texted and asked to contact them. We would offer free wi-fi and some courtesy phones for you if you wanted to contact them right away. Upon successful billing and filling of your prescriptions, a pharmacist would be waiting for you at a counseling window. She would take the time to go over everything with you. Upon completion of this fully billable service, you would proceed to the checkout window where you pay your copays before exiting our office.

We could set up different offices within so our pharmacists could perform different tasks throughout the day including medication verifications, DUR checks, taking doctor calls, making doctor calls, prior authorizations, immunizations, etc. We would have an office of specialists at your disposal. Once you enter a room, you are being billed for their knowledge and services. We would remove the fast-food mentality and retail experience from the sullied reputation of our profession and get back to what we really are supposed to be: Professional Pharmacists.