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Monday, March 26, 2018

levo-thy-ROXANNE

Change the pronunciation, hear it the same phrom now on, you will.

levo-thy-ROXANNE
With you now my phuture is more bright
Not hypothyroid
You can make all my thyroid levels just right

levo-thy-ROXANNE
Now I'm not tired and my head's right
No more hypothyroid
You fixed my symptoms and now I'm all right

levo-thy-ROXANNE
With you now my phuture is more bright
levo-thy-ROXANNE
With you now my phuture is more bright

levo-thy-ROXANNE (phuture is more bright)
levo-thy-ROXANNE (phuture is more bright)
levo-thy-ROXANNE (phuture is more bright)
levo-thy-ROXANNE (phuture is more bright)
levo-thy-ROXANNE (phuture is more bright)
Rox-

I knew I really felt bad
I felt so cold and so sad
Gained some weight and then fatigue set in
You make me weak when I don't have you

My hair and skin and nails
Their care it always fails
Need your T, I won't ask you again
It's a bad day

levo-thy-ROXANNE
With you now my phuture is more bright
levo-thy-ROXANNE
With you now my phuture is more bright

levo-thy-ROXANNE (with you now my phuture is more bright)
levo-thy-ROXANNE (phuture is more bright)
levo-thy-ROXANNE (phuture is more bright)
levo-thy-ROXANNE (phuture is more bright)
levo-thy-ROXANNE (phuture is more bright)
levo-thy-ROXANNE (phuture is more bright)
levo-thy-ROXANNE (phuture is more bright)
levo-thy-ROXANNE (phuture is more bright)


Friday, March 16, 2018

Semantics

This is where we are.
This is what we have become.
We are a slave to the system.
We are its whores.
We ask "What is thy bidding my master?"
Worse, we are afraid.

When I was an intern, I typed "Inhale 2 sprays in each nostril once a day" as the directions phor Phlonase Nasal Spray.
My Pharmacist Of The Day: You need to fix that.
Padawan CP: Why?
MPOTD: You can't inhale through your nose.
PCP: Come again?
MPOTD: You can only inhale through your mouth.
PCP: Wanna bet?
MPOTD: You only inhale through your mouth.
PCP: You repeating that will not make it true. I bet if I came over there and covered your mouth you'd inhale pretty sharply through your nose. Shall I?
(I was definitely on the path to the Dark Side early in my career.)

Which brings me to this.
Inhale: (verb) Breathe in (air, gas, smoke, etc)
Breathe: (verb) Take air into the lungs and then expel it, especially as a regular physiological process. (The second example sentence is 'breathe in through your nose'.)

But that's not why we are here.
When I started, and until quite recently, oral inhalers would be dispensed with directions as phollows:
"Inhale 2 puffs by mouth every 4 to 6 hours as needed" or
"Inhale 2 puffs by mouth once a day" or whatever the medicine required.

Today, with e-scripts, corporate pharmacy protocols, phear of lawsuits, and new pharmacists being trained to NOT think for themselves, we have to deal with this instead:

"Inhale 2 puffs into the lungs every 4 to 6 hours as needed."

I don't like it. Is there anything wrong with it? Sure. It doesn't say "by mouth" which means they CAN inhale it through their nose.
Phine, what about: "Inhale 2 puffs by mouth into the lungs every 4 to 6 hours"?
Really? Stupid and redundant.
Yet this is what is happening.
If the e-script says it, people are being trained to type it verbatim.
Our job is and has always been to make the directions clear to the general public (read: lowest common denominator). The more you add to something, especially directions, the more complicated it can become.

It's like "swallow your food into your stomach". Where else can it go?

In order to get ahead of the curve, I am going to change all directions phor solid and liquid oral dosage forms to this:
"Take 1 capsule / tablet / teaspoonful by mouth and swallow into the stomach 2 times a day".

#PhightThePower
#BreatheDeepTheGatheringGloom

Alexa? Siri? Anyone?

In the (not-too)-distant phuture, I see the next evolution of healthcare.
Just this week I received the prescription posted that included these lines in the directions: "Instructions to pharmacist. Please clarify directions. They are not clear."
No shit they're not clear. For centuries our job has been to make it clear. Whether to keep patients from harming themselves or their prescribers from killing them, that has been our job.

Later in the week I received a note phrom a pharmacist where an office called asking how to prescribe a medication. They wanted to know how to use (why to prescribe it), how to administer it, and for what duration therapy should continue. When the office staff said she'd "just google how to use it", the pharmacist provided adequate support, but was surprised by the dearth of knowledge. If you do not know HOW to prescribe a medication, why are you prescribing it?

It the (not-too)-distant past, prescribers researched. They went to libraries and called Drug Information Services at hospitals. Now they are calling retail pharmacists about new drugs.
(Carefully, CP walks the line of "we are drug experts so people SHOULD call us" and "this is a new expectation an office staff member has because her prescriber said research it".) Should we know? Many things we do. But even the greatest among us do not know all there is to know about everything, especially when it comes to new, specialty medications. Can I research it for you? Sure. But it is going to take some time.

As phor that not-too-distant phuture prediction?

I see an Amazon Echo in every office and Echo Dots in every room.
Nurse: "Alexa, what's a good blood pressure?"
Dr. Zoffis: "Nurse, I want a Z-Pak. You finish inputting the prescription."
Nurse: "Alexa, What dose should I give? How long do I give a Z-Pak?"
Dr. Zoffis: "Alexa, when I don't know what's wrong, is it ok to just give a Z-Pak and Tamiflu?"
Nurse: "Alexa. . . If I'm out of Vitamin B-12, can I just give a double dose of B-6?"
Nurse: "Alexa, what does asystole sound like?"

Of course this is likely what would happen:
ALEXA: "I don't know. Google it."



Friday, March 2, 2018

Pharmacists vs. Doctors, IV

As more and more professionals are responsible for prescribing, more and more professionals are responsible for irritating me.
As more and more professionals delegate more authority in their offices, more and more items fall further and further down the priority line.
As rapidly as technology advances, it seems our ability to develop social mores regresses or fails to advance as quickly.
If you are going to use the technology, please understand how it works.
If you are going to employ different types of technology, be sure you are using them correctly and in the correct circumstances.

If I call you, I expect you to call me.
If you need to reach me right now, speak to me.
(Translation: Do not leave me a voicemail.)

If you send an email in error, what is the worst that could happen?
I suppose the recipient(s) could read the email.
But, what if your email alarmed the recipient(s) and they took actions that resulted in harm to themselves or others?
If you just "delete it" from your screen, does that make all trace of its existence disappear?
Does it "unsend" itself and automatically erase itself from the minds of those who have seen it?
What if you realised your error and wished to recall it?
How do you recall it?
Do you send another email?
What does it say?
"Sorry. JK. lol."?
Do you leave a voicemail?
Send a fax?
Smoke signals?

Sounds silly, right?
No way that could happen. (Who uses smoke signals anymore? And the final telegram was transmitted July 14th, 2013.)
Except that it does. All day, every day.
Where, you ask?
In your local pharmacy.
Prescribers love to send electronic prescriptions but they have a difficult time knowing what to do when they are sent mistakenly, incorrectly, in error. This is where the delegation issue comes into play. If it's wrong and you know it, call me. Now. (Translation: Ixnay on the OicemailVay, comprende?)

I cannot tell you the number of times I have had this conversation:
CP: I have a question phor you.
Dr. Zoffis: What now?
CP: Which strength/medication/directions did you want our patient to receive?
Dr. Zoffis: Why?
CP: Well, you sent me a prescription this morning, which the patient purchased, and now I have a new prescription that seems to contradict the first.
Dr. Zoffis:
     Answer A: We left a voicemail to cancel the first one an hour ago.
     Answer B: Well since we sent this one it must be the right one.
     Answer C: Yeah, the doctor canceled the first one in our system.
CP: Let me be clear: That's not how it works. Simple, yet somehow confusing to offices everywhere. If you were to have handwritten the prescription and chose to cancel it, how would you have handled it? Would you have mailed a new hard copy to the patient? That's effectively what you're doing here. The patient could already have filled and started taking the medication by the time the new order arrives. This is what happens when you choose to cancel electronic orders via any means other than a live chat with the pharmacist. No. Counseling does not always catch your mistake because, like today, the patient's niece's boyfriend's Uber driver came in to pick up the prescription and knew nothing about a change in therapy. Your note on the new prescription to "cancel previous" is rather vague and will now be attached to every single prescription you send for the next two years.
Dr. Zoffis: Well, it's canceled in our system.
CP: Ok. I know it's tough to understand how technology works when you simply stare at your phone to get cat videos and your friends' photos of the birthday parties they held for their pets but your patients' lives are at stake. You know what's funny? I take the time to thank prescribers and their staff who call me directly to cancel prescriptions in error. They are surprised to learn they are in the minority.
Dr. Zoffis: So, what do you want from us?
CP: In the immortal words of Blondie, "Call Me". And since your patient left with your initial, incorrect prescription, you get to call him and tell him.
Dr. Zoffis: Um, We don't do confrontation here.
CP: Phine. I will call him, give the copies of both prescriptions, the documentation phrom our conversation, and send him to your office. What time y'all close?

Thursday, March 1, 2018

Why Are You Still Arguing With Me?

. . . Better yet, why am I still involved in this conversation?

CP: Thanks phor visiting CP's Pill Palace, How may I phrustrate you today?
Not Understanding This: I was here yesterday for my wife's medication.
CP: I remember. I mentioned that her eye drops were ready.
NUT: Yes. I am also looking phor a pill.
CP: Ok. They called it in yesterday.
NUT: Right. Where is it?
CP: It was too soon. I put it on file. We mentioned this yesterday.
NUT: Oh. What is it?
CP: Valtrex.
NUT: No. That's not it.
CP: Yes. Yes, it is. I typed it myself.
NUT: No. It's something else.
CP: Is it phrom the same prescriber who wrote the eye drops?
NUT: Yes.
CP: What are we treating?
NUT: Shingles on her face and eye.
CP: That explains the Valtrex. We just filled a month supply last week.
NUT: Well, I don't know what it is, but that's not it.
CP: Well, if you said it is phrom the same prescriber who wrote the eye drops and it is to treat her shingles, and you were expecting 2 medications, one of which is a drop and one is a pill, and you don't know what it is, then I don't know what other answer I can give you. Call the prescriber?
NUT: I did. They said they called it in.
CP: Did they mention the name? Or what is was phor?
NUT: I don't remember.
CP: <waves hand> These ARE the drugs you are looking phor.
NUT: These ARE the drugs I am looking phor.
CP: <waves hand> Have a nice day.
NUT: Have a nice day.
Uber-Intern: Why didn't you just use your Jedi mind trick earlier?
CP: I just wanted to see how long I could play this out until I got bored.
UI: We're not that slow today.
CP: But he's really nice so I was hoping he'd come around sooner.
UI: You must teach me the ways, Master CP.
CP: Much to learn, you have. Much to learn. . .

Monday, February 26, 2018

Pharmers Only

Pharmacies are constantly trying to come up with ways to make patients' visits more enjoyable. Instead of phocusing solely on prescriptions, they are offering new services. 
Introducing: "Pharmers Only", an in-store dating app that will provide matches while you wait.  

How does it work? 
Upon enrolling in the service, you will upload a list of your current medications and the desired medication profile of your potential partner. Every time you get a new prescription, an alert is sent to other patients who received medications on your "prepherred list". Both of you will be given similar pickup windows. It's called the "Kismet" pheature. 

What if I am already in the store? 
The app will ping you and a potential match alerting you there is a #PharmMatch nearby. It's the  matches-while-you-wait pheature. We expect it to be the most popular use of our app. 

What if I only take maintenance medications? 
This is the easiest use of our system. Simply review patients based solely on their medication profiles and our system will synchronize your refills with the match(es) you have selected for that month. 

Can I select certain medications to exclude matches? 
Yes. If your medications may produce an interaction with a potential match's profile, you can exclude those. 

What if I'm thinking a little more superficial? 
<sighs> Yes. You can exclude all profiles that have filled Valtrex, Denavir, or Zovirax in the past. Happy? 

Can I select certain profiles based on one medication? 
Dude. No. You cannot select "Birth Control" as the only criterion. 

Can you supply some of your lame pharmacy pickup lines to help break the ice? 
Of course. But you have to choose wisely. 

1. "I'm easily administered, like Lactulose. I can be taken orally or rectally."
2. "Single this Valentine's Day? Come to the pharmacy where we can treat your VD . . . blues."
3. "Call me Proair because you can use me every 4 hours as needed."
4. "You must be a 5-alpha reductase inhibitor because that is one Finasteride."
5. "You can always get it over the counter at the pharmacy. Just ask."
6. "Pharmacists come in prescribed doses."
7. "Are you here to pick up a bottle of insulin because you are extra sweet."
8. "I need to keep Amiodarone on hand because every time I see you, my heart skips a beat."
9. "A pharmacist's love is like Nystatin Suspension-you have to swish before you swallow."
10. "If you're looking for a short-term fling, I've got just this thing. Call me Medrol and I'll be all over you the first day before slowly slipping away."

Wednesday, February 21, 2018

Beggars Can't Be Choosers

. . . unless they are pharmacy patients. Then all bets are off and you'd better phind a solution.
Even then. . . 

Backorders happen. 
Any number of things may cause them. From weather (see Hurricane Maria in Puerto Rico) to bombings of factories, from an interruption in the supply chain to a shortage of raw ingredients to greedy manufacturers, there have been many reasons for shortages in my #PharmLife. Yet no explanation has been able to mollify every member of the public. Phor some reason we, a most trusted profession, are either lying to them, hoarding it all phor ourselves, or really bad at ordering and should be phired. 
Then, once you have convinced them you have not been lying for the last 6 months and offer them an alternative, they get angrier. 
Sometimes, the customer is just an ass. 

CP: Thanks for calling CP's Drug Emporium. How may I phail to meet your unreasonable standards today? 
Getting Really Upset at My Pharmacy Yet Again: I was told to call ahead so you don't mess up my life-saving blood pressure prescription. 
CP: Cut right to the chase, do we? I like that. 
GRUMPY-A: I need a specific manufacturer of my medication. If you don't have it, I shall have to go somewhere else. I want to know before I call my doctor.  
CP: Of the 25mg tablets, I currently have Teva. 
GRUMPY-A: Of course. That is one of the ones I cannot take. 
CP: As you are fully aware, because you always ask phor me when calling, this medication has been on backorder phor the better part of 6 months. I am quite phortunate today to have even the phew phrom Teva on my shelf. 
GRUMPY-A: I guess I'll just have to call around and see who has it. No one else seems to have it either. 
CP: Well, backorders tend to phornicate with pharmacy inventories nationwide. It's not exclusive to our little hamlet. 
GRUMPY-A: What else can I do? 
CP: Can you take the Mylan brand? 
GRUMPY-A: That is the only one I can take. Why? 
CP: I have the Mylan brand in 50mg. They are scored, but you'd have to split them. 
GRUMPY-A: <flabbergasted and appalled> But then I'd have to CUT THEM!!!
CP: Good to know you're phollowing. It's now up to you to determine which is the less inconvenient option. Do you want to continue combing the desert phor the needle-in-the-haystack or do you want to split 15 tablets in half with a tablet cutter while dreaming up new ways to annoy me with all the phree time you'll have now that you're not calling around? 
GRUMPY-A: I'll have to think about it. 
CP: Of course. Can't be too hasty when it comes your "life-saving blood pressure medication". 

"Now I got the gun you got the brew
You got two choices of what you can do
It's not a tough decision as you can see
I can blow you away or you can ride with me"


Monday, February 19, 2018

Shift The Blame - If The Real World Worked. . .

I went to the grocery store.
I had a list.
I was supposed to buy coffee and creamer.
That's it. Two items.
I came home with the coffee and forgot the creamer.
If this were my pharmacy, I would call the grocery store, yell at the manager that they were responsible for my forgetting the 2nd item on my list, demand a gift card for my troubles, and ruin their day.
This is not the real world, but it is my pharmacy:

Forgetful Lady Yelling: I came down to the pharmacy to pick up two items and you gave me one.
CP: Shouldn't you have noticed when I handed you one item?
FLY: That's not the point.
CP: Okay. What are you missing?
FLY: How am I supposed to know?
CP: Well they are your prescriptions and as there were only supposed to be two of them . . .
FLY: I threw the bottles away as soon as I called them in to you.
CP: And the instant they hit the bottom of your waste receptacle, you forgot what you were taking? What you were taking every single day?
FLY: Yes.
CP: I really hope I can forget this conversation that quickly.
FLY: What's the point of calling them in to you if I have to remember what I take?
CP: Okay. Look at your bottles. Stare at them. Is there something missing?
FLY: Yes. My stomach pill.
CP: Okay. It looks like I . . .
FLY: . . . and my cholesterol one, and my memory one, and my one for memory, and my blood thinner.
CP: Okay. That's 4 more. You said you were missing one of the two you called in earlier.
FLY: Now that I look at it, I only have that one.
CP: Well I have to get all of these ready.
FLY: You mean I have to come back?
CP: You don't have to come back. No. There are plenty of options for people when they forget to call in or leave with all of their medications.
FLY: Such as?
CP: You could just stop taking everything. It is the most convenient option but I'd advise against that. You could transfer everything to another pharmacy and go there instead of coming back here. Maybe they won't forget you're forgetting something. You could send someone else in your stead? That way you could continue checking for any other medications we may have forgotten you were needing.