How to Make Money in Pharmacy Without Really Trying

I like making money.  For the last decade at least this has not been a problem.  With an over-saturated market of licensed pharmacists and lower reimbursement rates from PBM's and state and local governments, retail pharmacy needs to find ways to make more money.


I realized that a lot of people take credit for things they already do.  They also have figured out how to charge for these things that they used to do for free.  For example, airlines used to fly your bags for free.  The space was empty anyway and you were seated just above them headed, most of the time, to the same destination.  When they realized they needed more money, they started charging for the bags to tag along.  


How can this translate to the world of retail pharmacy you ask?  It's called " a la carte pricing".  It sounds better than fee-for-service but hear me out on this.  If doctors require us to fax them for refills and look up prescription information even though they have a chart in their office, I am going to charge them for these services.  I know.  This was in the last few blog entries but this is where it gets good.  The examples will look something like this:


     Patient is Responsible for:

•      Handwritten Rx's--------------------$2.00 each
•      Rx Too Old---------------------------$1.00

     Offices Responsible for:


     If we have to call your doctor because information in missing or incomplete:

•           Wrong/Missing patient name----------------$3.00
•           Missing drug or strength---------------------$3.00
•           Illegible/Missing Directions----------------$5.00
•           Quantity missing----------------------------$2.00
•           Refills Unclear-----------------------------$0.50
•           Not Signed--------------------------------$25.00
•           Forgot to select anything on a preprinted Rx where all he has to do is check a box----------------------------------------------------$15.00
•           All Refill Requests you Require me to fax---$1.77
•           Looking up Refills you are Calling in to me-$8.23

     Computer-Generated or Faxed Prescriptions--Flat fee of $11.38 per occurrence

•           Wrong patient
•           Quantity (N/A)
•           Drug/Directions Mismatch (take 5 mg tab intravenously)

All prescriptions are required to be completed electronically and either sent electronically or faxed according to state and federal laws.  They may be issued to a patient directly, but please do not forget to sign them as per your state law.  Phone-in prescriptions will be free, for now.  The exception to this is offices that employ nurses who have an ADD-type disorder and omit information regularly in which case the above prices will go into effect.  Also, if your nurse does double-duty as a Micro Machines pitchman or commercial legal representative on TV or radio ads and I can't understand a damn word she says, please read the pricing chart above.  


Since we are already performing this task, we might as well get our piece of the pie too, right?  Insurances can't complain about this since it doesn't affect their bottom lines.  What are doctors going to say?  Let's think about this.  
     1. I don't like you charging me for forgetting to sign my name.  I'm a doctor!
     2. I don't like you charging me for always entering N/A on the quantity line when it should auto-compute.  I'm a doctor you know!
     3. It's not my fault you can't read the Prednisone taper I clearly wrote, even though it doesn't say for how many days and the quantity is "QS". I always write it that way.
     4. It's not my fault the computer put Oxybutynin ER first and I wanted the regular.  You should just know that because it's cheaper.  


It may seem petty, but how long have we given away our professional services?  We have automatic refill systems, auto-faxing to doctors for refills (which used to be a courtesy), and reminder calls to fill and pick up your prescriptions.  How much else are we willing to give away for free?  
This is not anything more than an attempt to be compensated for our time and energy.  This is time and energy that have to be redirected to fix something that never should have left your office in its current condition.  
    

Pharmacist vs. Doctors, the 3rd

And another thing...If you, Dr. Zoffis, are calling me, Herr Pharmacynic, to authorize refills, confirm prior authroization approval, give new prescriptions, or do any other professional work, please be prepared.  Let us remember the healthcare cycle: patient goes to doctor, doctor writes prescription, patient brings Rx to pharmacy, pharmacist fills Rx.  When refills are done, we go back to the beginning.  This means everything starts with you.  The doctor.  Lather, rinse, repeat.  


I implore you, as a former Scout, Be prepared!  Again, I do not work in your office but if you expect me to do your work I am going to have to charge you every time I have to have this conversation:


     Nurse: Calling in to refill a patient's prescription.
     ME: OK
     Nurse: They didn't give me their prescription number but it's for HCTZ.
     ME: OK. What strength?
     Nurse: Can't you just look it up?
     ME: Yes.  But can't you just look it up?
     Nurse: I don't have the chart but it's the same as before.
     ME: Correct me if I am wrong (and I rarely am) but did you not originally prescribe this medication?  And did you not put it in a chart? And if you knew you were going to call me (because I didn't know you were going to make me do your job too before you dialed my numbers) how did you not know I would need all of this information?  If you knew to call me for his refill then you knew you were going to do this to me.  Therefore, I am going to send you a bill for looking up each piece of information you don't have.  How do you know he even (still?) takes HCTZ?  How do you know the doctor didn't change it since the last visit?  Does he get 30 days or 90 days?  Is this even the right pharmacy?  What's his date of birth?  Help me!  Then pay me!
     

Pharmacist vs. Doctor II

Pharmacist.  Magician.  Receptionist.  Thinker.  I can do it all.  Just ask every customer who tried in vain (allegedly) to reach their doctor.  Why does everyone think we can work through to their doctor faster?  


     Patient: "You need to call my doctor because I can't get through."
     Pharmacynic: "Wow.  Neither can I.  I have to call the same phone number you do.  Did you hear the magic 'pharmacists press now to have all your questions answered' prompt?"
     (Im)patient: "Well what am I supposed to do now?  You need to help me!"
     Pharmacynic: "Okay. Revolutionary thought here but bear with me.  Drive. To. Your. Doctor.  Ta-da!


I think all offices should have a dedicated Pharmacist option on their phone lines.  We have an option for doctors to leave voicemails but the most we usually get in return is a refill line.  That doesn't help if I couldn't read a prescription for someone who just left your office and is here now.  It doesn't help with any questions about interactions or answer any questions I have about the voicemail your nurse left just seconds ago.  She is apparently charged for each second she spends on the phone and can't afford to enunciate or spell anything and now I can't get her back on the phone to answer my question.  


Most doctors' lines include options for other doctors or hospitals, for making or canceling appointments, for lab work, for billing questions, a refill line (if they don't require us to fax them), a worker's compensation option, and an option to give hours, services and directions.  Why don't we rank?  If we are expected communicate frequently with these offices, we need a pharmacist-only line.  I have asked some offices if they have back lines and have occasionally been granted these numbers, but only after swearing to not share it with anyone.  Right.  There's a whole black market looking to exploit doctor's private office numbers.  


Make it easier for me to get my job done and your life will be easier as well.  Since you are already expecting me to fax all refill requests and look up the refills you are calling in to me when you have their chart, it's the least you could do.  

Pharmacist vs. Doctor

In the beginning there was a doctor.  He wrote prescriptions.  There was also a pharmacist. He filled prescriptions.  And the world was good.  I am not a doctor, nor do I play one at work.  However, it seems that we as pharmacists have let the lines blur a little too much in what is each person's role in the whole healthcare dynamic.  One of my favourite quotes to customers is "I don't work in your doctor's office and he doesn't work in my pharmacy".  I often use this to great effect after a customer is sent directly over from his doctor after being told any or all of the following: "your prescription will be ready by the time you get there", or "it's on their $4 list", or "Augmentin is only a few dollars, don't worry".  Well, I can't tell you the last time I saw your doctor here, let alone actually spoke directly with him, so don't believe everything he tells you.  


Today I realized it has gotten so out of hand that we pharmacists haven't even noticed we are now employed by every doctor in town.  While waiting interminably on hold (pharmacy hold times aren't always better, I concede), to clarify a poorly written prescription, I heard this message: "We are requesting that all refills be faxed.  Please contact your pharmacy and they will fax us for you".  Another office used the similar "please notify your pharmacy to send a fax to us".  


Excuse me?  What?  When did we allow other people to tell us what our job is? (Oh yeah, when we sold out to mail order and PBM's over the last 10-15 years.  But this is different.) 


Anyway, I have decided that I need paid.  If the doctor requires I fax your refills to her, I am going to send her a bill at the end of each month for every one that I send.   Yes, most faxes are generated electronically but I still have to answer your phone call after you have already talked to the office.  Since the doctors would like to place the onus on us if a refill is not authorized, I would like to be compensated for this responsibility.  We all know that faxes do not get received, doctors ignore them, lose them, forget to sign them, etc.  As I have mentioned before, I cannot fill prescriptions I do not have.  The patients know we are the only ones they can yell at directly and therefore, since the doctor requires we fax them, we must be the most culpable if the process breaks down somewhere.  If the fax number is incorrect or missing or a doctor enters or leaves the practice, I have to track this down for you.  A precedent has already been set in other similar situations.  Doctors requiring pharmacists do NOT send faxes will charge the pharmacy for each one they receive.  Doctors also charge patients a full copay for any refills they require outside of an office visit.  


To further support this, my second resolution is to post on my hold message the following script: "Our pharmacy requires that all new, paper prescriptions be sent electronically or faxed.  Please contact your doctor and ask her to invest in this new technology and to stop hand writing prescriptions as we will no longer accept these."    Perhaps we should charge to fill illegible scratch.  I may be on to something here.  But that's another story.

The Future of Pharmacy

Brothers and Sisters in Pharmacy-Dom, please allow me to show you the future.  Thank you all for being here today.  Prepare to be amazed, dazzled, awestruck, and even a little weepy.  Over the next few paragraphs I shall outline for you the business model that will revolutionize pharmacy practice as we know it.

Having spent a few years in practice and devoting my life to studying the practice of pharmacy, the general public, and the evolution of our customers from thoughtful, reverent patrons to resentful, demanding, impatient douchebags (sorry, "guests"), I have arrived at the following plan for us all.  I call it "Pharmacy As Total Healthcare (P.A.T.H.)" Licensing agreements will be available to all levels of government.

The Basic Plan:  For a regular monthly fee assessed to the patient, we will perform all of the following:

1. Schedule you doctor's appointments for you.
2. Go to your scheduled appointments FOR you.
3. Get your prescriptions from these appointments for you.
4. Take these prescriptions to your pharmacist (me).
5. Fill all of your prescriptions for you.

     As of today, refills will NOT be allowed under this plan.  We will repeat this process on a monthly basis upon collection of the monthly fee.  If you agree to pay the entire year up front on January 1st of each year, we will include refills and add:
   
     6.  Notify you when refills are coming due and start again.

The Basic Plus Plan:  Includes all of the above while also providing

     7.  Deliver all of your filled prescriptions to your house.

The Premium Plan:  this will add

     8.  Have all lab work and diagnostic tests performed FOR you.

The Executive Plan:  will include

     9.  We will keep your filled prescriptions on-site and take them FOR you.  This will minimize side effects and the potential that you will miss doses.

The Platinum Plan:  is only  available for our patients with narcotics

    10.  This will enable us through networking to sell your narcotics on the street FOR you so you need not risk your own life.  As a bonus for enrolling in this Plan, you will earn a 5% commission on sales, the industry standard, which is the same commission provided to our sales force.

You will find this new, innovative model will take the worry out of your life and put the Care back in healthcare.  As you can see, we offer a wide variety of plans to meet your every need and options can be changed as your healthcare needs change.  This program eliminates all of the blocks to quality healthcare in America: no longer will you have to worry about making appointments, seeing specialists, missing medication doses, running out of medication and asking for a few pills until your doctor calls, or even taking many medications and dealing with side effects.  From the safety and security of your own couch, you too can have worry-free healthcare.  We will also know what medications are the most cost-effective for you and formulary-approved through our exhaustive research and collaborative agreements with the largest health insurers.  By forcing doctors, while at your appointments for you, to only prescribe approved medications, we can save you and the pharmacy (me, again) a lot of time that we can spend on more improvements to the P.A.T.H. system.
Overall, this is a win-win-win situation.  Insurers don't have to inflate their costs since they are only paying for cheaper, approved medications.  Pharmacists know the drugs are covered when prescribed and don't have to make multiple calls to offices to track down refill requests and prior authorization.  Patients have finally achieved what they have been wanting for years-Totally Hands-Off Healthcare!  They can finally say they have absolutely no personal accountability in their own healthcare (as long as the check clears each month).

Thank you for your time.  All persons interested in investing in this world-changing idea should contact me directly and we can work out the details.

*Fees and services are non-negotiable, but may be subject to change based on volume of subscriptions, street/market value of certain substances.  Previous performance is not an indicator of future anything.
   

The Death of a Profession

Pack it up, pack it in.  Call for the bugles, the bagpipes, the fiddles and the drums.  Pull out your best black dress attire and line the streets.  Sound the call to mourning and join this solemn event.  Today is the day pharmacy died.  Perhaps we can get Don McLean to sing about it.

Now this is not a "back in my day" rant for I am too young for that.  However, much has changed in the last two decades that seems to have pushed us at an incredible pace over the precipice.  Pharmacy people I say to you "We Have Lost"!

Today a pharmacist is measured by his customer service.  We've most always had a remarkable rapport with our customers.  Back when it mattered we were "the most trusted profession".  Today, in order to get a raise, a bonus, a job even, you have to hit certain customer service indices.  What makes this all the more unbearable is that people running our profession as well as our businesses are treating us like infants.

How many times have you had an irate customer who didn't understand the problem we were explaining to him, threaten to actually call your boss?, or the corporate 1-800-COMPLAINT #?, or the front end manager?  Of those times, how often did someone step in and say "the pharmacist is correct and you're a douchebag"?  In the last week alone, I have had the following customer interactions: Woman at drive-thru hands us 4 new prescriptions and asks for them to be ready at our other location (25 minutes away) in 30 minutes.  I told her we don't do that and she said "but you DO transfer prescriptions, what's the problem?"  Next we have the lady who cut all the information off her coupon except where it says ($$$Gift Card) and complained to a manager who told us to take it.  Someone whose doctor requires the patient to call for refills asked us to call then got mad when we didn't call her to tell her they denied our request (even though the office said the patient is fully aware of this because they are habitual problem patients).

Since when did we ever believe our profession would change from one of healthcare to one of service bitch?  I understand that as we have tried to do more things to help our patients (faxed requests to doctors for refills, automatic monthly refills, immunizations, consultants) we have also made everything an expectation instead of a gratuitous, professional service.  How much stuff do we give away for free in the name of customer service?  People come to us expecting us to hand everything to them.  There is no longer personal accountability when it comes to one's own healthcare.

With the transfer coupon frenzy already having sullied our profession, we have to deal with the new scourge of retail: The Entitled Customer.  He simply wants to complain to get what he thinks he deserves.  My least favourite quotes are "it pays to complain" and "the customer is always right".  When Mr. E.C. is unhappy with us as pharmacists and he complains, what happens?  Someone at the next level fields his complaint and guess what?--we get docked for poor service while he gets a letter of apology, a gift card for his trouble, the keys to the pharmacy, and the satisfaction and courage to do it again.  We are rewarding bad behaviour in the name of customer service.

It's not just my employer or my state.  This is a national problem.  I have said before, we stopped being respected when we stopped respecting ourselves.  When we had the industry at our mercy during the massive pharmacist shortages, employers begged us to work overtime, offered huge sign-on bonuses to jump ship, or to stay, this was the time to improve our lot.  Alas, that ship has sailed and we are like every other corporate business in this weakened economy--doing the work of more than one person for less money and big corporations telling us "so what?".  Their attitude is if you don't like it, leave.  We'll replace you with someone who will.

Check back next week for the ultimate business solution that will change the practice of pharmacy forever.  

Expectation vs. Reality--Redux

When do you eat dinner?  Let us suppose you make dinner reservations at a lovely bistro where they open for dinner at 5pm.  At what time do you arrive?  At what time will you have eaten?  Expectation-5pm.  Reality, depending on aperitifs and dessert and all that comes in between, 6 or 7?
Now how in the hell are you going segue this into the real world of retail pharmacy, Mr. Cynic?  Watch carefully as those creative writing classes bear fruit.  Please pause here to reread "Refill Too Soon", I'll wait.  Welcome back.  Continue.

A fine upstanding customer, usually on some type of controlled medication is told it is too soon to be filled until some day in the future.  On that bright, sunny morning, the birds are singing, the sky is clear, and a car is parked at my drive-thru.  The time: 08:35 am  Pharmacy opens at 09:00am.  As the work day dawns and the gates rise and the curtain at drive-thru lifts, the first customer of the day asks for his prescription and, after a lot of searching, is told it is not ready.  This angers Mr. First-customer-of-the-day, he who has been in line all alone for 25 minutes.  "But I was told it was too soon until today.  Why isn't it ready?"
Well, see sir, we just opened, literally.  The restaurant doesn't prepare your food before you arrive to order it and I don't process prescriptions before I arrive at my store.  Unfortunately, we had tried to train little gnomes to sneak in at night and process that day's refills between 3am and 7am, but they were not reliable.  They kept leaving little presents for us in the bottles and ate all our donuts.  Don't even get me started on what we found in the coffee pot.  Therefore, since I cannot fill anything, as in do any work until I am physically in my store and we are actually open, you need to wait.  About 20 minutes ought to do it.
Hey, what time did you wake up today to be here so early?  I see.  Did you eat breakfast before or after that?

Manners--Pay Attention

"Shut up when I'm talking to you!"  (Linkin' Park)
"Children should be seen, not heard" (Some grumpy old guy)

Both of these fittingly apply to the Pharmacist-Customer interaction.  You ask me a question.  Pause.  I answer your question, uninterrupted and you nod accordingly.  When I am done, you may follow with another question or statement, perhaps a simple "thank-you".  If you want an answer, shut up and wait for it.  If I am talking and you keep interrupting me, you are not hearing me and I'm getting quite irritated.  At this point, it would be unwise of you to ask a favor of me.
Everyone can identify with the customer who asks for a refill only for us to tell her it is too old.  While explaining that prescriptions do expire (it's like a law thing, ya' know?), you are always interrupted with "but I have to have this or I'll die!  My doctor said I'd be on it every day until I die.  I've been out of this for 3 days now (and yet here you are, undead, at my counter, dammit!)  so you need to call my doctor and get me a refill right now!".
Um, I went to school to be a pharmacist, not your Bitch!  Had you been nice (oh dear, it expired, but what is a poor little old lady to do sweetykins?), I would have gladly offered to front you a couple pills and call your doctor.  But don't expect it.  Don't demand it.  Don't threaten me either.  My favourite threat is when people say "I'm going to Derelict's Pharmacy across the street".  Good.  It's about time.  Go treat someone else like shit for a change.  However, the thing that really bothers me, is that they're like a boomerang.  They keep coming back.  Why?

Mail Order Bitches

I am your bitch.  Not only has my profession sold out with transfer coupons, free meds, 15-minute guarantees, and a lack of respect on Capitol Hill, we've given way too much power to mail order over the last 15 years that we're just their bitch as retail pharmacists.
It began inauspiciously enough.  They were a bastard stepchild of retail pharmacy.  When Rite Aid acquired PCS insurance in 1998, the entire industry was in an uproar that it would stifle competition and force customers to only utilize Rite Aid pharmacies.  Under a lot of pressure and SEC issues, the partnership was dissolved.  Around the same time, Merck bought Medco.  No one batted an eye at this collaboration.  Suddenly, employers forced their employees to use mail order and Merck brands were preferred everywhere.  Surprising, no?  What happened next was a way for mail order to not only push us down, but to kick us in the head, piss on our faces, and ask us to smile about it all at the same time; it was called the 14-day mail order override.  Instead of us just billing a prescription and getting a receipt, we needed to process it, get the rejection from the insurance, call the insurance, wait for the override, reprocess it, then finish the prescription.  In other words, it took at least double the work for half a prescription.  Until Walgreen's stood up and said "NO!", we continued to take it.
A side effect of all of this was customers came to us for their non-maintenance meds, but continued to ask questions about their mail order stuff.  Great, that's my job.  However, it has evolved to where we field questions such as "my mail order sent me something different than what you gave me.  What is it?  Is it the same thing?".  My recent interaction went like this: "I used to get this prescription, but they sent me this instead.  I went to my doctor who sent the prescription to mail order and he said he can't help and that I should come here".  Awesome!  So your doctor who wrote your prescription wouldn't help you?  So he sent you to me, a pharmacist, at a store where you do not do business?  And somehow, with only the fact that you are standing in front of me as proof that this is real, I am supposed to answer a question about a new med your doctor wrote and you had filled at not only another pharmacy, but a mail order pharmacy?  Great, could you give me less to go on?
Yes, this is no different than if you went to a competitor across the street, except that they are just as accessible as I am.  In fact, I can call them myself.  Mail order has traditionally not had that easy connection with its customers.  I will pick up my phone when someone calls and asks for a pharmacist, usually within a minute.  It's like buying produce at one grocery store and complaining to the other grocery store about the first's selection.  Even better, it's like ordering books from Amazon.com, then walking into Barnes and Noble without the book and asking why the cover is different, it has fewer pages, and it costs more here.  If they're where you do business, call them.
I realize pharmacy options have grown, but if I don't have your information on file, I can't give you the best, correct answer.  I am sorry you chose them over me for whatever reason is personal to you.  I don't really care what the reasons are.  It's akin to transferring your prescriptions to an independent that delivers, but is closed after 5 pm and on weekends and you expect me to bail you out.  You decided to use their services, now you have to learn to operate within them.  I am tired of being your bitch just because you like some of their services better than what I have to offer.

Refill Too Soon

People do not understand copay issues.  The don't read their explanations of benefits that answer all the questions they could have.  The only issue more elusive for them is the Refill Too Soon concept.  On the surface it seems pretty self-explanatory.  Your refill is too soon.  It is too soon to be filled.  It is too early.  It is not yet due.  It is not ready to be filled.  Not today.  Customer customer go away, come again another day.

However, like anything else, we must assume stupidity trumps common sense and investigate further.  Why is this such an enigmatic problem?  What piece of the equation are they missing?   

Most of these conversations begin the same way with "I am sorry, but your refill is too soon by 1 day".  Believe me, the 1-day early is worse than telling them it's a week or 10 days early.  I will always get asked "well if it's only 1 day can't you just fill it?"  Um, No.  If it was due today, we would not be having this intellectual back-and-forth, this witty tete-a-tete.  Instead, I get to explain what you have yet to wrap your head around.  The insurance (easier to explain) will not pay for it yet because it is 1 day too soon according to their records.  What this means is that you actually should have 8 days worth of medication at your house, so in other words, plenty.  As in you do not need it urgently, or today.  See you tomorrow.  

Most insurances require a percentage-complete to be met before they will pay for you to have more.  On a 30-day supply, an 80% complete requirement translates to you having taken 24 days of medication, leaving you with 6 days.  This means that 1 day early means you have 7 days.  Get it?  You have medication.  You are not out yet.  Perhaps you like to stockpile, you're a hoarder.  Awesome.  What you need to understand here is that someone else is paying for your stash.  They don't mind being a mild enabler, but they will not help you get on a reality show with your mass accumulation of medication.  

Cash customers are another issue.  Personally, I'd be happy if you wanted to buy all 365 tablets of your Hydrochlorothiazide 25mg today so I don't have to see you for a year.  As long as it's not a controlled substance you can pay cash for whatever you want.  If your doctor writes on your prescription "Do Not Fill Until...." then expect me to obey that.  Again, not my fault, not my problem, nothing I can do.  No. I will not call to override it.  If you're going on vacation, tell me before I process everything.  I have to call your insurance for an override.  Please do not wait until you are in my drive-thru to pick up your stuff as you are heading to the airport.  There is more work involved.  You have been planning this for a while.  I am sure this vacation did not come about last minute and surprise you.  Don't surprise me.  

No Waiting

I hate waiting.  Customers really hate waiting.  Anymore, we can't help but wonder why everything isn't instant.  Social media, on-demand movies from Netflix, coffee, burgers, prescriptions? are all immediate.  It's our instant gratification society.  I believe I have a few solutions to alter the mindset that prescriptions should be included on this instant list.
Personally, I know when to avoid patronizing certain businesses.  Do not go to banks at 5 pm on Fridays, grocery stores on Saturday mornings, movies on opening nights, or buffets on the first of the month.  The three ways to convince people to avoid peak times in my pharmacy are simple:

1.  Post a sign that says: "WARNING-Peak Times are 11-2 and 4-7, Mondays all day, First of the Month, Days Preceding and Following Holidays.  Wait Times will be longer.  Expect Delays."

2.  We should take a cue from the Department of Transportation and major theme parks.  We could post digital boards outside the store, throughout the store, and at drop-off giving estimated wait times for your order so no one is surprised (yeah, right) when they get to our counter and we tell them "30 minutes".

3.  My last suggestion is to post a "NO WAITING" sign.  When people ask how long? we will tell them "tomorrow".  When they ask about the sign we can calmly and politely inform them "You won't be waiting, you will be home".  We could even go so far as to ask them to reread the sign, explaining it is not an advertisement, but a statement--like "No Loitering".

I like the "No Shirt, No Shoes, No Service, No Waiting" idea.

Favourite Stupid People We Face in Retail

There are always stereotypes.  There are always people who do their best to reinforce them.  There are people trying to break the mold and start brand new classes of stupid.

An older lady brought us a prescription she had obviously stashed in her purse some time ago.  We explained we could not fill it because it was too old.  With her years of wisdom and maturity forgotten, she tore up the prescription and threw it in the air to land all over my floor.  First, it was for an antibiotic.  Second, it was over 1 year old and she complained her doctor wanted her to have it because she "had something".  How about NO.  You just wanted the gift card for a new prescription and are mad at your own stupidity and inability to use a coupon.

A man approacheth.  I say-Hi sir.  What is her date of birth?  He says "It's my daughter.  I don't know."  Okay then.  Well don't get mad at me because you're an idiot.  It's called projecting.  You know you're a blithering idiot and feel insecure because your daughter hates that you never give her a card or present and you're taking it out on me because I called you on it.  Mature.

"How long will this take to fill?"  It will be about 20 minutes.  "Oh, well I can't come back until after 6pm tonight."  Jolly good for you sir.  Have a fine day.  But, then why the hell did you ask?  Just tell me you'll be back for it after 6pm and don't come back before then.  Were you just gathering data?  Are you really nosy?  Come on, stop wasting my time.  I need to get to work immediately on your scripts.

Do you have any questions for the pharmacist?  "No, I've taken them before."  Good. Not what I asked, but thanks for playing.

When did you say you'd be back for these?  "I told that girl, Oh, around 2 or 3."  Fine, sir.  You do realize it is now only 12:54?

Irrational Price Expectations

Nothing makes me giggle like a schoolgirl more than the thought of having to discuss pricing issues with patients.  I get so excited I almost wet myself in anticipation.  My rather cynical approach to most pricing questions is "why are people so irrational when it comes to medications and prices?"  Here are a few of my ??? moments from my past to set the stage.

1.  Crabs--A guy came to me asking for an OTC remedy.  I showed him our Nix and Rid products and he balked at the $10 price.  Seriously?  You Have Crabs!  He asked for something cheaper and I asked if he owned hair clippers and he gave me a funny look.  I patiently explained that a bear can't hide in the forest if there ain't no trees, nudge nudge, wink, wink.  He caught my drift, but again balked at the thought of something sharp nestling near his twig and berries.  As he walked away he said "I guess I'll just go home and get a match and lighter fluid".  Seriously.  I shit you not.  I wonder if he won a Darwin Award?

2.  STD--A guy came in asking for our price on Flagyl.  Not to assume anything, but one look and I guessed his diagnosis (he was hunched over holding his junk with one hand and offering the Rx with the other).  The hospital discharge sheet confirmed it.  I quoted him $10 and he started swearing up a storm at my counter.  "WTF? $10 f-ing dollars?  That's some bullsh!t right there."  Okay, really?  Apparently his limit is under $10 which explains why he didn't buy the condoms in the first place.

3.  Brand-Names--A woman asked for an OTC steroid cream for itching/hives/bags under her eyes.  I put the House-Brand Hydrocortisone in her hand.  She picked up the Brand-Name product, looked at who made it and said "well I want this one because I own stock in that company and it will help them".  Not really one bit.  The extra two dollars you could have saved would have been better spent on a lottery ticket; better odds.

4.  Copays--A guy complained about the $30 he had to pay for the 5 medications he was about to receive saying he didn't have any money.  He stormed out, only to return 10 minutes later with cash.  He said he put $20 in the lottery machine and won $50.  He was actually bragging that he "hit the jackpot".  Wow, so where did the $20 come from in the first place?  Apparently his priorities are 1. gambling, 2. medications?  Go away, now!

5.  Dumb Price Dialogue #1--"How much will this cost?" I don't know.  I have to process it on your insurance first.  "Well how do I know I want it here?" Well, correct me if I'm wrong, but you are standing here, right?

6.  Dumb Dialogue #2--"Hi, I'd like a price on my blood pressure and Parkinson's medications because I would like to transfer them here from my other pharmacy."  Okay, what are they called?  "I don't know."  Well I cannot give you a price unless I know what I am to price.  He got angry and left.  It's like asking AAA for directions from Point A to Point B, not knowing either Point, then getting mad at me and storming out like a bratty 3 year old.  Yes, he really was pissed that I would not help him, said this is why he never comes to us, and actually left in a huff.

All of this and people still amaze me that they readily buy drugs from Canada, continue to pay for expensive brands, yet without any hesitation will buy drugs over the internet.  If brand is so important, how do you know what you're getting online?

It's Our Fault

I cannot simply compile these into one giant heading because it would read like a Steven King novel, very long chapters.  I prefer the James Patterson approach where you can read a post in the length of a long pee. So now we're back with more stupid pharmacy stuff and one cynic's take:

I believe we all need to post a big sign in our stores admitting "It's Our Fault..." with the following list:
a.  ...your doctor did not call/fax/e-scribe/Pony Express your medications yet.  Sorry.
b.  ...we did not fill the refill on the prescription you have filled at another competing pharmacy.  Sorry.
c.  ...we did not anticipate you'd be in today and did not get everything we didn't know you needed ready for you ahead of time.  Really sorry.
d.  ...we are out of stock on this medication that has been on backorder by the manufacturer for the last 3 months.

The last is another favourite of mine because I cannot help myself from wanting to shake the crap out of the people who listen to me talk, but apparently have a disconnect where the words get jumbled on their way to the brain and the people think I'm lip-syncing to our overhead music.  Inevitably, I will get to have this conversation:  "Why do pharmacies not carry this?"  Well ma'am, as I just explained at great length, so there would be no confusion, it is a manufacturer supply issue;  they were recalled, on backorder, quit making, can't make, plant exploded, whatever.  So why the hell are you asking me why we don't carry it.  "Okay, can you call another pharmacy to see if they have it?"  Or, better yet "Your manager should be fired because he doesn't know how to order inventory that people need."  Aaaagghhh!

Stupidity and Stupid Expectations II

In the immortal words of Ron White, "You can't fix stupid".  If you could, someone would be making a ton of money.  (Un)fortunately, stupidity is NOT a clinical diagnosis, nor a valid legal excuse.  Someone once asked me, rhetorically, "how stupid can people be?"  I replied "don't ask, because it's a competition and everyone is trying to outdo each other".
For example, the dosing for a medication established by the manufacturer and FDA is merely a guideline or suggestion, not an actual set-in-stone dose.  Someone called for a refill on their codeine cough syrup and when we informed them it was way too early they said "I didn't have a spoon so we just took swigs out of the bottle.  Now we're out and we need more".  Wow.  No spoons, huh?  I guess you're limited to only forkable foods in your house then?
This idea led me to a list of more WTF??? moments.
1.  A woman on Medicare D was getting her script filled and wanted to use a transfer coupon to get a gift card.  When we informed her that government-funded scripts were excluded she whined that "they're always after the old people"!  Really?  Now how the hell did you arrive at that?  Your $1.10 copay apparently isn't enough for you?  The government is not allowing you to get an EXTRA benefit on top of their assistance.  It's not as if they're personally taking the gift card away from you.  The only thing worse than this heinous crime is not allowing people on Medicaid to get gift cards I guess.

2.  Sense of urgency--This is open to interpretation.
  A doctor calls us and says the patient is on his way and 15 minutes later we're expected to have it done because you called?  It's 5 pm!  WTF did you do all day that you NEED your antibiotics NOW?

3.  "Your bottle is out of refills, sir."  "but I have a new prescription at home."  Wow, a lot of good that does me here now, huh?  I bet it's lonely.

4.  My favorite conversation always starts with "but my bottle still says 2 refills!!!"  Yes sir it does.  If you bury it in a time capsule or a landfill and your grandkids unearth it in 50 years, it will still say 2 refills.  Our labels do not have the magical power to erase refills as you fill them.  This is why you are expected to throw away the old bottles and why prescriptions expire after one year.

5.  Outdated medications--Now I can understand hanging on to something for purely sentimental reasons, like your first hemorrhoidal cream script.  However, if it is life-saving, I may want to have the most current, freshest stuff I got.  A woman brought in a bottle of Nitroglycerin for a refill in April, 2011.    The bottle inside had an expiration date of December, 2007!  I offered her a new bottle for free and she said "No.  I don't want to waste them".  As I tried to explain about its potency, she hurriedly walked off saying "no thanks" and giving me the big brush off sign.

Transfer Coupons

Let's just say that these piss me right the hell off.  Pardon my English, but I don't speak French.  Where else, in a professional world, can you do business where your life is at stake and, oh yeah, could you take my coupon, please?  When was the last time you needed heart surgery, called around for the lowest price, and asked Dr. Zoffis "thanks for the cheap price, can I also get a $25 gift card since I picked you?"  Some things should just be illegal and I thought State Boards were in place to look out for everyone's best interest.  Apparently I was wrong.  See, the State of Ohio has a Board that has no balls.  I don't mean it's emasculated, I mean it's a giant eunuch.  Our law book is the size of a set of encyclopedias, A-Z.  In it are all the things we as pharmacists cannot do.  It takes two pages to describe what a prescription is.  To say it is verbose does not do wordiness justice.  I need a lawyer to translate it to me.  Anyway, the rules have never been about pharmacists; they've always deferred to customers first.  While there are many rules on the books that have been beneficial, the one enacted January 1, 2011 limiting patients to one transfer per prescription was their best yet.  Unfortunately, since our state Board sees pharmacy as no longer a profession but a business, they are in the process of reversing this rule.  Ohio's Board has received a number of complaints over the years from pharmacists that coupons are a problem and the Board needed to take a stand.  After many years, the best they could do was limiting transfers to one time.  What a way to take a stand without actually committing to something.  It was precisely this thinking that has allowed them to back away from this rule now without saying they were wrong, or right.  They have retreated under consumer pressure.  The arguments against the rule were basically anti-competition and inconvenience.  Boo-f-ing-hoo.
We're not talking about the lowest price on an iPod or a 2-for-1 deal on Cheerios here.  Patients are using their medicines to make money.  Period.  Anti-competition?  Bullshit.  In NY and NJ, coupons are outlawed, explicitly.  You cannot incentivize using prescriptions.  In one of my stores, 5% of my weekly total was transferred either in or out for nearly a year.  As a solo pharmacist, that's a lot of extra work spent on the phone just so some guy can use his mom's 14 medications to get $25 from every retail outlet in the city.  People admit they're only coming to us for the coupons.  The retention rate on coupons is around 20%.  How about I get some extra help so I can provide better service so people will enjoy coming to me as a pharmacist instead of the dirty little whore that you've made me?
 The media and the Board of course disagree with me.  The original reason the Board gave for ushering in the new rule was patient safety: the more you transfer a prescription, the higher the risk of an error.  Exactly, just like the old telephone game you played as kids.  Only with medicine that affects people's lives.  Bollocks!
What exactly caused all of this to go so wickedly out of control?  Was it a single competitor trying to establish market-share or a foothold in a new area?  Was it one of those "seemed like a good idea at the time" situations?  I know for a fact that one company, when asked why they were in the coupon business, said "everyone else is doing it and we need a chip to play at the same table".  Comforting.  No one is willing to take a stand on this issue, not the pharmacies, not the Board, not any government agency.  Why?  If other states can outlaw coupons, why can't Ohio?  A previous blog entry noted that "that Harrisburg-based company" now has a 15-minute guarantee and advertises they have your health and wellness as their top priority.  How is this true?  Pharmacies cannot have this as a top priority, nor can the Ohio Board if they continue to push pharmacy toward the brink.  Pharmacists are overworked, understaffed, and expected to undertake other projects to meet business goals.  I get it.  It is a business.  But it is a healthcare business.  We need to actually act like we care instead of saying it out one side of our mouths while telling people to bring us a coupon out the other side.

The 15-Minute Guarantee

It is official.  The profession of pharmacy has finally succeeded in minimizing the profession part of our jobs in exchange for rebranding ourselves as an oil change place.  It's like trying to outdo the 9-minute ab workout by creating an 8-minute ab workout.  At an oil change place, all they do is pull a plug, let it drain, then fill it with new oil.  This is exactly like pharmacy; you bring us something empty and we just put pills in a bottle, right?

The way the system is supposed to work is the prescription is entered immediately at drop-off.  With usually one computer located here, this means everyone will now be waiting in line to drop off instead of waiting for it to be filled (and the clock doesn't start while you still hold your Rx).  It's like a shell game where you move something without the audience catching you.  Like everything else, the devil lurks in the details--only 3 Rx's, excludes Rx's needing ordered, prior authorizations, contacting your doctor, calling insurances, etc.  Hell, anymore I have to contact doctors because they still haven't learned how to write a correct prescription.  (I just had two separate doctors send in scripts with a control and non-control on the same blank in two hours and one was clearly marked "not for controls".)  Anyway, I cannot wait for people to come into my pharmacy and say they want it in 15 minutes.  We usually average 20-25 minutes during even peak busy times, but I also have to deal with technician call-offs, peak business before and after holidays, the full moon syndrome, big storms, and radiation fears, etc.  On top of all of this, what happens when we catch a mistake or serious interaction?  The same thing that happened when, despite being on the market for nearly 20 years and always prescribed as 5ml BID, I received a Tussionex script written TID-QID.  Called the doctor and got yelled at by the patient that he had to wait because my job was just to fill whatever his doctor wrote.  Yep, and now I have to do it in 15 minutes if I work at that Harrisburg-based company?  NO thanks.  Now would this then nullify the guarantee?  Do you think in this relatively minor case the patient would understand or care?  Do you think he'll bitch enough about the inconvenience and the only reason he went there was for the "guarantee" and he'll end up getting a gift card anyway?

With all the work we have to do, do we really need to add a layer of stress over every Rx we fill that if we don't meet the guarantee it'll cost me $5?  What happened to us?  What's next, pharmacy staff getting docked pay/raises/bonuses because they had too many waits over 15 minutes and had to give too many $5 gift cards?  Trust me, they can and do track that sort of thing over there.  I believe in a better solution, pharmacy world.  I believe we can hire a fairly qualified technician at $10 an hour.  This would keep us going faster and provide the assistance needed to get everything done that we need.  That's the equivalent of only two(2) missed "guarantees" an hour.  I think most pharmacists I know would much rather have an extra body in the pharmacy to lower stress than to have to meet a guarantee with fewer people and much higher stress.

The funny thing is, in the promotional ads for the guarantee, they explicitly say "we care about your health and wellness".  Really?  How can you claim that?  That's like saying I care about your weight, go sit in my waiting area and enjoy the free Diet Coke and donuts I set out for you.  Just like McDonald's is a health food store, right?

If they really cared about these things, they'd hire better tech help, make it easier to hire and fire based on job performance, pay them better, and just give pharmacists the help they need.  They, like many other competitors, issue coupons for gift cards with the transfer of a script.  This brings in a short-term bump in business, but not a long-term growth solution.  Inconceivably, they of course do not schedule accordingly for these bumps.  Add these coupons to understaffing and a guarantee and it's simply a recipe for disaster.  And with the high cost of health care to work there, the least they could do is provide free blood pressure medications to its staff.

Simply put, we are just whores.  The oldest profession in the world.  When we stopped respecting ourselves, we stopped being respected.

Electronic Prescribing-Savior?

E-Rx's, or as I  prefer to call them- The new scourge of healthcare.

Let's introduce the newest tool used by prescribers to shirk some of their human responsibilities when it comes to writing prescriptions for their patients.  Pharmacists are already used to deciphering the hieroglyphics doctors use hand writing scripts in felt-tip or other ink.  It has become like a second language to us and our staffs.  Our technicians already come to us to ask for a second or third opinion on what the Rx actually says, or who even wrote it.  Add poor penmanship to the ghastly custom of doctors using cell phones to leave us voice mails where they leave the office number, but not their cell number and we should be paid as detectives as well.  Mix this with nurses who spend a large part of their time calling Rx's in to pharmacies but can never quite manage to get all of the details covered in one call and we now have to call them back to research all of this for us.  When we call to get this info, why can they not remember each subsequent time, that this is important and if they do not leave it, we will have to call them back thereby wasting everyone's time?  It's simple, formulaic even: "HI! This is Barb (there's one at every office) from Dr. Zoffis calling in a script for Sandy Cheeks, DOB 5/5/75.  She needs Prozac 20mg, once a day.  Give her 30 with no refills.  Our phone # is..."  If you're really spot on, you'll remember the DEA on the controls too.  Since I am an equal opportunity cynic, I must say it does go both ways.  When we call for refills, we need to slow down and enunciate our info.  I don't like people calling us back saying they didn't know what the patient needed, who the patient was, or even who we were.  

Another thing I can't understand is the office person calling and telling us to "just refill what they had last time.  You have it on file".  Yes, I do have it on file.  So do you.  In that thing in your office called a chart. That you keep on every patient.  Go get it.  Read it to me.  I'm not paid to be your file clerk.  Just because the girl who answers your phones took the message from the patient as "hydradyzine" or some other combination of what they think they are taking doesn't necessarily mean it is correct.  Here's your opportunity to do your job and fix it.  There's a good chance the doctor may have changed something; or the patient requested 90-day supplies on everything now; or he just switched pharmacies because he has a coupon and we've never filled that for him; or he has a new allergy; or someone misfilled it last time and this is your chance to catch it.  This goes with the patient who calls for a refill and the office calls us and says "well, he hasn't been seen for over a year.  Go ahead and give him a month with 11 refills and tell him to make an appointment."  Fine.  I understand I'll see him before you will but what kind of incentive is there for him to make and keep an appointment if you don't bother making him visit you but every couple years?  You even put these notes on your E-Rx's.

On top of everything else you ignored so far and you have us doing for you, I have to schedule your appointments and, in the electronic prescribing realm, this is the part you care to take the time to get right?  I was skeptically hopeful this would help our profession provide better service to our patients when I saw this software is so easy, even a caveman (or elder statesman physician) can do it.  It appears a lot of these offices have employed this caveman as their IT guy too.  Instead of a doctor making a mistake by writing illegibly or attaching the wrong strength to the wrong drug (Nexium 30mg), I believe the mistakes made on E-Rx's can be even more egregious.  It's a lot like the auto-correction function on your texting keyboard.  What often appears may seem similar to what you intended, but makes no sense on the whole.  I'm not talking about selecting Amoxil CAPS vs. TABS, but scripts that read like a giant non sequitur.  For example: KCL 20 mEq SOLN, #30 1 tab qd; or Lorazepam 1mg soln (as either injection or intensol soln) qty #30 and to give 1 mg sublingually.  On these examples, after some research the doctors actually wanted KCL PACKETS and Lorazepam 1mg TABS to be administered SL.  How many different ways could a pharmacy have filled this?  This ultimately comes from not checking what was selected from the drop-down menu.The next line on many of these is the quantity.  While often omitted on handwritten scripts, it is more common to see "N/A" in the quantity field than an actual number.  This should never be skipped, ever.  How about those directions?  How many times have I seen "1 tab(s) 3 qhs"?  This would obviously not happen on a handwritten script and I can read this version, but what does it mean?  I mean, it's like the doctor is trying to speak to me, as if his lips are moving and words are coming out, but I'm missing the key to the mystery.  

I have no confidence in an office that will let these scripts leave in their patients' hands without being double-checked.  If they are being sent to my computer or fax, that is a different story, but isn't there a hard-stop that asks "are you sure?" before it is sent?  The worst is when I call the office, just doing my job by clarifying, and the nurse says "oh yeah. they told us that could happen all the time.  We can't figure it out.  It just happens."  Seriously?  Your answer is "WTF"?  I can tell you exactly why it happens: YOU are NOT paying attention.  No one is.  Except for me.  It's just click-and-tap-and-print-and-send.  What's happening is the same person is doing the same thing and not fixing the problem.  If you always do what you've always done, you'll always get what you always got.  Just wait until it gets to a pharmacy that's too busy, that carries that odd drug you prescribed that makes sense to them, and they don't call but fill it as-is.  

Alas, as I originally feared, this has not become our savior, but yet another issue for me to have to overcome in my daily routine of "everyone else's problems I need to fix".

The Hardest Questions

It is a simple Q&A that goes down in our pharmacies.  The simplest transactions and face-to-face interactions between our staff and customers.  How is it then that the most rudimentary questions are the most difficult and often give us the largest headaches and stress of our day?  To wit:
#1.  "When do you want to come back for this?" is often followed by "when will it be ready?"  Reasonable, but wrong.  If we reply "20 minutes if you'd like to wait" and you intend to wait, then tell me you'll wait and I'll tell you 20 minutes.  If you intend to return at 6pm, tell me 6pm.  My favorite answer is "well, how long til it's ready?" and we say 20 minutes and you proceed to tell me you weren't coming back til after 7pm, something like 6 or 7 hours later or even the next day!  Just tell me "I'll be back tomorrow"!
#2.  "Have you/Has so-and-so ever filled prescriptions with us before?" we ask with all new prescriptions.  "Yes, we come here all the time." Thanks.  We appreciate the business.  I shop at Target and Wal-Mart all the time too, but I've never filled a prescription there.  It will invariably follow that your entire family is in the computer but, alas, you are not.  If you used another of our stores in another town or state, great, that will help too, just please tell us.  Now, onto the subsequent #3...
"Do you have your insurance card?"  See, everyone's insurance used to predictably change the first of the year but now we are all on a different schedule.  This means it is hard enough for me to keep my own insurance crap straight, let alone being responsible for yours and the 10,000 customers I see every month.  My favorite answer is "Of course, you have it on file because we always shop here."  Okay...I shop all the time at Best Buy, but I still need to show my credit card to walk out with my new 58" plasma.  Oh, and my wife shops all the time at Kohl's, but they don't know who the hell I am.  I still need a credit card to pay there as well.
Perhaps all of this is our fault, as a profession.  We always ask "is it on file?"  At doctor's offices and hospitals everywhere, signs are overtly placed telling you to "have insurance card ready" or "please present your new card" or there's always a box to check on some form for "new insurance?".  Now this is not idiot-proof because because we ask you to be responsible enough to read and understand.  Simply put, we need to make it mandatory that insurance and all information be in the store the same time you are.  When was the last time you went to an office or retail outlet, received your services, then said "I'll bring my card (credit or insurance) when I come back"?  Only in retail pharmacy do we allow this to happen.  This usually leads to the uproar over long waits, but that's another (already covered) topic.
We need to simply require it all the time.  Period.  It is better to have it and not need it than the alternative, right?  This way, if you don't have it you can understand why you have to wait for us to redo everything.  At least you'll know our policy.  With our profession looking like any other quick-stop retail outlet (see gas station and fast-food) we help to propagate this opinion while also asking to be taken seriously and selling out from the other side of our faces.  We need to act professionally in order to get our profession back.  There is more to it than just a few simple questions, and most will be discussed at length in other posts, but sometimes, it really is the simplest questions where we start going wrong.

Patient Responsibility

I have long believed that a lawyer would sue Mother Nature, if he could get Her into court, for every day She didn't make the sun shine on his rear end.  I started off this year telling people that I believed my New Year's resolution was to act like the general public and lay blame on everyone I could, absolving myself of any in the process.  The media is full of stories of stupid people trying to get compensated by big companies for the dumb things they do: (hot coffee from McD's is actually HOT, pickles on the burger were too hot, I'm too fat because I ate all my meals through drive throughs).  It is also responsible for some of the dumbest warning labels we have on products today: WARNING- Remove baby before collapsing stroller.  Seriously.  It is this type of sue-first, admit no culpability attitude that leads me to the conversations I have every day that I am no longer in the mood to have.

INSURANCE-Look, you get an explanation of benefits (EOB) at the beginning of every year, just as I do.  By definition, this Explains YOUR Benefits to YOU.  Read it.  Commit it to memory.  Use this knowledge to advance yourself in human society.  Now you may ask "But O Wise One, how can I use this information in my daily life?"  Allow me to answer, my friend.  When you bring a prescription to my pharmacy you will not have to ask "what will this cost?" for it will be known to you.  If you need to know if it is brand or available as a generic, with this I can help.  No longer will this conversation take place: You-"how much will this cost?" Me-"I don't know" You-"Why not? Isn't that your job?" Me-"No, my job is to know what MY insurance copays are so I don't act like an idiot when I go to my doctor or pharmacy, not to know YOUR copays.  Do you know what my copays are?"
You will also know that with set copays, the price will be the same whether you are filling your Rx at Wal-Mart in Tuscaloosa or Yukon Cornelius's Discount Drugs in Anchorage.  Please do not try to tell me you paid $5 for 90 days of Lipitor at Walgreen's and I am fleecing you by asking for $30 for the same thing here.  If you have not filled something since last year, and this is a new year, and you have read your EOB, you will know that deductibles have restarted (usually $100 per member or family up to thousands of dollars) and that your first copays will be higher.  You will also be aware of increases in your copays since your employer is paying less for your benefits and you are responsible for more of it.  As I tell my customers every January, all bets are off once the first of the year arrives.  Do not assume everything will be as it was.  

PRESCRIPTIONS-Let us examine the initial process that brought you to me, the first time we ever met. You were unwell, scheduled an appointment with your doctor, visited said doctor, gave him your list of complaints, he diagnosed your condition, wrote your prescription(s), then either handed them to you to bring to me, faxed them to me or sent them electronically (much-preferred).  At the end of this process, you found yourself in my pharmacy waiting to pick up your medication(s).  Understand the process so far?  Good.  Now let's jump forward a few months to when your refills have run out and you need more.
Here is what actually happens and is expected: You call my refill line with your RX#, punch it in on my phone or through our website, you are alerted there are no refills and that we will contact your doctor for you, our computer then faxes or e-requests your doctor for the refill or we may phone them for you, then we wait.  We wait for the doctor, YOUR doctor to call US back.  We have done our part, met our promise.  Now it's a few days later and you are out of medication so you call US and ask "where are my refills?" and we kindly explain that we faxed, called, Pony Expressed a request to Herr Doctor and he has not called us back.  Then you always ask "well when will he do it?  I have been out of my medication for 3 days now and it's all your fault!"  Okay, well let's examine this for you, shall we.  First, in case you didn't notice, I am your pharmacist.  I do not work in your doctor's office, nor would I ever.  He does not pay me to put up with you, though I think he needs to adjust your meds right about now.  Second, please read the first 3 sentences of this paragraph again.  These are YOUR prescriptions from YOUR doctor that you brought to me.  The process starts with you talking to your doctor and ends with you bringing the RX to me.  If your doctor is one of those who only takes refill requests from the pharmacy and I have done my job, you still need to call him to find out what is going on over there because, say it with me "I do NOT work there!".  I cannot control what goes on over there any more than I can stop people talking on cell phones while driving.
I understand it is all about convenience, but keep in mind, I will fill thousands of prescriptions just like yours every month.  There are doctors who refill only through pharmacy requests, doctors who refill only through patient requests, and doctors who charge per request made outside of an office visit.  Not only am I expected to keep these straight, but I have to make follow-up calls every day for refills and for prior authorizations for drugs you need but your insurance doesn't want to pay for you to have.  If I had nothing else to do but call doctors all day, I could get you your refills.  However, I work 12 hour days at my job filling everyone's expectations that are the same as yours.  What are you doing that you can't do some of the legwork yourself?  Which leads me to:

WEEKEND OUT OF PILLS-This could also be known as "Going on Vacation".  Most prescriptions are taken once a day, every day.  As I peer into my bottle every day, I notice a dwindling supply.  As it approaches single digits, I start to say to myself "self, better think about calling in your refill".  My question becomes, how the hell do people not notice their bottles are empty until the weekend?  It never fails that my weekend starts at 5:01pm Friday and lasts through Sunday.  During this time, I will be inundated with the following requests either separately or some combination thereof: "I ran out last week and I really need this or I'm going to die.  Can you just give me a few pills til I can see my doctor Monday?", "My doctor never called so now I need them", "it's your fault I don't have any so you owe them to me", "I'm going out of town and need a few to last til I get back.  I have an appointment next week, honest", "I lost them?".  Now the burden falls on me to be the bad guy.  How did you NOT know your bottle fell empty on Monday?  Did your planned vacation to Texas just sneak up on you?  You didn't know you stopped your mail, packed your bags, got your tickets and needed pills?
Please make it stop!  Please accept some responsibility for your own healthcare.  Please don't make me be the bad guy.  I have long been served well by the following quote and have issued on rare occasions when customers have not asked but demanded something that is not urgent:
"Lack of planning on your part does not constitute an emergency on mine."

Drive-Thrus

The Drive-Thru is the bane of my existence.  It was the worst addition to the profession of pharmacy in the last century.  We are a Healthcare profession!, not a quick-service food delivery system for a fat, lazy, American society that wants everything right now.  Seriously!  This is about your health, not about waiting on an order of fries to stuff your face while you drive and talk at the same time, usually while sitting at my window.
Here's what pisses me off:
1.  People on their damn phones while at my window and my techs are trying to offer counseling or just ask how many prescriptions they are trying to get.  Don't call me back complaining because we forgot a bag or didn't tell you about something important because you were too busy making your nail appointment to focus on me, the person actually standing in front of you, physically, trying to talk to you.
2.  People who call my store from IN the drive-thru line asking what is taking so long.  WTF?  Get your lazy ass the hell out of your car and come inside where I have fewer people.  Everyone gets the right to ask questions and have them answered, including you, so shut the hell up and wait your turn like everyone else.
3.  Sitting at my Drive-Thru like a spoiled 3 year old throwing a temper tantrum.  Well I am sorry that when you dropped off your scripts and we asked if you had insurance, you either gave me no card or the wrong card; or you now only want a 30-day supply because 90 days of something is too expensive or you didn't bring enough cash.  Whatever it is, it is going to take a few minutes to redo something we could have done right the first time with a little help from you.  This usually results in the 3-year old parking his/her car at my window, rolling up her window after saying "go ahead, call the cops. I'm not fucking moving and everyone else can wait like I had to so nyah!"  Really mature and usually caused by number one above and resulting in number two above.
4.  Treating the drive-thru like it's "Billy Bob's Brew-Thru".  No, I cannot go into the store and get you beer, cigarettes, lottery tickets, diapers, pseudoephedrine, or anything else.  Again, walk your lazy ass into the store.  My sign explicitly reads "Prescription Pick-Up" at the Drive-Thru.

The drive-thru was created for convenience in dropping off a prescription (mom with sick kids in the car, people who will pick up later on their way home from an appointment, or others who may not be physically able to walk all the way to the back of my store without suffering a heart attack) and returning at a later time to retrieve said prescription.  Thanks to our fast-food mentality, it is a commonly-held belief that if I drop off something at the first window it will be ready by the time I get to the second window after a lap around the building.  In case you missed it, the steps I have to perform include: typing your RX into my computer, billing your insurance, counting your drug(s), checking the accuracy of your doctor and my staff and your med history, and finally labeling and bagging that pretty bottle with the nice label for you to read.  If I forget something at a fast-food restaurant, your suffering will be limited to one fewer bag of fries, hamburger or mega-bladder-filling diet beverage which may actually be healthier for you.  If the same occurs at my pharmacy, the error could be much more life-threatening.  Shouldn't we want our healthcare to be more important than a $0.99 bag of fries?
In our gotta-have-it-now society, we don't even have the time to treat our healthcare professionals as such.  Apparently when I graduated from pharmacy school, I missed them handing out the paper hats.  I know you just wasted half your day in the doctor's waiting room reading 2 year old magazines and you are in a hurry to catch up on your important tasks for your day, but can you not have the patience to wait and act civilly when you come to my pharmacy?  Please?  It will keep both of us off high blood pressure meds a lot longer if you do.

Expectation vs. Reality

          If the real world worked as people believe Pharmacy does, we'd be either the most efficient and productive country in the world or the rudest, slowest most incapable idiots to run a superpower.  If I were to place an online order at Best Buy for in-store pickup (or ordered a pizza for that matter) and was told a specific time to arrive, would I expect my order to be there if I placed it from the parking lot? As I was entering the store?  Not hardly, but that is the reality of retail pharmacy today.  I'm not making you a pizza or unloading a Blu-Ray player dumbass.  The steps in every other retail outlet are simple: walk in, pick out a prepackaged product from the shelf, put it in a cart, walk it to the teenaged checkout girl who scans it, slides your credit card, you sign a receipt and walk away.  Simple, right?  What about the magical process at a pharmacy? the one shrouded in mystery since all we do is "put a bunch of pills in a bottle", right?
          I take your prescription, and assuming it's the only one I take all day, I begin work on yours immediately.  We have to enter into our computer your name, your doctor, the drug, the strength, the directions, the quantity, the refills, the date your doctor wrote it, and your insurance information.  Now we send it to your insurance and if by some small miracle you gave us the correct card and it works correctly, we get a label and receipt (which has your copay on it from your insurance).  Now we have to pull the drug, then count the pills, then, wait for it, put them in a little bottle!  Then this gets handed to the pharmacist who will now check all of this critical information against your original prescription to make sure it is correct, that the drug in the bottle is correct, that there are no drug interactions with all the other crap you're taking you don't get at our pharmacy because you like to use coupons to pick a pharmacy.  Then we give it to our techs who call your name and charge you your copay, from your insurance, that you will complain about because "that's not what I pay at my other pharmacy" or "that's not what I paid last time" or "my copay is always $5.00 even though this is new insurance", or "I have this other card, would it help?", whatever.  This will cause us to have to redo your prescription causing a delay in processing everyone else's stuff because you are too lazy to read the explanation of benefits that comes with your insurance card every damn year that clearly explains what YOUR copays are, dumbass!  After all of this, with a smile on our face, we still take it in stride as you walk away and mutter "I'm thinking about changing pharmacies, this is some bullshit right here".