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Friday, September 28, 2012

The Golden Rule of Pharmacy

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

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

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

Monday, September 24, 2012

I believe...

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

I Believe...

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

Tuesday, September 4, 2012

Predictive Refill Programs

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

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

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

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

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

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

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

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