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Monday, March 25, 2013

New Low Part 2

Lovely office from across the street calls your friendly CP.
LO: Since you're right across the street, I figured I'd call you with my question.
CP: Ok.
LO: I was wondering if you could help me figure out what to give a patient of ours.
CP: Ok.
LO: He's a pediatric patient with a UTI. What can we prescribe him?
CP: You're asking me? How sweet and thoughtful. Any allergies?
LO: None of which we are aware.
CP: I have a couple suggestions for you.
LO: Great. He weighs around 45 pounds. Can you tell me the appropriate dose for him as well?
CP: Gladly. Anything to help a little tyke with an infection.
LO: And that's given how often?
CP: Twice a day.
LO: So we're giving him <repeats entire conversation>
CP: That is correct. And I happen to have those in stock so no matter which recommendation your doctor chooses, I, being right across the street, can readily fill your patient's prescription.
LO: Okay. Thanks. They don't usually use your pharmacy so we're going to call it in to the chain they typically visit. But thanks for your help friendly neighbor! You're always so helpful.
CP: Yep. And your prescribers can't figure out how to prescribe medications without consulting an expert first. And, despite years of practice, they have yet to learn the correct way to write a prescription. (They are required to spell control quantities and write a DEA on controls as I've told you multiple times, quite politely, my friendly, good neighbor.)  But the State Board will be contacting them on that next week. Have a great day!

Friday, March 22, 2013

Dr. Oz

It starts with "I saw this on Dr. Oz. Can you help me find it?" It ends with "well why did he tell me I could find it in any pharmacy? This IS a pharmacy, right? I'm just going somewhere else where they know what they're doing".
Thank you doctor, for setting back the relationship between doctor-patient-pharmacist. Thank you for reinforcing the "if my doctor says it, it must be true" belief many people hold dear, despite overwhelming evidence to the contrary.
Dr. Oz is a paid celebrity endorser. Americans love to take their advice from celebrities. If it's on the Internet or TV, it must be true.
I believe an occasional appearance on a TV program may prove useful and insightful to those watching (his humble Oprah beginnings). I believe a daily program must work hard (read "stretch") to remain relevant, topical, and informative. I also believe in sponsors. I believe in Dr. Oz having many interests that may steer his advice. I know Dr. Oz is a cardio-thoracic surgeon. I believe if I want advice from an expert in that field, I will seek him out for a cardio-thoracic surgical consult. If I am having allergy symptoms or in need of vitamin supplements, he will not be on my call list. If I need a tax law attorney, I am not going to consult my local family law specialist.
Yes, he promotes specific products (bad professional. Bad!). Yes, he promotes alternative medicines. I am not against alternative therapies. I believe if you believe they work, then they work. However, no pharmacist (or doctor) will ever swear "this product is a miracle and will cure you of all that ails you" when recommending a product to you. Dr. Oz does that. Doctors should not be "amazed" and "awed" by how a treatment works. Science backs them. While science is pretty cool, no professional acts as he does. He looks more surprised at results of tests than George W. Bush did when he correctly pronounced all the words of his speeches.
Yes. I have recommended Vick's VapoRub on the soles of feet for a cough remedy. Yes, I have recommended Buckwheat honey as well for some time. There are a few others I keep in my trusty Pharmacist TOOLbox. I do not tell people of the "Supreme awesome power" these possess over the soul of your ailment. Be professional. People do not need whipped into a frenzy.
You are a doctor. This amazement and awestruck attitude only serve to solidify your status as a TV huckster: a 21st Century snake oil salesman. It belittles the good that you can do and sullies the true potential of someone in your position. Oprah Winfrey corrected J.K. Rowling in an interview. That was a terrible moment in journalism. You are cut of the same cloth-thinking you are more important. You do a disservice to those of us in the profession of healthcare who want our patients to come to us. To trust in us. To believe in us. You are working against us, and for all the wrong reasons. Please stop.
Seriously. Please stop.

Wednesday, March 20, 2013

Favourite Daily Interactions...

Questions you really want to ask...

CP: What's your phone number?
All Customers: I don't know. I never call myself.
CP: Yet your phone is ringing off the hook while you stand there so people must just luckily guess it, I assume? Anyway, what's your address?
AC: It's West Maple
CP: So you write yourself often then?
AC: How's that?
CP: You don't know your phone number because you don't call yourself. Yet you rattle off your street address as though it were tattooed on my face. Your logic astounds me.

CP: Do you have any questions on your medication for the pharmacist today?
Many Customers: No. I haven't taken it yet.
or MC: How could I? This is my first time taking it.
or MC: How should I know? I've never taken it before.

CP: <?????> So you can't have questions BEFORE you take something? You can't ask questions like "what does this do? will it make my ass hairy? will my ears fall off? will it lower my sex drive? will I finally develop that third nipple I've always wanted?" Anything? You're the type of person that would take his Flagyl prescription home, start taking it, drink a bottle of Honey Jack, then ask if it's ok to have a little alcohol while on your medication.
The actual response you were looking for was "No. I cannot think of any right now. Is there anything I should know about this before I take it? I shall go home and read the lovely, informative pamphlet you so graciously provide me and ring you back with any questions or concerns as they may arise."

Tuesday, March 19, 2013

Direct-to-Consumer Marketing

I have never been a fan of Direct-to-Consumer advertising when it comes to prescription marketing. I just think it's bad policy to promote products that require a legal document to obtain. I do believe this is responsible for many of the problems we have with pharmacy today.
Patients see a medication they like. They call the pharmacy or doctor and ask for it. They get their prescription from the doctor, take it to the pharmacy and go home. However, in between all of this, they are complaining that it shouldn't be this difficult to get it. "Why do I have to wait?", is the lament. Because it's on TV, they feel they should just be able to ask for it, walk in to any store, and pluck it off the shelves.
Originally, the thought behind this was simple: New drugs are being manufactured. People are too shy, quiet, afraid to visit their doctors and speak up about their problems. They even trivialize issues that may be more serious. This DTC marketing will allow patients to feel better about opening up, about coming out of their shell and realizing there are other people just like them who suffer needlessly from these treatable disease states.
Now the most common ads we see are for Limp Penises, Weak Bladders, Allergies, and Arthritis, just to name a few. (Is there a more ubiquitous ad campaign than Viagra or Cialis have?)
People already ignore pharmacists' advice when it comes to OTC recommendations. They prefer the product that Dr. Oz told them was a miracle (that post is coming...) or they prefer what their hairdresser said her aunt's son-in-law thought worked for him. Instead of performing our professional duties, we just give them what they want. It may be not appropriate. It may be the wrong drug altogether. If may be harmful to them. The customer may always be right according to some dumbass corporate suit, but the PATIENT is not.

Friday, March 15, 2013

Out Of Stock

I realize medication out-of-stocks are an issue and do happen. Unlike an advertised sale at a Big Box retailer that sold out of a certain TV or Blu-Ray, the situation in pharmacies is not likely to be resolved when the next delivery truck arrives. We can't give you a raincheck for a medication. Especially if we don't know if or when we may ever get it again. At pharmacies, it is a manufacturing issue, not an ordering issue. When we explain these shortage situations, especially harder to convey during an OTC discussion, many patients still do not understand. We are often met with:

Patient: "Ok. I'll just go down the street to Captain's Pharmacy. They always have what I need."

or..."How can you not stock this medication? I need it to live. You need to tell your manager she needs to learn to order better the medications people really need to survive!"

or..."But my doctor said you had it. He wrote specifically for this one. You can't call him to change it."

or..."Well you need to call around and find it for me right now. I can't drive all over town looking for this."

I feel like the customer in Monty Python's Parrot Sketch when explaining this: "It is no more. It is an ex-parrot. It is bereft of life. It has ceased to be..." I also feel like this when explaining that someone's insurance cards no longer work.
If you've not seen it, check it out here. If you have, watch it again...(start at 2:20 if you're short on time)


This is a very broad subject and can stir a range of debate. If I tried to hit them all, this post couldn't be read with your morning Java.

Thursday, March 14, 2013

And so it goes...

Not sure who should get blamed more for this one, the doctor or the doctor?
Patient Advocate: I'm working with a patient to get her p/a approved.
CP: Fantastic. I know she has been inquiring about this for a few days now.
PA: I have spoken with the insurance and the doctor so far.
CP: And what do you require of me?
PA: They (there's that pronoun again) said you need to start the p/a process.
CP: Huh?
PA: They said you need to send a form that explains why the doctor prescribed this medication. Why he is not trying other medications that may work and if the patient has failed other medications so this one may be approved.
CP: How am I supposed to know that?
PA: They said you need to start it.
CP: Who is "they"?
PA: The doctor.
CP: Um...Wouldn't the doctor know why the doctor prescribed something for HIS patient? Wouldn't the doctor know if HIS patient has failed something in the past? I have no forms to fill out from insurances. I have nothing to send to the doctor. Usually I just supply them with a phone number.
PA: I gave the doctor the phone number but they said they needed the form from you to start everything.
CP: <Reprints reject> All I have to fax to the doctor is a rejection from the insurance. It simply states "Prior Authorization Required. Please have doctor contact us at 1-800..."
PA: They said there's a form.
CP: That's all I have ever received from an insurance and all I have ever sent to a doctor to start a p/a process. Ever. The doctors usually receive these, call the phone number listed, then, depending on the insurance, either complete the process over the phone or receive the forms via fax directly from the insurance. I am completely out of the loop once I send them the phone number.
PA: Which I gave them.
CP: To be clear. You gave them the number to call. The patient gave them the number to call. They had the number to call in their chart. However, unless I, CP, directly FAX them the same phone number to call, they cannot figure out how to start the p/a process?
PA: That's how they made it sound.
CP: You realize the inanity of this whole thing, right?
PA: I do. But I enjoyed talking to you.

Wednesday, March 13, 2013

It's Not All Bad

I am a big fan of ownership. No one is entitled to anything in this world and everyone is responsible for his or her own actions. Most of my posts have to deal with ownership. I hold my techs and pharmacists accountable for ownership on their part. Patients and all people should be held accountable too.
This is why I am happy when people "bother" me with questions about their healthcare. We all know the people and we all know how the conversation starts: "I hate to bother you because I know you're really busy, but..." While it's many times a trifling matter my techs could handle, I like these opening statements. It usually arises when someone has questions about their medication, insurance, interactions, or a recommendation.

I like when people notice their pills may look different. I like when they call to question it. There may be notes on the bottle or bag or someone else may have picked them up for these patients and not relayed the message but they noticed.
I like when they find old bottles and want to remember why they were originally prescribed this medication. They want to know if they still need it or if it can be tossed.
I like when they get new insurance and ask if we need it before they come to see us. I like when they ask if they can bring it by so we have it for next month when their refills are due.
I like when people remember theirs is a special order item; or there was an issue filling it last time and they call a few days early to give us time.
I like when people call their insurance to ask for a special override (vacation, moving, lost) then call us and tell us it's been approved and if we call the insurance, they'll give us the override.
I like when people ask us for recommendations: OTC's, vitamins, supplements. I like when they say we're accessible and their doctor is not.
I like when they say they trust us more than they trust their doctor.
I like it because it reminds me why I went to pharmacy school in the first place. It reminds me that, despite all the bad aspects of dealing with "the public", we are still dealing with human beings. While it takes a lot of these interactions to counter the negatives of our day, it is these that are the most rewarding.

Tuesday, March 12, 2013

Appearance is Everything

Appearance counts. Packaging matters. One of my biggest pet peeves is a poorly labeled/packaged product being dispensed to a patient. I checked with my trusty intern and found my alma mater is still teaching this as an important representation of our professionalism. Maybe the OCD that courses through our profession is responsible for this. Apparently, however, some people are not possessed by this.
We only have to touch the bottles one time. Our patients have to touch them every single day. If we hand them a sloppy-looking product, they are reminded of this daily. It is their indicator of how professionally we approach their healthcare. If they look like crap, the impression the patient will have every single time they touch the bottle is that we are careless, hurried, and just don't care. (Okay, we are a tad rushed at times.) If we can't even "slap a label" on it professionally, how poorly are we acting where it truly matters?
To this end, there are two packaging issues I really despise: plastic bags and undersized bottles.
I don't know where or why the plastic bag thing originated but a lot of pharmacies employ this for blister packs and other, oversized packaging. I hate this. Every store I have ever managed or worked has done this...until I arrived. Street drugs are packaged in plastic bags. Yes, let's reinforce the drug dealer moniker we carry. It looks horrible. It's tacky. It's unprofessional. Please make it stop.
Second in line are the just-too-small-to-accommodate-my-label manufacturer bottles. (Effient, Crestor 40mg, Aciphex, Bystolic, just to name a few.) It's worse if you are going to require that your medication be dispensed only in this unopened bottle. The least you could do is make it large enough to be labeled. Our shelves are full of every size of bottle imaginable. Why did you select this one? You're a wee bit too small. I think the manufacturers are playing with us. "Let's force them to label this bottle. But we'll make it 1/8" too small for a full label. That'll mess with their OCD. Either it looks like crap or they have to cut it to fit." Bastards. On the crazy side I occasionally see a labeled Zetia bottle. Really? As a patient, that would frustrate the hell out of me. That bottle's only slightly larger than a single KCl 20mEq tablet. Who tries to label it? We all have our other favourites (most Sandoz products come to mind--Losartan and Omeprazole especially.) Unless the manufacturer requires original packaging, I prefer to repackage everything. It looks neater. It looks professional.

Friday, March 8, 2013

Pharmacy School

Everything I need to know, I didn't learn in Pharmacy school.
Jimi Hendrix once asked "Are You Experienced?" Great song. Different meaning. Apropos of reality...

Sure the important clinical stuff was taught. And we had rotations for experience. But the true, real, day-in-the-life of a pharmacist was somehow overlooked.  Nothing can properly prepare someone for what it's like the day that switch flips; the day you check the Board's website and your status changes from intern to RPh as quickly as it takes you to click "refresh". It's that split second that reality hits.

I think all pharmacy schools should be required to offer a class entitled "What a Pharmacist Really Does". And I will teach it. It will be a traveling position as all schools in the country will need me to teach this class. It will be expanded to include guest lecturers in hospital, nuclear, and other specialty areas of pharmacy practice. The main focal point will be retail since most of the general information is the same.
From third party billing to impatient patients to prior authorizations to dealing with doctors and their offices to corporate requirements and customer service metrics to holiday schedules and immunizations to MTMs and OTC counseling and advice not taken to can-you-look-at-this-and-tell-me-if-it's-infected to addressing complaints to being a shoulder to cry on to counseling on life-changing medications and diagnoses to identifying stolen Rx rings and calling the cops and DEA and FBI to dealing with getting robbed at gunpoint to learning the laws but dealing with "grey areas" to professional judgement to "the law is the law" to transfer coupons to free antibiotics to being a most trusted profession to being a most hated professional to first of the month mania to end of the year craziness to new insurance cards to discount cards to vacation overrides to lost/stolen overrides to requesting police reports to requesting PMP reports to realizing this is just a normal Wednesday, I think there is enough material for a full semester. It would, of course, be a mandatory elective.

If you or your university would be interested in my lecture series, please contact me. I am sure everyone will want to have the best prepared students graduating from their university and this cannot be accomplished without my class...

Thursday, March 7, 2013


All I want is a little clarification. It's always a fine day when I get to talk to someone outside of my state. I still enjoy calling on transfers from out-of-state pharmacies. It gives me a chance to BS with the pharmacists and see what the profession is like elsewhere. Same can be said of speaking to out-of-state doctor's offices. The only thing I have discovered is we are all the same wherever you go.
I have conversations like this at my pharmacy and was really hoping we were special. Too bad for the pharmacies near this office. Now I know we are just as unique as everyone else...

Doctor's Rep: I have a patient who is on vacation in your state.
CP: Lovely. I bet she's having a terrific time. And?
DR: She left her meds here and needs me to call them in to you.
CP: Of course she did. One's health is always the last priority when packing for a long trip. Underwear, snacks for the trip, makeup, 11 different pairs of shoes and sandals, toothbrush, check. Medication that I take every day after brushing my teeth and putting on makeup? Whatever.
DR: Anyway, she needs Metoprolol refilled.
CP: Ok. Which one? And it's a FILL, not a REfill because we have not filled it for her yet. She may have taken it before, but we have not given it to her before.
DR: I don't know. 50mg?
CP: That was in the form of a question.
DR: The one she had before.
CP: Which we've established we've not given to her before. And that would be...?
DR: Hold on. Let me check.
CP: <trying not to weep, but planning ahead for what I know is coming next>
DR: Here it is. It's 50mg once a day.
CP: <And here it is, as expected> And which form of Metoprolol might that be? Tartrate or Succinate?
DR & CP (simultaneously) "I don't know"
CP: Of course not. Could you check that too?
DR: No. All it says here is Metoprolol.
CP: So all along you prescribe "Metoprolol 50mg once a day" and some pharmacy fills it like that? You've never received a call asking for clarification?
DR: Nope. She's been on it so long they just know.
CP: But you've been prescribing it all along and don't have it in the chart?
DR: No.
CP: Then I shall wait to hear back from you before I can fill this for her.
DR: So you're refusing to fill it for our vacationing lady?
CP: Nope. I'd like her to enjoy every bit of time she has to spend in our great state. The sooner you can get back to me with that, the sooner she can enjoy all we have to offer here besides aisles and aisles of overpriced seasonal merchandise.

Wednesday, March 6, 2013

Prescription Hide-and-Seek

I get paid to fill prescriptions.
I am fairly certain that if I filled no prescriptions, no one would pay me.
So I fill prescriptions and they pay me.
It is in my best interest to fill your prescriptions.
I am not trying to hide them from you.
I am not trying to avoid filling them for you.
I am not deliberately trying to sabotage your life by withholding your prescriptions.
I am not making up "requires prior authorization" because I find it humorous.
I am not telling you "we didn't receive the e-rx/fax/refill request/Pony Express/Morse Code" from your doctor because I'm too lazy to look for it.
No, we are not all just standing around back here ignoring you. (That's why we made eye contact and said "we'll be right with you".)
If there are 4 people behind my counter busy doing 4 things, i.e. typing, on the phone, at the drive-thru, and waiting on another customer, then you are not being ignored. It's called waiting in line. It happens everywhere. Just stand there like the good little boy your mommy raised you to be and wait.
I have better things to do than play prescription hide-and-seek. While I may not have received it, as of yet, I am going to fill it as soon as we possibly can.
When will that be? Don't know.
Just rest assured that when we do get it, however it arrives, it will get its own little slot in the queue and march single file, like an ant, up my screen to await its birth as a fully-fledged, completed prescription.
And I'll get paid.

Tuesday, March 5, 2013

I am Required to...

A pharmacist's job description as listed on the website of a national chain:

Applies professional judgment in the interpretation and dispensing of patient medication in compliance with the state and federal laws that govern the practice of pharmacy. Dispensing of drugs includes the packaging, preparation, compounding and labeling of drugs. Provides oral and written information to both patients and physicians. Performs drug regimen review. Receives oral prescription drug orders and reduces them to writing, and may contact physicians as appropriate (or oversee others’ contacting physicians) for clarification of prescription information. Position will be trained in the following professional functions: Quality Assurance, DUR, Dr. Calls, and Product Verification.

I know what I am required to do. I went to school and they taught me. I had rotations and they taught me. I have been working for a little while and have experience to remind me. I am always fascinated when other people tell me what my job is. I often wonder where they learned my job description. Over my career I have become:
-Prior authorization faxer
-Refill request caller
-Refill request faxer
-Bargain shopper (try all these discount cards for me)
-Pseudoephedrine police
-Insurance adjuster
-Priceline negotiator? (But it's $4 at...)
-Pez dispenser (just need a few until...)
-Refill Reminder (BTW, your bottle is empty...)
-Babysitter (come pick up your refills, they're good for you, that's a good boy...)
-Personal shopper
-Waldo expert (Where'd my doctor send my prescription?)
-Honorary Psychic Friends member (I know when your doctor will call me)
-Travel Agent (You're going where? When? Need refills now?)

Just because our MHW profession has sold out does not mean I can ignore my REAL job description and duties. We need to take it back. It starts with erasing the bottom of this list from the psyche of the American public and the retail giants who are interested in anything but the progress of our profession.
Let me do my job.

Monday, March 4, 2013

How Important is it?

Some people are quite tenacious when they want an answer other than the one you are giving. It may take a while, but I am not going to change my answer and you are still going to leave. Why are some people so argumentative?
GL: I would like to know if I can eat grapefruits with my medications.
CP: Ok. And what medications may they be?
GL: Lipitor and Norvasc.
CP: Well that would be no. You cannot eat grapefruit or drink its sweet, tart juices while taking either of those medications.
GL: Why not?
CP: <long consultation about the interaction takes place>
GL: Well what about if I take my pills at night instead?
CP: Again, <short reiteration of the interaction; emphasis on the "lasts around 4 days" part>, you cannot take this regimen and enjoy these juicy fruit.
GL: But what if I...
CP: Ma'am, no buts. You cannot take these together. Why are you so adamant about the grapefruit, may I ask?
GL: My son sent them to me from Florida.
CP: And that was a lovely gift. But you should share them, not eat them.
GL: But I want him to know I ate them.
CP: Maybe he's trying to kill you?
GL: I don't want them to go to waste.
CP: I like grapefruit.

Friday, March 1, 2013

A la Carte

I think...Retail Pharmacy needs to just admit we are Money Hungry Whores (MHW). I have decided, rather than fight it, to just embrace our new role. Let's rename all our chains (MHW RX).
First...I want to start with an a la carte menu. The one that they have at the Chinese restaurants with the tasty pictures. But...I want it to be fine print. I want it to look like the old NYSE boards where the numbers flip. I want every insurance copay for every drug in an alphabetical list on this screen. We can even put tickers in the waiting rooms and at the front door. And on the building's facade. This way, whenever anyone wants the price, we can tell them it is posted and while they are waiting for us to fill their prescriptions, they can locate the price. Maybe it will show up faster than we can process it. It's a race! 
I would also include our services: Flu Shots, Zostavax, Pez Dispenser (for the just-gimme-a-few crowd), where the price fluctuates daily or hourly depending on staffing conditions. If you want it at noon on Monday-$60 for the flu shot. If you wait until 7pm Thursday, $15. 
We'll create an app that will allow you to scroll through these. It will link all the pharmacies in the state to a central database. It will be like the DisneyWorld app. You can see where the wait times are the longest or shortest and go there based on how valuable your time is instead of worrying about the pharmacy's "rather arbitrary" wait time of 30 minutes. 
Customer service is the future. Professionalism is overrated. Our collective companies' motto is "We don't care about your health. We care about your wealth." Everything our "profession" has done to improve customer (note-not patient) service and compliance has been about more money. I say let's run with it. Let's all sit down with APhA, our other scattered local, state, and national organizations and tell them the corporations have won. Stop fighting it.