I'm Confused

Wife calls in for a number of her husband's refills. Easy for her, confusing for me...

Patient's Wife: He needs these 4 refills.
CP: Okay. It appears these two numbers are out of refills.
PW: "That don't make no sense." <verbatim>
CP: Sorry?
PW: How can he be out? He gets them when he's at the office.
CP: And when was he there last?
PW: 6 months ago.
CP: Okay. He filled these each month for the last 6 months. He is out of fills.
PW: "But that don't make no sense."
CP: But why not?
PW: Because he is at the doctor's right now! The doctor said he was going to be sending over new prescriptions at noon.
CP: And you do realize it is only 10:15 right now?
PW: Of course. He has an appointment right now. He is there right now. The doctor is sending his refills over at noon. But I don't understand how he can't have any refills left.
CP: Um. If I understand you, which seems to be unlikely, it goes like this: Your husband gets refills when he is at the doctor. This occurs every 6 months. He is out of refills. He is at the doctor presently. His doctor is sending refills later today. This means he will not be out of refills for the next 6 months. This means he will get his prescriptions today. So what is there to not understand?
PW: "It just don't make no sense. Whatever. I guess you can just fill whatever they send over later and hope he gets everything. But he shouldn't be out if he's there today." <verbatim>

CP: Um.

Answering Service

It must be nice...
The only thing harder than trying to track down a prescriber is...
Anyway, with the exception of 24 hour pharmacies and hospitals, most of us in the healthcare world have to deal with Hours of Operation. Most pharmacies are open 9-9, 8-10, or some other variant of a long day. Most prescriber offices are open 8-4:30, 9-5, or something along these lines. We all arrive early to get a jump start on the day. However, the problem I have is with places that close early. As you can guess, I have yet to meet a pharmacist who says "yep. work's all done. no more appointments scheduled. let's go home at 7 instead of 9 tonight and roll the phones over to the answering service". This means I am picking on the offices.

I called and left a message with an office that had written a prescription for Brimonidine. That's it. No strength. Patient came in at 3:44 screaming that she was without her drops and the office was still open so call them back!

I patiently listened to the office's machine: "We are open daily from 9am to 4pm..." I thought, this is good. It is only 3:44. Then the phone rolled to the answering service.

Answering Service Staff: This is the A.S.S. How may we help you?
CP: Wow. I thought they were open until 4pm. It's only 3:44. I was hoping to get an answer to a question I had on my patient's prescription.
ASS: They're not in.
CP: Yes, but since they're supposedly open until 4pm, and it's not quite yet that time, I was optimistically thinking you may be able to reach their back line. I was hoping they may have recently switched their phones over to you and may still be playing cleanup over there.
ASS: No.
CP: Do they pay you per word? Seriously, so what time did they actually roll their phones over to you today?
ASS: At 3pm.
CP: So a full hour early? Does that not bother you that you get to do more work because they thought it was acceptable to just shut down an hour early for the day? Don't you wish you could return the favour? Perhaps roll their phones back to them earlier in the morning or at lunchtime?
ASS: No.
CP: Wow. Perhaps you should just work in the office. Your attitude seems the perfect fit. I understand why the patient sees them now.

Patient: Well?
CP: Sorry, the office closed an hour early today.
Patient: So? I brought this to you last night. It's your fault I can't see now.
CP: Yep. Even though this was written last week and even though your office posts a closing time of 4pm and they left an hour early, and I called them at 8:34 this morning and had to leave a message they did not return, explain to me how this is my fault. Go on. Explain to me how it's my problem. You need to find a better doctor...and a better attitude.

Caption This

Found this and had to laugh. It's from an insurance company. That, in itself, is laughable.

Mom: We need her medication for ADD.
CP: I'm sorry. It's not covered.
Mom: But she needs it.
CP: Well they require a prior authorization.
Mom: How's that work?
CP: It's really a distraction technique meant to make us all do more work. It's like a circus.
Mom: Really? So how do I get her medication?
CP: Your doctor has to call to tell them why she...Hey look! A Teddy Bear!
Girl: Thanks!

(I know it's wrong, but isn't this how insurances make us feel?)

Notice how the pharmacist has a death grip on the arm?
"See this arm right here? That's how much it's going to cost your mommy because her insurance sucks".

Privacy?

Expectation of Privacy? Forget it at your local pharmacy...They may have ropes, painted lines, neon signs, arrows, and pits with punji sticks meant to keep people back. Nothing works. One, they'll still ignore them and crowd others. Two, sound actually travels. It doesn't go out 2 feet then hit a wall. This means others can hear you. It's nice we attempt to give you some privacy, but with the open floor plan stores favor, it's not going to happen.
I think we should install prison visitation booths. We could have a wall of windows and little chairs. There would be a phone on each side. A pharmacist would pick up one and counsel you so only your side of the conversation could be heard. Think about it: just like in the movies you could lift your shirt, stick your body to the glass and ask "does this look infected?" Ok...not like the movies...

Modern English

I love words, as many daily readers can tell. Dumbledore said "words are, in my not so humble opinion, our most inexhaustible resource; capable of both inflicting pain and remedying it." I also find them quite funny when placed in a certain order on prescriptions. Some of my favourites...

Take 1 tablet by mouth 2 times a day as needed for pain with food.
(Is that only for "pain with food"?)

Chew one tablet by mouth and swallow every evening.
(When do I chew it? and do I have to keep it there all day before swallowing it?)

A rather specific type of sex being prescribed here. Sorry, doctor's orders...

The Dumb Leading the Dumber

It is, at its most basic, a simple concept.
Get unwell.
Go to doctor.
Receive diagnosis and prescription.
Take prescription to pharmacy.
Fill prescription.
Go home and take prescription.
Refill Prescription.
Refills run out, go back to doctor to restart process.
Do Not Skip Steps.

Simple. Then how can it get so complicated? I offer the following as a lesson, a testament, to how wickedly awry the system can go. It is only one example. I have examined many others ad nauseum this week. One more won't be beating the dead horse...

Office Caller Inner: <on voicemail> Patient needs Lisinopril 10mg, 2 tabs BID with 2 refills. The old Rx# is 8675309 (nudge nudge)

CP: <calling back> First, there was no quantity. Second, your message said he takes 2 tabs twice a day. The Rx# you gave me was for his last refill last month which had him taking 1 tablet twice a day.
OCI: Okay?
CP: Sorry. I felt the question was implied and I needn't've actually asked it. I was hoping you could infer from the factual statements that something was amiss.
COI: Hold on.
CP: <patiently singing It's the End of the World by R.E.M in my head>
COI: It's once a day.
CP: And how did we arrive at that in the 7 minutes I was on hold?
COI: "Yeah, the wife had it wrong." <her exact quote>
CP: Sorry? You mean to tell me that the wife called in the refill to your office. She gave you what she THOUGHT were the correct directions and then you phoned them in that way?! Did you not think to actually look them up to compare them? Did you not verify the patient is actually, oh I don't know, still taking this drug? This dose? I guess I can randomly call in my refills to your office for whatever I want and just make up dosing because I know you're not checking it. That instills confidence in me. Unfortunately, this just reaffirms what I already thought about your office which is why I never refer anyone to you. Ever. What's worse is that you kept me on hold to call her back to double check with THE WIFE instead of pulling the chart. The chart which is located in your office. Fortunately for you, I did MY due diligence.

You Can't Have One Without the Other...

It's like a vehicle and gas. No one needs to tell you, hopefully, to put gas in the tank so your car will work. However, neither your car nor the valuable petrol require a prescription. In the world of medicine, most insulins and pen needles do require a prescription.

Okay, where is this going? Simply put, why can prescribers not understand that in order to administer insulin, primarily from pens, a patient requires pen needles? Why do they insist on writing hastily scrawled orders for insulin, but not the device to administer them? I like to call them back and politely remind them they forgot something...
(For today's exercise, let's assume I am speaking solely about patients who are initiating therapy on insulin. This is the first prescription they are receiving. The doctor obviously knows this.)

Forgetful Writer: What's the problem?
CP: You wrote prescriptions for this patient, new to insulin, to receive Levemir and Lantus insulin pens.
FW: Yes. I wrote an Rx for each one.
CP: You did.
FW: Then what's the problem?
CP: I was just wondering how the patient was going to get the life-saving serum from the pen and into the subcutaneous layer of her skin.
FW: I would imagine syringes would be most helpful.
CP: Actually pen needles would be more appropriate. Nevertheless, here's what I'll do for you. I will write a prescription, attach your name to it, then document that we spoke and send the patient on her way, none the wiser that I saved her multiple trips to my pharmacy or multiple phone calls to your office to pester you for something as important as her needles. Sound good?
FW: Absolutely. Thank you for saving my butt once again. I wish I had gone to pharmacy school like you. People always find you more approachable than I. You're also incredibly respected, intelligent and witty. Glad you have my back...
CP: Aw, so kind. I'm blushing. Just doing my job ma'am.

Doctors and Faxes

More fun at work...
Yesterday I received a reply fax from a doctor's office; a rather sizable clinic not especially nearby. It said "In an effort to promote patient safety, we will no longer accept faxed refill requests from pharmacies". I decided to have a little fun and send them a fax that says "In an effort to make everyone happy, we will no longer accept faxed requests to stop faxed requests. We will only accept certified letters addressed specifically to each pharmacist and technician, by name, currently employed at this location. Thank you for your efforts in this matter as we try to prioritize our time and resources. All future faxes will be ignored."

I'm thinking another option would be this:

"Dear favourite local office. Due to the overwhelmingly popular craze of doctors requiring, even mandating, that pharmacies are responsible for faxing refill requests on behalf of their patients, I find it unreasonable and impossible at this time to comply with your request. I have attached a list of the offices who have this as part of their outgoing message. Please feel free to contact every single one of them and get them to change their policies. When that is accomplished, we will be able to honour your request to not fax you for refills."
Also, please explain how you are "promoting patient safety" by not accepting refill requests. Had you simply said "in an effort to get recognized as a Green company we are trying to save paper", I may have bought it. Last time I checked, many offices have a HIPAA trash receptacle where these faxes could get "filed". It's the same place I file the blast faxes notifying me I won an all expense paid trip to the Bahamas or I've made the Who's Who List...again. (I am quite successful as I've made the list almost every day for as long as I've been a pharmacist!)
You have a trash can. Use it!

Do you also go through your spam folder and reply to all the Canadian Pharmacy and Dr. Oz miracle ads in an effort to stop them from clogging your inbox? No. It's called a "delete" button. Click it.

I also love that the faxed letter included a note, along with the list of 50-odd prescribers, that some of them may, or may not, at some point, possibly in the future, be getting a new technology, currently known as electronic-prescribing. Maybe. They think this may be revolutionary and make the refill process easier. Yep. Welcome to the phuture...

Pharmacist Phix-it-All

Doctor omits something from a hand-written prescription? Pharmacist calls.
Doctor sends out an incomplete e-script? Pharmacist calls to fix.
Nurse leaves incomplete information on voicemail? Pharmacist calls to fix.

Forgot to sign it? Pharmacist will call. 

Forgot the patient's name? Pharmacist will call. 

Wrote the wrong patient name? Pharmacist will call. 

Forgot his DEA# on a control? Forgot to write and spell the quantity on that control? No worries. 

Can't read the handwriting? Yep. We call. 

Yes. That is our job. In order to fill a patient's prescription, we must have all of the correct, complete information. This often means we need to track down a doctor, prescriber, nurse, records room, etc to do our jobs. I just wish these prescribers didn't have so much faith in us.

Basically, doctors don't change their habits. Despite repeated phone calls (I know I'm not the only pharmacist that cares about my license), these offices never change. It is the same problems all the time. I'm tired of excuses like "it's the software". Really? I have a customer service number I can call. You should too. Call it. Now!

I'm tired of the "why is your pharmacy the only one that calls us about this?" excuse too. No. I am certainly not. I also get "well we'll just tell them to go elsewhere". And patients say the same things: "guess I'll take this down the street. They always fill it."

Doctors have no accountability. Pharmacists will fix everything.

Street Dealers

Random thought...
Since corporate Pharmacy has invested lots of money into squeezing some extra coin out of everyone's pockets by coming up with Automated Predictive Refills, I wondered if this system would work in other areas of the drug trade. (Yes, it is a scam. Yes, I may or may not have sat in some corporate meetings at some time but that's not the point today.) The point is, could street dealers benefit from the same corporate philosophy to help grow their business? Imagine the revenue if they were to develop an automatic refill reminder program. Just a random text or call that says "Your refill is due" or "You have an order ready for pickup".

Unlike those of us in retail pharmacy they have no issue of refill-too-soon (you got the cash, we got the stash). They almost certainly wouldn't have to deal with the return-to-stock issues either (well, I don't really need it today, but since you have it ready and I drove all the way out here...). How happy would those recreational users be to get a friendly reminder it's time to resupply? Also, talk about a money-making scheme ripped from corporate greed: taking advantage of those who don't know they're being taken advantage of! Profits would skyrocket and these entrepreneurial types would be well on their way to graduating to the Big Leagues and leading corporate America. Although I think they may all work at Pfizer. How else can you explain the direct-to-consumer strategy. Perhaps street dealers taught Wall Street something...

Fair Play...

Prescribers' offices hand out cards with discounts on medications. These discount cards are all over print media and the Internet. While some patients do realize decent savings, they are in the vast minority. Mostly, these are just a means to distract your local, loyal pharmacy from doing its real job: Speed-filling your prescriptions for superior customer service recognition awards from corporate people who don't understand the profession!

Today I present you with the first Office Visit Card. Hand these out to your patients, on the streets, on Facebook. They're Free! Prescriber Services will be discounted. From X-Rays to MRIs, from blood work to blood pressures, you too can realize the discounts available at your local prescribers' offices. Simply present this card and let them struggle with how to get you these low, low prices. You can now bring your years of pharmacy experience of yelling at the staff directly to the offices of your prescribers. Let them enjoy the endless phone calls, the yelling and screaming about why your copay isn't $4.00 for a CT Scan. Make that 80/20 or 90/10 copay a thing of the past. Maybe by the time they figure it out, we may have actually received that e-script they think is instantly ready...

This Here's Not Legal

Had a customer present us with a regular sheet of 8 1/2" X 11" white paper. On it, scrawled in doctor scribble with a ball-point pen, was a patient name, address, Rx for Vicodin, and a signature. That's it.
When I told the customer this was not a valid prescription, I was yelled at. I wept.
This is a transcript of the witty repartee that ensued...

Bad Script: This here is good.
CP: Hardly.
BS: Uh-huh!
CP: Nope. Not in my State.
BS: Yes it is. I just took this to another pharmacy and they filled it for me no problem.
CP: Sure they did.
BS: Yes huh! My doctor even said you can call her and she'll tell you it's good.
CP: Really? A real doctor told you that? Right. How about "No"? Not going to happen. I am not going to call your doctor for a Vicodin prescription if she doesn't know how to write one. Never mind the fact that your insurance is State Medicaid. They require that all prescriptions be written on tamper-proof paper. Your Xerox copy sheet here does not qualify.
BS: Well I'll just take it somewhere else and they'll fill it for me.
CP: Go right ahead. I'm sure you'll find a pharmacist who no longer likes her license. Kinda like your doctor...

Just because you're trying to make a loud, obnoxious scene in my store does not mean I shall cave to your demands and reward you with the filling of a horribly illegal prescription. I have plenty of other prima donnas here that deserve more attention than you. Like the guy running in to refill a single Viagra because he apparently found a willing participant and needs to get back to the car before they realize what they've agreed to do.

Something's Wrong

Something's wrong with the world today. I don't know what it is. No, something's wrong with me. All these years of dealing with drive-thru customers and I, I just don't know how to act anymore. I think what I did was wrong. But now I'm not sure. Pharmacy patrons treat the drive-thru like it's Fast Food. Please allow me to confess my sins then tell me if I was wrong.
It was a beautiful, sunny Sunday morning as I headed to work. Feeling a wee bit peckish I decided a meal from McDonald's would hit the spot. As I neared the turn for their driveway I noticed a long line of cars already snaking around the building. There were 7 cars in line before the ordering station.
Then something came over me. An epiphany? A dawn of realization? Something happened that caused me to bypass that line altogether. I actually parked my car. Yes. I parked my car and walked. I walked to the front door. I entered the store on my own two legs. I walked up to the counter and what, to my surprise did I see? Nothing. There was nary a soul to be found inside this morning. Quickly I approached the counter to place my order. Apparently it surprised the cashier who almost forgot how to log on a register and that people would actually come inside in the morning.
Seconds later, as I left with my warm breakfast and Caramel Mocha in had, I noticed the position in line where I could have been had I decided to crawl through the drive-thru lane. I would not yet have ordered. Funny. I though about getting back into the line then and pretending I was at the pharmacy.
I would call the store from the drive-thru and ask what's taking so long?
I would honk at all the people in front of me.
I would get out of my car, walk up to the drive-thru window and scream "I just want a coffee! All you do is pour it in a cup!"
I would knock on other people's windows telling them to hurry up.
I think when I finally got to the front, I'd park and scream for fresh, hot hash browns and I wasn't going to move until I got them.

But I did not. I simply smiled as I got in my car and drove to work, at peace with the decision I had made to walk that day and wishing, just once, my customers thought as I did that one sunny morning...

Mom

When I was a child, I had a fever. My hands felt just like two balloons...

...And my mom took care of me. She told me what to do and when. She scheduled my appointments for me with the doctor and to have my hair cut. 

As I grew older, I gained responsibility for myself. I learned to do things for myself. At what point are you too old to have your mother doing everything for you?
I ask because of the number of people, especially women, who have their mothers call in, then pick up and pay for, their medications. The ones that get me most are the women on birth control. If I'm in my 20's, I don't think I want, or need, my mom taking care of my contraceptive needs. First, you're old enough to do this on your own. Be responsible and do it yourself. Second, while it's nice that you two can share everything in your lives, it's a little weird asking mom to refill your Valtrex while she's here. "Hey, it's going to be a long weekend so grab a bottle of Astroglide while you're at it, Mom."  I think the only thing creepier is the fathers tasked with the same duties. It's one thing for a father/husband to be sent for feminine hygiene products. In fact it's quite impressive when they do. It's quite another to be told he's restocking the Princess Procreation Party Kit.
These must also be the women who invite their mothers to their sex toy parties.

*Yes, not all birth control is taken for birth control. Of course I know that. And you, of course, know these are not the cases of which I speak...