Policy Impasse

What do you do if your policy conflicts with another party's policy?
Throw a fit? Cry like a baby? Send capital-letter faxes, essentially shouting at someone?
Most pharmacies have the policy where they "fax your doctor for your refill request". It's a courtesy, but most places offer this.
Many prescribers require pharmacies to only fax requests (e-requests go automatically, but that's different.)
What do you do when you receive a fax telling you you won a trip to the Bahamas? Or your information is wanted for the next Who's Who publication? Trash it. Throw it away. Discard it. To the rubbish heap with it, post haste!
But what if you are a prescriber? What if your policy is to not accept faxed requests? You do this:

"Attention. We are no longer accepting faxed refill requests. Please have patient call the office for refills."

Hmm. I just sent you a fax alerting you to a patient of yours who is out of medication and needs it from you. Would it not be prudent to contact said patient yourself to schedule their appointment with your office? It seems rather circuitous to fax me to have me call the patient to tell them to call you, don't you think?

Also, I assume you have this posted conspicuously in multiple places around your office? I assume you sent letters to all your patients notifying them of this policy change? I assume you are not relying solely on me and my competitor colleagues to spread the word for you?

Do you have a trash can in your office? Perhaps a HIPAA-delegated receptacle? Use it. Rather than wasting my time, and yours, faxing this back to me, devote your energy to dropping it into this bin. Gravity will actually do most of your work for you.

But since I'm making points here, wouldn't it be just as easy to sign the fax I gave you, and instead of sending me a letter telling me you no longer accept faxed refill requests, you could have faxed me that refill request? Simple. Fast. No phone calls. No extra work. Everyone is happy.

I know. Silly, right?

Look Before You Call...

If I've lost or misplaced something, I shall attempt to find it on my own, retracing my steps, until calling someone to waste their time bringing them into my search.
Why do people not look before they call? Why do people instantly get their feathers ruffled before I even pick up the phone to help them solve their problem? I never thought of the pharmacy as a place that was out to get people. Why the accusatory tone when calling me? I have way more instances where I "found" people's cards/rx's/bottles/etc. in their houses and cars than I do cases where we forgot to give it to them.

Average Customer: Hey, you didn't give me one of my prescriptions. I paid for it and everything. I drove all the home, a whole 1.5 miles, and now I have to come back!
CP: Yes sir it is still down here. Fortunately for you a fine upstanding citizen took it out of the shopping cart/basket you left it in and brought it to our counter. We were just about to call you.
AC: Somehow it's still your fault!
CP: And yet you still have to come here to retrieve it. I'll be waiting for you to slink back for that, along with your dignity...

True Story: I just left there and can't find one of my bottles.
CP: We sold you 3 bottles. They were in the bag before I stapled it shut.
TS: Well I opened the bag to take one and I jammed on the brakes and they went flying. Maybe it's in my car.
CP: Sure, I can wait all day while you check that.
TS: Yep. Here they are. Under the passenger seat.
CP: You realize I have to bill you for this? It's the new Consulting/Finder's Fee. If attorneys can do it...

Old Lady: Happy Monday. I just left my doctor and he gave me 2 eye drop prescriptions. I ran out.
CP: I tried to fill them but they are too soon. Do you get them from mail order?
OL: No. My one bottle is empty and the other is still good. But I need these today.
CP: Have you ever used another pharmacy?
OL: No. I come here all the time. Try them again.
CP: Sorry, they are still too soon. Do you get prescriptions anywhere else?
OL: No. But I send away for them though.
CP: <smh> Um. Silly question. Do they "mail" your drops to you?
OL: Yes.
CP: Okay. That's mail order. Have you recently received any eye drops from them?
OL: Well I got 2 packages from the company delivered to me on Friday but I haven't opened them yet to see what's inside.
CP: Okay. That'll be $25 for the wasted billing time.

Every Customer: You forgot to give me my insurance card back.
CP: I handed it back to you after I scanned it into our computer while I was rebilling it. I watched you put it in your wallet.
EC: Oh. I didn't look there...Yep. Here it is. <click>

A little information goes a long way...

...or does it?
A little knowledge is a bad thing. Think about those people you know who know just enough to make them dangerous. They're called general practitioners...(Just kidding. I meant Nurse Practitioners. JK, again...) They are your friends, or FB friends, who know a little about everything and are always the first to tell you how much they know.
Pharmacists know a lot. We do. Just look at the faith our patients have in us.
Real questions from real patients (NOT actors...)
1. "I read that red wine is good for my heart. What kind do you recommend?"
(Sorry, I've watched the awesome movies Som and Bottle Shock and I consider myself an oenophile only by the fact that I drink wine annually in Niagara, but I am far from qualified to help your heart.)

2. "I heard that ladies find bushy eyebrows to be attractive. Do you think I could use Rogaine above my eyes to thicken them? Can you research that in your spare time?"
(Yep. My spare time. So you can be a hit with the ladies at bingo night. Tell them you just took your Viagra 45 minutes ago and their motors will be revving.)

3. "I have to wait for my prescription and I need to know how long it'll take, but I want to know if I'll be okay. The signs out front said 'No Parking' and I figure I'm okay since I parked between the 2 signs. What do you think?"
(I think I'm going to call the cops. You'd better move your car. Don't worry. The prescription won't be ready for about 20 minutes so you've got time.)

Sometimes, to prove my earlier point, a little knowledge is definitely a dangerous thing. I would not have believed this one had I not been there to bear full witness...

4. Lovely Elderly Couple: Do you have this OTC product?
CP's Partner: What's it called?
LEC: Not sure.
CPP: What's it for?
LEC: Diverticulitis.
CPP: Anything else you can tell me?
LEC: It's either a capsule or a liquid.
CPP: Please allow me to show you what we carry that may fit the bill.
LEC: Nah. That's not it. You don't know what we're talking about. We're going to "Place That Knows Gibberish"
CPP: Good Luck!
LEC: Nyah!
CPP: They were pleasant.
CP: As I always say, a little knowledge is dangerous. Especially for us...

Out-of-Stocks

I realize there are out-of-stock issues. They happen. Sometimes it's a manufacturing problem. Sometimes it's an ordering problem. Sometimes, it's a popularity thing. I cannot predict that all my patients who used to get 30 days of their medications will all come in today with new prescriptions for 90 days. It happens. We have to adjust our order points. Inventory is fluid, especially subject to change with the seasons (Pharmacy Winter, Flu Season, and Pharmacy Summer).

CP: I'm sorry but we do not have enough to fill this today. We will have the rest in tomorrow. I can give you a few today to get started or you can come back tomorrow and receive the full prescription in one trip.
Miffed Father: You mean I gotta come back?
CP: Unfortunately, yes. We've had quite the run on this today.
MF: But I always get this here.
CP: And you always got 30 days. This new prescription is for 90 days. We have enough to cover 30 days.
MF: So you don't know how to order?
CP: I do...For you to get 30 days. Besides, you've had this prescription for more than 2 months. Why did you wait until now?
MF: I didn't need it then.
CP: I may have had it then.
MF: Probably not.
CP: You're right. But I don't have it now either so there you go. You should have waited one more day.
MF: Would you have had it then?
CP: Probably not. But we'll never know, will we? Let's play pretend. I'll pretend you dropped this off with the intention of picking it up tomorrow.
MF: And what do I do?
CP: You come back tomorrow. Guess what will happen?
MF: What?
CP: Your prescription will be ready with the full 90 day quantity inside. I'll even bump up my inventory to accommodate your future refills. Better yet, we will sign you up for our SERF program.
MF: SERF? Like the feudal laborer?
CP: That's the basis for the acronym: Super Easy Rx Filling, SERF. It works for you. You are the lord of your own refills. Simply sign up and the system fills your prescriptions, calls your doctor for refills, calls you to remind you to come get them, and in phuture upgrades, will eventually take your medications for you. This way we can ensure we will always be in stock.
MF: You're kidding, right?
CP: Only a little. But it's up to you to figure it out. See you tomorrow...

Where is it?

Why do people carry wallets and purses? Men and women keep their money, license, credit cards, insurance cards, etc. in their wallets. Women have purses to carry their overstuffed wallets and just about anything any other person would need in the case of an emergency. For what reason should you ever be without your insurance card? (Okay, forgetting to put it IN your wallet, but there I go expecting logic and reason out of the general public...)

How do people manage to shop a store for an hour only to get in line and realize "I forgot my wallet"?

Do people get pulled over for speeding and tell the officer "I left my ID at home"?

Very rare are the instances when I would get in my car and not need something that would be housed in my wallet.
Why do pharmacies not require that a photo ID AND insurance card be presented with all prescriptions when they are dropped off to us? (It is harder with e-scripts, phone-ins and faxes. I get that.) My doctor's office left a message confirming my appointment and 4 times during the 30-second reminder call, they said "you must bring your ID and insurance card with you or you will not be seen".

Pharmacies need to implement this policy. In a prescriber's office, there is no "I'll bring it back with me when I come to pick it up" because you're not actually leaving. Besides, we do all the billing BEFORE finalizing your prescription. It doesn't go into the will call bag/drawer/bin without a copay on it.

I was kept 15 minutes late Sunday night and still lost a prescription due to Herr Douchebag's ineptitude. First he forgot the insurance when he dropped off the prescription at 10:37 (saying he would return around noon). Then he forgot his wallet with his credit card, but had the insurance, when he returned at 4:07. Then he returned at 4:58 only to get to the front of the line at 5:07 (we close at 5pm) with an expired credit card. When we told him we could not take his new credit card over the phone from someone on the other end of his cell (the cell he was on every time he was in our store), he asked for the prescription back so he could take it to a competitor who was open later. Prescription was written last month.
End result: I filled a prescription, had to rebill a prescription, had to waste time for his 3 trips through my pickup line, then had to cancel the filled prescription so he could take it elsewhere. I need to be able to bill him for this...

Pick a Name

Pick a name. Any name. But be consistent. If your given name is Richard Douglas and you prefer to go by Dick, please make everyone aware. This includes your doctor and your pharmacy. If your doctor has you listed as Ricky and the pharmacy has you listed as Dougie, do not blame us if we can never find you in the computer.
Women are by far the worst. "My name is Cynthia with a C, but I go by Sindy with an S around my friends and at businesses that have a silent P in them. Also, my last name is hyphenated. It's Jones-Smith-Watson. I've had my doctor since I was single so he only knows me as Jones. Professionally I go by Watson, but the pharmacy has to have all 3 since that's what my insurance has on file and the IRS needs them all too."

Huh?
Seriously. Do not get mad at me because you cannot commit to a name. If you don't know who you are, then I shouldn't be expected to know either. We have enough trouble matching dates of birth with insurance companies and deciphering the hieroglyphics that doctors pass off as prescriptions without worrying if we have the correct patient.

Also, do not get mad at me if i don't know how to pronounce your name.
CP: What's the name?
Angry Customer: Smith
CP: I have one here for "Kate" Smith?
AC: It's pronounced "Yolanda"!
CP: What? It's spelled Kate. Should rhyme with Gate.
AC: My mom gave me this beautiful name and you people can't get it right. I hate you. I want a gift card for this heinous insult. You can't even pronounce a simple name.
CP: Please go away. Your mother was a hamster and your father smelt of elderberries.

(Yes. All of these cases happened. Names have been changed because, well, even if they weren't no one would know the difference.)

Irrational Entitlement Issues

Back in the day when there were more independents, many customers asked and expected corporations to match their prices. That was fine. Then the independents sold out to the MAN and in order to retain their customers and make them happy, pharmacies honored the price matching for them. However, it's been eleven years since they closed. I'm sorry but I can no longer match a price to a place that is now a parking lot. (Actually happened last year.) I'm sure if they were still in business, their prices would have climbed as well. Generic Percocet 7.5/325 from Mallinckrodt raised their price by over 300% recently. I'm not going to eat that.

Why do people insist on getting something they really have no right to receive? Here is my most recent, finest example:
A pharmacy was offering free antibiotics and other incentives to buy, sorry, "generate", customer traffic and patients for its pharmacy. I got into a discussion with a lady about their program after it ended.

CP: How may I help you?
Entitled Lady: I'd like this prescription filled.
CP: Ok.
EL: It's free, right?
CP: No.
EL: It says antibiotics are free.
CP: Not here. And over there, the program ended a few months ago.
EL: Well that's not fair. Pharmacies advertise them as free and I want them free.
CP: Again, not here. You are welcome to ask them, but as I already stated, the scam, sorry, "welcome offer", ended some time ago.
EL: I don't care. I wasn't sick at all when they had that and I didn't get to take advantage of it. Now I'm sick and I want free antibiotics!
CP: I feel your pain. It's just my luck I didn't start driving while gas cost less than $0.50 a gallon. I wonder if BP would allow me to take advantage of that now? I'll accuse them of ageism if they don't accede to my demands. I wish I could get coffee for less than $0.50 a pound, milk for less than $0.50 a gallon, and eggs for less than $0.40 a dozen like this is the 1920's. I wish the Black Friday deals were offered every day since I have to work and can't take advantage of the sales. Alas, such is life in 2013: where people are rude and expect everything to be given to them and prescriptions cost money and gas prices hover around $3. "Gobble gobble goo and gobble gobble gickel. I wish turkey only cost a nickel."

Priorities...

If you want to know where a person's priorities lie, ask if they have pets. If they do, stalk them on Facebook and you'll see lots of awesome memes, videos, pictures, and stories about their furry little babies. This is not about pets, pet lovers in general, or anything to do with animals at all. The reason I draw your attention to people with animals is to illustrate a problem. I am about to ask you two questions. Pharmacists, especially, will know where I am going with this before they read the second question. My point today, while slightly humorous, is intended to get everyone to think a little differently. To prioritize a little differently. Again, this is simply an example to help people understand where priorities often are placed.

My first question today, to all the pet people, is "Where are your pets' vaccination records?" Everyone will be able to tell you exactly where they are and often have them committed to memory.
(This works just about as well for those with children, but it is more poignant with pets. See question #2.)

My second question today, to everyone, is "Where are YOUR vaccination records?"

When I taught immunization classes, this was a favourite example of mine to illustrate how poorly we take care of our own health. This example is the perfect complement to the questions and statements we hear every day:

No. I don't know what it's for. I just take it every morning.
I know it's the blue one for something and the yellow for something else.
My doctor said I'd be on this until I die but I don't know why I am taking it.
It's not my job to know my insurance, that's your job.
What do you mean you can't just hand me a bottle of Lantus to get me through the holiday weekend when I have no refills and my doctor is also on vacation?

Discrimination

Discrimination-noun
the unjust or prejudicial treatment of different categories of people, especially on the grounds of race, age, or sex

Had a new one recently...If a company advertises a 3-month supply as $10, is it $10 regardless of quantity? If not, is it a discriminatory practice to charge more?
Without an asterisk to explain *typical 90-day supply, this is misleading. If someone takes a medication once a day and another patient takes 4 tablets a day, the quantities are quite different, yet the day supply is the same.

It is no different than explaining the car companies are not discriminating against you because you bought a truck with a 20 gallon tank and the little economy car only has a 12 gallon tank. Sure, it takes more gas to fill, but it's not discrimination. You're not sicker because you need a higher dose. 

A guy pulled out his phone and wanted to record our conversation. He was accusing me of discrimination on the grounds that he was "sicker" and needed a higher dose than the average person. He threatened to sue me and my employer. Medications come in different strengths, dosage forms, durations of action, etc because not everyone responds to the same medication the same way. 

Do bigger clothes require more material and are they more expensive?
Bigger turkeys weigh more and cost more. If you're feeding a family of 20 for Thanksgiving, is it discrimination because you require more food to feed them than a family of 4? 

I'm not sure if the novelty of his argument surprised me or just pissed me off for the insane logic behind it. 

Doctor Don't Tell Me What to Do!

Take this to your doctor...
Dear Doctor,

Why? If you know something will not be covered, why prescribe it?
When did it become MY responsibility to call you?
If you are going to hand this to a patient, it had better have your home phone number on it so we can call you. If the patient comes to my pharmacy at 7:15 pm, the night before the procedure you better make damn sure you can fix his prescription. In what illogical, backwards world do you live where you think this is how the healthcare world works? Tell you what we're going to do. I will call and find the alternative. I will tell you exactly what to prescribe. I will then bill you the full cost of the first prescription you wrote; you know, to cover my costs. Every time I see one of these letters, you get a bill. Each minute I spend on the phone on hold with the insurance or a member of your staff, will be billed my hourly rate.
Seriously...where in the world do you think this is at all acceptable? You better be certain you answer the phone when I call. Better yet, print your home address on these so I can send the pissed off patients to your house for the new prescription. I didn't go to school to be your bitch.

ThankYouForCallingWeHaveFluShotsCanIHelpYouOrCanYouHoldBecauseWeAreBusyAnd...

Hello Mr. Krinkle. How are you today?
Pharmacies now require their staff to answer the phones with such a long script, it's amazing we have time to fill any prescriptions.
"Thank you for calling CP Pharmacy where we offer all kinds of vaccines like Zostavax and the Flu Shot and the Tetanus shot, and we have a convenient drive thru and a $4 list and free antibiotics and we give gift cards if you complain at all and sometimes we even fill prescriptions when there is time and my name is Cornholio and I need TP for my bunghole and I am a pharmacist and how may I help you today?" (deep breath)...

I think it's stupid. We as a "profession" advertise the hell out of our services. I almost feel like those lawyers who prostitute themselves all over TV with ads that say "we'll make them pay". They give lawyers a bad name. Same here. If someone doesn't know we offer vaccines and have free antibiotics and $4 lists then I say "good!". Ignorance is bliss and I want them as my patient. It means they have no expectations and I can win them over because they just want a prescription filled by a friendly, caring pharmacist and they chose me for that reason.
The saturation of advertising our "professional" services is horrible. Everyone thinks my pharmacy has a drive thru, offers $4 generics, has free antibiotics, and offers other "perks" when I have none of these. It doesn't matter because everyone else's ads make it appear every pharmacy is The Money Hungry Whore pharmacy. While we all would like to make a profit, we're not all the same slut.
If they would take all the money they focus on advertising, from the little phone scripts (time wasted is money) to the little buttons the staff is forced to wear (pieces of flair), to the skywriting planes and robocalls, they may be able to hire staff that would actually be able to focus on filling prescriptions. Word-of-mouth is still a great way to build a business. Short wait times, friendly staff, and variety of services will be easier to achieve if the pharmacy isn't so focused on advertising/posturing who they wish they were. To the corporations I say, Shut Up and Put Up. Shut up your promotions and gimmicks. Put Up your best staff and focus on filling prescriptions. Show me a company that wants this to be a real profession again.
The next thing you know corporate will send some lackey in to stand behind us with a stopwatch and time every step of our filling process and dock us for typing too slow, or too fast, or not checking voicemail every 49.7 seconds, or...wait. Sorry. They already do that. If only they worried about getting them filled correctly instead of quickly...

Blankety-Blank

CP: Do you have your new insurance with you?
Proud Patient: Indeed I do!
CP: You're kidding, right?
PP: Nope. They said everything you need is on this card. Why are you so stupid? I use this same card at every other pharmacy and just used it at my doctor this morning. You're an idiot and I want a gift card and a free Duck Dynasty Chia Head or I'm going to hold my breath and...

<CP pushes button that drops PP into the Rancor pit.>

Mathleticism

To be a pharmacist, one must be good at chemistry. Check. And Math. Check. Really really good at math. Okay, check. To anyone else in the healthcare professions, math is an annoying conspiracy created by pharmacists to give themselves something to feel good about doing when they're not whining about how hard it is to count by fives. Huh?
Computers calculate doses now. Simply enter the weight and preferred product into the computer and poof! out comes a magical dose. No matter that it is impossible for a mother to administer this to her child. That's the pharmacist's problem and the mother's.

My finest examples come from these recent experiences:
1. "Give 1/10 tablet to your pet." Yep. 0.1 of a tablet. If it were the size of a personal pan pizza, perhaps this would be plausible. Tipping the scales at just over 3/16" around, means it is more likely one would get 10 irregular-shaped pieces and a bunch of dust. It would be easier to cut the tablet, grind it into a powder, get a mirror and razor blade, and make 10 lines for the dog to snort, than it would be to cut this into 10ths.

2. "Give your child 3.87 ml twice a day." Correct, 3.87 ml. We have devices that measure in 10ths, but not in 100ths. She can give 3.8 or 3.9, but seriously? What's wrong with 4ml. (After recalculating the dose with the weight mom provided while I was on hold with the office, 4ml was well within the appropriate dosage range.)

It goes back to reliance on computers to do all the work. Prescribers were told how incredible these systems were and how there would be no mistakes and "everything will be wonderful someday". Wrong. We not only see MORE errors with e-scripts, we see errors that never would have occurred with the old ink-and-pen method of prescribing.  As it is with all other aspects of the healthcare world, the bastard stepchildren, pharmacists, will play clean up and thank you for the opportunity to fix their mistakes and ask for more. Doctors still believe their job only involves the diagnosis and treatment selection.

The Double Standard

I had an appointment. I was late. I missed it. I called them and told them my test at the hospital took longer than expected. (When I arrived they told me they were already behind 30 minutes. I still had a window of opportunity to make my appointment on time.) As I said before, I called my doctor as I was leaving the hospital and explained what happened. This is what followed:

Office Lady: I just sent you a letter.
CP: Huh?
OL: You no-showed your appointment so I just put a letter in the mail.
CP: I'm not even 40 minutes past the appointment time. You mean to tell me that you typed, signed, enveloped, stamped, and mailed me a warning letter about no-showing my appointment? Already?
OL: Yes. But you called so you can ignore it. I can reschedule your follow up for tomorrow.
CP: Okay. I'm going to hold my doctor to the same standards tomorrow.
OL: Huh?

<Fast forward to tomorrow when I arrive 5 minutes before my scheduled appointment time.>
I set my timer and stopped it at the 23 minute mark when the nurse took me to the room.
After her 3 minute vital check and Q&A session, I restarted my timer.
I stopped it again at the 23 minute mark when the doctor entered the room.

CP: You do realize that by now I would have a letter with my name on it threatening to kick me out of your practice for being 40 minutes late? You are 49 minutes late. What's your excuse?
Dr. Zoffis: Sick people, longer appointments, scheduling, blah blah blah.
CP: Whatever. Don't threaten me again. I have yet to be seen within 20 minutes of my scheduled appointment time since I've been coming to this office and your staff has the temerity to send me a letter within 40 minutes of a no-show? When you scheduled me for a test at the hospital and the follow up here? You'll be getting my letter next month discharging you as my doctor. It will include the new office to which you will send my files.