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Tuesday, April 29, 2014

Secret Shoppers

Who came up with this idea? It's like getting your best friend to hit on your girlfriend to check her loyalty...or his. In this case it's not about trust. It's about being able to keep an eye on you from a remote location: to let them know Big Brother is always watching.
For those unfamiliar, here is the gist of the program: Regular people, or actual employees of a company, visit a company's stores and pretend to shop. They make some observations then send a report to corporate. Some of them actually buy things, but they are testing you.
They ask questions.
They check on your wait times.
They check to see if you walk out and put products in their hands.
They check to see if you ask them questions.
They check to see if your smock is clean.
They check to see if your name badge is on it.
I think they get close enough for breath checks.

The problem I have with this is not that I have to assist my patients. I developed that habit a long time ago in a galaxy far, far away known as my internship. It's the mark of a great pharmacist.
My problem with this culture of fear is that I am wasting my time not doing my job.

There are patients who walk directly to my counter and ask where something is. It is immediately behind them. It is in a shiny box with neon lights and a speaker that announces its presence. Rather than point it out to them, I must walk around and put in in their hands.
And here is what will happen: I will rush to finish your prescription. I will walk away from it. I will come back to it and forget where I was. Then I may miss something.

I try to provide "excellent patient service" when companies want "customer service". I think these types of programs have lead to a "factory of fear" mentality. Instead of being allowed to do our jobs, we live in fear of "THEM"; "They-who-shall-not-be-named"; "The Corporations".

I find it rather ironic that the companies put in place workflow designs and computer systems to prevent errors, but continue to open their pharmacies and pharmacists to more and more distractions.

Monday, April 28, 2014

Why You're in Line So Long

I'm popular. It's all about pop-u-lar. It's not about aptitude, it's the way you're viewed. So it's very shrewd to be very very popular, like me.
Being popular comes with side effects though. Since everyone wants a piece of me, you have to wait your turn. Whether it's asking a question, phoning in a prescription, or needing to be counseled, others are seeking my wisdom as well. You must be patient. There is only one of me. It's like going to the Vatican and hoping to high-five the pope.

But today is not about me. It's about my pharmacy. Many people understand having to wait to talk to the pharmacist. What they don't understand is #WhyItTakesSoLongToPickUpYourPrescription at the pharmacy. People wait in lines for seats at popular restaurants. They even wait weeks for reservations. Why? Because they are popular...and very good. So are we.

Every patient is entitled to the same treatment: you have the right to ask questions of the pharmacist. If you do this at the drive-thru or in line, it may take longer. But what else is to blame?

CP: May I help you?

The Patient In Front Of You:
I'm picking up for myself and I don't have my Fan Club Rewards Card so can you look it up so I can get my free pack of gum and I have to write a check but don't have a pen and didn't fill any of this out while I was in line so can I borrow yours and I need to buy these extra couple items which may or may not go on my Flex Spend Card so you'll have to let me know so I know how much the check is for but I also want to pay cash for the magazine I was reading in line and I have new insurance you need to bill but I don't have the card and it should be under one of my kids but I don't know which one it was and can you check to see if I also have anything for my husband, my goat, my neighbour, or my first grade teacher and no, I don't know any of their dates of birth but can you look them up or can I borrow your phone to call them because they come here all the time and asked me to check and those would be separate transactions because I'm not paying for their stuff too and I know the one thing needs mixed so can I ask the pharmacist a question while he's mixing it because they changed my medication and I'm not sure if I'm supposed to take both or just stop the one and start the other and I think I forgot to have something else refilled and of course I don't have the bottle with me but can you just look it up for me and refill it and maybe I'll wait for it or come back in a few minutes if it's no trouble and I think I need the pink one too while you're filling the white one for my heart or stomach or whatever it is but I know for sure that I just filled it last month because I just ran out, unless that was the one from last year and I think it stars with a "Q" or a "B" but it's not the blue one and my doctor took me off that other one so can you cancel the refills on that because I had horrible dreams with that one that my mouth stopped working one day and could you imagine how difficult that would be for me if that happened?

CP: I'm trying.

Tuesday, April 22, 2014


It is beyond time to do away with Latin and shorthand when it comes to prescription writing. Hand-written prescriptions are the worst since many prescribers drop periods and cross random letters with such careless disregard that we cannot decipher q.i.d. from q.d. from b.i.d. from t.i.d., let alone the abbreviations unique to the prescriber himself. It's also difficult when prescribers make a 4 look like a 6 which sometimes looks like an 8. With e-scripts, it is easier to read, but typing out the frequency is much safer and leaves no question.

Let's petition to have all shorthand removed from prescription orders.
No more abbreviations. There is no standard among healthcare professionals.
In veterinary medicine, S.I.D. means "once a day".
It does not exist anywhere else and this can confuse pharmacists who are not used to seeing it. (It may also be misread.)

One I have been seeing too much of lately is "SX". I learned it as "Symptoms". Some prescribers use it to mean "Surgery" and it can also mean "Sex", though I'm not sure why that needs abbreviated...
It's a little strange to see a prescription that reads "begin 3 days prior to SX" and question whether the patient can anticipate symptoms or sex or is having surgery.

No more Roman Numerals. Many prescribers never figured out any number beyond X=Ten anyway which results in prescriptions for 40 looking like this: XXXX. Wrong.
In some states, quantities on controls must be written numerically AND spelled. We have many prescribers who like to write it like this: X (10). So not compliant with the law. While X is indeed a letter, it is not a spelling of "TEN".

I realize we are in a transition period between full electronic prescribing and handwritten orders. I realize many prescribers are old school and have been prescribing this way for decades. It doesn't make it right. It doesn't mean it's safe. With the volume of prescriptions we see today, this is probably the easiest step we can take to ensure safety and accuracy in patients' prescriptions.

I tell my patients to look at their handwritten orders before they leave the office. If they can't read them, what are the odds I can?

Then there are the abbreviations that look okay until read aloud.

Friday, April 18, 2014

The Long and Winding Road


There are companies that do workflow studies. They observe your operations and note where you can save time, money, energy, and aggravation.
I try to do this myself. Yesterday's example is how NOT to save time.

We faxed a prior auth request to a prescriber.
A couple hours later I get this voicemail.

Random Office Lady: We received a fax for a prior auth from you. The name got cut off but I have the date of birth. Can you refax it to us so we can read the name. It looks like it was a problem on your end. But the name got cut off and we can't read it. Here's our phone number in case you have any questions.

She did not tell me her name. She did not tell me the office name. Only a date of birth and their phone number. That is less information than she received on my fax.

CP: Here's a question for you. Why the hell couldn't you have pressed the option for "Speak to Pharmacist"? or "Prescriber's Office"? Simple. Ask for the pharmacist, get the name, write the name on the paper, start the prior auth process. If you need another copy, ASK for it while you have me on the phone. Perhaps I should leave a voicemail with just the patient's name. You already called my phone number.

That's like the out-of-town office that used to have their ROL call us. We'd answer and they'd hurriedly say "doctor has a prescription and you need to call him back". They didn't want to pay for long distance. YOU ALREADY HAVE ME ON THE PHONE!

Thursday, April 17, 2014

The New Answer

Ruminating as I do, I developed a few ideas that should be presented to all 50 State Boards of Pharmacy and all professional organizations, national and state.
The first I shall present today. Pharmacies need to be removed from businesses where the pharmacy is not responsible for at least 50% of the business. It cannot be a loss leader. It cannot occupy space as a  department in a big box retailer. If we are going to reestablish ourselves as a serious profession, we have to take ourselves seriously. It's like the food court in a mall. You move from Chinese to Dairy Queen to Indian to McDonald's to Pretzels to Cookies. In a big retail store you move from Automotive to Gardening to Pharmacy to Baby Clothes to Electronics. I believe we should move to smaller-sized pharmacies. Stand-alone stores, if you will.
I know, "where will we put them? how will this work? is it feasible? what about robberies?". I get it. That's not the point. Logistics can be worked out later. Pharmacies need to be more independent. The big chains offer somewhat acceptable business models. The other locations, including grocery stores and discount clubs, have no business in pharmacy. We, as a profession, need to dictate how our profession is sold to the public. The only way around the 50% or grocery/club exclusion is if they agree to establish pharmacies according to the business model laid out below.
All hospitals that are built or being renovated in any way must have a separate outpatient pharmacy attached if they currently do not provide one. All of those doctor parks, where multiple offices are squished into a big building or spread over a large area, must include a pharmacy or two on property.

Pharmacies have no business being in retail business. What if we set them up like doctors' offices? We would have a receptionist sitting behind a glass window who greets you. She is your only access point to the pharmacy. She asks you to fill out forms to verify all your information is correct. You sign a permission slip allowing us to bill your insurance and "treat" you today. You will also sign that, should any issues with billing occur, you will be notified/paged/texted and asked to contact them. We would offer free wi-fi and some courtesy phones for you if you wanted to contact them right away. Upon successful billing and filling of your prescriptions, a pharmacist would be waiting for you at a counseling window. She would take the time to go over everything with you. Upon completion of this fully billable service, you would proceed to the checkout window where you pay your copays before exiting our office.

We could set up different offices within so our pharmacists could perform different tasks throughout the day including medication verifications, DUR checks, taking doctor calls, making doctor calls, prior authorizations, immunizations, etc. We would have an office of specialists at your disposal. Once you enter a room, you are being billed for their knowledge and services. We would remove the fast-food mentality and retail experience from the sullied reputation of our profession and get back to what we really are supposed to be: Professional Pharmacists.

Tuesday, April 15, 2014

Guns in the Pharmacy

Whenever there is an armed robbery of a pharmacy, the question arises as to whether or not pharmacists should be allowed to carry weapons at work. I received the following from Amber:

"How do you feel about pharmacists being armed. I am a concealed weapons permit holder and feel we should all be allowed to carry at work if we do not have security available. What are your thoughts?"

I agree. I've been robbed at gunpoint in my pharmacy. I always think about that before I discuss this topic. I know too many other situations that did not turn out as well as mine.

Most corporations have anti-carry laws in place. They do not want us to be armed. Fine. Then close the pharmacy. We are too open and accessible. We have security alarms and locks on our doors...yet we have 20 linear feet of open counter for someone to jump across to access what they want.

Why do people rob pharmacies? It's where the drugs are.

My problem with the corporate policies is this: They do not care for our safety. If we die during an armed robbery, we will quickly be replaced. However, when it comes to our families, we cannot be replaced.

My safety is paramount to the safety of my inventory. My staff's safety is equally important to me. How many fatal robberies will it take for companies to take proactive steps towards employee safety? I don't care for removing pharmacists from the pharmacy and putting them at little desks in the middle of the store for this same reason.

I ask: If you have your permit, should you be allowed to carry while at work to ensure your safety and that of your employees?


Thursday, April 10, 2014

Grating Expectations

This is another episode of "If the real world functioned the way people believe pharmacy does".
Let's start with the hypothetical:

Bank Customer: I have a problem.
Lovely Teller: Okay. How may I help?
BC: I threw away my payroll check.
LT: Okay. That's pretty careless.
BC: I need you to give me the money.
LT: Not without the check telling me you are entitled to it.
BC: Can you call my employer for it?
LT: What? Seriously? You threw away your money and expect me to call your employer's payroll department for a new one?
BC: Yes. Will it take long? I have to wait because I'm going out of town/shopping/to a casino/strip club and need the money right now.
LT: Piss off.

Now let's look at what actually happened in my pharmacy:

<Patient calls on the phone so this did not occur face-to-face>

Overly Presumptive Patient: I need to fill my prescription but I have a problem.
CP: Okay. How may I help?
OPP: I threw it away.
CP: That is a problem.
OPP: What do I do?
CP: You call or visit your friendly prescriber who will issue you a shiny new copy; or send one electronically to me since you can't be trusted.
OPP: Can you?
CP: Can I what?
OPP: Call my prescriber?
CP: You're so cute. If I didn't think you were being serious, I'd laugh.
OPP: But I get my prescriptions filled there.
CP: Yes. But in order to fill new prescriptions, I actually have to possess them. In order for me to possess them in order to fill them, you need to not throw them away. Instead of wasting my time and your one phone call on me, should you not have instead made a direct call to your prescriber?
OPP: They're too busy and I need it now.
CP: Could you not have visited them since you are presently in the car?
OPP: So you're refusing to help me?
CP: Pretty much. Give a man a prescription and he's good for 30 days. Teach a man to get his own damn prescription that he lost, and well, I bet he won't learn. But I can dream. Oh yes, I can dream. Hahahahahaha <click>

Wednesday, April 9, 2014

Customer Satisfaction Surveys

These are an exercise in futility. We are doomed to fail.
Forget focusing on the wait times. Forget whether or not we smiled. Forget whether or not we reminded you to call the 1-800-4-GIFT-CARD phone number. We are a profession. Even hospitals and prescriber offices that have been using feedback forms don't trivialize their profession to the degree that the pharmacies do.
Could you imagine a nurse on a hospital floor discharging a patient and saying "make sure you call the 1-800# to tell us about your stay"? Or the X-Ray tech wearing a badge that reads "How's my picture taking?".
Let's ask the real questions, important to our profession.

Did you receive the correct prescription?
Did you receive the correct medication?
Did you receive counseling/the offer to counsel on your prescription?
Did you hear about side effects from your pharmacist?
Did you ask the pharmacist any questions about your medication?
Did your pharmacist have to call your prescriber for clarification?
(If Yes, did she explain why?)
(If Yes, did she potentially save your life?)
(If Yes, are you thankful?)
Did you call the pharmacist after getting home and realizing you did have questions?
Did she answer them for you?
(Note: I did not say "answer with what you wanted to hear".)
Did you seek advice on OTC medications today?
(If Yes, were you satisfied with the knowledge of the pharmacist even though you may not have purchased the recommended/correct/any product?)
Would you seek out this pharmacy for its knowledgable pharmacist again?
Would you recommend this pharmacist to other people?

I'm not seeking a "5" or perfect score whenever I visit a business. I expect them to be good all the time or I wouldn't go there. I expect to be surprised once in a while with excellent service, but I do not feel it can be achieved every single time. I have had bad meals at well-renowned restaurants. It's an anomaly, not a pattern. Were it my first impression, I may change my tune, but they'd get a second chance. No one can be perfect all the time. Pharmacists need to challenge corporations to do away with the Satisfaction Happiness Index Taking (SHIT). Whatever the name, people are more likely to call to complain than they are to praise. This skews the results.
A better idea would be exit polls. Let's have a person using my checklist stand by the front door to get a Pulse Of the Customer immediately upon completion of her visit.

Tuesday, April 8, 2014

Pharmacists are too Available

We are too accessible. That is the nature of our profession. We have embraced this role for centuries. Prescribers are too insulated. You cannot reach them. Call any pharmacy and ask to speak to the pharmacist. Perhaps she will answer. Perhaps you will wait a few minutes. Either way, your request will be granted.
Try that with your prescriber. (I no longer differentiate among them. To me, they are all writers-of-prescriptions.) With any luck, someone may return your call from the office who has your answer. It is very unlikely to be your prescriber and the odds are infinitesimally smaller that she will pick up the phone herself...or quickly.

Why is this important, you ask?

CP: I need to speak with the prescriber about an error on a prescription he wrote.
L.ady A.ccepting M.essages E.nthusiastically: I can transfer you to the refill line.
CP: Not acceptable. This is important as I believe the prescriber is trying to kill his patient.
LAME: I can transfer you to his nurse's voicemail.
CP: How will that help? Is she in a room? Can I hold?
LAME: She is on vacation this week.
CP: Okay. It being a Monday and all, how will transferring me to her voicemail get my question addressed quickly?
LAME: That's all I can do.
CP: Is the prescriber in the office today?
LAME: Yes.
CP: May I speak with him? Or leave a message for him?
LAME: He does not accept phone calls.
CP: How about another nurse? You have other prescribers there. I assume they all would have their own nurses then? Could one of them pick up the phone to listen to my concerns?
LAME: They are not familiar with him.
CP: Dafuq? Must be a nice quiet week for the prescriber. Who tells him he has patients in the rooms? Who gets his charts? His coffee? Who enters his e-scripts for him? You're telling me the only person in the entire office who can answer a question about an error one of your prescribers committed is the nurse who happens to be on vacation?
LAME: I can transfer you to the refill line.
CP: How about this. I propose a race. I will fax this prescription to you with my notes about what is wrong on it along with your name as the person of record. I will hand the same copy to the patient and send her, complaining about gas prices and why this is taking so long, back to your office. See if you can get the answer before she comes storming down there and interrupts you filing your nails. I can hear it...along with your gum chewing. I'm betting on Angry Patient.
Go! <click>

Friday, April 4, 2014

That's Not How It Works

I do not understand all that happens in a prescriber's office. I do not profess to know it all. All I can go by is experience in dealing with many offices over my years in this profession. Prescribers understand less about pharmacists and their operations because they very rarely deal directly with us. We have to talk to a secretary who may let us speak with a nurse or assistant. Rarely the prescriber herself. Anyone who calls the pharmacy wishing to speak to the pharmacist need only ask.

It is situations like this that piss me off. Fortunately, the little girl's mother had a good sense of humour about it.

Girl's Mom: My daughter's pediatrician was sending over a prescription for her.
CP: I don't see it here. Wait. It's at the other store.
GM: Yeah, she said she was just going to send it there and I'm supposed to call you and you're supposed to call them and transfer it.
CP: You realise how insanely stupid that sounds, right?
GM: Yep. I'm confused too.
CP: So the shortest distance between two points is me doing all the work?
GM: Apparently. Sorry she's so stubborn.
CP: Not your fault. It is almost 5pm so she must be on her way home. At least you can always switch prescribers. I love the ones that can't put forth the effort to do their jobs correctly. It would make me question everything else about their attitude towards my healthcare as a patient as well. Too bad we were next on the alphabetical pull-down menu on her magical prescribing device. I wonder if she operates the rest of her life like this in the real world. That would be like driving up to the McDonald's drive-thru speaker near her house and placing your order for you then telling you to just drive by the one near your house to pick it up. Does not work that way.
GM: I know. Will it take very long.
CP: Nope. Already transferred it. Unlike some other professionals, I take care of my patients. Too bad that by doing this I only reinforced to your prescriber that I will do this. Damn.

Thursday, April 3, 2014

A Little Knowledge

"No I didn't pass the bar, but I know a little bit."
A little knowledge can be a bad thing. It is usually just enough to be dangerous in many hands. This is especially true in the pharmacy/healthcare world.

Resourceful Lady: I need these filled but I have a question.
CP: Go for it.
RL: Why did my doctor give me these?
CP: Huh? Did you make an appointment?
RL: Yes.
CP: For a specific reason?
RL: Yes. But I want to know why he gave me 2 of the same thing. I looked it up on the internet and they both do the same thing. Is it so I can pick one?
CP: <dutifully examines both Rx's with a trained eye> Okay. You need both.
RL: How can you tell?
CP: First, the Penlac is a nail lacquer. It's for your nails. The directions actually tell you to apply this to your nails.
RL: Okay. But why the second one?
CP: Uncertain of your diagnosis, I am. However, much from this paper I can glean. It is a topical antifungal. The directions tell you to apply to legs and feet.
RL: So I need both?
CP: Only if you wish to rid yourself of the problem that took you to your prescriber in the first place.

Wednesday, April 2, 2014

Ticks and Leeches

With spring upon us and Pharmacy Winter coming to an end over the course of this month, it is time to prepare for the next onslaught. Robins are a sign that Spring is coming. In the pharmacy world, our harbinger of spring is the first case of lice. As soon as it hits, it's time to order bulk quantities to get through the next month. This leads me to 3 stories:

An older woman approaches the counter and plops a plastic baggie in front of me:
OL: What is this?
CP: A bag.
OL: Yes. But what is in it?
CP: I don't know. I didn't put anything in there. Wouldn't you know since you put it in there?
OL: I found it and need it identified.
CP: <looks down> Lice...?
OL: Could it be something else?
CP: I suppose anything may be something else. Why? Where did you find it?
OL: In my son's underpants.
CP: <tastes bile> Crabs!
OL: "Oh, I am so kicking his 15 year old ass when I get home."

Lovely Lady walks up, places a baby food jar on the counter, removes the lid and pushes it towards me.
LL: What is this?
CP: <pushes it back> A jar.
LL: < pushes it to me> Inside the jar.
CP: <pushes it back> It's lice.
LL: < pushes it to me> My hairdresser friend said it's not lice.
CP: < pushes it back> It is.
LL: <pushes it to me> But my next door neighbour who's a nurse said it's not.
CP: <forcefully pushes it back> IT...IS...LICE. STOP PUSHING IT TO ME. Close the jar and leave. The products you seek are right there.

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?

Tuesday, April 1, 2014

April Fool

I think we should begin an experiment with the first of the month. People will think it's an April Fool's joke and we can showcase our 100 yard stares we've perfected over the years.

I propose an insurance-free month. Simple. We in the pharmacy bill NO insurances. None. Discount cards? Nope. Manufacturer coupons? Nein! Charge everyone full cash price for everything.

The point of the exercise is not to be mean-spirited. It is not to make money. (We'd lose many Rx's that way.) Instead, it is to give everyone the perspective on exactly how much health care costs them and their employers. When we tell people it'll be $25.00 for their copay and they ask "didn't my insurance cover anything?" on a $500.00 medication, it is not enough to explain it costs $500.00.

Let people submit paper claims to their own insurances for reimbursement.
Let Medicaid patients pay $50 or $100 copays at an ER when they visit with a sniffle. It'll take the crowds out of the ER.
Let people determine what they truly need to survive. Let people make their own, informed health decisions.
That's the way to cut costs in healthcare.

Dermatologists will need to figure out how to get their patients, well, anything since the only way they know how to prescribe is "put a DAW on it and give them a manufacturer coupon to make it semi-affordable". They do not operate in the same reality in which we live. Theirs is an insular existence.

Make people realise how much things cost. It already plays out, to a lesser extent, with men across the country who purchase 1 or 2 or 3 ED tabs every week or month. It plays out with pet owners who have to decide which services to pay for and which medications their beloved animals need since there is rarely insurance to cover that.

There are many other ways to cut costs. The first problem is making people understand what things cost. It is easy to know the price of gas, of milk, of a new car, or a house. People understand these things. Prescription and medical services are more complicated.