If the Real World Worked As People Believe Pharmacy Does...

Went on vacation...
Made a hotel reservation...
Left work late, hoping not to be too tired to drive...
This cynical thought occurred to me:
What if the real worked worked as people believe pharmacy does?

Hotel Operator: May I help you?
CP: Yes. I'd like to make a reservation.
HO: Gladly. Which night?
CP: Friday. And we will be arriving late.
HO: No worries. Safe travels.

Riding along in my automobile...
CP: Let's stop here.

HO: May I help you?
CP: Yes. I have a reservation.
HO: Under CP?
CP: Yes.
HO: I do not see anything here for you. We are booked solid.
CP: But I called the other night and made a reservation.
HO: I am sorry. There does not appear to be anything in our computer.

Option #1
CP: This is Holiday Inn, correct?
HO: Yes.
CP: I called the Holiday Inn by my house last week and they gave me a confirmation number and everything.
HO: By your house?
CP: Yes!
HO: In another state?
CP: Of course!
HO: Then your reservation is there. It does not transfer here. If you want it here, you have to call us here.
CP: Well that's just stupid. Aren't you all connected? I should be able to make a reservation and go to any Holiday Inn I want. That's ridiculous. What am I supposed to do now?
HO: Drive back home or continue until you see a "Vacancy" sign.

Of course there is option #2:
CP: This is Holiday Inn, correct?
HO: No. This is Best Western.
CP: You're all just hotels. Aren't y'all connected?
HO: No.
CP: Well that's just stupid. When I made my reservation on TrivKayExpedPriceElocity.com they compared rooms from all hotels. They make it sound like you're all the same. I demand a room right now, plus free breakfast in bed, plus a refund, plus...
HO: How about "No"? Hop back in your little engine that could and drive to your reserved destination. It's right across the street.
CP: I'm going to complain to corporate and I will bash your customer service online.
HO: You do that.

Three Worst Words...

...I'm a doctor.

Hip Hop Hip Hip Hop Hooray, Ho Hey, Ho! Who cares?

As if that explains everything.
Walk into a room: I'm a Doctor!
Walk into a bar: I'm a Doctor!
I've met people for the very first time and when I give my name I get: I'm a doctor!
Next time you "I'm a Doctor" me...walk into my fist.

If you are that insecure or egotistical that you need to remind, or flat out tell, everyone what you are, then you have bigger issues. I try not to tell anyone, doctors, nurses, other professionals, what I do. Who cares? Yes, I will treat you differently if I attempt to explain something to you and you interrupt me with the "I'm a doctor" line. You will henceforth be referred to as Doctor Pompous Ass Baggins.

Ever been in a hospital setting with a family member who happens to be a doctor? As the nurses, doctors, pharmacists attempt to explain anything that one person has to say: "I'm a doctor".
Good for you. I'm a pharmacist. Nice to meet you. May I finish?

Same thing happens in the retail setting with doctors and even nurses.
I don't proclaim to know everything. The key is knowing what you do not know and being able to learn something new from someone else.
You learn more from listening than from talking over everyone telling them "I'm a doctor! I'm a doctor!" Yep. And once you graduated, all learning stopped. There is nothing new anyone could impart upon you that you don't already know.

CP: I am going to counsel you on this.
Dr. PAB: It's okay. I'm a doctor.
CP: Thanks for the warning. Then I'll be sure to talk slow and use really small words. I've seen your prescriptions. If you don't even know how to write for this medication, I cannot allow you to take it without my help.

It Takes Two...

In any relationship, there is a corresponding obligation by all parties to understand each other.
If you are going to enter into a relationship with another party, you must do your research.
You must understand what this contract entails.
You cannot possibly enter into it completely blind.
That only leads to aggravation, hurt feelings, complaining, and a lack of understanding on both sides.
Then comes the blame game.

Long Time Visitor: I need to have these prescriptions filled.
CP: Okay. You've come to the right place. That's our business. Too bad someone is sick on such a beautiful Saturday.
LTV: I know. How long will this take?
CP: About 15 minutes right now. We are enjoying a bit of a lull.
LTV: Okay.
CP: Let me get your information: Name, Date of Birth, phone number in case there are any problems, current insurance card, names of your pets, eye colour, favourite World Cup team, and make and model of your vehicle.
LTV: Gladly. Thank you for being so thorough.
CP: Welcome! See you in 15 minutes, LTV.

...and then we closed...FOUR hours later, we closed. I asked Uber-Tech and Super-Interns if anyone came back for that liquid antibiotic that needed mixed. "Nope", was the unanimous reply.

Sunday morning. I walk in and make idle chitchat with the lovely manager who closed last night.

LM: Thanks for closing early last night.
CP: What?
LM: I got an earful from someone complaining her child was going to be sick all night because you left early.
CP: Say what? We left on time...
LM: Yeah. She wanted me to open the pharmacy and get the prescription. I told her that even if I had the magical code and keys to unlock the vault, I had no clue what I'd be doing back there and would get fired. She didn't care.
CP: You don't say.
LM: I explained the hours to her. How long have we been here? How long have we been closing at the same time every Saturday?
CP: At least 12 years. Better question would be: "How do you do business with a location and not do the basic research to verify their hours?" Especially with something as important as your child's prescription? My favourite sushi place is only open until 10pm certain nights. I make sure we close here promptly at 9pm so I can get there, have a beer, grab a couple rolls, and be out before they close. It's not their fault if I get there late.
LM: Exactly. Now quit getting complaints from silly people who complain about their own stupidity. Perhaps we should create a special category for them.
CP: Yeah. I'll put it right up there with the complaint we got from a woman who called corporate to say she didn't know how to refill her prescription. (True Story...)

It's a Couple

Interpretations vary wildly sometimes.
Perhaps it is perception.
Perhaps they just don't know what the word means.
Like literally.

Nursing Home Caller: I need to call in orders for a patient who is being discharged.
CP: Okay. How many do you have?
NHC: What?
CP: How many?
NHC: A couple.
CP: Uh-huh. Sure. No one gets discharged from a nursing home on just a couple. What's a couple?
NHC: I don't know. Like 8 or 9?
CP: Seriously? You call that a couple? When was the last time you were at a wedding where the priest introduced the "Happy Couple" and you saw 8 or 9 people standing at the altar?

New and Improved!

First, if it's new, it never existed so you cannot have improved upon it.
Second, if it has been improved, it already existed in some other form upon which an improvement took place. Comprende?

My question, the one with which my brain grapples, is: "What happened to yesterday?"
Today there are new "IT" drugs. Today there new medications to help treat conditions for which we already had a multitude of options. Yesterday was pretty good too. But why is today so much better than yesterday? (I'm not talking about revolutionary developments like vaccines or entirely new classes of medications.)
Doxycycline came out and was good for dermatologists. Then came Doryx and Oracea and doctors said it had to be brand. Then came Solodyn and doctors said it had to be brand.
First came Aldara cream, then the generic, then came Zyclara which must be better because it costs so much and isn't generic.

When medications need a prior authorization, prescribers tell patients to sign up for a manufacturer discount card or they have to pay for it. Why? Yesterday, the "IT" drug worked just fine according to these prescribers. Since the shiny new brand drug was approved today, how did this render the old drug obsolete?
Did yesterday's drugs lose all potency? Did they just stop making them? What happened to yesterday?

What did you prescribe last week?

Why did it change today?

What makes this so much better?

Dermatologists are by far the worst.

First they prescribe medications with DAW written all over them. Then, when a new drug (rep) comes along, they all switch to prescribing it. They send the patients to us with handfuls of discount/copay cards and tell them "you shouldn't have to pay too much at the pharmacy. Our drug rep told us so." Except that the prescribed drug needs prior auth on your primary insurance which is required before the copay card can work.

My questions are these: What did these doctors prescribe last week?

What did they prescribe last month?

Last year?

Last decade?

Last century?

The one-time "latest greatest thing" has now become an afterthought, supplanted by Big Pharma marketing dollars and flashy drug reps with copay cards who can't even bring me Starbucks anymore.

Today's Doryx 200mg and Epiduo are tomorrow's Monodox and Retin-A.

In some cases, the media are not helping. With the new 4-strain flu shot available late last winter, everyone was clamoring to get them. My problem is, there were not enough of these shots readily available for everyone to find them and people were turning away from getting the original flu shot in the hopes they would find the 4-strain.

They are likely to go unvaccinated if their search for this new shot proves fruitless. That is bad. While it is nice to have the option for a better flu shot, it does not mean the other one is not going to work.

Behind the Curtain

In The Wizard of Oz, the Great Oz tells everyone "pay no attention to the man behind the curtain". In pharmacy however, a lot goes on behind that curtain that warrants your attention. So far I have focused on why things take so long and what exactly goes into filling your (just your one) prescription. Today we will examine what exactly occurs behind the scenes that we need to do to get your prescription ready for you on time.

If you are a loyal follower then you probably know it takes a lot of work to get your prescriptions filled. However we receive it, electronically, fax, phoned-in, you personally delivering it, Pony Express, we need to start with the hard copy of the prescription. This is the order from the doctor that tells us what to fill. It's all downhill from here. Anymore, there is an issue with most prescriptions we receive. The first thing we need to do is call the doctor for clarification; on the patient name, the drug name, the strength, the directions, the quantity, the refills, the doctor who signed it or even the date it was written. Then we either get an answer immediately, are put on hold for someone to check the chart, or have to wait until later that day or days later for a return phone call. Sometimes, we will get a new electronic prescription to replace the wrong one only to find out it's the same error or there is a new mistake. Sometimes doctors will send us multiple copies of the same prescriptions. Sometimes they will make changes but not call to cancel the original ones. Sometimes they will send multiple ones to multiple pharmacies because they thought they didn't go through. Either way, we have to cut through the static, decipher their intent, then fill the correct one for you. This takes time.

Then it may need a prior authorization. We will fax the doctor the request. He will contact your insurance, if he really wants you to have it. Then the insurance will make a decision and notify the doctor. Sometimes the doctor calls us when it's ready. Sometimes they do not. Sometimes there are great offices that do a great job of getting these approvals instantly. Sometimes, not.
Sometimes we do not stock a particular medication. We can usually determine whether or not you need it that day. We will often call another pharmacy trying to locate it for you. Often, we will call your doctor for an alternative that we have in stock that will work for you.

Insurances: Maybe we have to call because a set of twins, or triplets, is trying to get the same prescription filled for each child. Since they share the same date of birth, the insurance thinks they are the same person. This necessitates a call to them pleading on your behalf that there are really 2 or 3 of them.

The point is this: There is so much that we do that most people are unaware was required to fill their prescriptions. When things run smoothly, no one notices. It is only when the system hiccups that everyone can see the machine's inner workings going a little wonky. I'd like to point out the little things we had to do, but I chalk them up to "that's what was required and it's my job to do this for you". That does not mean I haven't pointed it out to someone who is a little testy about his wait time.

CP: Yes sir. Your doctor did send it over to us an hour and a half ago. However, in that time, I had to call him back because he sent the directions over as "take one tablet by mouth every morning before breakfast twice a day (bid)". I was confused. Does your day have two mornings? And why did he bother telling us to dispense 120 tablets for a 90 day supply? At once a day, that's a 120 day supply. At twice a day, that's a 60 day supply. Then your insurance wanted to know why you were coming in too early for the refill. At once a day they were correct. Now that it is officially twice a day, they were okay with the explanation of a dosage increase. I am terribly sorry your doctor started it off wrong by sending us a flawed prescription. I am sorry he gets to take an hour and a half lunch and he sent the order while stuffing his face on said lunch. I am sorry you would rather have the prescription dispensed to you incorrectly than have to wait. The odd thing is, had you come in 5 minutes later, it would have been ready and you would have had no idea what all we did to fill it for you. Also, had you gone home first, you would have heard the message from us that we were working to fix your prescription so call us before you come here.

Brand/Generic

Doctors are dumb.
The only problem is they don't know it.
The problem with doctors, and the ever-growing number of others with prescriptive authority who aren't pharmacists is they think they know everything about everything. This includes how a pharmacy works and everything about medications.
Never mind they tell patients how my pharmacy operates when most of them have never spoken with a pharmacist let alone stepped foot inside one.

A new twist on the all-knowing prescriber overstepping his knowledge:

CP: How may I help you?
Patient of Silly Doctor: I need this filled.
CP: Fabulous. We are in the script-filling business after all.
POSD: Can I get that in brand?
CP: Most definitely. However, I must warn you that the cost could be exorbitant if your insurance chooses to be quite the prick.
POSD: I have to have it though.
CP: May I ask why the brand is so important with this particular medication? (No, it is not a NTI drug and it is a new prescription for this patient.)
POSD: "My doctor told me to get the brand because the generic will give me side effects." (Yep, actual quote.)
CP: Ok. I'll let that one go for a minute but she actually needs to tell me that since, you know, I am the one actually filling it. A DAW from a doctor could mean the difference between a small copay and the debt of Detroit.
POSD: Okay, I'll speak with her. Why would she say that?
CP: No clue. It's like someone telling me Motrin works better than Advil. If you've never tried this, how can you know the generic will cause side effects? It is a rather asinine comment and I will add the doctor to my Do-Not-See-If-My-Life-Depended-On-It List.

It's Too Soon

It is a complicated issue to explain. Insurances rule everything. So do those pesky state and federal laws. It should be simple, really: Your bottle is empty, therefore you get more medication. (Just like if your refrigerator is devoid of milk, you buy more to put in there.) Only prescriptions are a different issue. If you are out because you took too many, your doctor told you to take more, you lost them or you had them stolen, then we cannot simply hand you more. Our job is to know why you need them and make sure you are taking them correctly. Simple? Yes, except when it's not.

Restless Patient: Did my doctor call in my refill?
CP: Yes. However it is too soon to fill.
RP: But my kid dumped them.
CP: Okay. I am truly sorry you let your young child play with your Ambien bottle and they got dumped but it is still too soon to fill.
RP: But my doctor called in a new prescription.
CP: Indeed he did. But he didn't change anything.
RP: But it's new.
CP: Only its origination. He could call in the same prescription every single day promptly at 11:38 am. Unless directions or strength changed, directing me towards the conclusion you should have these early, I am unable to fill this for you today.
RP: What if my doctor tells you he's okay with the early refill?
CP: That would be different. Or you can call your insurance and ask if they allow for a lost/stolen override. I shall wait to hear from either you or your doctor.
RP: Meanie.
CP: Nope. Parent. Give your kid a fork. Let him put it in the electrical outlet.
RP: Oh. My. GOD! That is so cruel.
CP: Yes. But he won't do it again. Lesson learned. Just like letting him play with your prescription bottle. You're just lucky he didn't take any. Why couldn't you pick them up and put them back in the bottle?
RP: Ew. They fell on the floor.
CP: Right. How silly of me. Again, lesson learned. And unless your insurance and doctor allow for the early refill, an expensive, restless one too.

Help Me to Help You

I want to purchase something. 

I wish to know how much it is. 

Generally, I have an idea of the product I seek. 

A TV, car, US Soccer Jersey, whatever. 

I like to know what I am going to spend before I buy. 

I comparison shop. 

Seems rational. 

Except in this case...

Long Time Listener, First Time Caller: I'm calling to get a price. 

CP: Ok. Do you have insurance or will this be straight cash?

LTLFTC: Cash. I have no insurance. 

CP: Okay. For what prescription do you seek a price?

LTLFTC: I don't know. 

CP: You don't know?

LTLFTC: No. I haven't seen my doctor yet. I don't have a prescription. 

CP: Okay. Makes my job a little difficult. What's wrong with you? Why are you going to the doctor?

LTLFTC: I don't feel well. Can't you give me a price on something for that?

CP: Did he give you any indication what he may prescribe?

LTLFTC: No. 

CP: Drug name? Strength? Quantity? 

LTLFTC: No. Why can't you just give me a price?

CP: Okay. I can give you a range since I don't have any specifics. 

LTLFTC: Okay. 

CP: It will be more that $1, but less than $1,000. How's that?

That would be like calling Best Buy for a price on something in their store but not knowing whether it was a TV, washer, Blu-Ray, PS3, iMac, or that new-release DVD that just came out sometime in the last month.