The Goldilocks Directions Challenge.

Too Much? Too Little?
We have to find the set of directions that are "just right" for the label; the directions that are easiest to understand; that convey the prescriber's intentions clearly; the directions that, hopefully, leave the least amount of room for error and misinterpretation. 

Our job is, and has always been, to interpret what the prescriber wrote and translate it into patient-friendly directions; ones that can be easily understood. (From med-speak to patient-speak. . . so to speak.)

I thought of this after yesterday's Humira picture and could envision all the possible ways pharmacy staff would type this.
For some pharmacists and technicians, verbatim, seems to be the mantra. (My call center loves to type directions word-for-word. They're so bad they even type the typos, and sprinkle in a few new ones that weren't on the e-script. But that's how the call center TRAINS them.)

Should the directions for "Humira 40mg / 0.8ml Pen" be typed on the label as:

A. "Inject the contents of 1 pen subcutaneously every 2 weeks"

B. "Inject 40mg subcutaneously every 2 weeks"

C. "Inject 0.8ml subcutaneously every 2 weeks"

D. "Inject the contents of 1 syringe (40mg) subq every 2 weeks"

E. "Inject the contents of 1 syringe (0.8ml) subq every 2 weeks"

YES. I KNOW. THEY ALL SAY THE SAME THING. BUT. . .

Which direction allows for the least chance of a mistake on the patients' part?

Personally, I believe the MORE information you put on a label, the LESS clear and MORE confusing it becomes for the patient(s).

Answer the question I asked but consider the following examples as my reason for asking: 
Example 1:
Zofran is available as 4mg/5ml solution.

If you put both mg and ml on the label, it can lead to an error. I hate putting on the label verbatim what came through on the e-rx: 
"Give 2mg (2.5ml) by mouth . . . "

That is too much info that can lead to confusion by a tired mother/grandmother/sitter, etc. and the pharmacy staff typing it.

Example 2:
How many times have we filled prescriptions for elderly patients where prescribers don't always use the most logical strength? (Granted, they may be making dose adjustments, but keep it simple for this argument.)

Ativan 0.5mg Tabs : "Take 2 tablets (1mg) by mouth. . . "
or. . . "Take 1mg (2 tablets) by mouth . . . "

Both of these are real-world examples.
Both are confusing.
Both can be read backwards.
Both can lead to errors.
Remember, the more information you provide to help, the less helpful you truly are.

Answer Key: A.
The only correct, not-open-to-interpretation answer is "A".
Why? D complicates the directions with too much information.
B and D? Who measures anything in "mg"? (and patients will ask that exact question.)
E isn't awful BUT, the more information you type, the more likelihood you can make an error while typing. (Accidentally typing "1ml" or reversing the "1" and the "0.8" happens occasionally.)
C? That's the best alternative answer I will allow. If my techs type it, I won't send it back. However, it is still open to questions from patients ("how do I measure 0.8ml?")

In Fiduciary I Trust

At least, that's the motto by which they live, right? It's a trustee-beneficiary relationship. 

The beneficiary is trusting the trustee to make sound decisions on her behalf, right? 

Sitting in a prescriber's office, minding my own, when the conversation piqued my interest. (Couldn't help it. She was really quite loud for the quiet space.) 

Fiduciary Lady Opining: I'm your fiduciary. You know what that is? 

Recipient Of FLOs Largesse: No. 

FLO: I make your decisions for you and you trust me. 

ROFL: Ok. That makes sense. 

FLO: I look out for your best interests. 

ROFL: Ok. That's good. 

FLO: You're getting your shots today. 

ROFL: Hooray. Which ones?

FLO: Tetanus, Meningococcal, and . . . wait. Not this one. 

ROFL: Why not? 

FLO: It's HPV. 

ROFL: What's that? 

FLO: A sex disease. It was made for girls. 

ROFL: Uh-huh. 

FLO: For people with vaginas! You don't have a vagina, do you? 

ROFL: HaHa, no. 

FLO: Then you don't need this. They decided they needed more money so they said boys had to have it now too. 

ROFL: But I don't have a vagina. 

FLO: Which is why you're not getting this one. 

Poor Nurse: The doctor will be in shortly. 

FLO: He's not getting the HPV shot. 

PN: No problem. 

FLO: What's the name of it? 

(There was a conversation that went on for 3 minutes as they tried to figure it out and I couldn't take it anymore.) 

CP: GARDASIL!

PN: Thank you. 

FLO: What's this pertussis? I thought he was getting tetanus? 

PN: It's whooping cough. 

FLO: He's not coughing. 

PN: And we'd like to keep it that way. 

<PN leaves>

CP: Psst. 

FLO: Yes? 

CP: I'm talking to your boy too. 

ROFL: What? 

CP: Are you attached to your penis? 

FLO: What? 

ROFL: What? 

CP: How'd ya like warts on your naughty bits? 

<They both cringe>

CP: <holds out phone after googling "genital warts"> Here's what you can look forward to without the vaccine. Have a nice day!

PN: You can come back now, CP. 

CP: Thanks. I think you're going to give that HPV vaccine now. 

PN: Yes. You really need to stop doing that. 

CP: If people are going to loudly announce they're responsible for making decisions for their ward, the least they could do is ask questions in order to make INFORMED decisions instead of propagating IGNORANCE. I'd have no problem with her refusal had it been based on anything other than uninformed, empty rhetoric. 

Professional Differences

Why are the same laws not applied universally?
If you wish to understand the issue, look no further than any law affecting healthcare in America. States pass new rules/laws all the time. Some affect both prescribers and pharmacists and we must both obey and implement them.
Prior to graduation, I had to take a law class.
Prior to receiving my license, I had to take a law test (and pass it!).
I'm fairly certain prescribers had to do this as well.
In the years since I graduated, laws have changed and new ones have been passed.
This means that your practice has to be fluid in order accommodate these changes.
You cannot simply rely on what you learned in school. You have to evolve; to adjust.

Herein lies the difference between the prescribing and dispensing professions.

Pharmacists: this law takes effect 7/1/18. You MUST be compliant on this date or you shall be publicly flogged, pilloried, or stoned. There are no exceptions for failure to comply. If prescribers do not comply, it is incumbent upon the pharmacist to phone the prescriber to bring him up to speed, retrieve the missing information, and get lectured by the lady answering the phone (LAP).
LAP: What do you need?
CP: As of July 1st, your prescribers must obey these laws.
LAP: Laws? We don't need no stinkin' laws!
CP: You do.
LAP: We didn't know about this.
CP: You work in a urology group, right?
LAP: Yes.
CP: Urine trouble!
LAP: Lame. I've heard that one before.
CP: I know. Just like I've heard what you're about to tell me next.
LAP: 1. We've never had this problem with any other pharmacy.
2. You're the only pharmacist who calls us on this.
3. We never had to do this before.
4. Our prescribers don't do that.
CP: 1. Yes. I know.
2. Yes. I'm the only pharmacist who cares about her license.
3. That's because the law took effect July 1st. There were communiques.
4. They will.

Prescribers: you get an email from the state; you get a letter from the state; you get more of each, approximately 1 per week for 6 months leading up to Doomsday. You get to plead ignorance for months. There's something called a "grace period". For some reason, you are allowed to remain noncompliant and ignorant of the law change for months. You receive more, somewhat-sternly written letters with a picture of the Board of Medicine shaking its finger at you and a little "tsk tsk" added for effect over the next 6 months. Yet you still plead ignorant.

This reminds me of my favourite prescriber joke: 
Q: Why are doctors always on bottom? 
A: Because they can only fuck up!