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Tuesday, February 26, 2019

Your Rx, You Prescriber

CP: Why do people ask questions we can't answer?
ME: Why do you keep having conversations with yourself?
MYSELF: Yeah! I'm busy.
CP: You're my only friends. You get me.
ME: What's got your knickers in a twist, today?
CP: Two things. They're related, but I think I'll split them.
MYSELF: Phine. Phirst?

CP: Welcome to CP's Palace of Poultices, how may I help you?
Arguing WithOut Logic: I am here to pick up my prescription.
CP: Blessed be the Gods! Someone actually picking up a prescription. Validation that all those texts and calls and drone flyovers really work!
AWOL: Um. Yeah. I just need my medication.
CP: Sure. Was it called in today?
AWOL:  Yes. I just left the office.
CP: I don't have anything ready for you. Wait. There it is. I found it. It's at our other location. Did you used to go to our North Main St. store?
AWOL:  Yes. How did it get there?
CP: I don't know. I'm going to go with your doctor sent it there.
AWOL:  My doctor's office is infallible!
CP: It appears they are not.
AWOL:  I was in the office today and told them to update my prepherred pharmacy to this location. They said they'd send it here.
CP: Oh. In that case, the only logical explanation is rather conniving.
AWOL: Yes?
CP: They sniped it.
AWOL: Huh?
CP: The other store intercepted it. They must have been really slow so they just reached into the Matrix and stole your prescription from me before I could get it. It's really competitive to get prescriptions now. We have to employ full time agents to monitor the Matrix for the best prescriptions. We also just dump the ones we don't want anymore. The problem children as we say.
AWOL:  That seems a little far-fetched.
CP: Well since you don't believe your prescriber is capable of making a mistake by sending your prescription to the wrong location, I assumed my scenario would be no less implausible. I challenge your sense of reality with my alternate reality.
AWOL:  What do I do now?
CP: Call your prescriber. Have them phix the problem they created. Or go to the other pharmacy. It's literally 4 minutes if you miss both traffic lights.

Part II:
CP: We do not have anything for you. Was it to be called in today?
AWOL: No. Last week.
CP: I see it. We sent a prior authorization request last Friday, again Monday and finally on Wednesday. After that, we sent you a text and canceled the request due to lack of a response from the provider.
AWOL:  I ignored that. I thought I'd just come down here to pick up my prescription.
CP: Which isn't ready. You should call the office.
AWOL:  No. You should send the request again.
CP: Why? Because the 4th time is the charm? No, you should call them.
AWOL:  No. You can resend it.
CP: Why? So your prescriber can ignore it like you ignore our texts? It's not my prescription. Personally, it matters diddly to me whether you receive this medication or not. If it's not important to you, it's not important to me. I can hit "generate p/a fax" all day long. Twice on Sundays. I cannot, however, make your prescriber read it, act on it, or reply to it. In order to accomplish that, you need to take action. Complaining to me is like yelling at the TV while watching Top Chef to complain that your car is overdue for a tire rotation.
AWOL:  That makes no sense.
CP: Welcome to my reality.

Friday, February 22, 2019

Cut Down The Order

CP: I wonder what phresh hell awaits us today?
ME: It's not so much phresh as it is shampoo directions.
MYSELF: Lather, rinse, repeat?
CP: Got it. Let's get started. Welcome to CP's Playhouse of Pills. How may I help you?
Lack Of Solid Thinking: I am here to pick up my prescription.
CP: Awesome! I love it when people pick up prescriptions! I get to talk to them, to counsel them, to interact with them. Honestly, it's the best part of the process.
LOST: How much is it?
CP: Your total for this 90 days supply is $135.00.
LOST: That's too much. You need to cut down the order.
CP: I can do that. Just give me about 9 minutes to process the change order and. . .
LOST: What!? I just want 30 days. Just cut it down. It was supposed to be ready 2 days ago! I've been without medication for a week now and now I have to wait for it?!
ME: <whispers> what was that comment about your favourite interaction?
MYSELF: Shut it.
CP: Unfortunately, and I know this will come as a shock to you, we are not McDonald's. There, you place an order, receive a total, pay it, then they assemble your order. Here, your order is placed, then assembled, THEN you pay for it. . . or not. At McDonald's you can downsize from a large fry to a small one at checkout because you don't have enough cash. Here, we have to change the amount we billed to your insurance, then count that quantity, then slap a label on it, then tell you what it costs, THEN you pay for it.
ME: You know, when you put it like that, it is a little backwards.
MYSELF: Yeah, but try getting people to call for the copay BEFORE coming in to pick it up.
CP: We tell them that all the time but they never listen.
ME: Maybe we could make it a multi-step process: Until you call or reply to our text agreeing to the copay, we will not fill it?
MYSELF: Because they don't already get enough texts they ignore?
CP: They'd just call and say "I got this text but I didn't read it. What do you want?".
ME: Anyway. . .
LOST: So you're saying I have to wait while you get something ready for me that was supposed to be done days ago?
CP: No. I'm saying it already IS ready. You are welcome to it right now. You can pay me the 90 days copay and walk away right now. Think of it as the "Buy Now" option. OR. . . you can enter a change order, like building a house, which will delay production and completion by about 9 minutes.
LOST: I have this problem every time I come here! My last pharmacy made me wait too.
CP: Phunny.
LOST: What.
CP: You don't see the problem.
LOST: Yeah! You're all trying to rob me.
CP: If YOU have the same problem everywhere YOU go, I hate to be the bearer of bad news but, YOU are the problem. Despite repeated admonitions from pharmacy staff, you still have not heeded their advice. Call before you come to pick up your prescription. Ask your prescriber to only write for 30 days at a time. Either that or, continue to have this problem.
LOST: Just cut it down!
CP: Sure thing. I need about 22 minutes right now.
LOST: What!
CP: I now have a line, 3 doctor calls, and the obligatory 10 minute arguing penalty to impose in order to discourage future abuse of the staff and system. I'm sure you understand. We will page you when it's ready. Re-ready?
ME: Maybe we should add an isolation box for these people.
MYSELF: To keep them from loudly mumbling about our service and infecting others with their vitriol?
CP: That, and to keep them on display. We can make it like a hockey penalty box. We'll put up Plexiglass and let kids bang on the walls and scream at them until their prescription is ready. Re-ready?
ME: May make them think twice about arguing with the staff.
MYSELF: Either way, it'll be phun.

Tuesday, February 12, 2019

When To Ask

ME: Hey, CP. Here's one for you. 
CP: These never end well. 
MYSELF: When is the proper time to ask a question? 
CP: Before you do something you may regret? 
ME: So you may make an informed decision? 
CP: Ideally. 
MYSELF: Okay. Here's today's #Everyday discussion. 
ME: You start. 
CP: Phine. Welcome to CP's Palace of Pills. How may I help you today? 
ME: I am here to pick up my prescription. 
CP: It's not ready yet. We've had tech cuts and I have metrics to meet so I can't work on your prescription until next Thursday. 
MYSELF: Wrong post. Jump ahead. 
CP: Sorry. I thought this was an #Everyday post. 
MYSELF: Get on with it. 
CP: Sorry. And the name? 
ME: Abe Froman. 
CP: Date of Birth. 
ME: 5/5/75. 
CP: I see this is a new medication. Do you have any questions about starting this today? I can review the side effects if you like. 
ME: How could I? I haven't taken it yet. That's a really stupid question to ask. 
CP: Is it? 
ME: How could I know what I want to ask if I don't know what it's going to do? 
CP: <Stares blankly at this logic> Isn't this the best time to ask? 
ME: No. 
CP: Okay. Do you have any food allergies? 
ME: Yes. I die every time I catch a whiff of meat or nuts. 
MYSELF: <snickers. . . he said "whiff of nuts">
CP: According to your logic, it would make complete sense to blindly walk into a restaurant, order from the menu, then start eating, before asking if the chef put his meat or nuts in the food? 
ME: Of course not. 
CP: But you're going to blindly take this medication without any questions or counsel. 
ME: Right. 
CP: Good luck. Please sign here for refusal of counsel and acting like a git. 
MYSELF: Perhaps you should have named him Darwin instead. 

Monday, February 4, 2019


Thank you to the State Board of Alaska for their commitment to me and how I practise pharmacy in the Last Frontier. Without communications such as this, I would have begun to think I was doing my job improperly. Now I know. I know how busy you are and appreciate your taking the time out of your schedule to hold me personally responsible for refusing to fill prescriptions. I find it odd that you didn't pop in to discuss the matter personally with me so I may have been able to share some insight from my location. I know, you're busy and the citizens of the state have the loudest voice.
Let me tell you a secret. It is our licenses on the line every day. It took years of training to achieve it and we shall not throw them away thanks to a veiled threat made by my State Board.
Seriously. Do you really believe we have not been exercising our professional judgement until this point? You say "We all acknowledge that Alaska is in the midst of an opioid crisis." 
How did we get here? By pharmacists filling everything unquestioningly or by us refusing to fill everything unquestioningly or by prescribers overprescribing and expecting pharmacists to fill everything? I wonder. . .
I take issue with this statement as well: "Yes, there is an opioid crisis. However, this should in no way alter our professional approach to treatment of patients in end-of-life or palliative care situations. Again, the fundamentals of using our professional judgment, skill and knowledge of treatments plays an integral role in who we are as professionals. Refusing to fill prescriptions for these patients without a solid medical reason may call into question whether the pharmacist is informed of current professional practice in the treatment of these medical cases."
This begs the question, Are you generalising about ALL refutations to fill opioids or just "end-of-life or palliative care situations"? Your opening statement makes it appear as if you are chastising us for "refusals to fill". Period. But this sentence is misleading.

If I am to understand this letter and its intent correctly, pharmacists are trying to limit the opioids dispensed. That's good, right?
Until citizens complain. Oh. I get it. That's bad.
Opioid control good until patients complain. Then Pharmacists bad.
Honestly, did you really write this next bullet point?

"3. Controlled substance prescriptions are not a 'bartering' mechanism. In other words, a pharmacist should not tell a patient that they have refused to fill a prescription and then explain that if they go to a pain specialist to get the same prescription then they will reconsider filling it. Again, this may call into question the knowledge, skill or judgment of the pharmacist." 
I don't like how you worded it but seriously, if the prescriber is ignoring our requests to get a patient into a Pain Management practise and insists on making therapeutic changes that are outside his area of expertise, then this is a good way to help the patient. (Yes, I have used my professional judgement to reach this point.)

Just out of curiosity, what has been done to empower the Medical Board to investigate bad prescribers?
I'm sure all of those pharmacists with whom you spoke, prior to the writing and distribution of this acerbic letter, would have at least one example each of a provider who is locally recognised as a bad egg. I'm also certain you could find cases where your professionally practising pharmacist abided by your second point: "This means that if a pharmacist has any concern regarding a prescription, they should attempt to have a professional conversation with the practitioner to resolve those concerns and not simply refuse the prescription.", only to be rebuffed or threatened by said prescriber or office. 

Since we are all making assumptions here, I am going to go out on a limb and assume you sent a similarly worded and threatening letter to the State's Prescribers. It is only fair since we are all on the same team. I am in fact positive that your bullet points resembled these: 
1. Prescribers must use reasonable knowledge, skill, and professional judgment when evaluating whether to write a prescription. Extreme caution should be used when deciding to write a prescription.  

2. Part of being a licensed healthcare professional is that you put the patient first. This means that if a pharmacist has any concern regarding a prescription, and they should attempt to have a professional conversation with you, the practitioner, to resolve those concerns you should immediately avail yourself to address their concerns and listen intently. Pharmacists being healthcare professionals also means that they have medication expertise to provide during that dialogue in offering advice on potential alternatives, changes in the prescription strength, directions etc. Simply refusing to listen to a pharmacist without trying to resolve the concern may call into question the knowledge, skill or judgment of the prescriber and may be deemed unprofessional conduct. 

3. As a professional reminder, failing to practice medicine using reasonable knowledge, skill, competence, and safety for the public may result in disciplinary actions under Alaska statute and regulation. Know when a patient's therapy is outside your range of practise and when to refer them to pain management or another professional with more expertise. 

4If in doubt, we always recommend partnering with the patient's pharmacist. Feel free to call her and discuss your patients. We are all licensed healthcare professionals and have a duty to use our knowledge, skill, and judgment to improve patient outcomes and keep them safe.

Don't forget to also attach the relevant laws of Alaska governing the medical practitioners so they can feel threatened. 

In summary, I would like to see the letter you sent to the Medical Practitioners about their prescribing habits and how you are strongly encouraging (or threatening, as you did to the pharmacists) them to work cooperatively with the pharmacists in charge of the patients of Alaska.
I would like to see how you are handling complaints of the pharmacists against rogue prescribers.
I would like to see an outline for how investigations are to be carried out against prescribers and their prescribing habits.

In order to be valid, a prescription must be issued for a legitimate purpose.
In order to be filled, it is my duty to verify this.
If I cannot verify it, I don't have to fill it.