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Thursday, February 27, 2020


CP: You know what's interesting?
ME: That you have regular conversations with yourself and no one has put you in a straitjacket and locked you in a padded room?
MICE ELF: That zebra's stripes serve to keep flies away?
CP: No. Yes. Stop. People love to make comparisons to retail pharmacy and fast food. We both have drive-thrus, our companies value speed over accuracy, and we both upsell items at the register (you want fries or a flu shot with that?).
ME: Yeah. So?
CP: Fast food has evolved. People don't want ready-made grub. With Chipotle, Subway, Jimmy John's and even Sheetz with their Made-To-Order fare, the game has changed. People enjoy placing an order for a fresh-made meal. They will wait in line or stand around waiting for their freshness to arrive.
MICE ELF: Those MTO sandwiches are pretty good and worth the wait.
CP: Right? As people have decided to slow down, however trivially, they expect faster service at the pharmacy.
ME: All you do is put pills in a bottle.
MICE ELF: And all the Sandwich Stewards do is slap some salami on some bread.
ME: They better not be slapping their salami while making my sandwich.
CP: But you will stand inside a Sheetz and wait with a dozen other patrons until your order is processed. No one is complaining about the wait. They are milling about picking up a few impulse purchases and otherwise not interrupting the process.
ME: They also can't see the process to interrupt it.
ME: Let me guess. . . you're going to make the claim we need to Close The Pharmacy again?
CP: Well, at Sheetz, the person making my sandwich isn't running out to pump someone's gas, exchange a propane tank, or sell cigarettes while working on my order. She is focused on the task at hand, uninterrupted. It's less likely I will get mustard slapped on my buns when I requested spicy Mayo if she is focused.
MICE ELF: Ew. Thanks for that image.
ME: If you were locked away from distractions, you're saying there's an increased likelihood you would be laser-focused on the task at hand, the patients' prescriptions?
CP: Unequivocally. While the mustard won't kill me, missing that drug interaction or miswritten, mis-filled prescription may kill someone.
ME: Are you suggesting we should put pharmacies in Sheetz?
MICE ELF: That would be awesome!
CP: Sure. Patients scan their Rx into the kiosk, then scan in their insurance card, then walk away. If their information is incomplete, their order won't finalise. Once it's ready, they get a text with a barcode to scan with the price then pay it at the automated register. (If they want to change the price or use GoodRx, they have to indicate that at the kiosk or click "make changes". This way, they are responsible for the extra time required for this step.) Then they come back to the lone, narrow pharmacy window and a pharmacist hands it to them and provides counseling.
ME: Damn. And they can walk over and get a sandwich and some loaded totz while they wait.
MICE ELF: Brilliant!
CP: This is almost as good as my idea to put a pharmacy in a cineplex. Movie's over? Prescription's ready!

Monday, February 24, 2020

If You Don't Care. . .

ME: You tell people all the time that a company takes on the persona of its boss.
CP: Mostly, when I say that, it's about employees. They take on the attitude of their direct supervisor. If there is genuine caring from the top, it trickles down to all of the employees/direct reports and then is when you have a team.
MYSELF: Why is this important?
CP: After the NY Times article and the brouhaha that followed it, it seems apropos to comment on how bad retail pharmacy employers are.
ME: All of them?
CP: Yes. There isn't any singular benefit that causes one to stand above the other. We used to be able to differentiate them by their services but now it's just different bowls of vanilla ice cream.
MYSELF: And they're equally guilty of mistreatment of their employees and the bastardization of the profession in which they practise.
ME: What brought this topic about?
CP: My brain is full of lyrics and movie quotes, right?
ME and MYSELF: Yes.
CP: I was thinking about how the employers really don't care. They don't care about their patients (who get annoyed with the phone calls and texts and out-of-stocks and other corporate-controllable issues). They don't care about their employees (firing good employees but keeping awful ones, threatening their jobs, pushing metrics, killing bonuses, scheduling way too few employees per shift, etc). They don't care about patient safety (again, scheduling too thin, preferring staff to make phone calls instead of focusing their attention on the prescriptions in front of them).
ME: Got it. And. . . ?
CP: If you don't care, then we don't care.
MYSELF: Now move in now move out.
ME: Hands up now hands down.
CP: If your employees are complaining about how bad the profession has become, you should listen. If my technicians come to me with a complaint, I can either do something about it or ignore it. If I fix it, they know I will always have their backs and they will want to work harder for me since I will support them.
If I blow it off, if I do not take it seriously, if I upbraid them for complaining, they will quit caring and leave. They will be useless to me and I will be left to wonder why they stopped caring and are not working as hard as they were.
ME: You will have lost them.
MYSELF: It's the professional dilemma; our ethical divide. We are wired to feel obligated to our patients, to care for them, to do the best we can for them. Yet we are set up to fail by the corporate system.
CP: Right. We can't quit caring any more than we can quit breathing.
ME: I bet they'd try to take that next.
CP: But we can care less. I'm sure the corporate overlords hate the negativity, but it's negativity dressed as honesty. When patients ask why we don't have something in stock, why they receive too many phone calls, why we can't remove them from an over saturation of alerts even after they die, be honest; tell them it's "The System". If the retail giants don't care enough about the work environment they provide, about their employees' opinions, hell, about patients' opinions, then we shouldn't care either.
MYSELF: What you're saying is that, we can care about our patients, but if those patients have a negative opinion about the companies, we shouldn't do anything to discourage them from having those opinions.
CP: Precisely. Since the companies are doing absolutely nothing to change the negative opinions everyone in the world has of them, why should I try to change that perception. My patients will love ME for who I am, but we can both hate the company and how it does business. Like I said, if they don't care, then we don't care.
MYSELF: Throw your hands up!


Friday, February 21, 2020

Not My Services

UT: Why did I just get yelled at?
CP: Because you're a horrible human being?
UT: Phunny.
CP: Because we can't meet the lofty expectations of the public in today's "everything's accessible at all times" society?
UT: Sounds better.
CP: Which complaint was it this time?
UT: I was remonstrated because we do not offer a drive-thru.
CP: Ah, the joys of working with the public. You cannot get mad at me for not offering services we do not provide. I don't have a drive-thru. I am not going to knock a hole in the middle of this plaza just for you to idle away, polluting the environment.
UT: Either they pollute it with gas and emissions or they befoul the air with their complaints.
CP: Like the person who came to the drive-thru at another store and asked them to shop for her. When the tech told her it's in the front end and we don't shop, the lady pointed to the aisle and said "I know it's right there in front of the pharmacy".
UT: To which they replied?
CP: Since you know where it is, you can come in and easily find it yourself.
UT: Seriously great. One of your proteges?
CP: It was. We are not offering curbside pickup.
UT: Maybe we should post a list of services we do NOT provide. That way people can search online or read the poster while they wait.
CP: We do NOT offer:
-a drive-thru
-curbside pickup
-valet shopping
-prophylactic phittings
-24 hour service
-metformin tablet flavouring
UT: As you have said before, where you choose to do business is entirely up to you. If you don't like the services they offer or they are missing ones you need, don't shop there. If their hours aren't convenient for your needs, again, go elsewhere.
CP: I had patients switch to a local independent years ago. They were only open until 5pm weekdays, 10-2 Saturdays, and closed Sundays. Guess how many phone calls I received during their closed hours from patients asking me to help them? "I just need a few until my pharmacy opens." blah blah blah. You chose to do business with them now you have to operate your life within their operating parameters.
UT: I eat at local, cash-only restaurants. I'm not going to expect them to take credit cards or checks. They have an ATM. It's their rules. If you are an Apple Pay-exclusive patron, eat elsewhere.
CP: Right. You have options. "Of all the gin joints in all the towns in all the world (you) walked into mine." Next time, walk past my door.
UT: At least we excel at the services we do offer.
CP: They come to see the two of us which, in the healthcare world, is far more important than a drive-thru.



ME: What are we debating today?
CP: Refills.
MYSELF: Bartender!
CP: No. For as long as we have been filling prescriptions, we have had to deal with the most convenient method of communicating to the patient the number of refills remaining on her prescription while also fitting it comfortably on the label.
ME: I'll set the stage. We have a prescription for a patient. The prescriber writes it as:
"Take 1 tablet by mouth once a day"
Dispense 90 tablets
With 3 refills.
CP: Which is fine, unless the patient only receives part of the whole, original 90 tablets. Let's say they only are allowed to fill for 30 days at a time.
MYSELF: Let's show how this would look using the traditional methods of putting refills on the label:

A. 3 refills remaining (tells us there are 3 full fills of 90, but doesn't account for the remaining 60 of the initial fill.)
B. 3+ refills remaining (nice. but doesn't tell us how many are left in the "+".)
C. 3.67 refills remaining (nice. a math problem for refills. except patients don't know they were originally prescribed 90, some suck at math, and others think it's a price.)
And the non-traditional method:
D. 330 tablets remaining (specific.)

CP: Here are my issues with each of these:
A. Simple and direct. However, as you said, "3 refills" doesn't account for the partial quantity filled. In fact, this label will show "3 refills" for the next 2 fills, until the patient dips into the 2nd set of 90 at which time their bottle will show "2 refills" for 3 consecutive fills. Confusing for the patient.
B. "+"? How many? Is it an even number of fills? Did the patient buy 7 as cash so the "+" means 23 tablets? I have always loathed this option. Is it like a B+ in math? You need that for the next option.
C. Math is hard. It's only helpful if the patient knows the original prescribed quantity. Otherwise, what does 3.14 refills mean? (And no, you cannot cash it in for pi.) This is especially inconvenient with e-scripts since the patient never knows how many were prescribed.
D. I think this is the most helpful, unless you are dispensing something on volume and the remaining quantity is in the ten thousands (think Mesalamine enemas).

ME: What do you think the consensus will be?
CP: There won't be one. When labels were entered on a typewriter, then on a dot matrix printer, then on the first computer programs, spacing was critical, and basic. However, now that our computers can adjust the characters to fit lengthy directions on the label, the refills should be the next, easiest section to adjust.
MYSELF: Personally, I like the last option. But I also prefer that e-scripts are sent to us using quantity and units as well so as to lessen confusion.
CP: And isn't that the point? If we are supposed to make things less confusing for the patients, why do we still use old methods that require slide rule to understand? What say you?

Tuesday, February 18, 2020

Learn Something

ME: Hey, CP! Long time.
CP: If you're here, there must needs be a topic for discussion.
MICE ELF: What's got your smock in a snarl lately?
CP: Understanding. Or a lack thereof. Or rather, a lack of desire to understand.
ME: I'm guessing this has to do with people?
CP: Of course. I'm big on dialogue; having an open discussion with a back-and-forth where we learn from those who are more knowledgeable about a topic than we may be.
MICE ELF: It is helpful to keep your mouth closed so your ears and brain may work together to process the new information.
CP: It is. However, I find that people would much rather talk loudly, and over others, than engage in this type of learned dialogue.
ME: As when we are trying to explain, well, anything really, to our patients and providers.
MICE ELF: Yes. If theirs is the loudest voice heard, it must be right.
ME: Sounds like a defense mechanism used by those who refuse to confront their long-held, diaphanously-constructed belief system for fear they will watch it dissolve like candy floss in the rain.
CP: It's true. The question I have is this: Do you want to keep complaining? Or do you want to take a second, learn what happened, understand it, improve your life with the knowledge I will impart, and be a better person for it?
ME: As I said, it's too difficult to face you could be wrong.
CP: Yet people will argue with and interrupt me when I try to explain any of the following - you have a deductible, your insurance changed their formulary, the prior authorisation process, why I need the patient's information for a new profile, why we are not CVS or Walgreens and have to call them for transfers, or any of the multitude of reasons patients phrustrate the hell out of us daily.
Ask a question.
Allow me to answer it.
If you are unclear on the details, ask a follow up question.
Nod your head in assent or shake it to signal lack of comprehension.
However, under no circumstances should you interrupt me. I am attempting to help you. Take the wisdom I share and use it. Call your insurance or prescriber. Verify what I have told you.
MICE ELF: And. . . ?
CP: And next time I won't have to have this discussion with you, again, for the eleventeeth time.
ME: You're suggesting people should actually listen to what you tell them and then grow as a person instead of remaining ignorant and condescending and threatening?
CP: Essentially.
MICE ELF: Better to remain silent and look like a fool than to open your mouth and remove all doubt.
CP: Just shut up and listen. I'm offering answers, not excuses. I am telling you the likeliest reason for your current situation and how it can be remedied. I can explain it to you, but I can't comprehend it for you. If you're still talking, you're neither listening nor comprehending.
ME: Your biggest pet peeve is having to explain something more than once.
MICE ELF: That and having to redo work we've already done.
ME: And being interrupted while talking.
CP: All of which result from patients not listening but arguing with what I am saying. It does not behoove me to lie. I miss the good old days when patients trusted us and what we had to tell them. I don't know anything about particle physics and if I ever find myself in a discussion with a particle physicist, I find it unlikely I will interrupt her.
ME: You read all the signs at the museums and zoos, don't you?
CP: How else to learn? It's also quiet learning where just the 3 of us can talk.
MICE ELF: No wonder you know so much random minutiae.
CP: Shhh.

"Yes we're being condescending
Yes, that means we're talking down to you
With all that racket from your lips a-flapping
We assumed you didn't notice"


Tuesday, February 11, 2020

You Sound Like An Ass

CP: How may I help you?
AB: I am here to pick up my prescription.
CP: Name?
AB: Ass Baggins.
CP: Spelled?
AB: Just like it sounds.
CP: Don't say "just like it sounds" when I ask how to spell it.
Perhaps I misheard it?
Perhaps I am hard of hearing?
Perhaps you didn't enunciate or articulate it clearly?
Mayhap you mumbled?
But saying "just like it sounds" is demeaning to my staff. We need to type what your name IS not what we heard.
Sure, once you spell it and I can see the letters together in my brain it may sound like it looks, but then again, dough, cough, and plough don't rhyme, nor are they spelled as they sound.

Monday, February 3, 2020

CVS Response to NYT Article

1. I wonder how many people researched and worked on writing this response. My guess is that it was way more than their average pharmacy employs to fill prescriptions.

2. "we are fierce advocates for expanding the number and role of pharmacy technicians at our stores." and "CVS Health has been on the forefront of advocating for states to increase pharmacy technician to pharmacist ratios."

-Having followed this story all day when it broke, I can tell you that all across social media, and from the colleagues with whom I spoke, there is not a single person who stated "my pharmacy is getting way more tech hours". In fact, to a person, everyone agreed they are continually getting their technician hours cut. Not exactly "fierce" in their advocacy.
-Of course they want a higher ratio. That way, they can employ cheaper labour to do more work. However, this does not address that there is a limit to the amount of professional work one, single pharmacist can complete in a day. More prescriptions to check, more errors to catch, more immunizations to give while also requiring more phone calls to be made and conference calls to attend, and reports to be completed is a recipe for disaster. More errors will be missed.

3. "One of the best examples (of our investment in technology) is electronic prescribing."

-You can't take credit for accepting an already existing technology. It's like Apple Pay. It exists. Either you accept it, or you don't. But you can't claim credit for its existence.

4. "The automation of electronic prescriptions has resulted in a reduction of some pharmacy labor hours."
- Yes. Yes it has. However, as I have long said, "electronic prescribing has not resulted in FEWER errors, only more, legible errors". These new errors often are more complicated to address and fix than handwritten prescriptions. The resolution often requires multiple phone calls and communications sent to offices. This "reduction in some pharmacy labor hours" results in more work for the pharmacy staff as we cannot dedicate the required time to fixing them properly. That's nothing to celebrate.

"By automating 90% of data entry for e-prescriptions, we’re preventing human error and improving efficiency."
-Again, automated does not mean flawless. When mistakes are made, someone needs to fix them and with these labor cuts, there is no one there now to accomplish this.

5. "our use of metrics mirrors what’s commonly used throughout the health care industry. Over the past 18 months we’ve focused in further by narrowing the number of metrics we measure in half."

-Phunny. Everyone I spoke with said the same thing: They are being measured more than ever. I will concede that metrics, when used properly (as a counseling tool to provide teaching and focus) have some merit; the way pharmacy uses them is deflating. If you as a company are using them to withhold bonuses, to threaten, write up, or fire employees, then that is counter to the reason metrics exist. (You are doing that by the way.)
-When you don't make enough MTM calls, meet your quota for immunizations for the day/week, make enough antibiotic counsels or press the red button enough times during your shift, it is not helpful to have your boss yell and threaten you by saying you don't care about your patients. You have a serious disconnect.

6. "we conducted a survey of all of our pharmacists to gauge their perspective on the culture of patient safety in their pharmacies, and the overwhelming majority of responses were positive. Another factor that indicates job satisfaction among CVS pharmacists is our extremely low turnover rate, which has decreased over the past three years."

Call me Cynical, but I know you don't bite the hand that feeds you. When any company can tell how many employees have or have not taken the survey and when they can identify the role(s) of those employees, forgive me if I question their claims of anonymity.
Also, cynically, of course turnover rate has decreased. CVS and Walgreens have spent the past years buying their competitors and often closing them on the spot. It's hard to find another job when it's an either CVS or Walgreens job market. Oh, and with market saturation, no one is going to leave if they do not already have another job. The jobs just aren't there.
-What did CVS expect their pharmacists to say in the survey? "It's impossible to do my job with the resources you give me so I don't worry about it."
-Also, who defines what a "legitimate concern" is anyway? Obviously pharmacists have concerns, hence the New York Times article. Apparently these were not legitimate enough to warrant exploration by CVS. Instead, we have this puff piece denying responsibility, or that a problem even exists.
-There is also a difference between pharmacists being "concerned professionals, caring about their patients' health and wellbeing, and being 'dissatisfied employees'". You may want to research that.

7. "Patients who enroll in our 90-day program can opt-out at any time or choose which eligible prescriptions to move on or off the program."
-There are benefits to 90 days. For the company and its STAR ratings.
-There are benefits to the patients - fewer trips to the pharmacy.
-It's a little troubling when you have to tell a patient she has to pay $600 for 90 days of Levemir because your Pharmacy/Insurance/PBM company requires 90 days instead of 30 days. She'd have an easier time with $200 every 30 days but that's not up to her.
-You also can't claim it's an option when comments across all social media exposed district managers telling their pharmacy staff to "just sign them up so we get the credit and let them ask to be removed". Nice tactic. Rather defeats the purpose but, hey, it's a measurable metric and you have to meet those, right?

Apparently the authors of this response spend all day shielded away from the actual pharmacies they represent. If your ground troops are telling you one thing, perhaps you should get out more and listen. Maybe walk into a pharmacy and see for yourself if their claims have merit. My friends across the country, across all social media echoed the same thing. This is nothing more than a fluff piece designed to make CVS look good to the general public that does not understand how their system works.
Don't let that happen.
Continue to keep the pressure on by (re)posting the NYT article.

Sunday, February 2, 2020

Ask. Answer. Move On

Uber-Tech: What's new, pussycat?
CP: Whoa. Oh, whoa. 
UT: Please stop. It was rhetorical. And painful. 
CP: I'm going to try a theme for the week. 
UT: Sounds phun. 
CP: It is. Maybe I'll throw in a lesson or query at the end to tie the week together. 
UT: What's the theme? 
CP: Dialogue. Simply put, dialogue. 
UT: Can you be more specific? I'm asking to generate interest and keep the readers awake. 
CP: In order to facilitate any transaction, a question is asked and an answer is given. Should be simple, yes?
UT: Indubitably. I'm guessing this week will demonstrate how these simple transactions go awry? 
CP: Hopefully. 

Monday: It's Not Hard
CP: Welcome to the first Monday of the year. How may I help you? 
INH: I am here to retrieve my newly prescribed medications. 
CP: Delightful. First, do you have your new insurance card handy?
INH: You should have it. 
CP: We do not. It changed the first of the year. 
INH: It worked at the doctor. 
CP: Did you give them a card? 
INH: "No. But they knew they had to send my prescriptions here."
CP: Those two are not related. 
INH: I didn't have this problem at my last pharmacy. 
CP: Your insurance changed. Do you have the card? *
INH: They never needed it before. 
CP: Okay. Unless and until you can provide the answers I need, I am going to have to ask you move to the back of the line. Back. Further Back. Like outside the store, in your car, driving home to get your card. 

*people! put your new card in your wallet. toss the old one. you do that for your license or debit card. same concept/process.

Tuesday: It's On There
CP: Welcome to Pill Pauper's Paradise. How may I help you?
IOT: I need this prescription filled. 
CP: Okay. Just need to verify your information. What is the date of birth of the patient?
IOT: It's on there. 
CP: I can't read. And this isn't a Prego commercial. 
IOT: Why do you need it? 
CP: Does it matter? **
IOT: Yes. 
CP: I need to verify we have the correct patient/information/account, etc. 
IOT: I am the only Ass Baggins in town. 
CP: You'd be surprised. So. . . date of birth?
IOT: They don't ask me anywhere else.
CP: They must not care about their licenses or if you get the correct medication. You do realise that I could have your prescription entered by now had you only answered my question when I initially asked, right? 

**never trust the date from the office. had a grandfather take his grandson to the pediatrician and the office typed grandpa's DOB on the hard copy. had another instance where the office confused two patients and switched the profiles resulting in my patient receiving the other patient's Rx--same name, different DOB. just answer the question. 

Wednesday: Pick A Name
PAN: Where is my prescription?
CP: I don't have one.
PAN: This always happens!
CP: I did not find anything under your profile.
PAN: I called my doctor and they sent it.
CP: Okay. Under what name?
PAN: My maiden name!
CP: So when I asked you for your name, shouldn't you have given me that one instead? ***
PAN: Why does this always happen with you people?
CP: Look, if you don't know who you are, how am I supposed to know who you are? To me you're just another Buckcherry song. Shouldn't you be yelling at your doctor's office instead of me?

UT: I think of Sheryl Crow when people give their names at the counter. 
CP: "He says his name is William but I'm sure he's Bill or Billy or Mac or Buddy."
UT: Yep. It's just a matter of which identity we have in the computer.

***I don't care what you call yourself, just be consistent. it's not my job to know that you go by Susanne at the doctor, by Sue with your friends, and by Siouxsie here.

Thursday: Just Spell It, Douche Baggins
CP: How may I help you?
DB: I am here to pick up my prescription.
CP: Name?
DB: Baggins. Douche Baggins.
CP: Spelled?
DB: Just like it sounds.
CP: Don't say "just like it sounds" when I ask how to spell it. ****
DB: Why not? I always say that. It's easy.
CP: Yes. Easy to mistake it in a chaotic, loud environment.
Perhaps I misheard it?
Perhaps I am hard of hearing?
Perhaps you didn't enunciate or articulate it clearly?
Mayhap you mumbled?
But saying "just like it sounds" is belittling to my staff. We need to type what your name IS not what we heard.
Sure, once you spell it and I can see the letters together in my brain it may sound like it looks, but then again, dough, cough, rough, and plough don't rhyme, nor are they spelled as they sound.

****That's "C" as in czar and "P" as in psyche. We've been over this. Listen Llynda, and you too, Carin, naming your son MicEnZee may be novel, but you have to deal with this your whole life. I should only have to deal with it for the fewest seconds possible to complete our transaction. Spell it. Move on.

UT: You made it to Friday!
CP: You had doubts?
UT: Never. You're stubborn. Think everyone remembered the first post?
CP: Rephresh.
UT: We were talking about dialogue; how an interaction is a simple exchange.
CP: Ask a question. Question gets answered. Move to next question or statement.
UT: Hence the theme of Ask. Answer. Move Along.
CP: Right.
UT: What happened?
CP: Consistently, every day this week, each post received well over 100 comments.
UT: Phascinating.
CP: It is. It proves my initial point.
UT: That being?
CP: People like to make everything more complicated than it needs to be.
If I ask for you name, give it.
If it may be spelled multiple ways, spell the one you use.
If I ask for your DOB, I need it. Provide it without being phancy and move along.
If I ask for insurance. Provide it.
UT: If I ask what time you wish to pick up your prescription (wait for it, 30 minutes, tonight, this weekend, etc.) answer the question with a statement. Pick a time that works for your schedule. Sign up for texts or calls or whatever service your pharmacy offers and return when you receive the notification. It's not a debate.
CP: Right. You chose to do business with me. (yes, yes you did. your insurance may require my pharmacy, but there are other options around. I checked.) These are the requirements I have in order to conduct said business with you. Should you choose not to provide any of the required information, you are rendering our current, and likely all phuture, transactions incapable of being completed in a timely fashion. This will result in time penalties accrued and applied at my discretion.
UT: We need to employ the Soup Nazi from Seinfeld method to ordering. "Hold out your money, speak your information in a loud clear voice, and move to the side. . . It's very important not to embellish your order."
CP: Like the military: name, rank, serial number.
UT: Succinct.
CP: Or more recently, for the younger fans, Nate Bargatze's minimalist approach to ordering at Starbucks: "Coffee. Cup. Milk."