Students Are The Phuture

and I fear how they are being educated.

Intern (noun): A student or trainee who works, sometimes without pay, in order gain work experience or satisfy requirements for a qualification.

CP: I always strive to present real world, everyday situations to my students on rotations. I only have them for a limited time and know they cannot possibly see everything but I want them to see things and to practise things they may not see on their other rotations.
Me: Very noble of you. I know you love to teach.
CP: Exactly. That's why I always have hired interns and students on rotations throughout the year. I host as many as I can.
Myself: Doesn't it get exhausting?
CP: Not when I know these students are the phuture of our profession. I want them trained correctly. I think of it as training my replacements.
Me: There has to be a reason you are talking with us today.
Myself: Yeah. You don't usually let us out to play with others.
CP: It's the students.
Me: Obviously.
Myself: What about them?
CP: They just don't get it. The last crop that rotated through was full of some of the most clueless students I'd ever seen. I kept asking myself, and them, why did they pick pharmacy? Granted, this was a small handful, but the situation has become noticeably worse over the last 5-10 years.
Me: Examples?
CP: I had one student who looked as though he'd rather be anywhere other than in a pharmacy.
Myself: Isn't that where they're going to work?
CP: Yes. I understand they may not choose retail but, I've never seen someone so opposed to even making an attempt at learning anything.
Me: Example?
CP: I asked him to tell me what quantity we dispense on a Proair Inhaler and to calculate the days supply.
Myself: Easy. Grab a box and read it to see it's 8.5 grams.
CP: Precisely. Except he just stared at me. Like I was going to turn into a digital Proair board that would flash him the answers. Every day was like this. Absolutely no desire to learn anything or try.
Myself: Lame. What else?
CP: This one takes the cake; and is also the reason for the entire post.
Me: <about time>
CP: Shut it. As you notice, I defined "intern" earlier, correct?
Me: Yes. A student.
CP: I received a summary review from the students I had on rotation over the previous year and read all the comments so I could learn what worked and what I could improve.
Myself: Always learning. You're pretty smart, CP.
Me: Uh-oh. What did you see?
CP: I read this comment: "I think the students on rotations should not be expected to complete tasks an intern usually does".
Me: Dafuq?
Myself: I'm going to state the obvious here for you, CP. Students are, by definition, interns, and vice versa, correct?
CP: Correct.
Me: So, what was the point of the complaint?
CP: We had our hired interns working a few shifts while the students were there and apparently the students believed the interns should have done all the work.
Myself: But how would the students learn if everyone else was doing all the work?
CP: You are a genius. That's why we get along so well. I really am at a loss to describe how I felt after reading that. I still can't get my head around it now as the new rotation season dawns. As I have stated many times, I want to encourage people to love their profession. As a preceptor it is my obligation to foster their enthusiasm and channel it into a love for their chosen profession. These students decided to make pharmacy their career. I loathe the pharmacists who host students and complain about how awful the profession has become. If you're training my kid, don't sour her on her life's dream because you found the experience awful. Seriously, don't teach students. They are entering the profession today. Teach them how to succeed based on today's environment, not on the environment when you started.
Me: What you're saying about this last example is, you can't make them learn.
CP: "I'm trying to free your mind, Neo. But I can only show you the door. You're the one that has to walk through it."
Me: Deep thoughts, by Morpheus.
CP: I just don't know what the students expect anymore. I used to believe in the quality of program to make up for the lack of quality in the students. However, with so many schools open now, the talent pool has been so diluted that we are destined to become the homeopathy of healthcare.                                

Sometimes I'm Right

. . . and your prescriber is not.

CP: Honestly, it's not about who was right and who was wrong. I like my ego stroked as much as the next platypus, but at the end of the day the patient was helped, medical crisis averted, life went on.
Me: What are you on about now, CP?
CP: Helping people.
Me: Um. . . like, hooray or something? Want me to wave a flag? Should I call a press conference? Correct me if I am wrong, but don't we do this every day?
CP: Yes. Yes. Yes. And, yes.
Me: Why is this different?
Myself: Yeah. Why so special?
CP: Have we ever had a problem and when we told other people about it, they didn't believe us?
Myself: Like the fact that you talk to both of us in your head?
CP: Yes. I mean, no. We see patients all the time who are going through whatever ordeal is theirs at the moment and we don't understand them. We are tasked with helping them, but sometimes, sometimes the answers aren't there.
Me: So what do we do?
Myself: We listen and we dig and we offer support.
CP: Precisely.
Me: So what happened?
CP: We had a patient call us recently who had been experiencing breathing troubles. None of her providers could explain it. She knew something was wrong. She told her neurologist who ran tests. She complained about her new medication but was told "there is no way that medication does that". So she saw a new neurologist, who ran more tests, who also brushed off the potential for this newly prescribed medication to affect her this way.
Me: And they found what was wrong?
Myself: No, dumbass. It wouldn't be a good story otherwise. Keep going.
CP: She called me.
Myself: And then?
Me: And you said she was crazy.
CP: No. I told her that, while I had not seen instances of this medication causing these side effects (dyspnoea and crushing chest pain) and after asking her my litany of questions (did anything else change? did they rule out heart attack?)
{--for purposes of speeding this along, we had a lengthy discussion and she told me all about her tests and how long this had been going on, etc. . . --} I said it may be possible and that I would research it and call her back.
Myself: And then?
CP: I researched it and called her back. Were you not paying attention?
Me: Sorry. I thought you'd want a second to let people catch up.
CP: Thanks. Anyway, after a little digging, I was able to find a record of these effects occurring in a small percentage of patients.
Myself: And then?
CP: Dude. Seriously? Find a new movie to quote. And then she thanked me. She spoke with her new pulmonologist who didn't believe her either. However, this prescriber turned to the new prescriber in their practise and asked her opinion. She said she had never heard of it either. . . until she read a study in a journal last week about this exact scenario.
Me: Vindication for the patient!
Myself: And th. . . um. . . What next?
CP: She called to thank me. She said they were surprised I figured it out, but recognised I had a special set of skills.
Me: I love a good story.
Myself: Yeah. Can I have milk and cookies now? <yawns> I'm tired.
CP: Remember kids, just because no one has seen it, doesn't mean it isn't happening. Think of all the prescribers out there who spent decades of practise never seeing measles and now are scrambling to identify it.
Me: Sometimes it's the simplest explanations. We are so programmed to run tests when the simplest option would be to hold the new medication for a few days.
Myself: She stopped the new medication and her symptoms resolved over the next 2 days. Simple.
CP: And now I get pie. She promised me a fresh pumpkin pie this fall.

Chicken Pen

You know I need a chicken pen
To inject my insulin
Basaglar gone under the skin
For the dia-beet-us

#WhyILoveEScripts

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!

Professionally, No

Me: What conversation are we having today?

CP: A major pet peeve among pharmacy staff is when patients ask for refills by telling us to "just fill everything". 

Me: Agreed. Every time you write a post about patients and refills, this has to be the number one complaint. Why don't we like that again? 

CP: First, it's lazy. If you're too lazy to tell me which medications you are taking, too lazy to find the bottles in your house, too lazy to write down the numbers or names of the medication(s) you currently take, I'm too lazy to "just fill everything".

Me: Like you always say, I should not care more about your health than you do. 

CP: Right. 

Me: What else is wrong with the Customer Of the Day (COD) saying "just fill everything"?

CP: We could fill medications the patient no longer takes. We could fill old strengths, old combinations, or duplicate medications within a class. Maybe the patient had a reaction. Maybe a new prescriber changed therapies. Maybe they have some medications filled at another pharmacy in another form. The point is, we could contribute to medication mismanagement by just filling everything. It's our job to make sure their therapy is up-to-date. It's part of the CMR process for this reason. 

Me: In other words, it's professionally irresponsible to "just fill everything". 

CP: Succinctly stated. 

Me: Is there another part to this? 

CP: Yes. If the patient leaves with something they don't take, they'll ask to bring it back. If they don't leave with it, but notice they don't need it before they leave, we will have to put it back. Imagine the work involved if we filled an extra 2 prescriptions for every patient every day then had to return the same extra 2 prescriptions every day. It's not like we have anything better to do than undoing all our work. It's another reason #WhyYourPrescriptionTakesSoLong. 

Me: Got it. I have to ask. Why are we having this conversation? Usually you let people fight it out in the comments section of your posts. You rarely tackle the "just fill them all, let COD sort them out" issue directly. 

CP: The phone call I received recently. 

Me: Go on. 

CP: You agree that pharmacy staff everywhere despise the "just fill everything" mantra, yes? 

Me: Yes. They are very vocal in their opposition to this. 

CP: I received a phone call from a pharmacy to transfer prescriptions. 

Me: Okay. Normal. What's wrong with that? 

CP: I asked "how many" and was told "I'm not sure yet". Cute. But I knew where this was headed. 

Me: Let me guess, the pharmacist said "just fill everything"?

CP: Yes. The pharmacist, who likely loathes the "just fill everything" from his patients, told me the patient requested a transfer of "everything". 

Me: What did you do? 

CP: After madly cackling for nigh on a second then realising he was serious, I said "no". When he seemed stunned, I explained my reasoning. 

Me: You could have just transferred the whole profile. 

CP: True. I could have. In which case, again, I would have been performing needless work for a lazy patient who no longer wanted to be my patient. 

Me: <whispers> I can see why. 

CP: Shut it! Why would I waste my time, and the other pharmacist's time, to transfer prescriptions this feckless COD may not need? How far back do I go in the profile? Do I transfer the coochie cream from 6 months ago? Everything that is on hold and hasn't been filled over the last 6 months just in case the time is ripe to get that Belviq or Cialis filled? 

Me: I get it. What you're saying is pharmacists can't have it both ways. 

CP: Right. You can't complain about how patients act then encourage and engage in that same behaviour with another professional. 

Me: I see your point. 

CP: Thank you. Do you think others will? 

Me: Of course. 

CP: Thanks.

Me: You really need a verbal jousting partner, when CP's Partner isn't here.

CP: Intellectual intercourse? 

Me: Yes. 

CP: It's not my phault they keep cutting hours so I have to work just with you all night. 

Miscarriage of Duty

I have so many problems with this situation. Having been on both sides of the counter for this, I can sympathize with the mother and how poorly it was handled.

1. You're a pharmacist. You understand how these medications work. The woman was carrying a lifeless fetus in her womb. Whatever your personal beliefs about abortion, this is not killing a baby. She is inducing delivery of a deceased fetus. You are no more responsible for its death than the hotelier who gave a couple a room is responsible for them getting pregnant on one of his beds.

2. I know it's a "he said, she said" sort of situation but did the pharmacist really stand at the counter, prescription in hand, and refrain from giving it to her? If so, he's no colleague of mine and I'd be ashamed to call him one. Take her aside to explain it. Allow someone else to sell it to her. Under no circumstances should you explain it's for your own ethical reasons that you are denying the sale. I won't push my beliefs on you, you don't push them on me. That's how this played out in front of other patients. Yes. You are allowed to possess them. Yes. You, in Arizona, are allowed to deny the sale for this reason. However, your lack of empathy is uncalled for and galling. Call a pharmacy down the road and transfer it.

3. I do not agree with these "ethical, moral, religious" exemptions. If I believed the world was flat, I'd not take a job in a globe factory or store. (Is this the best analogy? No. It's lame, but it'll make people think a little about the inanity.) If you don't like vaginas, don't become a gynecologist. You don't get to pick and choose which medications you're going to dispense. An addict is dying in the street. Do you hand a box of Narcan over the counter to help save her and say "come back and we'll bill it later"? Do you hand a bottle of Nitroglycerin over to the wife of a man who is having chest pains out front? Definitely. Do you allow your beliefs to get in the way of saving someone's life? You cannot if you have any ethics at all.

4. When I was in my Ethics class in school, we had to watch these cheesy vignettes and determine if they were ethical responses from the pharmacist. The only one I remember was a man filling Estrogen for himself on his way to becoming a woman. The pharmacist looked at him and went "WHOA! NO way!" and handed it back. At the time, I remembered the Stone Temple Pilots song, Creep, and I said "It's not our decision. We have to let him become half the man he used to be". It's a legitimate prescription for a legitimate reason. While we may not agree with the intended use, there is nothing ethically wrong with it.

which leads me to. . .

5. "Arteaga filed a complaint with the Arizona State Board of Pharmacy. And, she wants a law in place that would require pharmacies to fill prescriptions approved by doctors." 
Whole buncha NOPE NOPE NOPE on this one. (If anyone wants to know why this is a bad idea, see "Opioid Crisis in America" and you'll learn what happens in these cases.) We are professionals. We are trained to use professional judgement. While I sympathize with her in this ordeal, there is no way in hell I am going to be a prescribers' bitch and fill whatever they write. That is not the job of the pharmacist. I can see it now:
"Sorry ma'am. Your prescriber is trying to kill you with this drug interaction but the law says I have to give it you and not question his almighty-ness."

To me this means she, like most of the general public, does not understand a damn thing about what our job is. We are more than just "pouring pills from big bottles into little bottles, label slapping, mindless automatons". When the social media outrage over this subsides, we will back in the shadows, doing our jobs of making sure your prescribers don't kill you. That you take the correct medications correctly.

Now that I think about it, I'm Batman.

https://www.khou.com/article/news/nation-world/walgreens-pharmacist-denies-pregnant-woman-miscarriage-medication-over-his-ethical-beliefs