Sunday, October 26, 2008

Customers Who Like to Show Off

Do you ever get customers that try to show off what they know about the drugs they are taking? It's always an interesting experience. Most of these customers only think they know what they're talking about. They read two sentences about the drug on, completely misinterpret the information, then spit that jumbled mess back out at you in an attempt to show you how smart they are. Most of the time, I have to stop for a second to try to figure out just what the person is talking about before proceeding with some form of an answer to whatever question they might have. Sometimes, the person doesn't even really have a question. They just tell you something about the drug as if they're giving an answer on a game show.

We have one woman who comes to our pharmacy who's especially annoying in this regard. I guess her boyfriend is a medical resident, so she apparently feels that his knowledge somehow transfers over to her. No matter what she's picking up or how many times she's picked up that medication in the past, she always has to speak to a pharmacist. It's not that I mind talking to customers or answering questions. Quite the opposite actually. However, her questions have no real point, or they start with a point but soon end up as just an opportunity for her to tell you how much she knows.

Take my last encounter with her: She picked up a new prescription for carbamezapine (it was being used as a mood stabilizer in her case). She asked me if the carbamezapine would affect any of her other medications.

I immediately thought to myself, "Great! This is a question that actually has some kind of clinical significance." However, before I could even get a word out of my mouth she starts reciting carbamezapine plasma concentration levels, how she knows it can make her drowsy, and that it might decrease the effectiveness of oral contraceptives.... Of course, she added, "but I'm not taking oral contraceptives, so I guess I don't have to worry about that."

What was the point of all that? She asked me a specific question relating to her other medications, but then she cut me off and started telling me random drug facts as well as how it interacts with a medication that she doesn't even take. Thank you very much for telling me stuff I already know. Who's the pharmacist here?

I've decided that any time she does this to me, I will respond by telling her everything I know about the drug and using as much medical terminology as possible. Therefore, after her little spiel, I told her about how carbamezapine is an inducer of the cytochrome P450 enzyme system responsible for metabolizing many drugs. I told her that it, over the course of several days to weeks, will cause the plasma concentrations of her Geodon to drop, and it might be necessary for her doctor to increase her dose to keep it therapeutic. I also told her that carbamezapine is the only drug (at least that I know of) that is capable of inducing its own metabolism. Therefore, what may start out as an effective dose for her may gradually need to be titrated up to make up for the self induced increase in elimination. I could have gone into the myriad of side effects it can potentially cause, but I figured that will undoubtedly come up the next time she comes in.

Listen... I think it's very good for all people to try to read up on the drugs they are taking. I also encourage everyone to ask questions about their medications to help them understand how they work, what kind of effects can be expected, and in order to ensure the medication is taken correctly. Just don't come to the pharmacy counter reciting a bunch of drug facts that really don't have anything to do with your situation. It's just annoying and serves no purpose.

As a sort of related aside.... If you ask a pharmacist a question about your medication and it seems like he's having a hard time answering you, it most likely isn't because he doesn't know about the drug. It's probably more that he's having a hard time explaining it without using fancy medical terminology.

For example, a woman recently asked me if I could recommend any supplement that might help ward off frequent urinary tract infections. I told her that Cranberry supplements might help help. She wanted to know how Cranberry worked, and I tried to explain that it's thought that an ingredient in cranberries actually works to prevent bacteria from attaching themselves to the lining of the urinary tract. I was trying to use as much simple language as possible, but couldn't quite grasp the concept of bacteria sticking to the lining of the urinary tract and why it would be beneficial to prevent this. I immediately thought of bacteria colonies growing on agar plates in biology labs, so I asked her if she ever took a biology class, and of course, she hadn't. I ended up relating it to mildew growing on shower walls, and explained that if the bacteria have nothing to attach themselves to, they just get flushed out of the system. That seemed to click with her. (Of course... Just how effective cranberry actually is for preventing UTIs is another story completely)

That's a simple example too. Sometimes it's just really hard to put things in non-medical terminology, especially when you start dealing with drugs with complicated mechanisms of actions that involve very specific receptors located at specific sites of the body. Therefore, if it seems like we're stammering when trying to answer a question, it's probably because we're just searching for the right words that the average person would understand.

Friday, October 24, 2008

How to Make Your Pharmacist Happy?

We pharmacists complain a lot about customers and doctors' offices. However, I don't really think we're asking that much. Just a few simple things would make us very very happy.

For customers:

- Always have your insurance card readily available. This is especially true if you've never been to the pharmacy before. You wouldn't dare go to your doctor's office without an insurance card. Why do you come to the pharmacy without one?

- When dropping off or picking up a prescription, be prepared to give the address (and possibly the patient's date of birth). We don't ask this to annoy you. We ask to help make sure we fill the prescription correctly, and when you come to pick it up, we ask to make sure we're giving the right prescription to the right person.

- Pay attention to the number of refills and the prescriptions expiration date. Both of these are on every prescription label. Therefore, when you are out of refills for a maintenance medication, you can call us 3 or 4 days ahead of time in order to allow us time to contact the doctor to get more refills. If you're completely out of tablets, have no refills, and you call us on Friday after 5:00, we're going to be really pissed off.

- Keep in mind that pharmacies do not receive orders on weekends. If you have a prescription that needs to be special ordered, please call us no later in the week than Thursday. If you call us on Friday, we will not be able to receive your medication until Monday at the earliest.

- Never wait until you are completely out of your medication before calling in a refill. Call us at least 3 or 4 days ahead of time. I guarantee you'll be much happier with our service if you call us several days before your refill due.

- Do not under any circumstances stand at the counter while waiting for us to fill your prescription. For one, this is a violation of HIPAA privacy laws because you can possibly overhear some private health information for another patient. Secondly, it's just plain annoying. How would you like it if I came to your job and stared at you while you tried to work? Your prescription will not get done any faster if you stare at me.

- We love to hear: "I'm just dropping this prescription off. I'll be back in a couple days to pick it up." If it's not something you need right away, and you're going to be back to the store in a few days anyway, then just give us that extra time.

- Understand that we don't have any say over your insurance company. We fill type up a prescription and submit a claim electronically to your insurance company. We have no control over how much they charge you. If your copay suddenly went up, we have no idea why (unless you have Medicare Part D, and we can take an educated guess that you hit the donut hole). Don't get angry at us if your copay doubled in price from last month.

- On a related note... If your copay does double in price, don't ask us to call the insurance to find out why. It's not our insurance company, and it's not our prescription. If you want to know why the price went up, you call the insurance company. There's a number on the back of your insurance card... You know... the one that you're supposed to have on you every time you go to the pharmacy. You can dial it just as well as we can.

- We also have no control over your doctor's office. Trust us when we tell you that we faxed the doctor for that refill a couple days ago, and your doctor has not responded. In addition, when we tell us that your doctor hasn't called in that prescription yet, don't look at us incredulously. We're not lying to you. If your doctor called it in, we would have filled it. That's how we make money you know.

For doctors and their representatives:

- Please don't have minimum wage employees who can barely speak English call in prescriptions to the pharmacy. It is very important that the person calling in the prescription to the pharmacy has some idea as to what he or she is calling in as well as the ability to clearly communicate it to the pharmacist. Pharmacists are amazingly good at deciphering butchered drug names and poor English. However, it would be a lot easier if we didn't have to waste our time doing so.

- When leaving messages on the voice mail SLOW THE FUCK DOWN!!!! It's not a race. We're not timing you, and I promise if you take the extra 15 seconds to clearly enunciate, it will not set you back. In fact, it will save you time in that we won't have to call you back to get clarification.

- Again with the voice mail... When leaving a message, ALWAYS spell the patients last name (and even the first name if it's an unusual name in this country). ALWAYS give the patients date of birth. ALWAYS leave a call back number for the office. Any time the doctor's name can't be easily spelled by a 3rd grader, spell it. Even if you've called in 1,000 prescriptions to that particular pharmacy in the past, still spell it. There could be a floater or a new pharmacist who's never heard of that doctor.

- Prescribers... Please write neatly. If you're a doctor, you've gone through 4 years of pre-med, 4 years of medical school, an internship, a residency, and possibly more training. Somewhere among all those years of school, you were taught to write neatly. There's absolutely no excuse to writing so poorly that we cannot make out the name of the drug or directions. In addition, please sign your name neatly. If you absolutely cannot sign your name neatly, circle your name at the top of the script, or neatly print your name below your signature. We fucking hate having to guess which doctor wrote the prescription. It's an epic waste of our time.

- When writing a prescription, write out the patient's complete first and last name and date of birth. Simply writing "J. Smith" on the top of a prescription is not valid when you're trying to prescribe Percocet. I've even seen some doctors write "Mrs. Smith" as the name. How many Mrs. Smiths are there in the world?


Seriously... these are all easy things. Most of them are common sense. If patients and doctors adhered to these simple rules, it would make pharmacists' lives much easier.

Sunday, October 19, 2008

Just One of Those Days

Another lovely day of dealing with the public. Here's a recap:

Barely two minutes after raising the gate at the start of the day, I got a phone call from a woman looking to refill a monthly prescription less than 5 days from the last time we filled it for her. I asked if she had some left at home and if she had ever picked up the previous fill. She said she never picked it up, and she was completely out. I checked our signature records and found, not suprisingly, that she was the one that signed for it less than 5 days ago. I relayed this information to her and asked her to please check again. She put down the receiver for about a minute and then returned saying that she had found it in her medicine cabinet. For one, I don't understand how someone could forget they picked up a prescription. What's more unsettling is that she argued with me for 5 minutes that she didn't have it without even checking her medicine cabinet. Wouldn't that be the first place you look? Those are five minutes of my life I can never get back.

About a minute after I hung up the phone with that lady, I get a call from an 85-year woman looking to refill her prescription. I asked if she had her prescription number. She said yes. The next thing I heard was "BEEP BEEP BEEP BEEP BEEP BEEP BEEP." Yes, she was dialing the prescription number into the phone as if I could decipher the touchtone sounds. I couldn't help but laugh. While she was dialing away, I did my best to suppress my laughter and literally started yelling into the phone, "NO, SPEAK THE NUMBER TO ME!" A hot girl who was at the counter picking up a prescription started laughing at me before rolling her eyes and walking away. Alas, the elderly woman could not hear my desperate pleas, and it took about 2 minutes before I could get her attention. I honestly think she thought she was speaking to a machine the entire time.

A little later in the day, a woman came to the counter to pick up a prescription. There was nothing unusual about her, so I barely noticed her at first. I just kept on entering in prescriptions about 15 feet away from her. Suddenly, a strange odor started to permeate my nostrils.... MOTH BALLS!!! This woman reeked so powerfully of moth balls that I could literally taste it in the air while standing all the way across the pharmacy from her. And the smell just wouldn't go away even after she left. I had to grab some Oust and deodorize the entire place.

Then there was the guy who was picking up a prescription for a 10 day course of Amoxicillin. He wanted to know if this medication was included in our special 3-month pricing for certain generic medications. I tried to explain to him that he's only going to be taking it for 10 days and that there was no need for any special pricing on it. He just stared blankly.

I suppose it wasn't all bad though. A middle aged, not terribly attractive woman who, judging by her profile, I'm pretty sure is a Vicodin junkie, told me she thinks she's in love with me because of my friendly, patient, and polite service. If you remember, the hot girl who was at the counter earlier in the day didn't think so highly of me. Story of my life...

It was a day that required alcohol... but I didn't even have any in my apartment. I ended the night sober and alone. Again, story of my life...

Friday, October 10, 2008

Once Daily Cialis?

Maybe I'm missing something here, but I thought that Cialis' claim to fame was that one tablet lasts 36 hours. Apparently, these new dosages (once daily comes in 2.5mg or 5mg) can be taken once daily every day, so that you're "ready any time the moment is right."

Again... Call me crazy, but I don't understand this. If regular cialis works just fine when you take it as needed, and it lasts up to 36 hours, then what's the point of taking a tablet EVERY DAY? Who would want to take a medication every day when you only have to take it as needed?

Are drug companies starting to run out of ideas?

Thursday, October 9, 2008

Retail Pharmacists Overeducated?

"After having been through pharmacy school and having worked retail for a year I remain unconvinced that retail pharmacists can't be replaced by robots, certified techs or some combination thereof. While I can describe several instances where I made meaningful interventions the fact is that I'm over educated for 99% of my actual job. Six years of doctoral level training simply isn't needed to count by fives, put pills in a jar, sit on hold with insurance companies and politely explain to customers that you have no idea why greeting cards aren't on sale this week. Even the bulk of counseling can be reduced to bullet points that any literate person could read off a computer screen or brochure.

Personally, I feel that the future of retail pharmacy lies with technicians filling prescriptions and a couple of pharmacists sitting in a district call center fielding questions about the more challenging issues regarding drug interactions and complex disease states.

Highly educated professionals should handle issues that require a significant knowledge base, not do menial tasks like order entry and prescription filling."

That was a comment left by an anonymous poster to my post about agreeing with The Angry Pharmacist. I think this is a poor and potentially dangerous attitude, so I want to address it.

First of all, I'm sick of my job being demeaned by uppity pharmacists who think you're only truly practicing pharmacy when working in a hospital or clinical environment. Retail pharmacists are looked upon as the dumb pharmacists. It's insinuated that all we do is call insurance companies and count by five, and therefore, we don't really have to know anything about drugs to do our jobs.

Let me state that I could have been whatever kind of pharmacist I wanted. If I wanted a clinical job, I could have gotten one easy. I probably would have been accepted to any residency to which I applied. School was fucking easy for me. I studied for a couple hours the night before exams, and still breezed through with a 3.7. I'm not a dumb pharmacist. I know drugs, and the stuff I don't know about them, I can learn as quickly as anyone.

I chose retail because I like it better, and I believe I make more of a difference in people's lives as a retail pharmacist than I would in any other area of pharmacy. I see my patients several times a month. Some of them, I see nearly every day. I'm on a first name basis with many of them. I've talked to them. I know their histories. I know their families. They come to me when they have questions about their medication. Hell, they come to me when they have questions about their general health. I've earned their trust because I work hard, and I care about them.

Do you know how rewarding it feels when one of your patients visits the pharmacy for no other reason but to tell you that the OTC recommendation you made for them worked really well? Do you know how good it feels when someone comes up to you and says, "My doctor said I should take this, but I wanted to check with you first because you know more about this stuff than he does." ? I don't need to be making interventions to feel like my job is meaningful. Simply caring and being an easily accessible, trustworthy source of information is meaningful enough.

Let me break it to you... No matter where you work, your job becomes routine and mindless. Whether you work in retail, a hospital, long term care, consulting, etc. your job ends up becoming a lot of the same things over and over again. After a little while at any job, we all stop using most of what we learn and instead become experts at the small percentage we have to know. Think about it... What do you really do in a hospital job? You input and check orders all day.

"But wait... I'm responsible for aminoglycoside dosing. I'm using what I learned in school."

I can teach a high schooler with first year algebra skills and no knowledge of pharmacy how to dose aminoglycosides. It's not rocket science. Every hospital has their own dosing parameters for the pharmacists to follow. The job is given to the pharmacists so that the doctors don't have to waste their time figuring it out on their own.

"I round with the medical team and give my advice on how to treat patients."

Sure... I guess you can say that's making a meaningful contribution while using your education. However, I've been on rounds with pharmacists, and most of them don't speak unless spoken to. Occasionally they'll get asked about which antibiotic to use in a certain situation or whether a particular drug needs to be dose adjusted in renal function. The pharmacist may or may not know the answers to these off the top of his head, and if he doesn't, he'll simply look it up. If the pharmacist can look it up, then anyone can look it up, and if that's the case, what makes the pharmacist so special?

"That's not the case for me though. I have the respect of the medical team, so they listen when I make suggestions."

That's the point I'm trying to make. Any job is what you make of it. I can work in a hospital and not do much more than input and check orders all day, and I'd still get a paycheck every week. In much the same way, I could count by fives all day and still get my paycheck working in a retail pharmacy. However, that's not all I do. I choose to interact with my customers. I choose to help them understand their medications. I choose to listen to them when they're crying on the phone to me about how their doctors don't listen to them. I choose to stay up to date on new drugs. I believe that's part of my job. I suppose it doesn't have to be, but I do it anyway.

Because of that, I can't be replaced by a robot or a tech. Sure, they can type up a script. Sure, they can count out the pills and slap a label on a vial. However, they don't have the knowledge to know if what they're doing makes sense. Furthermore, they can't provide the same kind of advice that I (or any pharmacist) can.

You take pharmacists out of pharmacies and prescription errors will go up 10 fold over night. You make customers call some remote call centers in order to ask a pharmacist questions about their medication, and you'll find that they'll be hesitant to do so. Just like you or I wouldn't be so keen on calling a doctor we've never met face to face for medical advice, patients won't want to call a pharmacist they've never seen before.

If you're still not convinced (and I'm sure you won't be), then I hope you don't end up becoming the victim of a prescription error made by a pharmacy technician who didn't know what he was doing. Maybe you'll bring in a prescription for Coumadin where the doctor mistakenly wrote "take 1 tablet 3 times a day" on it, but since the tech doesn't really know how Coumadin is supposed to be dosed, he typed it as it was written, and the robot dispensed it as it was typed.

Or maybe your doctor puts you on Coreg for a heart problem, but you find you get really dizzy shortly after taking each dose. Maybe you'd love to ask the pharmacist if that's normal, but alas, there's only technicians at the pharmacy, so they wouldn't know to tell you to try taking your Coreg with food because taking it with food slows the rate of absorption but doesn't decrease the extent of absorption.

Or maybe it'll be 8:00 PM on a Saturday night, and your baby will be running a fever despite the antibiotics the pediatrician gave him the day before. The baby won't stop crying, and your doctor can't be reached on the weekend, so the only person you can turn to is a community pharmacist who will be able to tell you what dose of Tylenol you can give the baby.

You're right though... If all pharmacists did was count by five and call insurance companies, we wouldn't be needed. If you take pharmacists out of pharmacies, you'll get the same kind of service from pharmacies as you would get from a fast food restaurant. I don't know about you, but I'd rather not treat my medications like fast food.

Wednesday, October 8, 2008

It's so bad that all I can do is laugh

As of this morning, my 401k has lost 23% of it's value. I've decided not to be upset over this. I'm just going to laugh as my money disappears. Luckily, I've only been contributing to my 401k for a couple years now, so I don't have a huge amount of money in it.

Long-time readers will remember that I freaked out earlier this year when I predicted an impending global financial meltdown. I'm not going to outline the whole argument, but I'll just say that if you don't think this crisis is related to what I was saying, you're kidding yourself. However, I'm not really panicked about things now. Maybe I'm just in a better place now, which is allowing me to better cope with all of this. Whatever the case, I'm more amused than anything.

I never really planned on retiring anyway. I always kind of figured by the time I reached retirement age, retirement will be a long forgotten concept to the average worker. Therefore, while I do contribute to a retirement account, I make sure to contribute to my regular savings account as much as possible. I'm incredibly grateful to have a job that allows me to do this... I just hope I'm able to keep this job for a long time.

Sunday, October 5, 2008

Agreeing with The Angry Pharmacist

The Angry Pharmacist wrote a great blog entry regarding the realities of retail pharmacy. I couldn't agree more with what he said, and I encourage everyone to check it out. I just had a few of my own thoughts that I'd like to add.

Since I started working as an intern during my second year in pharmacy school, I've been saying that pharmacy school teaches you everything except how to be a pharmacist. They overload you with pharmacology, therapeutics, medicinal chemistry, etc., etc., but they give you (at least they gave me) only ONE lecture over a 4 year professional program about the business side of pharmacy.

In retail, the business side of pharmacy is what keeps us having jobs. All those professors can lecture about patient care and medication therapy management all they want, but in the end, if pharmacies are not filling prescriptions, they're not getting paid.

By the way... Under the MTM model, just how many patients would we have to counsel an hour to make it profitable. A pharmacist is making almost a dollar a minute. How much are we looking to charge for these MTM sessions, and would we be able to have enough sessions to make up for a pharmacist's salary? I didn't even include the cost of all the time spent keeping records of our MTM sessions, nor did I include the cost of supplies (charts, storage bins, new computer software, etc.) to do so.

Moreover, does MTM mean that we stop providing medication counseling to everyone else? We used to do that shit for free, so under MTM if Mrs. Old Lady calls up with some questions about her medication, do we tell her she needs to make an appointment? I'm sure that will go over really well. One of the big reasons that the public looks so favorably upon pharmacists is that we're the most readily available source of health care information. With a simple phone call, anyone can speak to a drug expert within minutes. You start restricting what kind of information pharmacists can give out for free and suddenly, we're not any different from any other health care professional. However, if you want to set up MTM and don't put up any restrictions on free information, then what's to stop people from not setting up appointments and just demanding whatever info they can get over the phone or when they get their mandatory counseling upon picking up a new script? It's all very confusing.

Pharmacies fill prescriptions. That's how we get paid. That's the main service we provide to the public. We do our very best to make sure that every prescription that comes through the door is dispensed safely and accurately. In most cases, we are the last line of defense against medication errors. Every time we correct a prescriber's mistake or catch a potentially dangerous drug interaction, we are potentially saving someone from harm or (in the worst cases) death. In doing so, we save the health care industry probably billions of dollars per year by cutting down on serious adverse reactions and potential malpractice suits. That's the pharmacist's role in all of this.

Many people are worried that we'll be replaced by technicians or robots because it would save our employers money. Perhaps this is a real worry, but MTM isn't the answer to that either. If Walgreens or CVS wants to save money by taking pharmacists out of pharmacies, then why would they want to spend the extra money to have a pharmacist do MTM?

Furthermore, even the very best technicians cannot fill prescriptions as reliably as pharmacists. My store has a nationally certified technician that, by all accounts, is very very good at her job. Even still, I catch and correct a lot of mistakes she makes inputting scripts. Sure, technicians can type what they see on a script and fill it that way, but they can't ask the most important question, "Does it make sense?" A robot can't do that either. Only a pharmacist has the education and training do to so, and that's why we're vital to the success of the business as well as the safety of our patients. Our task is to make our employers understand this instead of trying to change the way we do business.