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.


thetwitchytechnician said...

There is no way in hell I'd stay in this business if there wasn't a pharmacist in there. A CphT could never completely function as a pharmacist.

Ray & The Casuals said...

No pharmacist warned me about taking lipitor and lipital ez. Now I can't walk. Pain killers..nobody told me that Naproxen and tylenol will raise my blood pressure- even though I asked. What's wrong with the system?

pharmacykid said...

You only had one lecture on pharmacy business?? I have an entire class on business and management. A lot of my fellow peeps complain "why are learning this . . . it's not gonna help us . . . etc etc" But what I've appreciated so far is that pharmacy is as much as a business as a health field (same goes for medicine, dentistry, optometry, etc). The more we realize this, the better we can operate pharmacies to become efficient in both earning potential and health care.

TheAngriestPharmacist said...

"No pharmacist warned me about taking lipitor and lipital ez. Now I can't walk. Pain killers..nobody told me that Naproxen and tylenol will raise my blood pressure- even though I asked. What's wrong with the system?"

If you think your pharmacist is dumb and/or lying to you, find a new pharmacy. And more importantly, tylenol doesn't raise BP. The mechanism behind NSAIDs raising BP is very weak (inhibition of prostaglandins in the afferent arterioles). Can it happen? Yeah. Am I concerned about that in the vast majority of patients? Heck no. Perhaps in resistant (or severely uncontrolled) HTN, I'd worry. Normally, it's a joke. That's probably why your pharmacist didn't say anything about it.

And, what the hell is "Lipital ez"? That doesn't make any sense. Lipitor itself can cause muscle breakdown, but it would be proceeded by many symptoms that should urge you to call your MD or pharmacist -- like reddish-brown urine, muscle pain, weakness and fatigue. It's FAR from your pharmacist's fault. It's far from the 'system's fault'. And lipitor isn't one of the prime suspects in rhabdomyolysis -- of course it can happen, but the incidence isn't as high as in some of the other statins.

Stop looking for someone to blame because you were to ignorant to notice your own adverse events. Sometimes bad things happen and no one can control them.

I guess you can blame me for your prostate cancer in 10 years...if you must...

Ray & The Casuals said...

The answer I just received is just so ignorant, rude and uninformed , I can't believe the writer is an educated professional. I suggest he/she does a little more homework. Being Cocky, defensive and narrow minded, and rude, doesn't promote healthy dialogue or knowledge.

Pharmacy Mike said...

And what exactly do you do for a living?

Ignorant and uninformed. I guarantee that you'll want to back off that statement here where you'll find a plethora of pharmacists (DRUG EXPERTS) who will back up what Angriest just said.

I also have no freaking clue what the hell Lipital ez is. I even tried looking it up online. I found nothing except for that it possibly might be a name for some baby formula, or some knock off version of Lipitor.

Like Angriest said... Tylenol does not raise blood pressure. It's a centrally acting prostaglandin inhibitor. NSAIDs like naproxen can possibly raise blood pressure, but it generally isn't something you worry about in younger patients. It's more of a risk in the elderly patients who have diminished renal function and who have hypertension that is uncontrolled.

You can call us assholes. You can call us whatever you want, but the one thing we certainly aren't is uninformed. We know drugs.

Ray & The Casuals said...

I don't recall calling anyone "Assholes"; however, if it writes like one, and smells like one,...
I apologize for my comment re: tylenol raising BP as did the Naproxen; however the tylenol was doing a great job on my liver, along with lipitor and, I apologize for mis-spelling Lipidil EZ.. however, being informed pharmacists, you should have easily uncovered this error.
The language and approach you guys are using sure is crude. In this manner, do you expect to win over the public?

Ray & The Casuals said...

I complained to my GP in January about cramps, muscle probs, etc and she ignored me.
Again I complained in June that I couldn't walk and I couldn't complete her office forms because my wrist was too weak. She ignored me -and added lipidil EZ (FENOFIBRATE). DRUGS.COM WARNS OF POSSIBLE SEVERE INTERACTION.
I went to 2 more doctors and asked 3 pharmacists, and no-one knew of this evil cocktail, nor associated my muscle complaints with these drugs. I AM an athlete and know my body; I can tell you something was not right!!
References: Shane Ellison M Sc; Stephen R Devries M.D. ; Duane Graveline M.D.
Thanks for listening.

Pharmacy Mike said...

Now we're getting somewhere...

Lipidil EZ is fenofibrate. I had actually never heard it called that before. Tricor is the brand name of fenofibrate that I know.

Taking fenofibrate with Lipitor is not an absolute contraindication. You're supposed to use the combination with caution because of a possible increase risk of rhabdomyolysis. The combination of fenofibrate and Lipitor is a much smaller risk than the combination of other statins like simvastatin or lovastatin. Moreover, fenofibrate is also the less risker fibrate drug. Gemfibrozil (Lopid) carries a much greater risk when combined with statins than fenofibrate does. A lot of my patients/customers are taking the combination of Lipitor and fenofibrate, and their doctors are well aware of the potential interaction. The trick is to use caution by monitoring for signs of muscle pain and weakness.

Yes, Tylenol can damage your liver... In extremely high doses. The maximum dose of tylenol is 4 grams per day (or 8 extra strength tablets). Since Tylenol is OTC, I'm sure your pharmacist has no idea how much Tylenol you're taking, or else I'm sure he/she would have cautioned you about not exceeding the maximum dose.

Moreover, since you never specifically said what either NSAIDs or Tylenol have actually done to you, I'm just going to venture a guess that you read about the potential side effects somewhere and are now feigning outrage over never having been told... even though you've not been harmed by either tylenol or naproxen.

By the way... raising blood pressure is low on my list of concerns with naproxen. I'm more concerned with someone taking it every 12 hours over an extended period of time and developing a GI ulcer.

Oh yeah... and naproxen can possibly (in an incidence of something like 1 out of 50 million) cause Stevens Johnson Syndrome, which is an incredibly severe allergic skin reaction (your skin literally starts falling off of you). Should we make sure to warn you about that too?

Ray & The Casuals said...

THEN SHE GAVE ME CRESTOR AND LIPIDIL, and , well, I can only tell you that I am still in pain even though I have stopped the meds 2 months ago, have taken a new blood test, that shows elevated AST AND ALT (no ck problem), and will see a new doctor. And no more statins. My nephew had an extreme reaction from Lipitor and was hospilalized (before I knew anything about my own situation); maybe there is a familial genetic predisposition in my family.

Pharmacy Mike said...

I'm sorry for your experience, but you must have seen the absolute worst doctors and worst pharmacists in the world.

One of the first things that ALL pharmacists learn in pharmacy school is that the statins can potentially cause rhabdomyolysis. We learn the warning signs. We learn the lab tests that can confirm the diagnosis. We learn which drugs interact with the statins that could increase the risk for developing rhabdo. Trust me when I say this... We are well versed in this area.

I don't understand how 2 different doctors and 3 pharmacists could have overlooked muscle pain and weakness while you were on lipitor. Something does not add up here.

I promise you though... I'm well versed on that "evil cocktail," and if you had complained of those symptoms to me or 99.9% of the pharmacists out there, we would have told you to discuss the issue with your physician right away.

Ray & The Casuals said...

Let me repeat, I discussed my complaints with the doctor and 3 different dispensing pharmacists.However, my doctor is going into varicose veins, etc specialty and is cutting out "general". Thank God before she kills someone. That's why I chose to find a new physician.
And not too many pharmacists are aware of the potential dangers of administering a fibrate and a statin together..caution is definitely needed.

Pharmacy Mike said...

That's where I guarantee you're wrong...

Most pharmacists know that interaction. I would have said just about all pharmacists know that interaction before you shared your story. It's a basic, uncomplicated interaction, and one of the first ones you learn about when studying statins in pharmacy school.

If you poll pharmacists and physicians, I'll guarantee that pharmacists are much more knowledgeable about that interaction than physicians are, even though I'm pretty sure that most physicians know about it also. That's why it doesn't make a whole lot of sense to me that 5 different healthcare providers saw your case and didn't at least have some suspicion that your muscle pain could have been caused by the statin.

I'm sorry that was your experience though. If you were my patient and complained of those symptoms to me, I would have at the very least told you what it possibly could have been and given you some information to discuss with your physician. Hell, if you were too shy/nervous/whatever to talk to your physician, I probably would have called for you.

I think I'm a pretty decent pharmacist, but I'm not extraordinary in any way. I'd like to think that most other pharmacists would have done the same.

Ray & The Casuals said...

Thanks Mike.
But it was all new to me; and I learnt on my own.
Now I have to hope to able to play tennis again; and will start a new leaf, more aware and knowledgeable when I see my new MD.

Anonymous said...

Toopen a hole new can of worms, in reading the on going posts by "the casuals" I can only say I've dealt with too many situations where the story keeps morphing as inconsistancies are pointed out. the on going theme seems to be- my problems are somebody elses fault. There may indeed be a problem that should have been better addressed, however, none of us know BOTH sides of the issue. so stop complaining to people who have nothing to do with your health care.

Ray & The Casuals said...
This comment has been removed by a blog administrator.
Pharmacy Mike said...

I've rejected and deleted a few comments...

I feel that the conversation has pretty much ended between Ray and myself. If anyone else has something constructive to add, I'll gladly post it (whether you sympathize with Ray or not). However, I don't think we need to resort to insults, so if anything comes off sounding like a personal attack, I will not post it.

Anonymous said...

I disagree about the statement that a robot cannot replace a pharmacist; that is probably the stupidest thing I have ever heard. Pharmacists provide absolutely no value. You are seriously deluding yourself if you think that. There is no aspect of drug therapy that the simplest of algorithms cannot crank out. As soon as I graduate I am going to work for 5 years and then retire. It seems you are still as stupid as you were a year ago, no offense.

Anonymous said...

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.

Anonymous said...

I would tend to disagree with the statement of 'simplest of algorithms' mainly due to the fact that disease is not merely measured in lab levels, vital signs, and cures or relief meted out in doses. It would probably be considered reiteration, but usually first of all the ill person recognizes that something is not right, and upon investigation concludes that it's something beyond self-diagnosis, then seeks advice, whether from friends, the friendly pharmacist, makes an appt with the doc, etc., After diagnosis based on clinical experience, labs, tests...then the choice of treatment is decided based on clinical experience, tests, labs, back and forth, When a drug prescription is written, it's dispensing is based on clinical experience, information, etc. Algorithms are helpful when starting out and passing pharmacology exams, but in the real world of retail pharmacy, they're just part of the schema for those of us that choose to look at people as beings with infinite possibilities. No offense taken. Imagine it'll just require a few more years of lab experience, some research projects, several intensive rotations, and juggling homelife with work, etc. And, if there's still need to retire, so be it. Some of us still manage to think we can live high off the hog with other's money--I think one of the most apt statements I read off a Cracker Jack insert was 'If you're getting something for nothing, someone is getting nothing for doing something.'

Anonymous said...

Honestly, I think you should use Tricor FIRST to get the TG down to where they need to be...then initiate the statin to get everything else to goal. Abnormally high TG levels can throw of LDL readings anyway -- if the lab just calculates it rather than drawing a direct LDL level.

Nonetheless, I'm perplexed at how Fenofibrate and Ator taken concomitantly could be overlooked as the culprit here. No doctor would miss that. After 4-6wks it's time for a lipid panel and LFT anyway. Beyond that, Ator has the lowest risk of myopathies...and the doctor changed him to rosuva? Who in the heck is he seeing to manage lipids? A dermatologist?

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