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.


Anonymous said...

I just posted this on Dumb Medicine, he had a smiliar rant...

I went through school and worked in all aspects of communty pharmacy (big box, chain, sm. chain, independent grocery) all to gain knowledge and information on how to grow my fathers pharmacy (which has been community owned for 75 years) into a viable business in today’s world. It is a tad bit belittling to hear people talk community work down like that. I venture a guess that after 5-10 years of “important work” they still have no idea how to make a business grow or make an extra dollar so you can go buy that next peice of “must have” technology, we all use our knowledge, intelligence, and experience differently and all aspects should be aknowledged and respected.

Let me add to this, that in the last 2 days, I literally caught 2 possibly fatal (more than likely for sure in the latter)errors:

1. 72 yr old Female, Knee Pain, no prior history of any benzos, Dr Writes "Ambien 30mg every HS"... 30mg starting dose of Ambien with no prior history???? How long do we want her to sleep???

2. 78 yr old nursing home pt, only prior pain therapy is Vicodin q46h prn, Dr writes "Duragesic 125mcg/hr patch q 72 hrs." Question dose as Duragesic maxes out at 100mcg and no history of any prior therapy with fentanyl (Duragesic). Dr calls back 12.5mcg/hr (doesn't exsist)..well then 12mcg or whatever is closest, I told him to re-write the Rx and send it back over to me.

Where was the Tech or Robot on those????

Anonymous said...

it's true. retail pharm is not as easy as it looks. you tell em mike

Anonymous said...

I agree that a good 70 - 85% of what we do could be done by a GOOD certified tech (and they are few and far between and BOY OH BOY am I GRATEFUL AS HELL for the one I have), but I don't agree that the Pharmacy could be run w/o a Pharmacist. We really aren't paid for the majority of what we do...we're there and we're getting paid, so you have to do it, but that's not why we're there. Here's the difference:

Pt comes in with an rx for finasteride. Pt is already on Flomax. A certified tech MAY know that they are both used for Prostate problems, but that would be as far as it goes. Would they know what to do with that?

Pt has rx for Lithium and presents w/rx for Zoloft or Paxil - If that were your 15 year old kid, would you trust that the tech would know that the SSRI is likely to cause him to start rapid cycling/major manic attack?

Pt comes in asking for a persistent cough and asks that you help select an OTC cough is on lisinopril.

Those are the easy ones and it's the stuff we eval daily without thinking about it. More than once, I've had a tech blow through a di and have two rx's in front of me that either interact (warfarin and Pletal) or are same class (Flomax and Uroxatral). The tech can't do that. Not only does it save time, but we definately save enough money to justify our salaries and more.

It's incredibly frustrating and demeaning at times when the pt points to the Fosamax and yells, "Just reach over and give it to me!!!!" We make a difference in a small percentage of the rx's we fill, but WOW that difference can be HUGE!

Anonymous said...

I agree with your response. Just a note-the position of checking scripts and handling the "challenging" issues is already out there. Just look at the mail order pharmacies. However, be careful what you wish for-an assembly line is just that.
Youwill be allowed to "solve" few issues. It will be done according to rules set up by non-pharmacists and must be done in far less time than the issue warrents. If you have not figured out that patient care involves actually dealing with patients in person one on one then you have not, in all the education, yet learned what constitues a professional.

Anonymous said...

All that retail pharmacists are paid to do is fill prescriptions. That can be done easily by a tech. If retail pharmacists really think that catching interactions, patient counseling, OTC consults, etc. are meaningful services they had better get together and figure out how to get paid for doing them. Otherwise its only a matter of time before retail pharmacists become obsolete.

Pharmacy Mike said...


Pharmacies make money by filling prescriptions. Pharmacists get paid to ensure that the prescriptions are filled safely and accurately.

If you replace pharmacists with technicians, prescriptions errors will jump at least 10-fold over night... I'm probably greatly underestimating that.

Filling prescriptions isn't the same as filling a fast food order. You just don't do what it says on the script. It requires thought and professional judgment. If someone gets a hamburger instead of a chicken sandwich, a customer is inconvenienced an unsatisfied. If you fill a prescription with Digoxin instead of Diltiazem, someone can die.

To assert that a pharmacist doesn't add any value at all to a retail pharmacy is pure stupidity.

Frantic Pharmacist said...

"You don't just do what it says on the script" I think boils it down to the essentials. I think the public is completely unaware of how often pharmacists intervene on their behalf, and perhaps we need to tell them each and every time about every single step we took, no matter how small, that doesn't just involve filling the order. How often have you spent half a day sorting through some problem with an Rx, finally getting it straightened out, and the customer comes in at the end of the day, pays their money and leaves without the slightest clue as to what you did for them? This contributes to a huge information gap in the public perception of retail pharmacists.

thetwitchytechnician said...

I just directed a friend of mine to a trusted pharmacist. Why? Because she had a horrible horrible reaction to an NSAID she was put on and both the ER and her MD said she was just "overstressed" despite her having these reactions shortly after taking the medication.

I'm just a lowly CphT and I may understand what ADE is but I don't have the faintest flipping clue how to educate a patient or find an alternative therapy nor would I even consider counseling someone on such an issue without extensive education, not just memorizing interactions, but understanding the mechanisms and pathways of each medication within the body.

Seriously think about how a "tech could do the Rph's job". Do you really really want some college kid counseling you on your baby? Or a tech who only studied the book for the exam without actual hands on experience with a serious side of "this is how this works"?

Anonymous said...

yeah they add value, but not any kind of value a computer can't match

Anonymous said...

I'm a pharmacist, but couldn't disagree more. Pharmacists will still be utilized by chains, but located a call center answering and addressing those detailed, clinical questions and interactions. The majority of most interactions are ignored and even if you fax the MD for a change, they will not change it and it gets filled by another pharmacist anyway. All drug interactions will be sent a pharmacist for review anyway and will not print until we approve it. The major chains will save millions by making pharmacists serve several pharmacies at once. Patients barely recognize technicians from pharmacists as it is and if it means more discounts via coupons for the patients, they won't mind. Unlike MDs, lawyers, etc., pharmacists give free advice. To think that a insurance company, government program, or patient will shell out $30 for 30 minutes of counseling is nonsense. We've sold ourselves as a commodity with the drive-thru, 15 minute wait times, and coupons for a capped salary. MD salaries are decreasing and we're next. Patients look everything up on the internet anyway and sadly, probably won't pay for our cognitive services. You have to admit, a PharmD is better suited for a clinical, hospital setting. The warm and fuzzy feelings you have for retail are admired, but chain profits in this new economy will require new technology via automation resulting in a decreased demand for pharmacists. I could be wrong though, what do u think? By the way, love your blog...