Thursday, October 28, 2010

"We Made the Mistake. You fix it."

At least that's what one medical assistant wanted us to do today.

Two weeks ago, the office called in a prescription for the wrong dose of Metoprolol. The patient was supposed to get 50 mg, but the office called in 100 mg. By the time the patient realized the mistake, he had already picked up the medication and started taking it.

Today a medical assistant called up and informed us of the mix up. She told us that it was supposed to be for 50 mg. Then she stated that the patient will be returning the 100 mg tablets and exchanging them for the correct ones.

I quickly corrected her by saying, "we won't be exchanging the prescription. It's against federal law to take back medication once it has left the pharmacy. It's been 2 weeks. The patient will have to pay another copay."

"You won't take it back?" she exasperatedly asked. "Other pharmacies have taken medication back before. You're going to force her to pay another copy?"

Now, I was a little pissed off. "Is that how it works?" I said. "You guys make the mistake, and we end up footing the bill for it? YOUR error prevents US from getting paid? Does that make sense?"

She paused for a couple seconds before saying, "well, I'm not going to argue with you." Then she hung up.

If this was an isolated incident, it would be one thing. However, it's something that happens quite often. The people working in doctors' offices seem to forget that we actually have to buy the drugs before we can sell them to people. Therefore, when they tell the patient that the pharmacy will simply do an exchange to make up for their mistake, they forget that the pharmacy ends up being the loser.

The only time I pull this exchange bullshit is if the error is clearly ours. If we make the mistake, well, that's our fault, and we'll do what we have to in order to correct it. If the doctor's office makes the mistake, and the patient ends up having to pay a second copay because of it, I'll often tell the patient to go ask the office for a refund of their wasted money. The pharmacy already gives away so much. There's no way I'm wasting more money when we had nothing to do with the error.

Tuesday, October 26, 2010

Is It OK to Have Secrets?

For the past 2 weeks, I've been wrestling with the thought of whether it's OK to keep some parts of your life separate from your significant other. I guess I've hit the point where I need some advice, so it's finally making it's way to a blog post.

To cut straight to the point: My girlfriend doesn't know I write this blog. She has no idea that I'm Pharmacy Mike or that Pharmacy Mike even exists. This blog has been a window into the inner workings of my mind. Therefore, in order to truly understand me, one would have to read my blog.

It's sad, but my readers know me better than my girlfriend does. My question is whether that's OK? If I'm in a committed relationship with this girl that someday might end up in marriage, am I obligated to tell her about this blog? Does she need to know?

Whether she needs to know or not is really the crux of my pondering. Do committed couples have to share every last details of their lives together? Should they be privy to their significant other's every thought and feeling? Or are there somethings that can be kept private in order to spare feelings?

I used to think that every person needs a little bit of privacy, but now I'm not so sure. It's not exactly like I'm overtly hiding anything from her. I've just never been comfortable divulging every thought that pops into my head. I usually don't speak without carefully considering the consequences of every word I might say. Moreover, every action I take is done so after great deliberation. Nothing I say or do is spontaneous. Nothing is unplanned.

I may say and do all the right things in this relationship, but sometimes I feel that I'm not being genuine. While it may not necessarily change my eventual action, I feel that the action is somehow less important than the inner monologue that leads up to that action. Without letting her in on what I'm thinking, I'm keeping her at an arm's distance. A big part of me thinks she deserves more honesty than that.

However, another part of me thinks that a lot of my thoughts and actions could be misinterpreted. For example, even though she knows about my ex-girlfriend and the basics about what happened, she doesn't quite understand the depth of my despair and how it took 4 years to be OK with everything that happened. Does she need to know that stuff?

I question where our relationship is heading, and what the next step will be. It bothers me that despite being together for almost a year now, she still has no plans or desire to move in with me any time in the near future. Moreover, even if we wanted to live together, I struggle with the logistics of our jobs being over an hour apart. I feel like we're both waiting for the "right time," but what if we never find the right time. Then we have to go and make the time.

I see that as a potential problem because I'm pretty much settled where I am. I own a condo and have a high paying job. Rationally, if one of us were to move, it shouldn't be me. However, how can I ask her to move here and be an hour away from work? Even though she doesn't really like her job and would like to find a new one, in this economy, how could I expect her to leave her job without another one lined up?

I have so many questions and concerns, but I feel like bringing them up will rock the boat and possibly ruin a good thing. Therefore, they remain mostly as an inner narrative. I act as positive as I can in order to mask my doubts. I do this to protect both of us, but am I actually doing more harm than good?

See, this blog is just one of the many things I keep to myself. Should I open up and share my innermost thoughts with this girl, or is it fine and maybe even normal to keep some things to myself? If I were to open up, I think it would make sense to let her know about this blog first. Of course, that brings to light a lot of things about my past that she'd probably rather not read. However, those things are part of who I am, and it would be nice to no longer have to hide from them. It could be liberating.

My question to my readers is simple: Should I let her know about this blog, or can I keep it to myself?

Monday, October 25, 2010

Saturated Fat and Dietary Cholesterol Are Not the Enemies

This post is in response to Harry's comment on my last post. He wanted more information about how saturated fat isn't evil.

Dietary cholesterol from animals and dairy products has a very small effect on blood cholesterol levels. One can expect dietary cholesterol, no matter how poorly one eats, to make up for roughly 15% of blood cholesterol.

This makes sense. Think about the drugs that block intestinal absorption of cholesterol, like Zetia. Zetia lowers cholesterol levels by roughly 10% to 15%, which is about what would be expected if you blocked dietary cholesterol.

Moreover, as pharmacists and other medical professionals are learning, there's not much evidence to show that Zetia has any mortality benefits. We know from Merck's very own trial that Vytorin does not decrease mortality or reduce plaque size any better than simvastatin alone. In fact, there was a small (but insignificant) increase in plaque size in the Vytorin group.

Enormously high cholesterol levels are still bad for you. However, these levels are are due to the body's overproduction of cholesterol, which is where Statins come in. Statins have established mortality benefits, and they work by decreasing the body's endogenous cholesterol production.

(As an aside- Statins also are known to have antioxidant and anti-inflammatory effects, which may also play a huge role in their reduction in mortality. Clearly, when it comes to Statins, lowering cholesterol is only part of the story.)

Now, the question becomes why does the body produce lots of cholesterol. Well, in some people, there'a genetic predisposition for it, i.e. homo- or heterozygous hypercholesterolemia. In other people, the body produces high levels of cholesterol due to our poor diets.

As is well known, cholesterol is vital to the body. It plays an important role in cell membrane integrity. It also acts as an antioxidant in that it cleans up free radicals.

Consuming a diet high in processed sugars, trans fats, hydrogenated oils, and rancid fatty acids, our bodies produce more cholesterol. Some of it acts to help clear up our bad diet. However, some of it gets clumped up into the mess and ends up leading to blocked arteries. In this way, high blood cholesterol is more a marker for disease than disease itself.

As for saturated fat...

Modern research is finally starting to shed some light on this too. The following quotes are taken from Wikipedia (which despite what some may say isn’t a bad source for quick information. Obviously, I wouldn’t use it if writing a formal report, but most of the information is from valid sources that are cited in the articles):

In 2010, a meta-analysis of prospective cohort studies including 348,000 subjects found no statistically significant relationship between cardiovascular disease and dietary saturated fat.[8][9]”

“In 2009, a systematic review of prospective cohort studies or randomized trials concluded that there was "insufficient evidence of association" between intake of saturated fatty acids and coronary heart disease, and pointed to strong evidence for protective factors such as vegetables and a Mediterranean diet and harmful factors such as trans fats and foods with a high glycemic index.[10]. Pacific island populations who obtain 30-60% of their total caloric intake from fully saturated coconut fat have low rates of cardiovascular disease.[11]”

“Mayo Clinic highlighted oils that are high in saturated fats include coconut, palm oil and palm kernel oil. Those of lower amounts of saturated fats, and higher levels of unsaturated (preferably monounsaturated) fats like olive oil, peanut oil, canola oil, avocados, safflower, corn, sunflower, soy and cottonseed oils are generally healthier.[13] However, high intake of saturated dairy fat does not appear to increase the risk of cardiovascular disease.[14]”

We all know this information to be true, but we’ve been mislead so long that we have trouble accepting it.

Here’s another article that contains some interesting information: “”

I’ll just briefly mention a bit from the article about the Masai, a nomadic tribe in Kenya and Tanzania that were studied in the 1960s. They got 60% of their calories from fat and half of that was saturated fat. Despite this, they had an incredibly low incidence of coronary artery disease and very low cholesterol levels. However, when some tribe members moved to Nairobi and began eating a more modern diet, cholesterol levels sky rocketed, despite the reduction in saturated fat.

There are so many other cultures that we wonder how they could eat what they eat and remain so healthy. The French are a classic example of people who eat loads of butter and other sources of saturated fat, and they are some of the healthiest people in the world, and that’s even with them smoking far more than we do. The Japanese eat plenty of shrimp, seafood , and other foods that are very high in cholesterol and saturated fat, and they have a low incidence of heart disease.

When you start piecing the evidence together, it becomes readily apparent that the common medical belief that saturated fat and dietary cholesterol is bad for you is simply wrong. Eating healthy basically comes down to eating whole wheat carbohydrates in place of processed and added sugars. Eat plenty of vegetables, some servings of fruit, and grill, bake, or pan-sear your meats as opposed to frying them. Appropriate portion sizes are also important. It doesn’t matter what you eat if you eat so much of it that you’re 50+ pounds overweight.

It sounds so simple, right? It would be if we weren’t so addicted to high glycemic index sugars and fried food. It’s harder to quit sugary and fried food than it is to stop smoking. Just try, and you’ll see what I mean. It’s an addiction, and it’s very very hard to break. I know how unhealthy this stuff is, and I still have a lot of trouble giving it up, especially when society is not on the same page. If you want to quit smoking, there a bunch of nicotine replacement products and self-help classes you can take. If you want to stop eating junk food, people look at you like there’s something wrong with you, especially if you’re not overweight. When a group of people get together and order a pizza, it’s just about impossible to be that one person who chooses not to eat it for health reasons. Eating these kinds of food are a personal problem, but it’s also a societal problem. Since society is doing nothing to help people change their eating habits, most people will not be able to do it on their own, even if they knew how unhealthy they're being.

Anyway… that was my long-winded explanation as to why saturated fat and dietary cholesterol is not bad for you. You can do more research on your own, and in doing so, I’m confident you’ll come to the same conclusion. It’s the one that makes the most sense. It’s funny how good science usually makes sense.

Saturday, October 23, 2010

I Hate Recommending OTC Meds

"I have a cold. What can I take for it?"

I get this question at least once a day, but I never feel comfortable answering it. It's not that I don't know how to treat common cold symptoms. I just don't know how to explain to people that the answer isn't necessarily in one medication bottle.

Whenever people ask for a recommendation about what to take for a cold, the first question I always ask is what symptoms they have. I can't make a proper recommendation without knowing what symptoms I'm trying to treat.


Great... I'll always follow up by asking whether the cough is productive or dry, but the answer doesn't really matter I suppose. By this point, we all know that dextromethorphan does absolutely nothing to relieve coughing. Therefore, all OTC cough suppressants are ruled out. For productive coughs, most pharmacists will recommend Mucinex. However, if we're going by evidence, there's not much evidence that guaifenesin loosens up mucous, so I always hesitate before making that recommendation.

According to the American College of Chest Physicians, acute cough should be treated with a first generation antihistamine, like clorpheniramine, and pseudoephedrine. They also say naproxen can be used to help reduce cough. Nowhere in the entire executive summary of the cough guidelines does it mention guaifenesin, dextromethorphan, or any opioid cough suppressant for that matter. There's very little evidence that they actually reduce cough.

How do you explain that to a customer though? When there are dozens of products in the OTC aisle that say "cough and cold" on the box, how do you explain to people that most of them are unlikely to reduce cough? You have to see the looks customers give me when I go out in the aisle and grab a box of store brand "Allergy Medication" (containing chlorpheniramine) as a recommendation to reduce cough. They think I'm crazy.

Moving away from cold medication... People often ask about vitamins. "What brand multivitamin should I take?" is a very common question. My response: You probably don't need to take a multivitamin.

People have this obsession with vitamins. They think they're the answer to all their ailments. However, in most cases vitamins are a waste of money. Unless a doctor diagnoses you with a specific vitamin deficiency, there's really no need to take a multivitamin. In fact, a recent large study showed that taking antioxidant vitamins not only didn't increase life expectancy and reduce the incidence of diseases like cancer, but people who took them actually had a 16% increase in mortality.

The modern diet, as poor as it might be in terms of overall health, usually provides enough of all the important vitamins to stave off any deficiency condition. About the only vitamin that a normal person might need to supplement is Vitamin D, and that's because we lather sunscreen all over ourselves, and sunlight is needed for the body to produce Vitamin D. Otherwise, if you aren't malnourished, you probably get plenty of vitamins in your diet.

You can show people a million studies on this stuff, but they won't listen. It's ingrained in their minds that vitamins are good for you and Robitussin is a great cough medicine, and there's nothing you can do to change their minds. After all, it must be true; they saw it on TV!

Or if they didn't see it on TV, their doctors said it was true, so it must be. You ever try to convince someone that what their doctor said is entirely incorrect? It's very difficult, especially when just about every doctor says the same thing.

For example, every doctor tells you to avoid saturated fat and cholesterol like the plague... and every doctor is wrong. No matter how hard I try though, I'll never get those health nuts to go back to drinking whole milk and eating whole eggs instead of just egg whites.

The problem is that conventional wisdom is murky at best instead of scientifically tested truth. Since I know that the evidence is quite shaky, I can't in good conscious recommend what others would without batting an eye. Therefore, I've come to dislike the part of my job that involves counseling on OTC meds.

I'm my employer's worst nightmare in this regard. I actually prevent more OTC sales than I facilitate. That can't be good for business even though what I say is backed by the most current scientific evidence. That's why I'm so happy to be promoting flu shots. Flu shots are the rare occurrence in pharmacy where what's best for the patient is supported by science and good for our business.

Tuesday, October 19, 2010

I Don't Work For Free

"Glad to know the employer is making money off of the pharmacists training and risk. When will pharmacists learn no to give their talents away?

We have already labeled ourselves as less than human by working long hours with no breaks or lunches.

Bad for the profession..Stand up for yourselves. Shame on you."

This statement was a response to my post about how I love to give flu shots. I disagree with it.

For one, there is very little risk involved in giving flu shots. Most people don't have any significant adverse reactions to them. Moreover, there's not much technique involved in giving one. You simply take the syringe and stick it in someone's shoulder muscle. It's really hard to mess that up. I hardly consider flu shots to be one of our "talents."

Finally, how exactly are we just giving these flu shots away. We make $15-$20 profit on each shot. That's good for the profession. It actually is smart business to do more flu shots because they are great for your gross margin. In addition, I do get paid to give them. I make nearly $60/hour to be a pharmacist. That salary encompasses all of my professional responsibilities. I'm not a mercenary. I don't get paid per task I perform. My company pays me that because I am a pharmacist and capable of performing the duties of being a pharmacist.

Quite honestly, flu shots are one of most worthwhile things that I do. I am preventing disease. My flu shots might prevent people from being hospitalized with the flu, and in that way, it saves the health care system a lot of money. I don't see how this is a bad thing.

Of all the useless things we do in the pharmacy (dispensing Zpaks for colds, codeine products for cough, free antibiotics, etc.), there's no way I'm going to "stand up" and refuse to do something that actually is beneficial to both our business and our customers' health simply because I don't get paid more to do it. I get paid enough already.

Pharmacist's salaries are not one of the problems with the profession.