The Ole' Apothecary

For centuries, doctors have been writing prescriptions as notes, like a mother writing something down for her son to pick up at the grocery store. "Go pick up an ounce of laudanum for your grandmother, Mrs. Victorian-Age," he would say, and then write it down for the pharmacist to refer to. In earlier times, a prescription was also often a recipe (hence the symbol "Rx," meaning "take thou" or "assemble the following ingredients and prepare them as follows"). But today, a typical medication order consists simply of a single drug name and strength, the form of industrially prepared drug delivery system, instructions for use, and the quantity of medication to be dispensed. In this age of drug misuse of all kinds, and involving biologically profound substances, a prescription is much more of a negotiable instrument than a message for an errand. It is much more in the nature of a personal check. Why doesn't the law require it to be so?

In Germany, all pharmacies receive a single, nationally standardized prescription form from doctors. I saw one during my 2005 visit to Berlin. It is smaller than a U.S. personal check, but is printed on white paper with burnt-orange borders. Written or electronic, it enforces clarity and uniformity in a process (pharmacy) that deserves it. The persnickety German people have gotten it right, and I applaud them, as do I do Australia (see above).

The U.S. will make progress toward this ideal next year, when tamper-proof prescription forms will begin being used, in accordance with a federal mandate that all Medicaid prescriptions be written on forms with security features similar to those in personal checks (watermarks, micro-printing, etc.). But, the healthcare system should go the distance, and encourage, as a standard of practice, a model U.S. national prescription form for hard-copy prescriptions (electronic prescriptions are a work in progress regarding standard transmission).

One model which could be considered for this is the standard, security-paper prescription form used by the U.S. Department of Veterans Affairs (the VA). Yes, there would be little or no room for graphic creativity on the part of the individual practitioner. But these documents should be viewed as coin of the realm in healthcare, not as an artistic endeavor. Also, a standard form would be much easier to file, retrieve, and read. Pharmacy board inspectors, DEA inspectors, and other law enforcement officials would delight in the improved form when they have to sift through stacks of prescriptions during a protracted investigation.

Pharmacists complain about the ineptitude of "office workers," and also the incomprehensibility of thickly accented persons, in calling in prescriptions over the telephone. Barring a few recently established electronic exceptions, when was the last time you called in a personal check to your local retail store? It is high time for prescriptions to be issued routinely in text only, and verbal orders be officially discouraged. The standard form, and the computerized prescriber order entry, should be the most common media for issuing prescriptions in the U.S. How about this as a goal for patient safety and healthcare efficiency standards?

Recently, a pharmacist friend who reads this blog asked me the following:

Perhaps you can comment on the following observation. I have noticed that many pharmacists who have left retail pharmacy still have scars long after they leave retail. Pharmacists relate "war stories" from their years of retail that are, in a way, analogous to soldiers in combat. Perhaps it is the experience of slinging out prescriptions at lightning speed with employers who are seemingly unaware of the fact that we can kill someone with each Rx we dispense. In other words, retail pharmacy is an extremely stressful environment, perhaps like a battlefield.

During a 2003 visit to Washington, DC, I stumbled upon an extraordinary monument on the grounds of the American Pharmacists Association headquarters building. It was a column honoring the pharmacists who served in the U.S. Armed Forces in all this Nation's wars. Then, I remembered my father's remark of a few years earlier. After listening to some of my retail pharmacy stories of struggle, he, a World War II combat veteran, said, "It's like you've been at war. You know what it's like to be in a war."

We community pharmacy professionals (pharmacists and technicians) have indeed suffered the slings and arrows of outrageous interactions, wholly analogous to battle. We stand in foxholes called pharmacies, and are exposed to constant fire from multiple adversaries: the consuming public, the management, the regulators, the payers, the academicians, and the indifferent legislatures. To my friend I say, not only are we often close to causing patient injury, we are also often liable to legal injury to ourselves and our employer, emotional injury from the tracer bullets of public ridicule, and spiritual injury from the intellectual tension we endure every day, wondering if we are sinners or saints. Despite the fact that the retail war ended for me 14 years ago, I still suffer from post-traumatic stress disorder, and it is exacerbated every time I hear or read a story of professional struggle from my colleagues. I remain a comrade-in-arms with my fellow community pharmacy professionals, and I believe this will be true for the rest of my days on earth.

This year, I've had to make a lot of doctor's appointments. Nothing life-threatening, just some nuisance conditions. One of these appointments was with the only dermatologist in my part of Texas. I had to make it for three months in advance. When I arrived at the office waiting room for the first time, I beheld what was, for me, an unprecedented sight: people coming in and out like it was a restaurant! They would check in at the desk and crowd into the waiting chairs. My appointment was for 9:30 A.M., but it wasn't until 11:45 that I was at least ushered into a patient exam room. There, I waited an additional 20 minutes before the doctor his-self and a medical student came in to look at the rash that had tormented me for almost a year. ONE LOOK. "Psoriasis," he said. He gave me a prescription for what turned out to be a miracle steroid---a true cure.

But, at what price?

No, I'm not talking about the office visit co-pay price in dollars. I'm talking about the price in time. My time. His time. As a pharmacist, could I command such crippling control over a prescription customer's time as this physician did to me? Three months of waiting for the privilege, then two hours of waiting-room time for the privilege, for less than 10 minutes of his expert scrutiny.

Now, wait a God-damned Enbrel minute---I possess expert scrutiny, too! I have drug product knowledge at my fingertips that many people need. I have pharmacologic and clinical knowledge that is coin of the realm in my pharmacy sphere of influence. But then, how is it that I have been forced to piss away any rational, courteous control of my time? Anybody can walk right in and interrupt me when I am occupied with a clinical problem. I had a technician once who decided that my upturned pant cuff was sufficient license for her to reach down and correct it while I was on the phone with a doctor! No, sorry, this is no time to rescue the helpless bachelor. Do your fem thing later, please, I am clearly entitled to finish my work without such impudent distraction. But, my whole pharmacy career has been one of impudent distraction, at the mercy of the telephone, the dutch door, the prescription counter, anybody who wants to chew on me has license to begin masticating at any time they please. Would Dr. Derm with his three-month wait put up with such insults? You can fill in the answer to that one.

Tonight, I was reading a Drug Topics article about dealing with pharmacy robberies, and the piece listed some of the factors contributing to the recent rise in drugstore heists: drive-thru as a perfect getaway alley; the tightening of illegal drug traffic pushing addicts toward legal drugs (the pharmacy); and patient rage (the Florida lady that shot the pharmacist dead because she was told to go to the back of the line). Add these things to the crisis in preoccupation for our occupation, and you have a milieu I would never recommend to today's graduate pharmacist. Pharmacy students, interns, new grads, you have beaten back a monstrous set of challenges-- financial, academic, social---to get to your seat at the NAPLEX and its resulting license to practice pharmacy. Do not do as your predecessors have done for centuries, which is to settle for the total rape of their precious time!