The Ole' Apothecary

Its first direct-to-consumer ad had an American yodeler standing on top of, oh, a Montana butte, I suppose, yelling its trade name. Zyrtec was heralded as quite an allergy product. "Prescription" Zyrtec. Well, it is prescription no more! It is about to become yours for the asking and for the putting down of a few doubloons on the front counter while the cashier rings up someone else's cigarettes and beer. But, it makes me wonder. How it does make me wonder---what magic occurred when the patent on cetirizine expired? One day, you had to get a "doctor's care" to obtain the drug. Now, seemingly without a clinical decision, but with an economic decision, you ain't gotta see no doctor no more to get Zyrtec, and you ain't gotta go "argue" with no pharmacist no more to get it, neither ( thought I'd throw in some double negatives here, since nobody knows that they're incorrect any more, and they will soon be worthy of the main text in the New York Times).

Who took the clinical risk out of cetirizine by a wave of their contractual pen over paper? What annihilated the learned intermediaries' value? What neutralized the doctor, the nurse practitioner, and the pharmacist, when the end of Zyrtec's seventeenth patent year clicked shut?

In Texas, prescription drugs are termed, legally, "dangerous drugs." Why, seemingly overnight, is there no "danger" with Zyrtec? An even more bizarre situation exists with Prilosec. In 2003, it went off patent, and then, of course, over-the-counter. But its cousin proton pump inhibitor stomach acid blockers, such as Protonix, Prevacid, and Nexium, all still under patent at last check, remain "dangerous." Me, I think that cimetidine, a histamine-receptor antagonist stomach acid blocker, now OTC for many years, is really dangerous, since it interacts with so many other drugs, and yet is allowed to fly through the air with the greatest of ease into the mouths of those who take prescription drugs that are its substrates for trouble.

I'll repeat Led Zeppelin's line: it makes me wonder. But, for the OTC drugmakers, it's buying them a stairway to heaven. The hell with anything else, huh? Let's repeal the pharmacy acts of the 50 states. That just leaves federal law. Maybe then we can get the DEA agents to do all the scut work we've been stuck with for the past 30-odd years. Let THEM police every hydrocodone prescription! The only danger is political, not clinical.

All this blog talk about patients constantly transferring prescriptions makes me want to stop this here carousel and teach some history. [Ole' Apothecary taps on the podium three times with his hickory stick.]  Attention, please!

 I have never enjoyed the privilege of working in an independent community drug store for many years, but I have had the privilege of being a local community pharmacist in a small agricultural community for many years. I worked in an outlet of an "independent chain;" that is, a drug store chain that was not publicly traded and therefore was strictly beholden to its customers, not to its stockholders.  

The management at this company treated its pharmacists with at least enough respect that we had autonomy. In fact, there were no district supervisors in that 55-store chain until a year after I began with them, and even then, a supervisor's visit was assistive, not punitive.  I was encouraged to become as much a part of the community as possible, to establish warm relationships with my customers.  We had come to town to set the pace for competition, but, asit turned out to be,  as benevolent conquerors.

 I knew we were "a chain," but sometimes I had to pinch myself when I saw the townsfolk coming in and asking for me by name, and my co-pharmacist by name, too. And, it was such a pleasure to greet each of them by name, too!  After three years, I could have run for Town Council, so many friends did I earn. I knew their names, and could even give you a precis of each of their drug profiles.  Needless to say, one doesn't run out on a friend, and there were few instances of people transferring away. They came in to see their pharmacists. I think that, if we had gift cards then, it wouldn't have made such an impact.  They had the gift of friendship.  

I sit here scratching my head, thinking, isn't that what community pharmacy was all about? About the friendly pharmacist who knows you and is always there to help you, talk to you, know you?   If today's publicly traded drug store chains could learn this simple principle--and we'd have to pump it into them like total parenteral nutrition, I guess--wow, how their stock would soar!

Loyalty is priceless.

At a housewarming party this evening, I heard a fellow pharmacist fret, "What will Wednesday be like?" I'm getting ahead of things, of course, but, what do you think Wednesday, January 2, will be like? Or, if you're reading this in the new year, what was your January 2 like?

The first workday after a holiday, and probably moreso the first workday after the whole winter holiday season, is awash in "catch-up:"  time-dependent matters such as insurance coverage, prescription expense records for income tax purposes, and, from what I understand for 2008, another step in the implementation of the National Provider Identifier (NPI)  number that is supposed to replace the DEA number as provider identification in many instances. It is also the launch date for many post-holiday illnesses, the return to school, and the return to the pace of the workaday world. We rushed into the holidays, and now we rush out of them. It's the hangover of the workplace itself.

Because I was on the other end of the retail storm for so many years, today I am extremely careful with the pharmacies I patronize. I always order my prescriptions electronically, and at least 24 hours in advance.  In my lifetime, I've never knowingly gone to a pharmacy counter in person to request a refill on an expired prescription. I always give the pharmacy ample time to seek authorization. But, that's the Golden Rule operating.  The public doesn't follow that rule often enough. It usually follows the Leaden, or Lead-Ass, Rule, which reads, "The whole world revolves around me." Hence, most of the events surrounding the opening post-holiday bell are driven by indifference to pharmacy procedure--indifference from the public, from physicians' offices, from managers, and from the regulators. Indifference as usual.

Tell us: how will you be treated, or how were you indeed treated, on the second of January 2008?

On January 1, 1993, the pharmacist-counseling provisions of the Omnibus Budget Reconciliation Act of 1990 (OBRA'90) took effect. Ten days later, I filled my final retail prescription. I didn't plan it that way, but in hindsight, it was a stroke of genius that saved my professional life. The following changes to retail working conditions came along after I left:

1. drive-thrus
2. cell phone proliferation
3. Medicare Part D
4. Online adjudication of prescription claims
5. The Oxycontin robbers
6. regulated pseudoephedrine sales
7. tamper-resistant prescription pads
8. gift cards
9. the Accutane dispensing process
10. HIPAA
11. factorial increases in prescription volume
12. supervising a technician army
13. the Internet

Had I stayed in the community pharmacy realm, I speculate that I would also be dealing with regulated dextromethorphan sales, regulated Ora Base sales (being used as a local anesthetic for IV drug abuse; the drug police can't tolerate such a thing!), regulated guaifenesin sales (IMHO: hey, it's a muscle relaxant derivative; maybe drinking a liter of it gives you a buzz?) and perhaps, in 2009, a chaotic melding of many prescription entitlements, and federally dedicated software, if one of the "universal healthcare" candidates gets the White House next year.

Chain pharmacists, let's say you earn $10,000-$15,000 per year more than I do as a hospital pharmacist. Because I am willing (and absolutely delighted, THANK YOU, GOD!!) to forgo this blood money, I am avoiding, not only the baker's dozen factors I have listed above, but also the following:

1. pharmacy rage (akin to road rage or going postal; the nastiness and stupidity of many (not all) members of the public)
2. starvation (I enjoy a half hour of uninterrupted nourishment-taking)
3. captivity (I have enough colleagues on duty with me so I can Elvis, i.e., leave the building if I need to)
4. disrespect (I am in an environment that, well, has the flaws of any workplace, but sticks to the subject of pharmacy, and the managers treat me accordingly; also, my boss is a pharmacist, and his boss supervises patient services only)
5. floating (unless, of course, you like the variety and the challenge)
6. vacation negotiations (I read that you don't always get the vacation you order; at my place, we cooperate, but the
deal is almost always final: I want the first week in June, I get it)
7. long hours (I have 8-hour shifts)

So, now, you complain, "Oh, I can't do it, I've been in retail too long, I can't make the change." As I once heard a hospital pharmacist exclaim, horsepuckey! You are a trained and intelligent pharmacist. You can learn, and your new hospital employer will welcome you into its short-staffed ranks. That's what I found to be true in the early 1990s, and it is still substantially true today.

After I left full-time retail, I worked full-time for a relief pharmacist agency with the unwritten agreement that I wanted to learn hospital pharmacy. I did not try to work for, say, Johns Hopkins, on my first day. I found a temporary, full-time assignment at a 50-bed rural hospital at which one pharmacist had gone on maternity leave. There, I learned the basics of hospital procedures and standards, and sterile product (IV, TPN) preparation. It worked. I still had some retail assignments in the mix, but the following year I took a job on my own at a VA hospital. Now, I am a staff pharmacist at a busy, growing, technologically savvy community hospital in the sunny,warm, winterless Southwest, and I enjoy the best job I have ever had in pharmacy. God willing, I'll spend the rest of my days as a pharmacist here. There is no going back.

My recent blog readings tell me that some chains are losing pharmacists because their software is particularly oppressive. The pharmacist who has filled prescriptions for my parents for 25 years is now in the grip of such software, and my Dad tells me his whole mood has changed for the worse. This is a pharmacist who seemed to be able to endure anything, but now the curve is really sloping down on retail pharmacy if he is unhappy and showing it. Well, not only is life too short to endure all 20 of the points on my list of curses, but you are worth better! You do not deserve that kind of mistreatment, nor should you tolerate it any longer.

I am devoting the comment thread on this post to pharmacists and technicians who are considering a switch to hospital pharmacy. Please let me know what I can do to help. For those who enjoy community pharmacy practice, I must be full of bull; don't listen to any of this, and stay where you're happy. But, if you are suffering with the problems I've described, there is a way out. I know. I took it. It was the best professional move I ever made.

Pharmacists, your daily dose of sadness and anxiety is simply not worth $15,000 a year.

The more I have thought about it, the more I think something's fishy in pharmacy. Literally. Have you ever heard of the coelacanth?

It was a fish that was thought to have become extinct 65 million years ago---until one of them was caught off South Africa n 1938. Lurking in the back of my mind for many years now is the notion that we pharmacists might just be coelocanths: living fossils thought to be extinct, but brought back from the biospheric dead by a society that is hasn't made up its mind about letting us go.

At the turn of the 20th century, pharmacy was still an ancient craft, but living in the modern era. If you look through old prescriptions from that time, you will see only recipes--the symbol "Rx" has been said to represent "recipe," Latin for the imperative verb "take," or "take thou." There was no overarching FDA to interfere with the physicians' time-honored orders for emulsions, concoctions, decoctions, and other mixtures carefully and skillfully prepared by the pharmacist. Merriam-Webster cannot get off this concept: the old dictionary still defines pharmacy as the art of preparing medicines. One can even go back to Shakespeare's Romeo and Juliet for a public concept of the pharmacist that has survived even into this era of pharmaceutical "care."

Then came World War II.

Most pharmacy students learn about the effect of that global cataclysm on pharmacy. As the planet mobilized for war, the drug industry mobilized for change. The floodgates of research were opened. Investigators turned useless antihistamines into priceless antipsychotics. Alexander Fleming's botched cultures from 1928 began a revolution in the treatment of infectious disease that was fleshed out in the 1940s. New cardiovascular moieties issued from the vats of the drugmaker geniuses, as human physiology, instead of witchcraft, was applied directly to medicinal chemistry. Drug therapy was transformed, from the herbal cookbook products of Civil War days to pure, specific, active organic compounds of the future, in a decade. The delivery systems for these drugs were re-engineered, away from tablet triturates and elixirs, and toward committee-designed capsules and tablets.

In a flash, the traditional craftsmanship of the corner drug store pharmacist had become obsolete!

What to do with us?

So, it is said, we then became taut-lipped dispensers. In the 1950s and early 1960s, we gave out these slick new drug products under prohibition from discussing them with our patients. But, they had to use us for something, so they gave us more knowledge (B.S. degree in pharmacy mandated), and, in the 1970s, farmed us out as junior doctor-nurses working under some kind of dispensation from the American Medical Association. We were to educate our patients so they wouldn't drive their cars into a wall on Dimetapp Extentabs, but we were not yet allowed to let our knowledge interfere with the physicians' reign over the sacred writ of medicine. It is heard a bit less often today, but "Shut up and fill the prescription!" was not an uncommon doctor-to-pharmacist consultation (some state governors have rediscovered this phrase for political purposes today).

As the 20th century drew to a close, drug products were becoming less like simple remedies, and more like complex instruments. It was said that physicians couldn't handle all the knowledge that was needed to possess about them, so it needed to be farmed out to a coterie of supportive personnel, to be called Doctors of Pharmacy. Who better for this than the educated dispensers, the people who handled and processed them all these years? It is almost as if the right to exercise healthcare knowledge was the child of the right to simply handle the stuff. We were "already there," so they gave it to us (I still wonder how the clinical pharmacologists feel about this).

I sense ambivalence in the healthcare community about this decision, if it was indeed a decision and not an accident. I say they are ambivalent because, no matter how much ammunitiion they give us as clinical professionals, our status has scarcely changed from a trade to a true profession. With all the enacted intellectual requirements for the job, tell me what you see, right now, at any chain drug store pharmacy department. With all the current empowerment from CMS, how many independent pharmacist-practitioners are there? And, above all, to what extent does the 21st-century pharmacist walk with a dignity commensurate with his or her responsibility, respected by the public, nurses, and doctors? For a good measure of that, read the other pharmacy blogs.

I smell a coelacanth. Tell me the thing that will prevent pharmacy from going the way of the "recipe." I'm all ears.

Like so many other pharmacy students, I was starry-eyed in school. With the facts beckoning to me--the structural formulas, the clinical pearls, the often eloquent professors, the promise of having a "key role" in healthcare--I felt as if I was marching forward as one soldier in a victorious army. Although I was exhausted the day I took my state licensure exams, I was made to believe that waves of great adventures in practice would momentarily carry me forward.

Whenever today's pharmacy students read the phrase "key role" in connection with pharmacy, they are riding Michael J. Fox's Delorean "back to the future." What followed for me was a common tale, but true. My huge buildup was followed by a crushing letdown.

As my first full-time job in a chain drug store pharmacy ran its course, one question crowded out all others in my mind: compared to what my "key role" was supposed to be, what were they paying me for? Apparently, they were paying me to do just what the public's most common misconception about pharmacy says. They seemed to be paying me to "put those tablets in those little bottles."

Add to the irony that the state in which I was practicing had just enacted a law that established counseling requirements 15 years before their time.  So, I should have felt as if I was standing on solid ground if I spent most of my time acting the part of a pharmacy professional. But, in fact, that would be like trying to be a cubist artist in a Sherwin-Williams paint store. I was hoping for a blue period. Instead, I just had the blues.

Over the years, whenever I would hear the phrase "request for drug information," I thought of the two most common drug information requests posed to me: "How much will it be?" and "How long will it take?"

The public's demand for pharmacy services is highly selective. Or, if you will, my advice would register with people only if I told them what they wanted to hear. But I was trained to be otherwise. I was supposed to tell  the truth as I saw it professionally. I did that quite often, but with mixed results. In one instance, I geared up for explaning to a patient the possible effects of taking Flagyl with alcohol. His response was that my job was only to fill the prescription (or, my job was not to interfere with the toot he was planning that night). And, many times, my answer to the question, "Is this stronger than that?" would be a struggle to educate, and not get caught in the myth of "stronger," but instead, discuss the merits of each choice. Most of the time they didn't want the facts. They just wanted a magic potion. So, all I ended up doing was arriving at the literal definition of pharmacy, a discussion of poisons, and, by emotional extension, witchcraft (my CB handle was "witch doctor"). Uh, Mr. Patient, how much of "key role" don't you understand?

Thankfully, the wisdom of years took over. I began to understand that I can do only the best I can do with the tools I have, and stop expecting to be a clinical hero all the live-long day. Once I decided to come all the way in, and sit all the way down, in the reality of my service as a pharmacist, I succeeded in opening the gates of Hell, and letting myself out.

Yes, the older pharmacists (the ones from World War II and the fifties) will try to top this, by telling me about their gentian violet suppositories, powder papers, emulsions, "Lahey Clinic III," and their mitte tales doses, but this is my old-time memory.

October 18, 1978. Gasoline was 60 cents a gallon, the Shah was still in Iran, Jimmy Carter had his energy certificates posted in every workplace, and I was driving my father's 1972 Chevrolet Caprice, which had its fuel economy measured in gallons per mile, and could have been used as a third rocket to launch the Endeavour. That day, I began my first permanent, full-time retail pharmacist job, for a chain outlet in a very small northern New England town.

Actifed, Benadryl, Dimetapp, topical hydrocortisone, and that whole pile of topical antifungals were Rx-only; or, if you will, they were labeled with the federal legend, "Caution: federal law prohibits dispensing without prescription" (somehow, I felt that line was easier to spot). Rogaine, Zantac, and Prilosec had not yet been born. Glyceryl guaiacolate had just been renamed guaifenesin, diphenylhydantoin had just become phenytoin, and dioctyl sodium sulfosuccinate had just been shortened to docusate sodium (somewhere, sometime, salicylazosulfapyridine had, thankfully, become sulfasalazine).

For more than two years, America chowed down on a very successful analgesic called Zomax (zomepirac, McNeil). We stocked it by the thousands. In 1983, it was pulled from the market because of a number of anaphylactic reactions. I still feel that it was pulled because it was too effective, the same way I feel that Exanta (ximelagatran, a direct thrombin inhibitor) was not approved by FDA because it might eliminate the warfarin monitoring empire.
The store, relatively new, was averaging 60 prescriptions per day. The average prescription price was about $7. During those days, I became knowledgeable about every aspect of the operation, because, for the first six months I was there, there were no technicians, and I was the sole octopus. On the cheapest possible manual typewriter (computers would not arrive for another seven years), I typed prescription labels that came off a roll on a stand and into the platen. I calculated the prices using a hand-held calculator, and figured the daily totals on a tally sheet where I would enter the costs on one column and the retail prices on another. I can still see where the EES-200 and the Dimetapp Elixir (brand name, and by the gallon!) were kept. The store's cash registers were still noisily mechanical (digital machines would not arrive for another two years); in the event of a power failure, we'd pull out a crank, screw it into the side of the register, and relive the 1800s.

Third-party claims were prepared and submitted manually (I have no idea how any business could function on all that floating paper!), and prescription card claims such as PCS and PAID were processed by running the card through an Addressograph imprinter (credit cards worked the same way then) onto a Universal Claim Form, or UCF (why didn't Medicaid use the UCF?) Both my warehouse and wholesale drug orders were placed verbally, by telephone (Telxon devices came in some time around 1980, but only for the wholesale orders). The warehouse order was done by reading down page numbers that represented quantities and items. The wholesale order was taken by sheer pronunciation of the drug names, and often I would get an order taker who had been thrown to the wolves and just couldn't hack the storm of syllables (one poor young lady was so frustrated that she actually said, not sarcastically but frightenedly, "Do you want me to find someone more experienced?" No way. I rooted her on: "two by one hundred P-H-E-N-A-Z-O-P-Y-R-I-D-I-N-E 100 mg...") . Some years later, I remember marveling at the concept of automatic replenishment when I first had it explained to me; sounded like something out of H.G. Wells at the time.

Being alone, I had firsthand access to my patients, and as the years passed, my patients became my friends and fellow denizens of the town. The biggest career mistake I made was moving away from that marvelous place. I could have grown with it, and become an institution in my own right. There were typical retail "tough moments," but the big picture was an elegant one.

You must read this post---http://www.theangriestpharmacist.com/2007/12/09/why-did-you-ask-if-you-are-smarter-than-me/.

It speaks volumes about what causes the members of our profession such frustration.


Try something for me---take this same scene, and, prior to its commencement, let's say that the couple had to make an appointment to be seen by the pharmacist, then wait an hour in a waiting room, and, finally, be ushered into a private office for an uninterrupted and focused consultation.  Would they have responded the way they actually did?

 What you read here is an eloquent and thoughtful pharmacist consultation, and the understatement of the year is that it gets lost the the shuffle that all of us community pharmacists know.

In better times, the pharmacist will be charging this to a claim containing his/her NPI, but we have not arrived at better times yet.