The Ole' Apothecary

My Dad is 87 years old and hard of hearing. But, he is in excellent health for his age, and a new medication is big news to all of us. A couple of months ago, he told me he had been taking levothyroxine since last October, and he didn't even know what it was for, and hadn't even mentioned it to me. After I explained it to him, I asked him what the geriatrist told him when he made the decision to order this medication, and what his pharmacist of many years told him. The answer: nothing!  For my Dad, OBRA90 and its state-level children were not worth the bathroom tissue they are printed on. I made my father promise me to tell me about any new medication that is prescribed for him to take.

But, why should I have to make a real point to do that? The answer is, with the exception of some states and some pharmacies, silence is the norm at the Rx counter. Now, perhaps my father doesn't remember anything that was said, but an effort must be made, especially in the elderly, to buttonhole them with the fact they are about to start taking a new med, what the new med is for,and what to expect. To me, this transcends OBRA90 and transcends pharmacy. It is just common sense and common courtesy. So what if they seem impatient, impertinent, or indifferent? You've done your job, and you've also covered your glutes. Besides, YOUR Dad is entitled to know what he's being asked to take for medication. 

"I'll order you an antibiotic and a cough syrup," says Dr. Ewrite to Ms. Ima User. She picks up her  PDA with Ms. User's medical record on it, clicks the lines  "Bug-omycin 500 mg tid," and "Tussionex 5 mL po bid,"  and enters the dosage unit quantities.

 The prescriber asks, "Which pharmacy do you use, Ima?"

"Kroger's. I'd like to pick these up at the station inside the Kroger's on the Loop."

 "Ok, sure," says Dr. Ewrite as she completes the prescriptions by entering her electronic signature, selecting the requested pharmacy station, and clicking the "send order" button. 

About 15 minutes later, Ima places her thumb on the Kroger pharmacy station's scanner. Her third-party coverage transaction is completed, her bank account debited for the co-pay or co-insurance, and the prescriptions dispensed down a chute much in the same way as a soft drink.  The station's computer screen then reads, "To speak to a pharmacist about these presciptions, pick up receiver to talk." When Ima does so, the pharmacist covering the Krogers/Loop station as one of his 50 assigned stations answers from his home on the other side of the state. At the same time, a full description of the prescriptions appears on his home screen.  "What can I expect from these in the way of side effects from these?" asks Ima. "Perhaps diarrhea from the Bug-omycin, and drowsiness from the Tussionex. Be sure to finish all the Bug-omycin."

"Thank you," replies Ima, and hangs up the receiver. She removes her bag with the two labeled medications and patient literature, and heads home to start going on the mend. 

OK, fellow Red Sox fans, fess up. When you first heard of the oral contraceptive Yaz, didn't you give out a hearty giggle?

"Yaz" is the nickname of former Red Sox left fieldler Carl Yastrzemski, who played for the crimson hose from 1961 to 1983, and was the last man to win baseball's Triple Crown (best in home runs, runs batted in, and batting average, 1967 season).  His uniform number, 8, was retired by the Bosox some years ago.

 I often wonder how Yaz feels about Yaz. 

It has been surprising to me how many community pharmacists have expressed a desire to change over to hospital practice, but say they don't believe they are able to do it. One retail pharmacist, 10 years out of school, read off to me a litany of reasons why she couldn't make the switch. The points she cited seemed to me to be based on fear run wild, and not based on the facts. The facts are that you, as a pharmacist, are a highly educated and infinitely adaptable human being, and if you are a recent graduate, your education has included some added, intensive clinical training. And, in retail, how many times a day have you adapted to change? I promise you, you've got the right stuff. You just don't know it yet.

Speaking as one who did make the change, I promise you that you, too, can do it. I didn't even have a Pharm.D. degree, and I did it (I graduated in the 1970s and made the switch in 1993). Yet, I had an e-mail exchange with a recent graduate (Pharm.D) who works in retail and feels that she couldn't do it. Stuff, nonsense, and, as General Schwarzkopf said, bovine scatology! Not only can you do it, but you shall be welcomed by your new colleagues.

I walked out of full-time retail pharmacy forever in 1991. Then, I went to work full-time for a relief pharmacist agency with the stipulation that I wanted hospital assignments. My boss' clients knew they were getting a retail refugee with virtually no hospital experience. I began in a small (52-bed) rural hospital, learning, on the job, the basics of medication profile review, I.V. and TPN (total parenteral nutrition, or hyperalimentation as it used to be called) preparation, and working with doctors and nurses on a live, regular basis. I was looking for progress, not perfection. In 1993, I stopped taking any more retail assignments, left the agency, and joined a small government hospital with many more beds and an active acute inpatient care ward.

Today, I work in a fairly busy community hospital pharmacy department with a hectic IV/TPN program. The hospital recently completed a two-year conversion to computerized prescriber order entry (electronic doctor orders, so, no more bad handwriting) and bar code medication administration (nurse scans bar-coded medication tied electronically to the patient). We have no outpatient pharmacy connected with the inpatient area, so I do not have to deal with any of the headaches of third-party billing, "cash register" customer relations, forged/altered prescriptions, or the threat of armed robbery. My decision to change over from retail to hospital practice is the best decision I have made in my pharmacy career. True, the pay rate is less than retail, but not by very much, and I have no desire whatsoever to exchange my dignity and my peace of mind for the devil's dollar difference. I urge all current pharmacy students (unless, of course, it is a family or personal calling) to consider forgoing any of pains and perils of the world of galley slave pharmacy, and come directly to healthsystem practice, where, after all your training, I think you belong!

Jochebed (played by Martha Scott): The Lord has lightened my burdens.

Moses (played by Charlton Heston): He would have done better to remove them.

----The Ten Commandments (1956)

As I read the blog posts of the prevailing pharmacy blogs and compare their contents with my own experience in community pharmacy, I came to a conclusion: they are all swimming against the tide. No, they are swimming against a tsunami!

Outrageous behavior on the part of the general public is what is normal. Logic, kindness, and appreciation for the pharmacy's work are the true aberrations in our experience. Don't expect them! Expect the unexpected as the main course in your professional banquet. Why this non-stop rant-and-bitch festival? What does it accomplish? More importantly, what does it change?

At a continuing education conference I attended some years ago, the executive secretary of a state board of pharmacy pleaded with the pharmacist participants for action. This was one of our regulators, telling us to, civilly, revolt! "Take back your profession! Storm our offices!" he said. I thanked him afterwards for his encouragement, but I was the only one, and I was astonished to see the madding crowd of pharmacists just walking out of the room.

We are the licensed pharmacy practitioners of the world---pharmacists and pharmacy technicians. The profession rightfully belongs to us---not to the public, not to the regulators, not to the community pharmacy chains, not to the health systems, but to us. We are the ones who studied, interned or served as technician-trainees, and who step forward every day to solve drug-related problems in healthcare. Without us, there would be no meaningful interpretation of "care by drugs" on behalf of the public or other healthcare workers. Nothing would issue. Drug delivery systems would not be explained. Therapy questions could not be answered. I.V. compatibilities might not be checked. Proper guidance for drug taking would not be readily available. It is our venue, our milieu, our setting, our turf. We've heard other healthcare professionals fiercely defending their bailiwicks (how many times have you been hit with the war cry, "I'm a nurse!") but we have scarcely defended ours, except in the context of puerile rants that do little to relieve our pain. When, at a crucial juncture in our self-defense, are we going to proclaim, "I'm a pharmacist?"

NOW is the time. Why now? For those who remember the sixties pop group The Association and mechanical wristwatches, we've got the 17 jewels that dictate the rules. 

Pharmacists are highly trained healthcare professionals who are in desperately short supply. If push comes to shove comes to job change, we have the ace that it is just too damned difficult to replace us, especially if we are doing a good job. Now, we are entitled to, well, pick your phrase: flex your muscles, feel your oats, stand your ground. There is no more reason why one such we are should have to tolerate the galley slave conditions that have been the bane of community pharmacy practice for decades.  In fact, considering the legal obligations that have been laid upon us over the past 15 years, we should have a private office befitting our duties. We should be able to communicate with our patients with the same dignity doctors enjoy.  In this matter, I speak not of credentials, but of sheer decency.  Does your doctor have to interrupt your physical exam 6 times to talk to insurance companies or answer other patients' questions?  In any case, your time with your patients for drug informations is sacrosanct. Pharmaceutical care, and not being an insurance ombudsman or time-and-motion-studies victim, is the reason you are there, the reason you are licensed and trained.

If chain pharmacy management continues to oppose this, it is time for the rank and file of the profession to respond with action at the state boards of pharmacy or action with a job change.   Author new regulations and file them with the board. Make pharmacy care happen at your pharmacy.  Train one or two pharmacy technicians to be the third-party coordinators.  These are just ideas in broad strokes, with little detail, but they are suggestions on how I believe we should be thinking and acting as pharmacists in the 21st century. 

It is difficult to say what is impossible, for the dream of yesterday is the hope of today, and the reality of tomorrow.

---Robert H. Goddard (a real rocket scientist, at his 1904 high school graduation)

Hey, Rocky, watch me pull a rabbit out of a hat. Nothing up my sleeve---PRESTO!

---Bullwinkle the Moose (Rocky And His Friends, cartoon TV series, 1960)

At that long-ago high school commencement, young Robert Goddard did not lecture on the virtues of liquid rocket fuel composition. He appealed to drama and emotion. He spoke of dreams and hopes, hardly the stuff of the college laboratory assistants, who would speak to the undergraduates of ebony bodies and spectrophotometers. But, the subliminal belief seemed to be that we were practical Houdinists, ever pursuing, not the natural, but the supernatural. We were chasing theatrical transformation, and implicit in our pursuit was the reward of an audience's applause, and even its worship. Perhaps we were becoming the Baalists from the book of Judges, that our first priorities would be, not God, and not even mammon, but rather, change.

I remember my first romancing of the magic. It occurred on the first day of my seventh-grade science course in 1963. My teacher wore a white blouse, a plaid skirt, and severe-looking eyeglasses. We students sat in rows of wooden desks before this our first altar of science: a black workbench on which was perched an apparatus similar to the one at left. The teacher announced that she was going to make pure oxygen, the gas of life, by heating potassium chlorate with manganese dioxide. We sat with our notebooks open, dutifully transcribing her every word. In almost ritualistic fashion, she pronounced "MAN-gan-ees." It seemed as if the intonation of that word was going to shake the walls of the room. Manganese! It sounded more like an embassy than an element. Did the United States have diplomatic relations with the Manganese? After heating the mixture and collecting the gas, the teacher inverted the bottle and plunged a small burning dowel into it. The tiny flame burst to life, engulfing the entire section of wood that was submerged in the gas. The quiet room burst into oohs and wows.

Our teacher offered only that this was a demonstration of the behavior of a gas that does not burn, but supports combustion. To this day, however, I felt it was a magic show, akin to Houdini's orderly presentation and execution of his footlocker escapes. And, wasn't the popular youth science TV program of the time called, not Mr. Goddard, but Mr. Wizard? It might have been more appropriate for our teacher to wear a cape and wield a wand. I think it likely that our first attraction to science consisted of what would amaze instead of what would educate.

Amazement might be considered to be a component of enthusiasm, and enthusiasm a component of successful education. But, for many years following that oxygen demonstration, I felt that there was always a lot of enchanter in more than a few of my science educators. Many seemed to be to be as much performer as pedagogue. Beneath the surface of progress was prestidigitation, and we would soon get busy applying for admission to colleges of carnivals. Even CBS's Eric Sevareid, as he covered the 1961 launch of Alan Shepard on the first U.S. manned space mission, referred to the event as "the greatest death-defying feat . . . " Mothers and fathers soon wanted their children to chase after the magical dreams of the practice of science. To what extent did an obsession with magic enter into our decision to pursue the practice of pharmacy? Nothing up my sleeve.