The Ole' Apothecary

Did you have one once? Did you? Your own pharmacist?

These days, the only way you can get one is if you are married to one. Turn over in bed, caress the neighboring shoulder, and ask for drug advice anytime you want. And, you know this pharmacist by name, and the pharmacist knows you by name.

But, that's the way it used to be, and without the bonds of holy matrimony to make it possible. You would open the door of the drug store, and an overhead bell would tinkle. You would get a warm "hello" from across the store as your pharmacist looks up and greets you by name. There might even be an interval of cordial badinage before you get down to business and ask for your prescription. And, in the air, there would be the aroma of menthol, cinnamon, chocolate, and the hum of a big, old soda cooler, the kind you would open up from the top, like a hope chest, and reach in for a mightily chilled glass bottle of sugar-sweetened Coca Cola, which you would open by inserting the top into the opener on the side and prying down. Then, in your hand, would be placed a finished prescription product that had been handled as a jeweler would handle one of his treasures in trade.

Well, the pharmacy I worked in back in 1978 wasn't that seductive, but the personal touch was there. Before computers and before the smothering domination of entitlements, it was possible to cultivate some very good relationships with my patients. They knew my name, and if I wasn't on duty, I would hear later that they would ask for me by name. I could get them to smile, and I could often reassure them, without the need for hard-drive-generated tomes of information, that this or that side effect would present itself in thus and such a way. Yes, there were customer-relation problems, but they were framed in terms of relationships among people, not the acts of war that I hear about today.

I'll say it as many times as I have to say it: pharmacy is on a collision course with reality. The days of personal pharmacy service have been lost to a tsunami of prescription orders, and yet, it is this very personal service that we must be able to conduct for our patients if they are to receive our professional pharmacy care. We have to know their drug therapy with the same completeness with which we know their names. If the counseling laws and the academic dicta are to mean anything, we have to relate to them wholly as people and as patients. You, out there---you have to have your own pharmacist again, and soon.

The Pharmacy Alliance (TPA), a fellowship of pharmacists and pharmacy technicians dedicated to the dignity, self-respect, and integrity of the pharmacy profession, plans to hold its first, and organizational, meeting in Galveston, Texas, United States, in the spring of 2008.   Check back here for an announcement for the exact date and location for the meeting, or, join the discussion by subscribing to  our newly created mailing list at

http://groups.yahoo.com/group/ThePharmacyAlliance

ThePharmacyAlliance@yahoogroups.com

Messages sent from subscribed addresses are sent to all group members.

In just 3 days, we have grown to 24 members. Pharmacists and pharmacy technicians are welcome to join TPA.

This is to certify that

(name)

is a

REGISTERED APOTHECARY

and having been recorded as such by the commission,

is authorized to conduct the business of an apothecary

in the state of (confusion) as provided by law.

I chose my blog title based on the moniker granted to me by this particular state license (issued to me in the late 1970s, so yes, I really am an apothecary!), as well as on the debate Romeo has with the pharmacist in Shakespeare's play (http://oleapothecary.blog.com/1890622/). These things remind me of my professional heritage, but I still struggle with the drag that this heritage makes on my professional development. Are we all still perceived as apothecaries "conducting business," or as modern clinical pharmacists providing pharmaceutical care to patients?

here is another yin and yang we live with, like the strong central government vs. states' rights. Do our patients see us only as gatekeepers from whose hands they must pry the potion, or as competent caregivers from whom they can glean valuable information on their health? This controversy generates a lot of the friction one reads on my brother pharmacy blogs. The chain ownership sees us only as a sales draw, while other forces impinging upon us (regulators, academia, or our own professional wishes) require us to be wielders of drug facts, not spatulas. The "pry the potion" game carries over into institutional practice as well. Physicians write unusual doses (more often than not, too high instead of too low) that they often insist shall stand despite the literature data we present to them to the contrary, making us feel more often adversary than adjunct. I can understand their presenting a good reason for a certain dose, but, too often, the decision is clothed in the bark of, in so many words, "Shut up and verify the order as written."

As the stakes get even higher in what our professional opinions mean---the next step may be to credential us as well as license us (see the post below, on residency)---the friction over the apothecary vs. pharmacist, tradesman vs. professional dichotomy will increase. Like so many facts in human affairs, the future of pharmacy may be decided, not by the disciples of our profession, but by the courts of law.

A major impetus for residency training in
medicine is privileging and payment.
Although physician residency training is not
required for medical licensure, institutions
and other health care organizations will not
credential a physician who is not at least
board eligible (i.e., has completed
appropriate residency training), and third-
party payers will often not recognize them
for payment.

---portion of 2006 ACCP Position Statement, p.723.

The gauntlet has been thrown, the line in the sand has been drawn, and the next great paper chase in pharmacy may be on! It is a case of apparent 2020 foresight, with 2020 being a year, not a visual acuity measurement. The American Society of Health-System Pharmacists’ (ASHP) House of Delegates has passed a resolution calling for all pharmacists who conduct direct patient care to complete a residency, beginning in 2020. The move may have been made in response to a 2006 American College of Clinical Pharmacy (ACCP) position statement supporting the change. But, academic pharmacy demurred. At its Orlando, Florida, annual meeting, the American Association of Colleges of Pharmacy (AACP) shelved a similar policy statement for additional study.

ASHP seems to believe that, as medications become more multi-faceted, licensure alone will not a pharmacist make. ACCP’s statement seems to want to cast pharmacy in the medical-education model. Up until now, the power of the state was enough to “credential” a pharmacist (my jurisprudence professor called a pharmacist license a “ticket”). But, starting in 2020, if ACCP and ASHP have their way, pharmacists who provide direct patient care―that is, observing the patient and making direct changes in drug therapy―will instead be empowered by the training recognized by their employers and institutions.

One section of the ACCP statement makes what seems to be a remarkable proposal. Among the 400,000 pharmacists that will be needed in the U.S. by 2020, it envisions what amounts to a caste system, as follows:

• 100,000 order fulfillment pharmacists: (or, if you will, dispensers; grunts; should we invoke India, and call them “untouchables?”) These pharmacists would not be engaged in direct patient care, and would not require a residency, but may require “system engineering” backgrounds to ensure safety in dispensing systems

• 165,000 primary care pharmacists; residency required; these pharmacists would practice in “community pharmacies and other ambulatory care settings”

• 130,000 secondary and tertiary care pharmacists; residency required; this is for the hospital and intensified ambulatory care settings

• 22,000 managerial, industrial, and other pharmacists in non-patient related areas

• 3,250 pharmacy faculty

That second caste is the one I find revolutionary. It suggests that, by the end of the second decade of this century, there will be a credentialed pharmacist on every street corner in the U.S., one whose primary function will be medication therapy management for which (s)he will bill the payers. Perhaps this is what the Commonwealth of Massachusetts had in mind when, in 2003, it removed the regulation of pharmacy from the rough midst of hairdressers, pipefitters, and real estate brokers, and placed it in the glow of the Department of Public Health with, among others, nursing and respiratory therapy. Or, is it?

Tell me that again―beginning only 13 years from now?

Heavens to William Procter, ACCP, please read the other pharmacy blogs!

For starters, click on some of the links in the blogroll to the right of this article, and sample the testimony of today’s community pharmacists. Read their statements of “direct patient care.” These men and women, many of them Doctors of Pharmacy, are whiling all the days of their pharmacy practice counting grams of pseudoephedrine for the police and narcotic dosage units (you call them drug delivery systems now, I hear) for the DEA, serving as ombudsmen for the pharmacy benefit managers and indentured apologists for the drug makers’ prices, traffic monitors for the cosmetic aisle, and, in one instance, refereeing a drunken brawl at the drive-through window. By what prestidigitation, what sly politics, what deus ex machina, are you going to erase this picture in a decade, that has held pharmacy hostage for a hundred years? One hundred sixty-five thousand respected pharmacists, with private offices, desks, and computers, calmly and gracefully working with patients and their medications? Well, crack my emulsion, where do I download that there residency application?

I suppose that, at this point, some may see me as that New York Times writer who, in the 1920s, scoffed at Robert Goddard’s liquid fuel rocket as a viable spacecraft because “it cannot react against a vacuum.” Forty years later, after Apollo 11, the Times had to say it “regretted the error.” My regretting my view remains to be seen, but much depends upon something ACCP said later in its proposal:

The profession continues to seek acceptance
(by the public) of the pharmacist’s role in
managing drug therapy. Implementation of drug
therapy management services under Part D of the
Medicare Modernization Act provides the
potential for a significant change in the public’s
perception of pharmacy practice. However, the
profession must continue to pursue the goal of
achieving pharmacist provider status under
Medicare and other third-party payment systems.

I take “the public” to include those who sell chain drug store pharmacy services to the public. Again, pharmacy is, at the moment, on a collision course with reality. Does ACCP envision, over the next decade, the rise of thousands of independent pharmacist practitioners, who hang out a shingle like other healthcare professionals, and accept new patients? Well, as pharmacists, we can get National Provider Identifiers (NPIs) of our own, to enable us to bill third-party payers for pharmacy services (f you a pharmacist, You can, too; It is free, at https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart.)

According to this proposal, pharmacy will be a very different profession in 2020. Under this scheme, the public will get used to visiting pharmacists―165,000 strong, if you believe this― in a way similar to visiting doctors, nurse practitioners, dentists, or chiropractors. But, who can see them doing it under anything other than an independent shingle? If ACCP thinks it will be a Walgreens shingle or CVS shingle, dream on. In the mid-1990s, one New England chain began building pharmacist offices next to their prescription departments. Within two months, the offices were being used only to store totes, those heavy plastic cases used for merchandise shipping.

As a child growing up in the early 1960s, I watched a cartoon series called Adventures In Space. The human-piloted spacecraft in the series was adept at traveling throughout our solar system as easily as I would take exits on an Interstate. The year? Nineteen seventy-eight! If ACCP’s 2020 vision for pharmacy comes true, nobody will be more pleased than I, but I am still an eyeglass wearer. Show me. Open my eyes.

Across cyberspace, pharmacists speak loudly of a yearning for respect and independence. The blog writings make some recurring statements:

• Pharmacists have earned working conditions befitting their professional status
• Pharmacists have earned the right to influence their degree of reimbursement, and to throw off the yoke of the rapacious third-party formulas
• Pharmacists have earned the right to charge fees, as other professionals do, commensurate with the independent application of their healthcare knowledge
• Pharmacists have earned respect from their patients and managers

 
Notice that we don’t say we deserve it. We say we’ve earned it. It is already ours. But, to a great extent, we don’t have all of these things yet.  For all these decades, the desires of so many pharmacists have scarcely inspired a plan of action to attain them. The biggest obstacle to change is mammon. All of us feel that nagging urge to rise up, but most of us sense, however falsely, that in doing so, we would risk losing the societal security blanket that issues from our often frustrating daily labors on the bench or in the I.V. laboratory. We want the golden eggs, but we often hate the egg-laying goose with a passion.  Professionally, we want somehow to make a major course correction without rocking the boat. Over the years, we have clung to the old habit of pharmacist surrender to the many puppet strings of law and custom that control us.  But, in the end, we are beckoned by Mark 8:36:  “For what shall it profit a man, if he shall gain the whole world, and lose his own soul?"

 If the obstacle to change is fear, then the pathway to change shall be faith―faith in ourselves!

 We are highly educated healthcare professionals. The entry-level degree for the profession of pharmacy is now a Doctorate. Doctor means teacher. A teacher is one with sufficient knowledge such that he or she can impart that knowledge to another person competently and independently. In other words, a teacher is an authority. A teacher is an expert!  Pharmacists are experts in almost all things concerning drug products. As Jim Plagakis says, one cannot conduct a pharmacy without pharmacists. We should look in our collective mirror and stand tall, saying to each other, “We are pharmacists, and we shall own our own expertise!”

It is like the old comedy line: we don’t know our own strength.

In the current issue of  Drug Topics (6 August 2007), an article reviewing a poll on the current level of pharmacy influence on healthcare stated, “Clearly, healthcare professionals are leaning heavily on the pharmacist's medication knowledge and expertise today, as are so many others, including patients. It's no wonder then that the pharmacist's influence is climbing. But talk to some people in and out of health care, including some R.Ph.s, and you'd never know it. Many don't see it. Some don't get it. The surge in pharmacy influence just may be one of the best-kept secrets in health care today.”

 We pharmacists of 2007 are like the generation of women who, 35 years ago, first heard Helen Reddy sing I Am Woman. We are at a point of spiritual awakening, but feel the pain of its soundings.  Yet, the voices of the pharmacy profession cannot stir this consciousness disparately.  We must rise together, with one voice, and speak as one. I think the first step is for us to speak at a common table, to each other. We need a national organization that goes beyond merely representing us. We need a national organization that is us. We need unity, a unity beyond the profession we share. We need a new pharmacy alliance.

Plagakis has described such an organization as a bowl. It is a bowl of ideas that is up to us, the pharmacists and pharmacy technicians (the licensed pharmacy professionals) to fill. We ought to fill this bowl with ideas of how to realize our strength in the healthcare hierarchy: how to refuse oppressive working conditions; how to obtain the appropriate remuneration for our knowledge, not our elbow-grease; and how to make manifest the respect we already command.  Once these ideas are in place, we should begin the process of organizing them into a philosophical fellowship of pharmacy professionals, a professional action society, the likes of which have not yet been formed or tested in the world.  It will be a group of people whose first changes will be in their hearts, and it will revolutionize the  practice of pharmacy merely as its final act.

(Standing behind anti-rotten-egg riot gear)

I believe that the continuing education (CE) requirements for U.S. pharmacists are woefully inadequate. They should be increased, in both number and difficulty.

To start with, the number of required CE hours should be doubled in every state. They have not been changed in 30 years. Also, at least half of these hours should be live, at least to get us to interact with educators, and, at most, to get us to interact with our peers in the profession.

Who are we kidding? How can we possibly stay as valuable and as indispensable as the market experts say we are if we don't change what we do for continuing education? Today's new drugs are more biological than they are chemical. Soon, drug therapy will be akin to surgery. The need for studied additional expertise in pharmacy is greater than ever. How can we justify our existence by using the CE standards of a past century?

I do not expect to be popular with this view, except perhaps with the CE vendors. I do expect to stand on it, and say that the emperor is wearing no clothes on this issue. If we do not grow, we will surely go. We like to argue breathlessly that we are highly educated healthcare professionals, but with each passing year of our practice, that education will rot on the vine unless it is nourished by new information.

According to Wikipedia, as of 1 July 2006, the state of Oregon recognizes pseudoephedrine and all pseudoephedrine containing products as Schedule III controlled substances, and requires a prescription to purchase them.

So, why not require a prescription federally?

 If this synthetic precursor for illegal methamphetamine manufacture is so dangerous, then why keep it pseudo-OTC, and why, in the name of Maimonides, make pharmacists practice pseudopharmacy by making pseudopharmacies in 29 states pseudoephedrine bean counters? And, this isn't pseudo-ridiculous, it is totally rotten.

 Heavens to Harvey A.K. Whitney---we are bound by OBRA and HIPAA; we can get NPIs; we must be doctors of pharmacy; why must our departments be forced to step back into a previous century and be clerks again? Put this drug in the clinical arena as a prescription medication, and pharmacy should be able to justify the burden.

 The federal Methamphetamine Epidemic Act does not require pharmacies to oversee pseudoephedrine distribution. Neither should the states. So,Let all of America's pharmacies control it with equal, and fair. professional commitment. As in Oregon, the proper mechanism should be "Rx Only" from sea to shining sea.