Thursday, January 31, 2008

ENTITLEMENTS--BY GOSH, THEY'VE GOT IT COMING!

I wish to recommend a tremendous movie, called Amistad. It is the story of a band of Africans from Sierra Leone. In 1839, they were captured and impressed onto a Portuguese slave ship, to be sold into slavery in Cuba and then shipped to the United States for resale to plantation owners or other slave holders. In one of the film's early scenes, a member of the ship's crew is seen doling out ladlesful of gruel to the starving blacks in the ship's hold. As the miserable captives eat the meager portions of cereal from their cupped hands, each stares at the other's stash of food, so hungry that his eyes threaten to take his neighbor's meal, like children in a schoolyard fighting over a treat or a possession. This scene is, to me, entitlements in microcosm. I've got mine, and don't you dare take it away! I'm entitled! I've got it coming!

This victim psychology is something we in pharmacy deal with every day. I always thought that health insurance existed only to prevent people from going broke, not to provide them with a shadow livelihood. But, many people see their third-party entitlement (insurance, if you will, but I like to call it what it is) as a way of life. That's why you get some people coming up to your counter expecting only their own personal knowledge of their coverage to be sufficient to pay for the drug. "It's OK, fella, I'm covered," and they just stand there, and you have to start extracting the documentation from them. Or, as some blogs quote, they will say, "You mean, I have to pay for it?" The manifestations of victimhood continue with such shining clinical interventions as, "It's not covered? Well, call the doctor back and have him prescribe something that is covered!" My favorite battle cry came one day with a combination declaration of entitlement and an attempted infliction of guilt on the pharmacist: "I'm an AFDC mother!" I was expecting the Secretary of HHS to personally materialize behind the lady, brandishing the Holy Medicaid Truncheon and demanding I cease and desist my impertinent demand for payment.

For those who want to call me a cold fish at this point, I believe that prescription coverage is a lifesaving arrangement for many people. Without it, they would die, because they cannot afford the antineoplastic, anti-HIV, or cardiovascular medication that is keeping them alive. To me, those people represent the proper application of our social safety net. But most members of the madding crowd of prescription patients see their insurance coverage as a carte blanche to avenge every slight they've ever received in life, browbeating every pharmacist and technician to get their way. Prescription entitlements are the perfect weapon for many people to express their often unbridled anger, and the pharmacy staff, not the patient, then become the victims.


Posted by oleapothecary at 11:22:14 | Permanent Link | Comments (0) |

Wednesday, January 30, 2008

THE UNINTERRUPTED PRACTICE OF PHARMACY----HOW COME WE DON'T HAVE IT?

You are a neurosurgeon. You are in the middle of a crucial moment in attempting to repair an Arnold-Chiari deformity, which involves the positioning of the brain and spinal cord. But, you're required to wear a cell phone headset because you must personally deal with insurance inquiries and patient complaints at all times on duty, even while you are on this most extremely delicate lifesaving mission. The phone rings six times during the moment of truth as you adjust the patient's cerebellum, but, in your practice, you are required to personally field these calls, talking on the phone about DRGs, and complaints from patients about surgery scheduling, as you slice into this high-risk patient's physiological soul.

Pharmacists are not neurosurgeons, but the analogy is credible. We are involved in exacting work to interpret the contents of prescriptions and drug profiles so we can fulfill our professional obligations safely and competently. Why, under the canopy of heaven, must we have to face constant interruptions to deal with matters outside of our practice? You remember your pharmacy school interview, your clinical rotations, your student loans, your NAPLEX, and then you get your first job---do you wonder where the respect went? One fellow blogger has posted his stories about sacrificing clinical performance for commercial speed, and risking errors in the process. I remember one parent in a pharmacy documentary, pleading with the pharmacists that might have been in the TV audience, to do good work, because her child died of a narcotic product mixup that was the result of haste at the pharmacy.

For those owners and district managers who see only profits and a prescription assembly line, the silence from pharmacists is coming to an end (in my case, I just got the hell out of retail; they can find someone else to terrorize--I'm getting their recruitment notices, but I just tear them up). They might have had that silence from us old-timey druggists who received galley-slave indoctrination in the 1960s and 1970s, but slavery was abolished in the U.S. in 1865, and it is going to come to an end in pharmacy very soon. The younger, groomed pharmacy graduates are not going to stand under that same excrement chute. They are going to demand their professional money's worth. They haven't come this far to be shat upon ("shat" is the presumed past imperfect gerundive form of "shit.") They will demand work environments in which they can do what they are trained to do---review drug therapies and respond to clinical challenges---without the front store madness. They don't know from Rexall. Then know care plans. So, to the owners, I borrow a childhood warning I remember: if you don't like it, lump it.
Posted by oleapothecary at 09:22:37 | Permanent Link | Comments (1) |

Saturday, January 26, 2008

"MEDICAL MARIJUANA"---WHAT THE HECK IS UP WITH THAT?

I'm heading you all off at the pass: I believe that cannabis is a valuable drug. I believe wholeheartedly that there are many people who use marijuana therapeutically for a number of ills, and they should have a right to use it legally. Now, my punch line: according to current U.S. federal law, they don't have that right! Cannabis is a Schedule I controlled substance, meaning that, legally, it has no accepted medical use in the U.S., and generally cannot be prescribed outside experimental protocols! If I started to stock marijuana in my pharmacy and fill prescriptions for it, even prescriptions from legitimate prescribers for a genuine medical purpose, never mind the Board of Pharmacy. The police would get there first, and, depending upon the locality, would charge me with some form of possession with intent to distribute!

So, somebody--DEA, Board of Pharmacy, anybody---please tell me why DEA hasn't marshalled its forces and conducted massive raids across the states of California and Nevada to destroy this system of medical marijuana as quickly as you can say Comprehensive Drug Abuse Prevention and Control Act of 1970. Here we are, pharmacists all, busting our humps to inventory our CSs, being vigilant about prescription forgeries, dutifully avoiding erasures on our 222 forms, and keeping our controlled substances registration certificates current, while, meantime, back in the Twilight Zone, a horde of pot outlets have sprung up, doing with impunity what I could only do with, well, plenty of punity.

OK, yes, the raids will end up snatching the grass from ailing grandmas, aggravating the stutter of the lady I saw in the documentary, and leaving the bejointed migraine sufferers to revert to triptans. But then, the severe punishment of CSA violators would mean something. The law itself would mean something. Why punish pharmacy, DEA, when you are apparently allowing all this cannabinoid lawlessness? I guess you are afraid of bad press with the grandmas. Well, we pharmacies are afraid of bad press in our pharmacy newsletters. We don't want our names next to an agreed board order or become the jetsam from an adjudicatory hearing, which is part of the reason why we obey the law.

Tetrahydrocannabinol has been underdeveloped. As oral dronabinol, it seems to be ineffective in even touching the pain and suffering of the patients who need it. I am still waiting for a pharmaceutical manufacturer to market a much more potent cannabinoid drug product, perhaps a metered dose inhaler or a high-dose, sustained action capsule. But, until that day, I shall continue to call the purveyors of medical marijuana what they are---OUTLAWS!
Posted by oleapothecary at 23:24:18 | Permanent Link | Comments (1) |

Friday, January 25, 2008

PHARMACY ALLIANCE IS REACHING THE PHARMACY TRENCHES

We wish to thank "The Angriest Pharmacist" for his spotlighting The Pharmacy Alliance (TPA) on his blog.  Since the post, interest in TPA has exploded, with numerous pharmacists, technicians, and students boarding our train. To all, welcome!

As one of us recently wrote, TPA will work for the pharmacy professional in the trenches because it is made up of the pharmacy professionals in the trenches!  There is no barrier between the organization and those it serves. Our goal is to gain dignity, self-respect, and integrity for our profession.  On April 19 and 20, 2008, at the Holiday Inn/San Luis Resort Galveston Complex, Galveston, Texas, we will meet to discuss our plans of action.

Subscribe to TPA's mailing list and join our discussion group!

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

mailing list address:  ThePharmacyAlliance@yahoogroups.com

Posted by oleapothecary at 16:19:52 | Permanent Link | Comments (0) |

Saturday, January 19, 2008

IF YOU CAN'T GET RESPECT, GET GOING!

One of my customers came in to my store one day to complain that his wife had had a vaginal problem that she never discussed at sufficient length with the E.R. physician she had seen that morning. I called the E.R. and spoke to the physician about it. he ordered her an anti-fungal vaginal cream. The couple was so grateful for my intervention that we became lifelong friends.  But friendship is not your object in being a healthcare advocate for your patients; the practice of pharmacy is!

 You've complained many times online that the physicians' agents (the "office nurses") are often inept when communicating prescription information. But, you are not inept. You can speak the healthcare language fluently, because you have been trained to do so. You are valuable--very valuable. Therefore, you are entitled to the same respect given any other working professional, and you should demand it!

Your company needs you a lot more than you need them. You need not take any lip from them, any staging of a disadvantage from them, or any neglect from them. If you can't get respect, get going! The healthcare world is your oyster right now.

Posted by oleapothecary at 10:41:23 | Permanent Link | Comments (0) |

Friday, January 11, 2008

THE FRONT DOOR OF YOUR PHARMACY IS OPEN TO THE PUBLIC STREET

No, this is not to be taken as a gigantic ego te absolvo for your difficult prescription patients, but a perspective on why they are the way they are: probability.

There is the old joke about assembling 10,000 monkeys and 10,000 typewriters. One of those monkeys is likely to write something comparable to Shakespeare.  The same might be said of the whole spectrum of human personality lurking just outside the door of your pharmacy, which, unless you are violating the Civil Rights Act of 1964 or some such law, is open to everyone. You want it to be open to everyone.  Your pharmacy is a vital draw, and your front store pays the freight.  The additional price you pay for this degree of welcome is that the entire gamut of human character, good and bad, walks in to get medication. 

Despite what you and I have talked about, both in private and on these blogs, some people are outstandingly welcome. I remember a lady from the early 1980s, whose young son had multiple medical problems, topped by a very brittle diabetes. In my pharmacy, the lady was always serene. She was the happiest lady in the world, always kind, always patient, when she had every excuse in the world to bitch.  I'm sure you also get some loving couples, who have weathered depression and world war, and now march into the 21st century. Nothing seems to faze them. Probably, today's troubles are trivial when compared to the times they have endured and survived.  They are happy for everything they have.  They are also likely to be grateful to wake up in the morning and see each other across the pillow.  Then, there are the courageous psychiatric patients,  who, despite facing a phalanx of pills every morning, are aware of their surroundings and can measure the struggle going on in their minds, and maybe do so better than some "normal" people.  They can tell you accurately about what is bothering them, and most of them seldom act as chaotically as their medication profiles suggest they would.

If you find people that misunderstand the rules of pharmacy, stop and think a minute: why should they have to understand them? Oh, sure, you can tell them about controlled substances, and most will get it, but some won't get it because it's just not their job to retain it, even if it applies to them. I'm not saying, forgive them for it; I am saying, forgive yourself by not beating yourself up over why they can't get it. There are only so many rules you can load a person up with. You could post all the rules on a board for people to read, but they would either be ignored or forgotten.  Their "job" in life is to live, not to practice pharmacy.  Yes, you will enforce the law, but don't expect all of your customers to fall in line like ducklings following the mother mallard.

In pharmacy, as in life's terms, two adages come to mind:  "Easy does it."  "Live and let live."
Posted by oleapothecary at 21:55:56 | Permanent Link | Comments (1) |

Wednesday, January 09, 2008

LET'S HAVE A SCHEDULE II-a; WHY MAKE CHRONIC PAIN PATIENTS HURT EVEN MORE?

The latest Drug Topics states:

Beginning Dec. 19, prescribers will be officially permitted to issue multiple Rxs for up to a 90-day supply of Schedule II drugs. While some doctors had given multiple prescriptions to patients in the past, prior to the rule it was unclear whether the practice was legal. Many patients with chronic conditions complained that it was costly and difficult to visit the doctor monthly to receive a new Rx. DEA received nearly 300 comments after the rule was proposed, with the majority in favor of the change. The final rule clarified that the Rxs must be sequentially filed and may not add up to more than a 90-day supply of Schedule II narcotics.

Well, this ole' druggist believes that refilling, instead of filling, narcotic prescriptions for people who need them would not be out of line with the "war on drugs," which should be a war on the illicit use of drugs, not a war on the sick and suffering.  I propose a new controlled-substance schedule, to be styled "II-a." An example of drug product to be placed in this schedule would be narcotic-NSAID combination products such as Percocet.  Schedule II-a controlled substances would have to be ordered in writing, but a 30-day supply could be refilled twice, so each prescription would be valid for a total 90-day supply of medication.  Why are we forcing chronic pain sufferers to deal out their pain relief like playing cards? 
Posted by oleapothecary at 17:22:13 | Permanent Link | Comments (3) |

Monday, January 07, 2008

VOTE FOR THE PRESIDENTIAL CANDIDATE WHO KNOWS WHAT IT MEANS TO GO TO WORK

Whenever Richard Cory went downtown,
We people on the pavement looked at him ...
   
                --E.A. Robinson


The other day, one of the pharmacy technicians I work with came up with a powerful piece of gut wisdom that hit me between the eyes like a small rock flying through the air and thumping my skull. He said that the person who should be the next President of the United States is the one who knows what it means to go to work, raise a family, and, as I added, "stand in line like the rest of us." Now, I don't want to go down the current list of presidential candidates and say who I think is most "workworthy," but I was deeply moved by this technician's pinpointing of one of the things that really raises my epinephrine about those running for office.  The ones that worked, or had to run a business,or had to spend time worrying, anticipating, waiting for letters to come in the mail, negotiating with customers, and generally not enjoying great privilege, are the ones who, I believe, have earned the right to political leadership in America. 

Part of my displeasure with the practice of community pharmacy lies in the indifference, and perhaps ignorance, I feel that legislators possess, each time they pass laws or promulgate regulations that are binding on us pharmacy professionals.  Unless they work in pharmacy themselves, they don't have to live with those measures. They just get them enacted and add the politicking to their CVs.  As I watch the candidates and the media this morning, I wonder if any of those people who are shaping and staging the election process give a hang about those of us who pay the nation's freight with our minds and hearts.

Our "leaders" passed the pseudoephedrine rules, and they get to feel good while we have to devote a lot of precious pharmacy time to their police work.  They established counseling regulations, but are probably unaware that it can't be done very often, and is enforced very selectively.  They unleashed Medicare prescription coverage to score points in political altruism, but they are not the people who have to spend the better part of each day juggling the information for the patient. 

Give me a candidate who has felt the grind of work, and I'll give you a candidate who knows the pulse of this nation, and ought to be taken seriously when he or she speaks about our future. Such a candidate is not a "man of the people," but is an actual person.

Posted by oleapothecary at 11:02:02 | Permanent Link | Comments (1) |

Sunday, January 06, 2008

WITH THE EDUCATION SYSTEM GUTTED, HOW WILL WE GET OUR FUTURE PHARMACISTS?

About 10 years ago, I was driving across the Coolidge Bridge from Hadley to Northampton, Massachusetts, when I heard on my car radio that the South Hadley public schools were reinstituting the honor roll system. I nearly jumped into the river. Reinstituted? When did they ever stop it?

I would later learn that public schools had been eliminating academic competition because it would make some students "feel bad about themselves." So, the system of personal discipline that used to be the hallmark of education had been deemed to be too traumatic, and was scrapped for a time. I also learned about the practice of social promotions, whereby students would be advanced to the next grade regardless of academic scores. And, I learned about functional illiteracy, wherein students who had been advanced by the social promotions only appeared to be able to read, but could not do so when tested in the real world. A recent Boston Globe article told the story of the once-superb Boston English High School now being lucky to get quorums to hold classes. I could pin blame on all this, but this is not a political blog.

We are in a period of simultaneous expansion of pharmacy education and the chain drug store industry. Two or three new schools of pharmacy are about to be launched in the state of Tennessee alone, each presumably maintaining the brutally high new admissions standards. And, a look at the minutes of state pharmacy board meetings shows that new chain drug store outlets are opening all the time. With today's limp commitment to college-preparatory education, where will the schools get the pharmacy students, and, consequently, where will the big pharmacy combines get the pharmacists? The potential $150,000 annual salaries can surely make people study hard, but how many good and interested students will there be to fill the pharmacy school slots and, after that, the pharmacist positions at WAG, CVS, Rite-Aid, and the rest?

Something's gotta give. I've read about a pilot program under discussion in Virginia, whereby refill pick-up kiosks will be set up for after-hour transactions at some retail pharmacy outlets. Could this be the beginning of a gradual trek to replacing pharmacists with automation? At about the time of my Massachusetts bridge crossing, I predicted that something like this would take hold by 2005, but I may have been 10 years too soon. Still, the sad thing I see here is the possible reduction in the number of working pharmacists due to further intellectual decay in our society: the steady erosion of substance into shadow.


The whole pattern points to the destruction of the profession of pharmacy by mid-century. Well, the 98-year-old Ole' Apothecary will be long out of the profession by then, but I do hope, at least, to be running one kilometer a day and having sex once a week. I just hope there are a few people in 2050 who know what a kilometer is, and can at least speak some English, even if they can't write it.


Posted by oleapothecary at 10:32:57 | Permanent Link | Comments (1) |

Wednesday, January 02, 2008

DISPENSING ERRORS IN THE DOCKET---PHARMACY'S INCONVENIENT TRUTH

Correct me if I'm wrong, but, prior to the 1999 report To Err Is Human (the landmark document on the prevalence of medical errors), I don't remember pharmacists getting officially disciplined by boards of pharmacy for dispensing errors.  Contrary to the possible sentiments of the authors of that report, the media, and the public, I am saddened by this practice. The use of this "Sword of Damocles" principle of quality assurance by our state pharmacy regulators is not very fair.  The vision in my head was that of U.S. troops in Vietnam stepping on those feces-coated wooden spikes that were hidden strategically in the jungle.   It is apparently convenient for the boards to place the pharmacists and technicians---the co-victims of the chaotic drug distribution environment---in legal harm's way, without approaching the owners of the businesses about the conditions that often contribute to dispensing mistakes.  Why should they usually be held harmless and incognito, while pharmacy personnel are the ones that get written up by name in the Dear Abby sections of the BOP newsletters?
Posted by oleapothecary at 16:01:19 | Permanent Link | Comments (2) |
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