The Ole' Apothecary

You lock the door behind you, or, you say goodbye to your 24/7 hospital mates, and you head for your car. And, you might even drive a ways down the road, or even get home and just climb into bed, before it hits you like a dart heated to incandescence in your soul: you did something wrong!

How you remember the error is remarkable. Some kind of photograph of the medication order stays in your memory as a latent image, and then you develop it later. No, it wasn't one ACE inhibitor, it was another one that you dispensed. No, it wasn't dextrose you mixed it in, it was normal saline, in which the drug is much less stable. Or, did you have the decimal point in the wrong place in your calculations? If your partner is still on duty, you telephone frantically. But if your store is closed, you will fret, depending upon the issue, until morning, when you will telephone frantically at the opening of business.

Racetrack pharmacy, fast food pharmacy, the conveyor belt, the assembly line, pick your favorite metaphor, but pharmacy is a chaotic stream of events. Professionalism yields too easily to the need for speed, and amidst the pursuit of speed come mistakes. problem is, the mistakes grate against the professionalism. All day long, you wear the white coat and labor in front of your ornate certificate bearing the signatures of the board of pharmacy that licensed you. But suddenly, with the development of the error portrait in your head, you become adorned in a dunce cap, and the board appears in your dreams as a panel of Torquemadas about to install you in an iron maiden for your mortal sin against Cosmas and Damian!

Most of the time, however, the goof-up is small, but once every few years, it is a dispensing of real trouble, such as the methyltestosterone given out, instead of propranolol, to a growing boy, or a half-teaspoonful instead of a half-milliliter of concentrated opiate solution for a toddler, or glacial acetic acid instead of 0.025% acetic acid for a healing adult face. Maybe a recent post on another pharmacy blog clarifies the error rate for all of us, which may be only five a week, but that may be five too many if even one of them approaches death or disfigurement. This is why a pharmacist's success is tied to his or her dignity in practice. A pharmacist should always take ample time to focus naturally on his or her prescriptions, but the fact is they cannot take time. Time is stolen from them by the forces of brute commerce. It is time that the time be given back to them. Then, at last, most of their homeward-bound and evening fears will go away.

Myself, I wouldn't really want to have the keys to the entire drug store, and in my retail years, I never did. However, if the keys to the front door of the whole shebang had already been entrusted to me, I would feel a crisis in trust if they were taken away. One of the Nation's biggest pharmacy chains recently announced that its pharmacists must surrender the front-door keys they had previously possessed. The reporting pharmacist said that, if the company trusts her with a half-million-dollar inventory (and, I add, a considerable stash of controlled substances), why does it not trust her with the custody of the rest of the store in an emergency? Again, the self-respect of the pharmacist is trashed. In a sense, it is also an insult when yet another pharmacy chain tells its pharmacy staff that it must serve as a checkout station for any amount of merchandise a customer may want to present to it. I didn't know that pharmacies have grocery scales like the main checkouts---or, do they, now? I guess I've really been away from the bench for an age and a day, haven't I!

Fellow pharmacy professionals, don't give up your keys. Don't give up your vital professional focus on prescriptions in order to ring up somebody's bananas along with their Pop Tarts and their bling. Don't give up your dignity, self-respect, and integrity! You are a healthcare center, and the company needs you as much as it needs its own name.

You've heard the stories: Steve Jobs and Steve Wozniak toy around in their garage, and the result is Apple, Inc. Bill Wilson and Dr. Bob Smith meet in a summer house in Ohio, and plant the seeds of Alcoholics Anonymous. A fellow jots down some ideas on a table napkin, and the ideas take off--literally. They become Southwest Airlines.

Great entities had small beginnings. Well, here's one that I am part of. A chance discussion between two pharmacists in a Galveston, Texas, townhouse led to one of them grabbing a legal pad and writing down the bones of what is still small, but has the potential for becoming the premier movement in community pharmacy for the 21st century: The Pharmacy Alliance (TPA).

I've had a few honors in my life. I have had the honor of being accepted into the Masonic fraternity, where I've made some the finest friends, and learned much about self-improvement. I have had the privilege of working with pharmacists, technicians, store managers, sales associates, doctors, and nurses who are paragons of excellence for this country and for the human race. But what is to take place in a couple of months is, to me, beyond historic.  It feels more like something celestial, a gift from the heavens. It is something that has been long desired but never realized: the uniting of pharmacy professionals to restore dignity to our profession, relieve the real and constant pain of our daily work, and set us on a path to genuine accomplishment. I don't know about my pharmacy fellows, but this Ole' Apothecary has always wanted a group like this, and now, it's really happening. Now, I think it possible that all those attacks from customers, all the oppressive regulations, all the supervisory whippings, all the days starved and full-bladdered, and all the moments of abandoned self-respect, can be redeemed, and exchanged for real progress. The Pharmacy Alliance will be the vehicle that will blaze the trail to that progress.

TPA members will hold their first international meeting at the Holiday Inn On The Beach, San Luis Resort Galveston Complex, Galveston, Texas, US, on Saturday and Sunday, April 19 and 20, 2008. There, in the Grand Ballroom, they will sit down to "fill the bowl" with simple declarative sentences to foster dignity, self-respect, and integrity in the practice of pharmacy. Just by chance, we chose as our initial meeting date April 19, which is the anniversary of America's "shot heard round the world" at Concord, Massachusetts, in 1775.

Join the TPA discussion at http://health.groups.yahoo.com/group/ThePharmacyAlliance/

It was 2001, and I was both hungry and lazy. On my computer, I came to the Papa John's Web site, and noticed that they took pizza delivery orders online. Wow!  I had not yet gone to this level of commerce before (I have since done a world of online business for a large variety of things, but back then, this was new). I filled out the online form, and was even able to leave directions to my residence. Click.  About 20 minutes later, my "meat lover's" arrived.  No voice required. All that was missing was being able to charge it to my credit card so the deliverer could just hand me the pie and take my signature. That wasn't available yet, but the online delivery order was.

Just after my first bite, though, it hit me. What the ----?  The pizza clerk who received and processed my order has more rights than I do as a pharmacist---(s)he gets a legible order!!  For a meat lover's pizza, he gets a clear order.  For Myleran, I have to accept a hasty scribble? What if the doctor meant Mylicon (a stomach antiflatulent) , not Myleran (a cytotoxic, chemotherapy drug)?  Doesn't matter. Who do I think I am, anyway---a pizza clerk?

Yes, I know there are pitfalls to electronic orders, but the principle abides:  I need dough, but my patients are entitled to the same communication system enjoyed by someone who kneads dough.

Part of our angst as pharmacy professionals is that our patients, doctors, and nurses do not see pharmacy as care. They only see pharmacy as pills. Pills for the taking.  Whoever contacts us, they only want the pills. They go for the pills. I believe they'd like this country to be like Mexico, where you go into a pharmacy and buy all the pills you want, and "pay no attention to that man behind the curtain!"  Giving the pill is also perceived as us being nice guys and doing them a favor, cutting them some slack, being "so awesome"  (I never use the word "awesome" unless I notice that real awe is involved; the first moon landing was awesome).  This idea of getting the pill prompted, some years ago, a bill in the Texas legislature that would allow oncologists direct access to cytotoxic agents without going through a pharmacist.  The bill never got anywhere. I'm glad someone in Austin also thought that pharmacy was not just about getting pills.

Tonight, I had an encounter with a nurse that had a pill issue.  She wanted to do a favor (see above paragraph) for a patient. Yes, you see, pharmacy is, to some people, all about doing favors, and nothing about pharmacotherapy and the context of healthcare. An outpatient visited her inpatient unit to get his outpatient I.V. tobramycin dose (sic) and also to say he could not afford his Zyvox pills and hadn't picked up his four-day-old prescription on file at his pharmacy, and wanted me to just send over one pill. I declined, saying I had no order for the drug and had no way of billing it. Besides, what is the connection between that infection and this one after four, or however many days? Is the doctor who ordered the tobramycin aware of the Zyvox prescription at all, and was it meant to be a part of his current regimen? She gave up pursuing the pill, because she wasn't interested in reseaching all these questions. She didn't care about all of these things that "the pill" really meant. I gasped at her attitude toward my profession, that she could make such empty-headed gesture.  It's all about them pills, ain't it? It's all about...

Yesterday, 13 February 2008, was a watershed day in my career.  At a staff meeting in my hospital department, my director announced that the hospital will no longer be hiring new pharmacists who do not have a Doctor of Pharmacy degree. I don't have one. I find myself grandfathered into this pharmacy staff, a fact about which I have mixed feelings. On the one hand, I love my present job--it is the best job I've had in my career, and my present job is secure despite the change in clinical programs. On the other hand, I feel as if a giant vault door has slammed shut behind me. I have already decided I am not interested in pursuing a Pharm.D. degree, and now I face the prospect of being ineligible for something that an increasing number of my colleagues over the next 10 to 15 years will possess---clinical privileges. They will enjoy the authority of independent authorship on such things as changing anticoagulant therapy, i.e., writing new, original warfarin orders.  This will not be a predominant part of the workday, but it signifies that, right before my eyes, the B.S. pharmacist has just entered official second-class citizenship, and is bound for extinction, like the apprenticed pharmacist who was my very first boss in 1976 (he got his pharmacist license by working with a pharmacist and then passing his boards in 1948, no degree involved).

But, this revelation goes far beyond my status. It makes me want to point to all of you Doctors of Pharmacy who are working at the major drug chains, and to scream, "What are you doing? With your training, your scarcity in numbers, and now, your clinical privileges, why must you answer the phone in 20 seconds, as one major chain demands?  You are not slaves, you are top professionals!

In 1978, during the last time there was a glut of pharmacists, I had to work for an old-fashioned fart of a man for a few weeks.  He told me about his first job as an apprentice pharmacist, probably around 1930.  He was told that, if he had nothing else to do, he was to push a rag around on a counter, and received the warning, "If you stop moving that rag, you're fired!"  This galley-slave posture has followed the pharmacist for three-quarters of a century. I've lived with it a great deal during my working life, and always wondered how it could be allowed to jibe with my so-called professional status. As long as all that was expected, legally and professionally, of a pharmacist was proper drug distribution, I suppose the old hortator could crack the whip and keep us rowing the boat.  But, not now, and certainly not after I walked out of that staff meeting yesterday. No way! None of you folks should tolerate this excrement a day longer! You are in-the-flesh independent practitioners of pharmacy.  You are now empowered to alter patient care with your own plans. Are you planning on doing this like a dog---like that beagle named Uno that just won Westminster this week? Uno is a pretty dog. But, he's a dog, and you're not!

Your Ole' Apothecary is pissed. He's out for bear.

Pharmacists e-mailed me. A friend in the Washington, DC area wrote me to say she saw the article.  Sometimes, we the profession placed front and center by the fourth estate, but this one was a prize.

Unless you've been living under an Abbott counting tray all day, USA TODAY's cover story this morning was all about pharmacy working conditions vs. dispensing errors ("Corporate Policies Can Play Role In Pharmacy Errors," http://www.usatoday.com/money/industries/health/2008-02-11-prescription-errors_N.htm) . There it was, complete with an interactive graphic of a prescription department and how errors occur, with a relevant story at each click. On Lincoln's Birthday 2008, we dreamed about freeing ourselves from our own slavery,and the Nation talked about us pharmacy professionals. The winter of our discontent was top-drawer, hard copy at last!

It may have been a headline for "The Nation's Newspaper," but it's every day print for us--the perfect storm of prescription activity, the pressures from corporate owners, the public, the regulators, and the pharmacy benefit managers. For those on the outside, I can assure you that the tales of travail are true. The forces that impinge upon the Nation's apothecaries are not unlike the capers in Joseph Heller's Catch-22,  a story of absurd pursuits in which the military leaders keep raising the number of missions their men must fly in order to be rotated home. This is the second time in about a year that a major news outlet has had something important to say about pharmacy; last year, ABC's 20/20 ran their piece about pharmacy workload. The pain of our profession as practiced in the community is on prominent display across the land.

We must strike while the iron is hot. I sent a heads-up about The Pharmacy Alliance to USA TODAY this evening, and let them know that their reporters are very welcome to join us at our Galveston, Texas, meeting in April. I also invite them to join our discussion by subscribing at http://health.groups.yahoo.com/group/ThePharmacyAlliance/. Jim Plagakis told me tonight that "celestial powers" brought on this news item. Star light, star bright, light the way to our success!

In all the posts I've read, I've never heard this feeling mentioned, but I'm certain that everyone who has worked in pharmacy has experienced it---the countdown to quitting time. 

Every phone call has a string attached. Every medication order has an asterisk.  Every customer has a hair up his or her ass.   It's a perfect string of torture, and the clock is full of molasses--those hands won't reach the top of the hour, or your relief is perilously close to being a bit late to relieve you.

The saddest part about this is that the recurrence of this wish to count down the last minutes becomes your measure of job dissatisfaction.  If you want out on the street this bad, then how bad is your job experience? How much are you supposed to take? 

Yes, there is something wrong with the job if every minute in it hurts.

Many of you know that I left retail for hospital pharmacy 15 years ago. One source of reaffirmation for my decision to do so is the ultimate record of customer complaints, a Web site called Planet Feedback (http://www.planetfeedback.com).  Type in the company name, and you'll get pharmacy-customer feedback (some of them compliments!) from around the Nation going back several years.  They make me glad to be out of community pharmacy, but they also reinforce my commitment to reform through The Pharmacy Alliance.  They do this because many of the customer problems are generated by the system, not by the pharmacy staff. It is the job, not the profession, that needs changing.