Sunday, March 30, 2008

THE PROMOTION OF CONTROLLED SUBSTANCES ON TELEVISION

The Controlled Substances Act. Just the phrase raises some of the hairs on my body. Then there is the phrase, The Corresponding Responsibility Clause of the Controlled Substances Act. Brrrr. That means that, as a pharmacist, I must be careful to fill only those controlled-drug prescriptions that I'm confident are for legitimate medical purposes, and I cannot turn a blind eye if I suspect a pattern of malprescribing, which I cannot turn into maldispensing.  Since 1971, U.S. pharmacists must meticulously account for a number of different categories of drugs, not just opiates, as habit-forming substances, and must steer their way through a five-schedule hierarchy of agents every day of their working lives.  I remember a time when the prescription prices for these drug products were forbidden to be advertised. Now, what has changed?

Now, I see these genteel ads for certain sedative-hypnotics, and also for one neuropathic-pain reliever, on television!  Men and women are shown fast asleep in their fancy beds, courtesy of these high-priced, high-hyped drugs.  Yes, I know that I, and a prescription, stand in the way of public drug abuse, but, off in a far corner of my 56-year-old noggin, I hear an old song lyric:  

If I were the president of this land, I'd declare total war on the pusher man. God damn the pusher!

I cannot get this out of my head: if the collar is white, then the intent of the sale of these drugs has the imprimatur of the powers that be. This is not crack or weed.  But these are white-collar abuse drugs, offering a white lie for our country. Pharmaceutical-carewise, it's like the soft porn on cable.  If you look in the product literature or in the magazine advertising, you will see a teeny-tiny letter C embracing a Roman numeral IV, which means that, for this advertised drug, the product is in the same abuse schedule as diazepam or alprazolam, the former once being called a "mother's little helper."  How can pharmacists discuss the careful use of these potentially habit-forming drugs with the public when they are hawkable on TV?  I don't care how "mild" these agents can be shown to be.  God damn these ads. . .take them off the air!
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Thursday, March 27, 2008

PHARMACY ON PINS AND NEEDLES

No, I don't mean anxiety. I mean decorum. Let me get my prejudices out first. I admit that they are prejudices.

I was born in the early 1950s.  I have a photo of my Dad wearing a hat, a plain suit, white shirt, and dark tie. A home movie of my family of four from 1957 is classically TV Land-campy: my dad and I wearing the same checkered shirt and pants, my mother and sister wearing the same flowing pink dress, and we're at a picnic! The color and flavor of life in my childhood were terribly bland and orderly and clean. My TV role models were Lucas McCain in The Rifleman and the Cartwright family in Bonanza. In all of my public school years, I never saw a male teacher without a jacket and tie, or a female teacher without a business-style dress or skirt and blouse.  I was born into it, raised with it, and worked in it for years. This decorum applied to retail businesses and hospitals as well, perhaps into my early 20s (nurses wore white uniforms with caps bearing a nursing school pin).  To me, decorum was an accurate reflection the attitude of the workers: orderly dress equaled effective performance. It told me I would expect pride in the work being done by the wearers.   I will not apologize for my worldview of proper attire, because it is mine.

At a major chain convenience store this morning, I stopped to get a fill-up for my car.  The pump was out of receipt paper, so I went inside to ask for my receipt. The young lady behind the counter had a pin in her nose. Now,  piercings are nothing new to me, but this one was protruding from her skin just like a pin stuck in a pin cushion; that is, (if you've seen one of these movies), like the pins sticking out of the head of "Pinhead" Doug Bradley in the Hellraiser series!  To you, this may speak of style, but to this Ole' Apothecary, it suggested savagery.  Did she want to stick pins in other people? She may be an excellent worker, the pride and joy of the Nation's purveyors of easy butts and beer, but her effect on me was one of revulsion.

A few years ago, I went with my Dad for his eye exam at a top New England hospital. His ophthalmologist is the darling of the department,  the wonder boy sailing down the canal of Schlemm with banners flying.  In this office, the technician who performed my Dad's eye chart exam had one of these pieces of hardware on her upper lip.   Granted, she had been placed in a position of trust by her medical-Hollywood boss, and I knew she wasn't about to plunge the thing into my Dad's eye. But, it made me quietly question to myself her commitment to her craft.  Cain bore the mark of Cain, but, to me, this lady bore the mark of chaos.

Pharmacy professionals surely operate perfectly well with all kinds of dress.  Indeed and in deed, they do their work competently no matter what they are wearing or what is attached to their faces, and they are welcome to scoff angrily at my views as being the product of a century that is rapidly receding into history.  But, I still believe that anyone in pharmacy who festoons their face with pseudo-weaponry and expects to be taken seriously by their patients may be disappointed.  It hasn't happened yet, but if I was in the middle of handing my prescription form to a pharmacy worker whose lip is pointing back at me with an arrowhead's cousin on it, I would pull back my arm and run out the door. That is my old-fashioned, semi-Victorian, grey-flannel-suit,  fuddy-duddy, party-pooper story, and I'm sticking to it!


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Monday, March 24, 2008

PHARMACY IN MY SMALL TOWNS--GIVE ME "RURAL" EVERY TIME

No I cannot forget where it is that I come from;
I cannot forget the people who love me.
Yeah, I can be myself here in this small town,
And people let me be just what I want to be.
--John Mellencamp, Small Town
In the late 1970s, when I began to work full time as a retail pharmacist, independent pharmacy and the simple life were on the run. There were quite a few independents left, but cities and suburbs were soon teeming with large stores owned by out-of-town interests which succeeded in buying up the individual pharmacist-owners and decimating the practice of community-based pharmacy as we had known it. Almost unconsciously, I chased the kind of pharmacy I knew as a little boy by leaving the big city and, ultimately, staying out of it. I spent my first five years working in northern New England towns near the Canadian border. City friends mocked me, saying, "What the hell are you doing way up there in the middle of nowhere?" But that ridicule never reached me. I was enjoying too much satisfaction in caring for people.

In the choice of urban versus a rural work setting, I'll take rural every time. It was hard work that bore a resemblance to present-day chains, but once I walked out the front door at the end of the day, I felt as if I was on vacation year-round. It was quiet, there was no traffic, and there were no strangers. Also, had a personal stake in the community, because the community was small enough to know me. In those days, there were no telephone messaging systems; almost every phone call I received in my store came from a voice I could put a name to. Almost every face at my counter had a first and last name, and a parent or a child I knew. There was little industry in the region. Most people had something to do with growing crops, and, granted, many families were on state assistance. But, most of the time, the attitude toward me was one of respect. The state board inspector even remarked to me once, "People are glad you're here."

The weather climate wasn't for sissies. Deep snow and arctic cold dominated the long winter. Shoveling snow was an art form. Most people had radiator-hose heaters installed on their engines, and would plug their cars into a wall outlet to keep the fluids from freezing. On Christmas morning, 1980, I woke up to minus forty degrees, and a car that had jelly for power steering fluid. Yet, thanks to the heater plug, I got the engine to turn over.

To call the towns "close-knit" was an understatement. One time, I had to reach someone because I had forgotten to give her some important information about her prescription. I called directory assistance and gave the name and town. The operator didn't find the exact name, but said that there were 12 listings in that town with that surname. I played a country hunch. "Pick one." I asked. She gave me one of those 12 numbers at random. I dialed it (yes, rotary dial phone!) and asked the person at the other end if he knew the lady. "Why, sure!" he said cheerfully, and in a second, I had the exact phone number!

I remember the sight and sound of one old fellow who ran a small grocery store at the same fork in the road for 50 years. No, this doesn't sound like pharmaceutical care, but it went the way it went. " I want my two Bronkosol inhalers, one for my pocket and one for my boat." he'd ask. What did he do while he waited for his refills? "I'll go outside and have a little smoke."

In a local grocery market, one could write a check without showing any identification, probably since no one with an out-of-town check would ever travel far enough to write one that far north, so, physically, there could be no strangers, and, at the time anyway, most people wrote checks were solvent. One day, however, I was asked for my I.D. in that store. No problem, this city boy didn't flinch. I pulled out my driver's license cheerfully and let the cashier record her information, just as I had allowed all my life previous to moving into town. As I walked away, I heard a voice berating the cashier, "Do you know who that was?" I turned around and waved to Mrs. W., a frequent flyer at my pharmacy. It was a warm feeling indeed, one you cannot buy. Another few years, and I could have run for public office. My present job is in a medium-sized city, but it is a desert community, and has much of the humble attributes of the isolated towns of my past.

  Even thoughThe Pharmacy Alliance is working to generate future respect for our profession, I believe that there is still respect to be found right now, where the population is low and its behavior is mild. My rural experience had been in the days of a pharmacist glut; who knows how valuable pharmacists are up there today? If you have had enough of the madding crowd, head for the forest, or the mountains, or the desert, to practice pharmacy. I can tell you, firsthand, that you shall be welcomed and prized, and, off duty, your whole life will be a holiday.



       
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Saturday, March 22, 2008

       

     

      
THE FIRST COMPANY TO TREAT PHARMACISTS WITH RESPECT WILL HAVE S.R.O. AT THEIR HUMAN RESOURCES DEPARTMENT

             
CHIEF SLAVE: To be a slave in this household is an honor.



DEMETRIUS: To be a slave anywhere is to be a dog.




--The Robe (1953)





Pharmacy employers everywhere: I am now going to tell you exactly how you can corner the market on pharmacists, and do so tonight.



A recent post to The Pharmacy Alliance's mailing list tells the story of a pharmacist staff meeting held at a major drug chain after a strike.  Keynoting the meeting, a top pharmacy manager was said to have outlined some psychological razzmatazz, and then told the pharmacists present that, in so many words,  none of their idealism would be satisfied by his company's pharmacist positions, that all they can expect from their job with that company was a paycheck.   The report said that, even with this fact being made clearly known--that they were told, "life's a bitch and then you die"--nobody quit.  Nobody left the room!



Why we take this bovine scatology is unclear. With the availability of pharmacists being as low as it is, I don't know why that fellow didn't see a group of disgusted healthcare professionals barreling out the door like Moe, Larry, and Curly. But, we take it. We compound the felony. With our deafening silence, we allow the multi-outlet moguls to serve us defecation stew and laugh as we clean our plates and beg for more.  Yet, as the blogs show, we are in pain. We loathe what we are allowing to happen to ourselves.  Is this a case of identification with our captors?



I'm not sure about which major drug chain has attracted the lion's share of pharmacists, but I know how one of those companies can get it, and get it overnight. All they have to do is show us respect.



We know we are well-paid. We know that there is a standard smörgåsbord of employee benefits. We take (at our peril) the bait of lucrative sign-on bonuses. But, if we are honest, we know that these are not the things that would make us run to fill out an app or follow a recruiter for Big Box Pharmacy.  What we dream of, what we crave, is to be treated personally well as healthcare professionals and as employees.



To the Nation's drug chains, I, with my 13 years' experience with you,  tell you this: the thing your prospective pharmacists crave the most, the thing that will make them storm your offices looking for a job, will cost you much, much less than your so-called benefits!  So, now, tell me how smart you are.



We know that the public is hard to deal with. But, when we have a legitimate disagreement with our patients, do not take their side automatically for the sake of repeat sales. Respect our side, which will most likely involve a clinical decision!



When a prescription storm descends upon our departments, don't snarl those degrading words, 'That's why you make the big bucks."  We make the big bucks because we are empowered to keep people from being killed, and thus saving you from multi-million dollar lawsuits! How dare you let us hang out to dry! Do not flinch at sending us more technician time and more cashier assistance!



Try going all day without eating. Who else has to do that? It makes you weak and angry, and being weak and angry are very bad for a pharmacist, who must concentrate on accurately handing out deadly chemicals.  Like every other employee on earth, pharmacy personnel must have nutrition and rest. Give them official time to get it!



Chain owners, I dare you to try this experiment.  Offer the above points in a print or Web ad or in a recruitment mailing for pharmacists.  Your phones will ring into the ceiling, your human resources officers will be buried in paper, faxes, and uploads, and your pharmacy managers will be begged to take resumes at store level, and it will hardly cost you any money.  Go ahead--make your day!





       
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Friday, March 21, 2008

       

     

      
PHARMACIST AS WHIPPING BOY, OR EVEN AS TOILET PAPER

             
The Pharmacy Chick (http://pharmacychick.blogpharm.com/) moved me to discuss this subject tonight. She wrote about a customer who expected much service, and she gave much, but he demanded so much that she had to draw the line. Read the crucial line that reveals his attitude toward her. I interpret it as, not one of respect, but of disdainful abuse. It reminds me of many occasions in which I, an educated drug expert, stepped to my pharmacy window to help a patient, and received, for my efforts, a flood tide of emotional excrement. "You thief!" "You son of a bitch!" "You're getting a kickback from the doctors." Or the gestures, such as throwing empty labeled prescription vials at me for refills, or the incessant tapping of the fingers on the counter while I was filling, as if the person did not want me to do my job for him in peace and dignity.



Is it the "store" motif that inspires them to pull this stuff? That is, do they (I'll add physicians and nurses to the list) believe I am a clerk, and that gives them license to attack? Clerk, pharmacist, technician, no self-respecting employee deserves such odious assaults. The greatest pain of my community pharmacy years came when I met with ferocious degradation from people from whom I expected civility. Maybe doctors, too, get this treatment from their patients, but somehow I don't think they get it at the same volume and with the same bitter language.



One time, I gave a patient the standard warning about avoiding alcohol while taking Flagyl. It might have been that, in doing so, I was ruining a weekend of revelry he was planning. Nevertheless, in exchange for me doing my duty to protect him from harm, I was met with, "It's none of your business. Just shut up and fill my prescriptions!" He had also chastised me during the intake process when I asked his address. "What do you need that for?" he screamed. Funny, but if he feared becoming conspicuous, he succeeded. I remember his name to this very day, and the incident occurred almost 30 years ago. Another man, in response to my usual questions, started to brandish his "qualifications" for being an exception (he was of the same fraternal organization that I was, he was a major store owner in town). Was I belittling him so much merely by asking his address and his drug allergy history? I left those two occasions feeling wounded.



Some physicians, I am convinced, spend their professional lives making up for slights made on them by their peers, by taking it out on pharmacists. Consciously or not, I believe that they see in us a healthcare professional whom they believe to be on a lower rung on the ladder, and take the opportunity to bully. One local doctor, who had part interest in an independent competitor to my chain, would chastise our staff for phoning to clarify his scrawl. Every time, "What do you mean, you can't read that?!" (No, I just wanted to call and let you crap on me.) A psychiatrist once wanted to read his wife's gynecologist's written Rx for Premarin to me over the phone and have me fill it. When I wouldn't do that, he wanted to call it in under his own authority, but I insisted that it was the gynecologist's prescription and under that doctor's scope of practice, not his (go ahead, argue with this, but there was someone else's prescribing involved). I asked him to bring in the prescription, and he agreed in principle on the phone, but failed to actually do so. "Oh, I forgot it," he said almost gleefully. He was surprised when I refused to fill the prescription, but walked out silently, and thankfully, I never saw him again (this was a psychiatrist, someone presumed to be compassionate and understanding of human nature). Up to a point, I can deal with the ignorance of some members of the public, but these other people were supposed to be healthcare colleagues, and yet they ignored my right to the same respect and professional cooperation that I always give to them.



I'm not an isolated recipient of these attitudes. Read any of the sites on my blogroll.



In the film Natural Born Killers, the character played by Woody Harrelson has been bitten by a snake. He goes into a drug store and asks the pharmacist for snake antivenin (suspend your disbelief at the technical and legal details for a moment), saying, "Hey, chief, a snake took a chunk out of me a way back, so would you mind getting off your fat ass and get me some snake juice?" The pharmacist is portrayed as an obese, dazed, frightened, helpless individual who is about to be run over irresistibly by this steamroller of violence (Harrelson ultimately shoots the poor fellow dead, and pillages the pharmacy area). All the motion picture industry has done here is to join the crowd of the public, the regulators, the office nurses, the chain proprietors,and the prescribers, to berate and abuse the pharmacist, who is just doing his or her duty, trying to practice prudent pharmaceutical care.



Tonight is Easter eve, and I predict that there will be a pharmacists' rising against this treatment. The rising has been in the works for decades. It is my hope that it will begin on the 19th of April of this year, when 15 pharmacy professionals sit down in a hotel ballroom in Galveston, Texas, as The Pharmacy Alliance, to plan a rebirth of their calling( see http://health.groups.yahoo.com/group/ThePharmacyAlliance/).

       
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Thursday, March 20, 2008

       

     

      
A PHARMACIST'S REFUSAL TO DISPENSE

             
Nothing I have ever done in pharmacy has been as provocative as my refusal to dispense.  I do not decide on such a course of action lightly, but if I must refuse to dispense a medication, it is done according to my professional judgement, and with the patient's well-being in mind.  



In my 1970s jurisprudence course, I was instructed that I had an absolute right to refuse. But, in recent years, politics has diluted that right. Of course, I am referring to the practice of some pharmacists in refusing to fill some prescriptions (routine or emergency oral contraceptive agents) for moral or religious reasons.  As the controversy intensified, I feared that the political reasons for refusal were going to get confused with the clinical ones, and every time that I or a colleague would balk at giving out a drug, we would be called on the carpet as the new 21st-century lepers of healthcare.  I don't know if that problem has arisen, but I condemn such a thing, and I would never hesitate to refuse to dispense if I felt that the patient would be placed in harm's way.  This new dictum of "shut up and fill it" does not, and should not, pass muster as professional conduct.  That kind of politicization of healthcare decisions is a formula for tragedy. Don't let it crawl onto your bench.

       
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Wednesday, March 12, 2008

       

     

      
CHAIN OF FOOLS--OR, HOW BIG PHARMACY GETS YOU WHERE YOU LIVE

             
No, I’m not talking about pharmacy proper, not about us pharmacists and technicians. It’s about the consumer; or, how a consumer becomes a consumer. I once had that title waved at me like a knife, as a defense in a prescription dispute, thus: “But, I’m a consumer!”




I pondered consumerism today as I stood in line at a major drug chain checkout counter with my lonely little newspaper, an unambiguous 50-cent purchase: scan, ring, two quarters, wham, bam, thank you, Sir. But, ahead of me stood a woman in negotiation mode, brandishing the dreaded sale flyer. I wish I had an extra hour of sleep for each instance I had to wait in line for the sale-flyer ombudsman to issue his or her ruling or complete a transaction. In any case, the woman was going out of town, and wanted a sale item that was apparently out of stock. The cashier took out her rain-check pad and took the lady’s name, etc., so she could have the sale item reserved for her upon her return to town. I had seen this scene played out many times during my own retail pharmacy days, and didn’t think much of it right away.



But, as I continued to watch and consider, it dawned on me. How much time and energy was this pursuit of one commercial product taking out of the woman? I don’t know what the product was, but she stopped to inquire about its availability, and then negotiated to reserve her purchase, all because of the company’s weekly sale booklet that so many of us are trained to peruse.



I came to believe that the experience could not be all “purchase” for her. It has to be part “game.” There must be some kind of a challenge path set out for her to follow to go through so much trouble to buy some wet-naps or dishware. Maybe yes, it was the specific product she wanted, but without the small drama of it being “on sale,” she wouldn’t have pursued it. What a deal for the company! The rain check has caused her to actually make an appointment to return to the store!What a way to generate repeat business on other things: get your customers to be tenants! Her time and patronage have now been claimed by Dewey Cheatham Pharmacy, Inc. For the quest for one sale-priced widget, she invited this faceless company into her life.


I suppose you could tell that I’m not a couponer. I just don't appreciate, personally, the concept of sale items. I don’t want to be enslaved to chase people’s products. I'd much rather buy them when I say so, not when they say so. No way am I going to place a reservation on something just because U. Bendover Drug puts it up in lights and wants to lure me back to buy toothpaste or dark chocolate as well. Seems, then, that I wasn’t cut out for retail, so why I spent 13 years in it is hard for me to explain. Oh, how these folks must be well trained to torment you at the pharmacy counter!

       
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Monday, March 10, 2008

       

     

      
PRESERVING YOUR GOOD NAME

             
I shall not mention any names here. Well, what I mean is that I won't single out any names parents have given their children in good faith. No matter what my opinion may be about a certain name, that name will be perpetually justified by the namer, who would protest, "Well, it's the name we chose, and fooey on you!"

Pharmacy professionals record patient names. This chore is part of our job. So, we get to see all names. Other pharmacy bloggers have written on the subject, and recently they began to post the "name of the month" as a device for ridicule.  It is unfair for me to single out names for such treatment as they have done, because, as it is with beauty and the beholder, good nomenclature is in the eye of the author.
 
My sense of personal names comes out of the prejudice of growing up in the 1950s and early 1960s in the United States , and by the philosophy held by my parents when they gave me my name. When I asked them why they chose my name, they said, simply, that they wanted me to have "an American name that [I] could live with." I am grateful to my parents for giving me a simple, prosaic, "American" (read Anglo-Saxon, even though I am not one) name. When asked for it, I do not need to spell or repeat it to anyone. So, my parents named me as they did, because they felt, as I do now, that a name is a bearer instrument. The named person either has to live with it or change it. It is what one is called and what one calls oneself, so it is both a self-symbol and a self-description.


However, parents of the late 20th and early 21st centuries believe that this essential word of self should be all bling and no clothing. They are in an unending contest to see who can choose that sequence of characters that best proclaims the uniqueness of their little one. I sense that they are naming their baby for their own sake, and not for the child's. We even go through eras of vogue names, where every boy is named one thing and every girl one thing, and now, appropriately, we see a young TV news reporter whose name is so typical of her vogue decade that we can guess her age with confidence. Some names today seem to be entirely synthetic; they have more of a basis in a random computer character generator than they do in culture. The only common name to be found now is the most uncommon name.


 All of which makes my plain, old Western name the most unusual name in sight! In the eight years I have worked at my current hospital, I have yet to see even one newborn baby boy be named with my name. So, back in 1952, my parents were both stylish and nurturing.


Ah, philosophy in pharmacy!

       
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Saturday, March 08, 2008

       

     

      
ENSURING PHARMACY PRACTICE MEANS LETTING OTHERS DO THEIR INSURANCE HOMEWORK

             
Since when is doing the chores of an insurance ombudsman part of the practice of pharmacy? Let's consider getting rid of them! It is really the thing that is crippling pharmaceutical care. I have often heard that "counseling is the first thing to go" when it comes to saving time, but it is that specific patient contact inherent in counseling that makes us valuable. The little boy in the USA Today story who got the methyltestosterone by mistake, instead of the prescribed propranolol, might have been saved all that agony if the pharmacist had had a chance to review the drug with the parent, which I assume (s)he was unable to do.



Getting others to do the insurance work is the "I" part of the DSI (Dignity, Self-Respect, and Integrity)principles of The Pharmacy Alliance. Our professional integrity is on the line if we, as pharmacists,continue to accept having our time taken up by this scut work instead of defending our true responsibilities according to the APhA Oath of a Pharmacist. One point of that oath reads as follows:


I will apply my knowledge, experience and skills to the best of my ability to assure optimal drug therapy outcomes for the patients I serve.












       
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Friday, March 07, 2008

       

     

      
PHYSICIANS' "AGENTS" SHOULD HAVE TO BE LICENSED TO TRANSMIT PRESCRIPTION INFORMATION

             
Drug screening is supposed to use what is known as a "chain of custody." Each person on the team carries responsibility for possession of a blood or urine sample, and thus holds a personal stake in the process. In terms of basic drug knowledge, shouldn't the same professional rigor apply to prescription data? Shouldn't the doctors' "agents"---the office staff people who verbally or electronically transmit prescription information to the pharmacy---be in the licensure (read "responsibility") chain? I propose that if they are calling in prescriptions in a state that has licensure requirements for pharmacy technicians, then they themselves should be pharmacy technicians before they dial up their first pharmacy with a script. If they are nurses, they should still have to qualify as pharmacy technicians in order to do this work.



Many times over the years, I have sensed that the people calling in prescriptions to me from doctor's offices were unqualified and untrammeled. They confused or garbled the drug names, could not interpret basic regimen abbreviations (e.g., q.i.d.=four times a day), or seemed to be working alone and deciding for themselves whether or not prescriptions should be refilled. The law that may establish the authority for the "physician's agent" seems to give that person at the telephone too much latitude and too little accountability. I believe this person should be a responsible monitor, not a careless mouthpiece. She or he should be accountable to the Board of Pharmacy or the Board of Medicine for the acts that are clearly part of healthcare. How they have been able to do their thing with relative impunity for so many decades is beyond me. It's time to close this dangerous loophole.



And, in the countries in which the predominant language is English, these "agents" must also be able to speak clear, idiomatic English. This is a matter of life and death, not political incorrectness.











       
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