The Ole' Apothecary

"Oh, come on, Ole' Apothecary, bite me! Why don't I tell you about some of the doofuses I worked with?"

OK, OK, a few exceptions. Fooey. Doesn't matter.  As a class of worker, pharmacists are not lazy, and that is the understatement of the century.  It's hard to be lazy when you're institutionalized, anal, a stickler for details. We are such sticklers, and we should be proud of that, because our insistence upon accuracy saves lives.  In terms of endurance, we accept our healthcare mission as persistently as a police officer attends to crime or as a firefighter fights fire.  Too many of us cover our departments, and other departments, too often, to the detriment of our personal and family lives.  I sense that this level of commitment is global; in Germany a few years ago, a pharmacist told me how she sleeps in the store when it is her turn in town to cover (this system supplants our system of our open-24-hours pharmacies, which they do not have in Deutschland).

So, who would dare deny us some simple requests? Add it up: we have a manic work ethic, we are in short supply, and yet we take it up the rectum almost each and every time our management hands us another and another and another meaningless task to perform in the name of their image and at the expense of our duties.  That is a lousy equation. It doesn't add up.  Why don't we claim the right to say no?

Some prescriptions on a patient's profile do not jibe, and you pick up the phone to call the prescriber to get dosages changed and even get one expensive drug discontinued. But, instead, you are forced to put it down to deal with an angry patient who wants you to call an insurance company to investigate a rejected refill. Say no! Insurance is the responsibility of the insured. Make your physician call.

It's 5:30 P.M. You haven't walked away from the computer monitor in six hours. Your stomach is empty and your eyeballs are floating in urine.  Yet, there is a line of E.R. dischargees and office patients clutching their paperwork in a line to your counter that is nine-deep.  Beg off! Eat something and micturate.  The madding crowd can wait a bit for you.

You are the pharmacist-in-charge, and you work in a state where there are no requirements for pharmacy technician training. You also work for a company where the store manager hires the technicians.  The manager sends you someone who reeks of alcohol, a bad attitude, and little experience.  Send him back like a steak! You have the right to protect the public safety by hiring only qualified individuals for your pharmacy staff. 

Despite outward appearances (i.e., being in view of a stack of bananas or a giant photo of Hanna Montana), each pharmacy is a healthcare precinct. The location is licensed by the state as such. The people in the department are tough and serious, and as long as they adhere to their traditionally intense diligence, they are entitled to respect.  Now, more than ever, they are justified in rejecting unreasonable, distracting demands imposed upon them by non-pharmacy management.

The front door of your retail pharmacy is open to the public street.  In the realm of pharmacy customer relations, there is just no escaping the vagaries of human nature.  I couldn't escape them, so,  in 1993, I escaped community pharmacy altogether.

Oh, you can rant, rave, and question. You can cajole, train,  complain, urge, bicker, dicker, hortate, and whine. But, these folks will be found at every apothecary's venue, be the apothecary young or "Ole'."  I found them at every one of mine, and your blog stories simply repeat my experience exactly, along with the 21st-century twists of Medicare Part D and pseudoephedrine.

Emotion and consumerism go hand in hand: branded drugs, unbranded snacks. Questions? How often have you thought of questions to ask in an untimely, rather than in a timely, manner? And the insurance card is really a MasterCard, so you present it at the checkout counter; these folks don't appreciate the need for the pharmacy staff to process the claim in advance. After all, the other purchases they make don't follow this model, and as much as you'd like them to learn this, they don't.  And, since the prescriber doesn't have to be the one to face the patient about specific coverage, he or she can pronounce everything to be covered, whether it really is or not, and you can even get, "Well, call the doctor back and tell him to prescribe something that is covered!"  Sitting duck, whipping boy, there we are, the bullets flying, the cat o' nine tails whizzing through the air and onto our butts.

The saddest part of pharmacy is the really big picture: the type-II diabetic who won't seek to weigh less than 150 kg, and the chronic lunger who won't seek an end to his or her chain of Camels.  All of us---government, physician, pharmacy, are supporting these bad choices.  We could see some creative rules in place in future years, like PBMs having us look at cholesterol and nicotine levels to decide coverage. Wanna bet we don't?  Human nature.

In my life, I have never been present at the founding of a brand-new organization, let alone being one of the founders.  Last weekend, at the San Luis Resort Complex in Galveston, Texas, I experienced something so new and so powerful in pharmacy that I remain amazed, but also chastened in that there is going to be so much work to do. Seventeen pharmacy professionals simply gathered together to create the framework for pharmacy's new network for working conditions. The discussion was at a very high level, very thoughtful and rational.  I left with the feeling that we quietly made history.

Our Web site is under construction, It really is happening. We're under way!  Minutes of the meeting will be ready soon.

The Apathetic Pharmacist has not posted to his/her blog since October.

1. Behold, how good and how pleasant it is for brethren to dwell together in unity! (Psalms 133:1)
2. Nations have included it in their names: United States, United Arab Emirates, United Kingdom, United Arab Republic.
3. "United we stand, divided we fall." (Kentucky state motto)
4. E Pluribus Unum ("Out of many, one," a U.S. motto)
5. "...in order to form a more perfect union ..." (U.S. Constitution preamble)
6. There is a parcel service that wants to consider itself united (I don't know if I would even want to ship something via the Divided Parcel Service, would you? I drove to De Moines, but my package went to Dubuque!)

So, a number of entities and statements in our world see unity as a good thing. Or, as some say, there is strength in numbers. Political parties talk about the need for party unity. What about the healthcare professions? What about pharmacy?

As a child of the 1950s, I remember riding in my father's car along the outer part of Commonwealth Avenue in
Boston. On each corner, or on each block, I would see a neon sign that read, simply, "Rx Drugs." No company name, not even a distinctive logo, other than the old, familiar symbol of the profession, "Rx." Now, I had an idea about chain stores, but, was "Rx Drugs" a chain? (If I only knew what heresy I was committing by this error!) It was a chain--a chain of stores representing a single practice, not a single company. In those days, there was little or no price competition. In fact, pharmacists wrote their prices down in code (many independents used the acronym "P-H-A-R-M-O-C-I-S-T" for the numerals "1-2-3-4-5-6-7-8-9-0" to codify costs). Pharmacists of that time, like their physician contemporaries, were almost exclusively independent practitioners. They occupied independently located shops. It was against the law for them to be combined with other retail operations. The entire store constituted the licensed pharmacy area (the "pharmacy area only" permit of modern pharmacy departments is a product of the late 1980s), so the front door of the store could not be opened to the public unless a licensed pharmacist was on the premises. If you visit Germany and Australia today, you will see this same arrangement. That structure of pharmacy goes back to medieval Europe. At least in its organization, community pharmacy was united in purpose.

I cannot vouch for how hospital pharmacists related to community pharmacists in those days. I do know that, now, there is a huge difference in perception. I'm told, sketchily, that retail pharmacists tend to look up their hospital brothers and sisters, and some hospital folks look down on their retail counterparts. Foolish! That dichotomy does go by the board, though, when one entity is out of a drug and needs to borrow it fromt the other entity, and that always happens. The classic example is Nimotop (nimodipine), a calcium channel blocker used exclusively for bleeding in the brain. Not many community pharmacies carry it, and on several occasions, desperate pharmacies or patients have come to my pharmacy for the drug. Then, there is Valcyte (valganciclovir), something my inpatient pharmacy doesn't stock, and had to obtain from a nearby community pharmacy. If there is any disunity of practice, it gets promptly trumped by a commonality of need.

But, what about unity of practice? Despite dispensing pressures, don't we all breathe the same air? Don't our licenses still authorize the same practice of pharmacy (so far, anyway)? At one time, in the absence of the principle of pharmaceutical care, there may have been a difference among us because of the need to deal with certain products and procedures. But we hear, at least, from some academic and regulatory authorities, that pharmacy practice is supposed to be pharmacy practice, wheresoever dispersed. Hospital pharmacists do the same medication therapy management that retail pharmacists are now presumed to do. There will be eventually, once again, only one academic degree for pharmacists, the Doctor of Pharmacy (Pharm.D.) degree, and it is more clinically oriented than ever before. In community practice, there is certainly pressure from all that prescription volume to keep the conveyor belt moving and damn the clinical interventions, but we cannot allow pharmacy to collide with that dangerous reality. We must stand together to safeguard the taking of sufficient time to solve drug-related problems. We are not just dispensing belladonna and phenobarbital elixir any more.

If the authorities are wanting to write into reality that a rising tide raises all boats, then I believe that all pharmacists, from whatever venue, should rise, in like manner, together, in their common problems. They should be in constant communication with each other, and stick up for each other, no matter where they work. I feel for the pharmacist who must tackle a drive-thru, pseudoephedrine, gift cards,Medicare D, and about 10 other issues I never had to confront in my retail years. Consequently, when my commmunity pharmacy friends hear about the huge changes in sterile product production as a result of USP Chapter 797, they should then understand what it takes for infusion pharmacy and inpatient pharmacy to get vancomycin I.V.s to their outpatients, and also that most inpatient pharmacies are not licensed to fill outpatient prescriptions routinely.

Under new management, that old symbol of professional unity, "Rx," should glow again at each of our practice sites. E pluribus, unum!

It is less than two weeks to go now---the groundbreaking meeting of professionals who comprise The Pharmacy Alliance (TPA). By sheer coincidence, that first meeting will come to order on the 233rd anniversary of the American colonies' "Shot Heard Round The World" in Concord, Massachusetts. Even though I have been out of community pharmacy practice for 15 years, I stand foursquare with my retail brothers and sisters in their quest for that triad of principles: dignity, self-respect, and integrity (DSI). Hospital practice, and my hospital department in particular, seem to provide DSI naturally. However, today a part-time co-worker told me a story that shows how pharmacy professionals from all venues can fall victim to abuse. She told me about her former employer.

Despite this particular pharmacy director's protests, the hospital's administration showed no love for clinical pharmacy programs. The director resigned, and was replaced deliberately by a pharmacist with little hospital experience who was expected to tow the line of traditional dispensing services. My colleague had been allowed to implement an anticoagulation clinic with a month's worth of patients. A few hours before the deed was done, the house supervisor called her over to inform her that the administration was vaporizing her clinic at close of business that day.

We just observed the 40th anniversary of the murder of the Rev. Dr. Martin Luther King, Jr. At the time of his assassination, King was fighting for the dignity of the Memphis garbagemen. Four decades after the fact, my pharmacist colleague was being treated like one of those sanitation workers, erased without a care about her humanity. Would the hospital have done this to a physician project? Does it still see pharmacy as a trade--as part of the zone of spatulas, suppository molds, and DeVilbiss nasal douches? Does it have the same misconception about pharmacy that Merriam-Webster has when it defines us by reprinting that Byzantine "the art of preparing medicines?" Is this why managers believe they can off our work as if we were slaves?

TPA is not asking questions like this. We will be writing a set of principles, a platform of purpose on which all pharmacy professionals will be able to stand with confidence. Pharmacy has never had such principles before. We have been alone in a vortex of forces, going down the drain. Not any more!

Our meeting in Galveston may just end up being a gathering of new friends, or it will be the start of the most powerful pharmacy fellowship since the medieval guilds. In any case, it will be a new beginning for pharmacy unity and hope in the face of the traditional polarization and despair.

Main Entry: nos·trum
Pronunciation: \ˈnäs-trəm\
Function: noun
Etymology: Latin, neuter of noster our, ours, from nos we — more at us
Date: 1602
1 : a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness
2 : a usually questionable remedy or scheme : panacea

As Steve Allen used to day, "All seriousness aside, now . . ."

A group of words jump out at me when I confront pharmacy's over-the-counter products of old: nostrums (see above); mountebanks; remedies; concoctions; elixirs; those fuzzy, magical ideas of "taking something for what ails you." People have been coming into drug stores for these things from the time of Romeo in Mantua. Some of these products are as modern as today, taking rationally designed ingredients and turning them into a mosh pit of relievers (H2-receptor antagonists mixed with neutralizing antacids, or acetaminophen combined with diphenhydramine to relieve a headache at bedtime). Although it wasn't called that publicly, the placebo (the word is a promise; I means, "I shall please") effect is a big part of sales of these items. Make it look, sound, and maybe, taste like relief, and it shall relieve what's buggin' ya. So, here's a fertile collection of medicinal doo-dads from my life and my memory, and I invite pharmacy workers from all places and times to add to this knowledge, since this hardly scratches the surface of the "somethings" we have taken over the decades.

It was before my time, but we all know that Coca Cola, a pharmacist's invention, was once "the real thing," containing real coca in small amounts, for a pause that really refreshed, or so I suppose.

Me, I can't get away from the romance of Thayer's Slippery Elm Throat Lozenges, subtitled "Nature's Gentle Demulcent." The inviting, mild flavor of elm bark, packaged in the serif-font-lettered yellow box, just reeked and eeked of "relief is on the way, guy. Don't you worry."

As a child, I remember the antacid-laxative Sal Hepatica (somebody set me straight--was it magnesium sulfate mixed with sodium bicarbonate?), billed as the one-shot remedy for heartburn and constipation (customers were asking me to special order this name as recently as 1980).

I don't know what it was for exactly (another laxative?), but I also remember a childhood TV ad for something called Caroid and Bile Salts Tablets. This may have been last seen advertised the same year that David Seville came out with his hit single, Witch Doctor. How appropriate.

I think it was a steam-vaporizer additive from the 1890s that made it into the 1980s, called Save The Baby (a disclaimer, probably written in on the label later, advised that the product does not actually save babies).

As I kid, I always wondered whether or not Carter's Little Liver Pills contained liver, and I must have seen the last of the TV ads under it's full-fledged name. I do know that this trademark suffered from sequential amputation. The name was changed to Carter's Little Pills, and, I think, Carter's Pills. All this may have gone on as the last of the phenolphthalein left a number of laxative products, and they all became plain old bisacodyl, each in a different colored package.  Speaking of bisacodyl, I am now going to do what I have always wanted to do, and that is to request that all people, nurses especially, pronounce the popular trademark name of this drug correctly. The name is Dulcolax. To the best of my knowledge, it is pronounced "DULL-koe-lacks." Please, please--it is not pronounced "DOO-koe-locks!"

In my own era, the 1960s, we had a real doozie of a common cold remedy, Contac capsules, with their "tiny time pills," which did more to introduce the timed-release dosage form idea to the public than anything else I could explain. Sure, it dried up your stuffy nose: the original formula included belladonna alkaloids! It also removed all of the moisture from your mouth. I think it is still out there under that name, but no longer with its secret weapon of anticholinergia.

There is one remedy that seems to defy pharmacology and has been in my medicine cabinet since I was 12. It is Excedrin. I first took it when it came on the market in 1964, and it was the only thing that would relieve my headache in minutes (it still is). It was originally a mixture of aspirin, acetaminophen, salicylamide, and caffeine (salicylamide was removed from the formula around the year 1980). The powers that be criticize the safety of the mixture, but it is so efficacious for me that I have never felt it to be a mere survivor of the old OTC Babbittry; I personally find it to be a reliable analgesic. That's my body talking, not my pharmacist license. Take it off the market, and, instead of it, I'll be taking individual doses of aspirin, APAP, and NoDoz for my headaches.

Nowadays, we have an OTC drug labeling regulation that ensures we shall know, in clear language and spacing, what we are taking, what it is for, and how to take it. I urge my readers to refer regularly to this "Drug Facts" panel on the package when using any medication they buy without a prescription. But, despite this government safeguard, the spirit, if not the specter, of old-time hucksterism still lives on in the design of the "relievers" we look for in the drug store in the year 2008.  The ghost of products past is as near as your TV, radio, or computer. Beware, and always ask your pharmacist, even if you think we will tell you something you don't want to hear, and that's likely to happen.

The pharmaceutical buyer in my department is also a pharmacy technician.  She is smart, pleasant, efficient, and detail-oriented. But, I am a tad jealous of her. Not that she doesn't deserve it (she sure does!), but she has something that I've craved for 32 years, but, as a pharmacist,  have never had. She has her own desk.

The workers of the world who have had a desk---a single piece of wooden or formica space recognized as their own reserved work area---may take it for granted, but I don't.  Yes, I have the prerogative of an electronic signature, and passwords, and a pharmacist license that is "alive and in full force and effect", as it says on it, and also a paycheck that I am grateful for.  But, in my one-third of a century as a full-time worker, I have never enjoyed the anointment of a piece of furniture at which my work is performed and protected, and a chair at which nobody else can sit officially.

No, the pharmacy bench doesn't count.  Our deserved prestige is not to be found in the standing, but in the sitting.  The buck, or pill, may stop here at my bench, but it is not like the desk in the Oval Office where Harry Truman sat pondering the final blows against Japan, or where any of my bosses have sat, and in a room where they can shut the door and do their work in privacy.   I used to think that a desk was the ultimate emblem of responsibility, that only people in power had desks. But, I've never been entitled to a desk. So, what kind of power does a pharmacist have? It is possible that we pharmacists, despite our extensive training and trustworthiness, are left powerless?

I had to talk to someone in authority at my bank. I didn't have to talk to the branch manager; any empowered company service representative would do. I was directed to the office (sic) of one of these people. Looking through the glass, I saw her as a ditzy Britney Spears type. As I waited for her, I saw she was striking a classic conversational pose, twirling the telephone cord and gazing at the ceiling as she spoke on the phone, leaning back from her totally clear desktop. I looked at that desktop and compared it to my benchtop over the years, buried in stock bottles, prescriptions, claim forms, vouchers, and telephones with blinking lights, and scarcely a carefree chat on that phone. But here was this young lady, sweating nothing and enjoying everything, and she had her own desk and her own damned office, and I had to wait outside until she was ready to receive me!

Pharmacists are entrusted with the lives of their patients.  They are also now entrusted with the reimbursible authority to manage their patients' medication profiles. Since 2003, they take their place in the professional world with the title of Doctor.  Yet, retail or hospital, they continue to be forced to stand, run, shuffle, and struggle like fried chicken clerk puppets making minimum wage.  That is just plain sick---masochistic, even.  When we start a new age of dignity, self-respect, and integrity, we had better pull up a chair at our own desk.