Friday, May 30, 2008

BESIDES BEING DUMB AND DISRESPECTFUL, GENDER BIAS CAN ALSO BE DANGEROUS

My department had a interesting visit today. Representatives from the government of a Middle Eastern country came to inspect our computer system, since they are considering the implementation of the software we use.  Later, the female colleague who was conducting the tour shared with me a fact that, in spite of my years of experience, I found astonishing: male healthcare professionals--especially those from a foreign, patriarchal culture---discount the professional recommendations of female healthcare professionals!

You may count me as among the naive, but in this matter, even I am shocked.  When it comes to vital medical information, I would expect gender differences among the principal actors to vanish. My friend explained to me an additional nuance: these men would listen to her if she was asking for direction or for an order, but would dismiss her out of hand as a woman if she offered a warning or advice.  In other words, they accept subordination, but reject direction.

Considering the large number of physicians that have emigrated to the United States from Southwest Asia, where cultures place women in some kind of lower caste, this may be a larger problem than has been brought to the stage.  Speaking for myself, there is no place for this stance in healthcare.  Donne's "every [person] is a piece of the continent, a part of the main" must apply.  One must accept the warnings of all trained minds, or people will sicken and die.

 Biased doctor, What if a woman who is a pharmacist calls you and says she has calculated that your patient's nitroprusside drip is running too fast,  the patient is liable to cyanide poisoning, and that he should consider weaning him off and/or changing to nicardipine?  Egad, don't hang up on her! But, even if you do, please listen to her and weigh the facts.

I do not know how to tell men from these ancient cultures to let go of their lifelong training against women, but if any of them are reading this, even if you think you should reject me as a Caucasian from a land foreign to yours, heed this warning: listen to your people!
Posted by oleapothecary at 00:14:12 | Permanent Link | Comments (4) |

Saturday, May 24, 2008

I CAN'T BEAT UP ON THE DOCTOR, BUT I CAN BEAT UP ON THE PHARMACIST

My latest acquaintance as a patient is with a pain-management doctor for my "lumbago."  In his waiting room is a terse sign informing patients that if they are more than 15 minutes late for an appointment, they will be rescheduled for another time.  At least, in the case of this physician, I was taken within a few minutes of my appointed time, unlike some medical folks who keep me waiting all morning. But, the situation underscored for me the different paradigms: people have to wait for the doctor, but they do not have to wait for the pharmacist. Access to a physician is under controlled conditions, usually by appointment only and guarded by several storm-trooper staff members, usually nurses who could tell the Homeland Security a thing or two about how to improve the Nation's anti-terrorist rules. Not so in the community pharmacy, where people feel free to barge in, interrupt, yell at, and even throw vials at you.

Why does this difference in respect go on? I must admit that a recent predatory poster to one of the pharmacy blogs said something that rang true. In so many words, he said that pharmacists have a hard time getting past the perception that they are clerks.  Doctor of Pharmacy, counseling, and drug use evaluation mandates aside, all the public sees--even in the year 2008--is a group of people putting pills into bottles. As many a truth is said in jest, the jokesters like to chide us as being "pill pushers," and that zinger reveals a belief in what we are to them.

The media compound the felony. On video, pharmacy is usually represented by a spatula gliding across a blue Abbott counting tray, and nothing more. The camera doesn't even show the faces of the staff, just the pesky dosage forms rolling along. There is no surgeon's scalpel, no uniformed nurse, no image of healthcare rescue. On the European and Australian blogs, pharmacists refer to their pharmacy as a "shop."  Doctors practice on you, but when you go to a pharmacy, you are just shopping. They're clerks.

Pharmacists' interventions often make a big difference in the patients' drug therapy, but they are usually uncelebrated, and often take place behind the scenes.  And, they are undramatic.  Successful prevention does not register in people's memories as effectively as successful rescue or cure. And, when a drug is withheld from the patient by the pharmacist, even for sound clinical reasons, it is perceived by many patients, and even by many prescribers and nurses, as deprivation, not as service.  The duties contained in the practice of pharmacy are too often discounted by non-pharmacists of all types, lay or professional.

All of this leaves the patient, marching into the pharmacy on a prescription mission, ready once again to rag on the healthcare professionals on duty in the "shop."  They have just come from genuflecting at the altar of medicine, and now that their "religious" healthcare dealings are over for the day, they are ready to try their luck on the pharmacy midway. There should be some guy in a straw hat and a striped jacket stationed in the store, handing out baseballs and bellowing,"Step right up and see if you can dunk the pharmacist!"  To those of you who are rushing in to say I am wrong, and that you respect what we do, I must break the news to you that you are in a small minority.

Posted by oleapothecary at 11:18:35 | Permanent Link | Comments (2) |

Wednesday, May 21, 2008

I'D LOVE TO FILL PRESCRIPTIONS FOR THIS BIRD

This fine feathered fellow would always provide me with accurate information. Hey, in my retail days, I might have asked him to come to work for me. Bet he could keep his refills current better than some humans. 

See  http://www.foxnews.com/story/0,2933,356850,00.html
Posted by oleapothecary at 20:34:46 | Permanent Link | Comments (0) |

Sunday, May 18, 2008

WE ARE ALREADY BEYOND THE YEAR 802,701

With respect to technology, your Ole' Apothecary is not ole' fashioned.  Although I'm sure many of you can beat this date, I embraced the digital age at age 38, on November 6, 1990, with the purchase of my first home computer, a Macintosh Classic.  That little unit, out of the box, boasted of 1 MB of RAM and no hard drive (what did I know?).  I went back for the (huge, 40 MB!) hard drive, then for the other 3 MB of RAM to max out the memory, and soon, back again for my 2400-baud external modem, which could only push telecommunications software (the word internet would not cross my tympani for another year and a half).  For a while, I stopped buying any additional peripherals, and just read books.  I was addicted, and have enjoyed this addiction long enough to know that the babies born the year I bought my Mac will be voting for president for the first time this year.  Today, I enjoy 3000 times the memory I began with, many, many times the data storage space, and a global communications system unmatched in its significance since the invention of moveable type.

Soon (if it hasn't happened already), there will be no more need for almost any kind of removable storage media such as compact discs or digital video discs. Such a fact flies in the face of the chronology to be found in George Pal's 1960 film version of H.G. Wells' The Time Machine. The movie tells of the year 802,701, when people will be listening to "talking rings," already obsolete in 2008. 

The betterment of our lives, and of our profession of pharmacy, is obvious. All we need to do is to maximize the intelligent use of this equipment.  How about e-prescribing software that forces the prescriber to enter, for each electronic prescription, the specific drug names, dosage forms, and strengths, in fixed fields with a minimum of free text, in a nationally standardized format? The software developers must have pefected it already, but we have not yet cut out all the bickering over it. Will we do so prior to the year 802,701?
Posted by oleapothecary at 19:16:45 | Permanent Link | Comments (1) |

Tuesday, May 13, 2008

THE INFECTIOUS DEMAND FOR ANTIBIOTICS

You take a pill, and it "kills" your infection!  Ever since Alexander Fleming found those first zones of inhibition due to Penicillium,  humanity has been agog over the concept of the anti-infective drug. The pain of centuries of hideous, contagious illness had been brought to an end.  It was like a medical V-E Day. 

Today, the sense of victory resonates in the availability of these drugs, but the quest for continued biologic triumph has resulted in their massive overuse.  That the society is awash in antibiotics has much to do with the greatest, and perhaps most costly, of all public misconceptions concerning drugs:  that antibiotics kill viruses.  No, they do not! Except for some antiviral products,  most antibiotics attack only the vital processes in bacteria or fungi, not viruses.  But, don't try to push this principle on a society suffering from winter upper respiratory infections such as the common cold.  They want to take a pill to kill the cold. They demand it, and even in this new century, the doctor seems to be ordering it on demand. 

I remember January and February of 1982, an awful winter for youthful infections in northern New England.  We stocked and dispensed amoxicillin suspension like cans of soup.  We could have reconstituted a few liters of the stuff in advance, and pumped it out of Reconsti-Tubes instead of distilled water. Were all those maladies bacterial? Or, were they all prophylactic measures taken against the dreaded secondary infection? A movie, The Trigger Effect, even celebrated the ritual of visiting the pharmacist for some of that "pink stuff." 

A drug to kill the bug---it has to be the practical craving of the age. Perhaps that is why the gods of big pharmacy chose that class of medicines as loss-leader freebies.  That has to be the height of pharmacological pimping. Why not give away some statins or ACE inhibitors, to promote preventive medicine instead? Oh, no, tetracycline and the like are cheap, short-term, and whoring.  Yet, flood the environment with these substances, and you promote the continued spread of resistant beasts.  When the first articles ran concerning the rise of super-bugs, I said to myself, "At last!" Finally, the gluttony of bactericides and bacteriostats was coming home to roost.  I wasn't full of glee, but rather, relieved that there was evidence requiring some degree of prescriptive restraint.

There has to be a day coming when vial upon vial of creature-cide capsules and tablets will remain partially full at patient bedsides. That will be because they will not begin to quell the fulminant infections of the future, the illnesses amplified by half a century of  extremely dumb chemical consumption.  There will be nothing left to prescribe, but there will be plenty left to invent.  The pharmaceutical manufacturers will continue to tweak every structure-activity relationship they can fit on their story boards, in order to tease the next peculiar cell wall into disintegration and the next billions of dollars into their coffers.  On it shall go: the cycle of demand, resistance, innovation, and more of those three.  It has always been catching.
Posted by oleapothecary at 00:41:26 | Permanent Link | Comments (1) |

Monday, May 05, 2008

THANK YOU VERY MUCH, NO MORE

For years, I recall that the one type of product one could not buy with a credit card was the grocery item.  Everything else could be bought with plastic except unprepared food.  Was this intended to be some kind of wisdom intrinsic in the economy, not to allow people to go into debt for ground beef or Rice-A-Roni? Anyhow, even this wisdom ended in 1992. That was the year that card readers went up at every food store checkout in the U.S.A.  Something added, something lost, though. For some reason, 1992 was also the year when the retail clerks of the Nation stopped saying two precious words: "Thank you." 

To me, an Ole' Apothecary who worked in his Dad's health-and-beauty-aids store as a pre-Apothecary, "thank you" was a required expression.  One did not take another person's money without showing gratitude for their patronage. In fact, in my Dad's store, the gratitude was always preceded by respect: the cashier, when quoting the amount of the sale, was to ask, "$-.--, please."  So, we celebrated each purchase. And, as I remember, most businesses taught and practiced the same.

It is the height of indifference, and even a form of crudity, to me, for a store patron to have to hand over his or her hard-earned money---money they could spent anywhere, but chose to spend at the store they selected--and get only a receipt presented in silence.  If such cashier behavior is tolerated by the owner, then it must mean that the owner does not give a hang about his or her customers.

As a young cashier, when I would forget to say those two precious words at the conclusion of a sale, my wiser customers would say, 'You're welcome,"  and shame me into a belated, and thus meaningless, "Thank you."  They, and my father, were just plain right. Right up until the day of my departure from retail in 1993, I thanked my customers, one at a time. 

Today,  as the customer opposite some cashiers, I try playing that same "you're welcome" game that was used on me, and these folks have no idea what I'm trying to get across to them. Apparently, they have never been instructed to say, "thank you" in their working lives   Gratitude, like thrift, has fled the earth.  Could the reasons for the shrinking U.S. dollar be spiritual as well as economic? 
Posted by oleapothecary at 19:46:41 | Permanent Link | Comments (4) |

Saturday, May 03, 2008

I DRIVE MY CAR TO ARRIVE ALIVE, NOT TO BECOME AN "MVC"

On September 24 of this year, I shall observe the completion of 40 years as a licensed operator of motor vehicles.  Besides being a rite of passage, that great day four decades ago was a declaration of independence for me. From that day on, I could come and go in the world as I pleased.  But never did I want driving to mean risking. 

I took my cue from the wise motto emblazoned on the inside surface of the Massachusetts inspection sticker, placed where the driver could read it constantly. It read, "DRIVE SAFELY--ARRIVE ALIVE."  I have always believed that this was my primary purpose as a driver: to get where I was going without incident or injury.

However, with the passing of each year, I observe more and more drivers disagreeing with me. They make driving into something much more than just traveling.  They have made it into a contest (the "commuting Olympics," maybe?), as if one's position in life is punctuated by one's position in traffic. These people have to be first, or even alone, in their travels. Their philosophy is, "I am the only car on the road," or "I have to be the first car, no matter who is nearby." Each day, when I travel on the loop here in my Texas home town, I watch people constantly jockeying to be ahead of the pack, applying just enough extra speed in the silly attempt to achieve their brand of leadership.  Funny thing is, after six or seven of them pass me, we all end up at the same red light.

I am convinced that this mentality is the thing that leads to so much needless injury and death, and I'll bet a few of my shrinking American dollars that some of your friends and family have had to succumb to the crunch of metal and glass on the roads and highways. Yet, people have to be first, have to be first, have to be first, when they drive. I don't.  I surrender. Go ahead--pass me. You win every time.   I am not signed up for any highway decathlon. You can go play your dumb game, and maybe die trying.

Philosophies of driving are relevant to pharmacy because, as a hospital practitioner, I end up dealing with the drug therapy of crash victims. They are sometimes lined up five or six at a time, from the same "MVC" (motor vehicle crash) as it is stated on the Emergency Department board.  As long as there is this particular application of silly human ego, there will be this vehicular carnage.  Not much else  I can do, either as pharmacist or citizen, but to do the things that ensure my live arrival at my destination.

Posted by oleapothecary at 08:11:50 | Permanent Link | Comments (2) |