There for the Asking...

In one of my earlier posts, I joked about Miss Ellie, the Lady Druggist on the Andy Griffith show. I grew up watching that show with my Grandma and Grandpa, back when everything was in black and white. Life back then was kind of like that, too. As a kid, my parents didn't mince words. Right was right and wrong was wrong, and they taught me the difference in no uncertain terms. It was only when I got out into the world  and started to interact with other people that I started to realize there were shades of gray. I think that is what is so troubling to me now, and why I can't make sense of the environment I live in 40 hours a week. I have a standard I have set for myself on how I practice pharmacy, and little by little my autonomy has been chipped away, until there is such a disconnect between what I believe and what I am told to do that my mind and body are rebelling.

Picture, if you will, a scene from one of those old black and white Westerns. Young Tom and his sweet young wife Susie head west in their covered wagon, full of grand ideas and dreams about what they're going to do once they reach the promised land. Things go pretty well for awhile. Land as far as the eye can see, and oh my! The stars are so bright and the air is so clean, why a man could really make something of himself out here! Then, all of a sudden, something seems amiss. The music shifts into a minor key. The horses start to panic. Dun Dun Dunnnnnnn....!!!! A rattlesnake is on the trail, why one more step and Tom would've been bit! Tom dispatches the snake with one shot, the music swells, and we all breath a sigh of relief. Whew!! That was close! But alas, art imitates life, and things start to go downhill. Literally. It's not long before the bad guys have kidnapped Susie, the Injuns have showed up, the wheels start to fall off the wagon as Tom races for his life, and the whole contraption, horses, wagon, Tom and all their wordly possessions Thelma and Louise it off the cliff and go bouncing down the slope to ruin.

If I had my way, I would take all the time in the world to help you with the medication piece of your healthcare puzzle. We would sit down in that consultation room I never use, with a computer that isn't there, and go over your medicines, how you are feeling, any questions or concerns you might have, and hey, do you want a cup of coffee, how is your wife doing? Grandkids? Kind of like they show on the commercials. Like that. In color. HD. Surround sound. Happy music in the background.

I am starving for that kind of interaction. I don't like feeling annoyed or nervous because my technician tells me there is a patient who has a question. I don't like holding up one finger, making eye contact, and telling the patient ''be with you in a minute'' when I know it is probably going to be much longer and I am only going to have a few seconds to spend with them. I don't like it when one of my long time patients comes in with tears in his eyes because he just found out his wife has terminal cancer, and I have to talk to him in the middle of complete chaos and get pulled away much too soon for either of us to express what we are feeling.

I think you and I are on the same page. It doesn't have to be like this, and we both know it. Someone has poisoned the water hole. I'm still going to give you the best I can, every day. I honestly can't do otherwise. My gut won't let me.

Happy Trails, Pardner!

BP

What Would You Say

There are times when we know things we would rather not know, and see things we would rather not see. We are bound by the privacy laws, and so we have to tread lightly when we see someone in trouble. 

People come through drivethru without their drivers license on a regular basis. We have to record the ID information on the hard copy prescription, and it has to be a valid picture ID (driver's license, military ID,

State ID, or Passport). For some reason, people take offense when we ask them for their driver's license. My first instinct, when they start to get sassy, is to call the police and tell them there is a person in such and such model car just leaving my drivethru who is driving without a license. I have never done this, because it's just not worth it 

Things start to get a little murkier when the person who drives up to the window is obviously impaired. I say obviously, although there are people who seem to be in a permanent state of impairment. Either way, if your speech is garbled, your eyes are at half mast, and it takes several seconds to turn your head in my direction when I ask you a question (picture the cartoon turtles on Looney Toons), chances are you have no business behind the wheel of a car.

Ditto for the elderly patients who cruise slowly up to the drivethru, see that they are too far away, and back up and pull forward several times before they zero in on the drivethru drawer. Or the ones who pull up, start to roll forward, and slam on the brake. Or the ones who hit the building or run over a cone, and pull away as if nothing happened. I have almost been taken out by one of our patients who lives by a local fast food joint. My quest for a greasy burger almost turned fatal when Mary pulled her big boat of a car out of her driveway in a Mr. Magoo maneuver, narrowly missing several other cars who had to swerve and slam on their brakes to miss her." Oh by George, Angus, why are people always honking at us?''.

There are some things that are more heartbreaking than others. I remember a little girl, about 4, standing in the cart in her bare feet, wearing a saggy two piece bathing suit with her hair still wet. It was 9:30 at night and the air conditioning was going full blast, so she was shivering. Her mother fit the meth addict profile, sores on her skin, stringy hair, tattoos, piercings, shaking, talking too fast, not tracking, bad teeth, bad hygiene. She purchased the decongestant of choice for the local meth cook. I couldn't do anything about it, and I think about that little girl every once in awhile and wonder what I could have done to help her. The ones that are really sickening are the ones who try to get their kids to 'say thank you to the nice lady'' which is a ploy to 

seem like a great parent and use the child as leverage to soften us up in case we suspect anything. 

There are cases where people use their kids to get pain medications. We see emergency prescriptions from dentists, rapid care facilities, and hospital emergency rooms on evenings and weekends. When we see the same child's name at different stores, from different prescribers, with the same group of adults, we hope to God they are not hurting the kid to get doctors to prescribe this stuff. We refuse the prescriptions from people known to do this, but always worry that the kid may actually be hurt and need the medicine. And what kind of sick bastard would do this? 

Another dilemma we encounter is the patient who has always been on top of things, who starts to slip, and we start to notice. How far do we let it go before we say something? We are lucky to live in a small community where we can usually contact a family member and discreetly hint that maybe someone needs to start checking on Aunt Susie, because she doesn't seem to be able to keep track of her medications like she used to. This is tricky because of the privacy laws, but we can usually get the person's relative or friend to catch our drift without breaking the law. 

We do the best we can to stay objective and professional, and still try to do the right thing when it comes to the stupid and dangerous things people do. I like the show "What Would You Do'' with John Quinones because it really brings up some moral dilemmas we all face. To get involved or not. To say something or do something, or just walk on by.

What we see is mild compared to what social workers, emergency room personnel, foster parents, child advocates, elder abuse investigators, policemen and firefighters, and a whole lot of other people have to see. I don't know how they do it. 

BP

With Respect to Privacy

HIPAA notwithstanding, privacy in the retail pharmacy setting has a long way to go. The consultation window is a nod to the idea that the conversation between patient and pharmacist should be private, but it is woefully inadequate. Likewise the little sign on the floor 6 feet away from the counter that says "Please Wait Here" .
This may satisfy the letter of the law, but there are several problems with this scenario.

How would you like to have to stand at a counter and speak to your physician about erectile dysfunction, a yeast infection, or a rash in a delicate place? Yet when you have questions about the medication you were prescribed to treat these conditions, that is exactly what happens between you and your pharmacist.

Some of the newer pharmacy departments do include a more private area or even a "consultation room''. Which would be great, except that we don't have the support staff to cover while we sit down with you and go over your medications and answer your questions in private.

Even when the chains started giving immunizations and providing health screenings ( which, as you probably know, is a response to the shrinking reimbursements they receive from insurance companies, and not because they are so concerned about public health), the most they could provide was a screen and a folding table with a cheap plastic tablecloth. Oh, and one cheap chair, and one nice chair (for the patient).  I am embarassed when I have an elderly lady that can't get her sleeve up high enough for a flu shot, and has to slip her shoulder out of her top so I can reach her little skinny deltoid muscle. "I'm sorry ma'am, is it ok that the whole store can see your bra?''. I offer to take them to a room if they want, but most of them tell me they are ok with it. I'm not ok with it, because it just isn't right.

The drivethru is another place that your privacy is compromised, especially if there are two lanes. Even though we speak to you over the phone, the speakers on your side blast your business across the parking lot. Drive by sometime with your windows down and you will see what I mean.

As a patient, there are a few things you can do to help us out. If you need to talk to us privately, ask to speak to us in the consultation room. Even if the store does not have an official room, there are places that can be cleared of other employees and made into an impromptu private room. A technician or manager can "hold down the fort" for a few minutes so you can get the attention you deserve.

On the flip side, if you are waiting to drop off or pick up your prescription, please keep a respectful distance from the patient we are working with, and please don't raise your hand as if you are hailing a cab, or try to make eye contact with us so you can ''just ask one quick question''.  In my experience there is no such thing as a quick question. It's just like you learned in kindergarten, wait your turn.

I once had a guy so far up on my patient's back that I thought he was her husband. She and I were discussing a very private matter , and he was right there looking over her shoulder and listening. I guess she was probably too nice or too intimidated to tell him to back the hell off. Anyway, I finished talking with her, and turned to walk away, when I heard "what do you have to do to get waited on around here". There was Mr. Snoopy Pants, chomping at the bit to get waited on. "Oh, I'm sorry, I thought you were her husband, you were standing so close to her !'' He didn't bat an eye. I don't think it even occured to him that he had done anything wrong.

The chains have us down to minimum staff and are promising maximum service. This is not fair to either one of us, but this is the hand we have been dealt. If you have a question about something out front, try to ask someone other than the pharmacy staff. I know, the managers and store staff are usually hiding in the office or in an aisle, but the front register person should be able to flush them out for you. If you have a question about medication or over the counter products, please be patient and we will help you as soon as we can. We don't like not being able to get to your question, and we don't like having to  broadcast your business to everybody in the waiting room, either.  

A few years ago, I was walking up to the front doors to unlock them for the day, when I saw a desperate man jumping up and down and trying to get my attention. "Gosh, he must really need me to fill his prescription in a hurry''. I yanked open the doors, wondering what was wrong. The guy just about knocked me over in his haste to get in the store. "Do you have any colored toothpicks!!!!?????'' Don't be that guy.

BP

Be Nice!

One of the hardest pills to swallow when dealing with patients is putting up with the verbal abuse. Actually, the patients are not the only people who feel free to let loose on us on a regular basis. Nurses and receptionists, doctors, insurance help desks, insurance reps, our store managers, our corporate managers, and , my favorite,  other pharmacists, feel free to lambast us at will. One of my happy go home songs is REM'S Bang and Blame (..."you bang on me, beat on me, hit on me, let go on me....you let go on me...."). Think the lyrics are a little extreme? Walk a mile in my Merrells.

I'm going to be completely truthful here, because this is my blog, and because I am not allowed to say what I think anywhere else. I've been doing this a long time, so keep in mind these are the status quo, not isolated occurences:

1. Nurses and doctors are never wrong and can never say they are sorry. Period. I can count on one hand the times one of them has actually admitted to causing the patient and us extra grief and work.
They order the wrong medication, the wrong strength, something the patient is allergic to ? They call us (or usually the patient calls us or them, or we relay the message). Guess what they tell the patient?
"Take that back to the drug store and have them refund your money" . We can't sell it , so it goes in salvage. Never ever has the doctor's office offered to pay for their own screw up. Or the gas, time, and aggravation the patient had to put up with because of their error.

One of our doctors, who we thought we had a good relationship with, called us and chewed us out for trying to cheat her patient because we gave her the brand name drug instead of the generic. When we pulled the hard copy, it turned out that her nurse had called it in as Dispense as Written, Brand Name Only.  Guess who never could admit it was her office's fault or say sorry, and guess who we don't give a shit about helping any more than we have to.

When we screw up, we admit it and take it in the face. It's wrong to lie and say you didn't make a mistake when you did. Not only is this dangerous, but it is immoral and stupid. There are pharmacists who lie about errors, and in my opinion they are a pathetic excuses for healthcare professionals.

2. Most insurance help desk reps that I have dealt with are pretty nice. They have a thankless job, too, and I'm sure they get yelled at all the time.  They usually are polite and try to help. The reps who are trouble are the ones who tell you it's a software problem, or who otherwise try to pass the buck by acting like we are incompetent.  When they get high handed and mean, we hang up and call back and try to get a nice one. And maybe we slam the phone down when we hang up on the mean one. 

3. When Medicare D first came in, it was confusing for everybody. We tried to help people figure out what to do , because most of these patients are elderly and on a ton of medications . My pharmacy manager actually had an insurance salesman tell a little old lady to switch pharmacists, because he had the guts to call the rep and ask him to help the lady pick a different plan , because the one he put her on did not cover some of her medications. That rep was a complete ass. He yelled at my pharmacy manager on the phone and was extremely rude.  He was willing to take the lady's  money, but he did not want to help her select a Medicare D plan that gave her the best coverage for her medications.

4. I had a pharmacist call and chew me out first thing on a Sunday morning because he had called and talked to "Mary" on Saturday and transferred a prescription for us to fill, but when the patient got there Saturday night we did not have any record of it. Actually he yelled at my tech for a few minutes before I told her to give me the phone. First of all, I had to tell him 4 times that there was no Mary at my store, Mary works at Mr. Happy Drug down the street.  Since he continued to be shitty, I told him that yes, I remembered his patient because he yelled at me in drivethru for 10 minutes right at close, and then proceeded to come into the store and bang on my window and yell at me after I had closed for the night. So, I was  late gettting off work, I got yelled at, and now Mr Know It All Rph was yelling at me.  I let him have it and he fell all over himself apologizing. Too little , too late, my friend.

5. Our store managers have a high school education, or at most a Bachelors in business or another field other than pharmacy. The pharmacists go to school for 5 years, sometimes 6 years,  and have a ton of experience and  knowledge. The chain stores put the store managers in charge of the pharmacists, so they feel free to yell at us and say whatever they want to us because corporate backs them up and throws the pharmacists under the bus.

6. And now, the patients. . Do you know who treats us the best (other than the drug abusers, who are sweet and fake until they don't get their way.)? The people who have nothing. The poor people, the little old ladies that cart their buddies or their neighbors around and sometimes buy their medication for them. The people who are going thru hell because a family member is fighting cancer. The people with a child who has cystic fibrosis, or who is fed through a tube, or who will never be able to be out of bed or their wheelchair. The guy who is paralyzed from the waist down, pays cash for everything, and  who always has a smile and tells us to have a nice night.

Do you know who treats us the worst? The pillars of society that have a sense of entitlement and feel they should never have to wait , that they should be taken care of first, that we should bend the rules to make things easier for them. The people with religious symbols and sayings on their cars and checks and t-shirts that yell at us every time things don't go their way. If you can't even be nice to a store clerk, it seems to me that you are witnessing for the other team. You are not invisible, and we don't forget who treats us badly. Ever. What would Jesus do? I don't know, but I'm pretty sure he wouldn't be screaming at me in drive thru.

BP

Robber, Faker, Methamphetamine Maker

Along with the increase in other pressures involved in pharmacy practice, the amount of robberies have increased , and the vulnerability we feel standing there behind the counter has added another nerve-racking dimension to our job. We are sitting ducks. The "security" system consists of "high definition" video cameras . Those grainy images on the tv news are supposed to help the public identify the latest hooded wonder, but they are little consolation to the employees involved in one of the most traumatic events of their lives. Adding insult to injury, upper management has become increasingly callous to our plight and harasses employees to show up to work their next shift,  implying that you are not a team player if you can't bring yourself to return to the place where 24 hours ago you had a gun pointed at your head.

We have always had patients who have trouble limiting their use of pain medication and nerve medicine.What happens in a lot of cases is that people get hurt in an accident or at work, and then it seems that they never get weaned down off of the medication. In fact, the dose and amount of medications seem to escalate over time. Pain has a huge psychological component, in other words, it is self perpetuating. The more you hurt, the more tense and anxious you get, which in turn makes you hurt worse. Unfortunately, addressing this component of pain management takes time, commitment, and collaboration between the physician, the patient, and ancillary practitioners, such as counselors, physical therapists, massage therapists, and mental health professionals.

Many patients sign a pain contract , promising to only see practitioners in one pain management group. They also promise to limit the number of pharmacies they visit. It gets a little dicey for them and for us when glitches in the system occur and their prescriptions are delayed. When a patient is desperate and in pain, they  are willing to try anything to get their medication. The stories they fabricate would be funny if the situation wasn't so sad. "I was sitting by the pool, and I dropped my bottle and all my pills spilled out on the pool deck, and my dog got hold of some of them and died". Couldn't you have saved at least some of the pills? ''It was raining".

Then there are the people who sell their medications. When we see a carload of people come through drivethru  and pick up scripts for boatloads of pain meds, it does not inspire our confidence that this is a legitimate transaction.

Last but not least are the Meth Heads who come in and buy pseudoephedrine and ephedrine tablets. We are pretty good at spotting these people, and our goal is to get them out of the store as soon as possible. It is hard not to profile someone who has tattoos and piercings everywhere, talks 90 miles an hour and can't stand still, is exceedingly polite (until the state limit is exceeded), and talks about how their poor old Granny needs this medicine so badly. Spare us the stories, we will sell it to you if it goes thru on the register. We hate doing it, but we let the State Police do their job and try to stay neutral.

So, forgive us if we are a little jaded. It would be so much easier to believe all the stories and excuses, but we are entrusted with patient safety. We hate being the drug police, but this is yet another component of our job that we do not control. As the big dufus in Blazing Saddles said so eloquently "Mongo just pawn in great game of life".

 Later,

BP

But I Have Insurance!!!

Yes, yes you do. Remember when your insurance company used to send you those booklets every year, the ones with the people on the cover that couldn't possibly work for your company because they are laughing and smiling and having fun with their families? The ones you were supposed to read, but never did, because it didn't make any sense anyway, and you figured you'd deal with it when the time came? Now you are directed to a web page with the same shiny happy people, but you have to remember another damn user name and password just to get into the website, and there are so many tabs, links, and healthy living tips , it's hard to even find your benefits.

I don't know much about the medical insurance side of things, except that medical offices dedicate a whole staff of people just to work on insurance problems. They send the bills in, and you get an EOB (explanation of benefits) either in the mail or online. I assume in between times there may be some phone calls and e-mails sent back and forth before the whole kit and kaboodle is hashed out and finalized.

Now step into the "Jamaican Airlines" of the medical world. Remember the show "Living Color"? They had a skit with a family running an airline, and they all had about 15 different jobs: '' I'm the ticket agent, the baggage handler, the stewardess and the pilot! You are only the navigator? You don't have enough jobs, you lazy lima bean!''!

As your pharmacist, I am the greeter, the phone answerer, the question taker, the recommender, the counselor, the prescription taker, the profile updater, the insurance or coupon enterer, the prescription enterer, the insurance problem fixer, the prescription filler, the prescription checker, the prescription bagger, the prescription filer, and the cashier. I also run the drive-thru (2 lanes), do what the store manager tells me to do, put the drug order away, send the drug order for the next day, fix the printer, the cash register, and the computer. Oh, and I am often the bearer of bad news (don't shoot the messenger !). Theoretically I am supposed to have technician help, but it is often non-existent, at lunch, break, or out for an appointment, or incompetent. Rarely do I have a full staff, if any staff at all.

Here is how this process works. You go to see your doctor and receive a prescription carefully selected to treat your particular problem. You bring the prescription to me, and hopefully present your current insurance card (not last year's, your Medicare Card, your AARP discount card, any other discount card, or handwritten numbers on a slip of paper). I will enter the prescription and run it through the insurance. If the numbers are correct, and the planets align, and we keep our fingers crossed, I receive a paid claim. Visions of glory and angels singing, HALLELUJAH!!!!

The relief and happiness may be short lived. I have to tell you the copay, and if it is high, or the drug is not covered , or it needs a PA (prior authorization), woe unto me. And you. You have spent most of your day at the doctor's office and have waited for me to process your prescription, only to find out it is more than you can afford, or not covered at all. This tends to make you frustrated and angry. I get that. This is why we cringe when we have to tell you how much your medication is going to cost. This is why I may get a little short with you, because I have had this happen time and time and time again, for hours, days, and years, and it never changes. I want to help you, but I have no power to do so. All I can do is contact your doctor's office (who is probably at lunch or gone for the day by now) and/or your insurance company's pharmacy help desk. This takes time, and you are already tired and probably not feeling well. The stage is set for yet another unpleasant encounter between the two of us, when neither of us are to blame and the people who  are sequester themselves so we can't strangle them with our bare hands.

What can you do to make this process less painful for both of us?

1. Insist that your insurance company send you a new insurance card at the beginning of the year. I believe that insurance companies should have to pay a fine for every day they do not get the insurance cards in their customers' hands. Tell them a piece of paper, or worse, having to call them and have them read the numbers over the phone, is just not acceptable, especially at the beginning of the year. If they refuse, get your HR person or boss involved.

2. Try to read your booklet and familiarize yourself with the basic copays for generic and brand name drugs. No, you will not understand it all, but it may help you get the general idea of how it is supposed to work.

3. When you do get a new card, please please please shred the old one. Then tell us it is a new card so we can compare the numbers to what we have in your profile.

4. If there is a glitch, give us both a break and come back later (at least an hour). We will make some phone calls and try to resolve the issue. Sometimes (but not always) we can give you a few doses to start with until we can get the insurance fixed. We understand if you are sick and really do try to get you going as quickly as we can but we can't break laws and we can't give away expensive medications. We also can't control how busy we are at the time.

5. If your insurance company requires a prior authorization, this means they want more information from your doctor. Either the medication is expensive, and there is a cheaper alternative, or there is a perceived conflict with one of your other medications , or they have some other reason they don't want to pay for it . Simple as that. While you are welcome to pay cash,  if you want them to pay for it , we are going to have to jump through the hoops. We will call your doctor's office and give them the phone numbers to call and the message the insurance sent back to us. After this initial contact, the ball is in their court. Some offices are very good at getting PA's and some are not. If yours is not, you may have to call them several times. We can call them, but they do not hurry for us, either.

Like all the other things we do, insurance problems require time and patience from both of us. We are not your enemy. Give us a chance so we can help!

BP

I Pity the Fool

I used to know a pharmacist who looked and acted like John Belushi. He would say stuff like ''oh, the colored toothpicks, yes, they are up front in aisle 3 (and under his breath 'right next to the I don't give a shit aisle').  The same guy would say "hey, have you got a kid who wants to go to pharmacy school ? Send him over to me so I can slap the shit out of him ".

I pity the fool who believes the treacly commercials and thinks pharmacy would be a great career. If the pharmacy schools and chains would be truthful in their job listings and ads, no sane person would ever apply.

ATTENTION ALL PHARMACISTS!!

Are you looking for a rewarding and stimulating career at one of our professional locations? Here are a few of the perks you can expect when you work for us:

1. A generous salary and benefits package that is geared to getting you hooked on nice things and starting a family before you know what is really going on. Kind of like the trap where they drill a hole in a coconut big enough for a monkey to put his hand in, chain the coconut to a tree, and put a treat inside. The monkey's hand fits when he puts it in, but he can't pull out the fist holding the treat. By the time he figures out 

that the only way he can get away is to let go of the treat, the hunter has come along and bashed him over the head with a club.

2. No lunch breaks,no 15 minute breaks,  no food in the pharmacy, no drinks in the pharmacy, no food or drinks in the pharmacy refrigerator. And you won't be needing that hard wooden stool we give you to sit on either. 

3. Expert technician staff, who will of course get lunch and breaks, and  will also be allowed to go home early, come in late, leave and come back, not show up at all, and call in sick for days at a time .

4. Be your own boss! We often allow you to work 8 to 14 hours straight with no help.

5. Hone your clinical skills! Give shots, take blood pressures, check cholesterol, check blood sugars, check A1c, check body mass, and mix compounds, all with no help and in between your regular duties! No appointment necessary!

6. We will provide 2 smocks a year. They will not look like the ones in the commercials! Those ones are white and crisp, yours will be yellowed, pilly, floppy and sweaty!

7.  You will learn to dispense dangerous, poisonous products to all manner of people, while you are pulled in different directions and subjected to a cacophony of noise and visual distraction.And you will do it pleasantly (or else).

8. Learn how to hold your temper while we proceed to disrespect and belittle everything you do , and let the technicians, customers, managers and cashier say and do whatever they want to you!

9. Enjoy the feeling you get when you have produced 60% of the stores profit and get treated like a bag of shit!

I KNOW YOU ARE PROBABLY SAYING WOOHOOOOO....!! SIGN ME UP!!!!!

You may have to wait in line quite awhile, though, because according to the powers that be, there are a ton of people just waiting to take these jobs!!

BP