Dazed and Confused

There are some days when people say things that are so puzzling, so..... jaw-droppingly dumb, that you are literally struck speechless. It's the kind of thing where the "crickets chirping" sound effect really comes to mind. What's even more irritating is that the person saying these things to you starts to get agitated like you are the idiot.

Today a woman had the entire pharmacy staff searching for prescriptions that her doctor 'should have called in.' She was getting quite annoyed. Finally, after several minutes of multiple people scrambling around, I asked her if the doctor's office may have handed her the written prescriptions. She exhaled loudly, sniped "well yes they DID, but I left them at HOME."

Crickets. We all just stood there.

Another person wanted us to transfer a prescription to another pharmacy. He did not, however, know the name or phone number of said pharmacy.

Silence. Crickets.

Another person needed a refill, and was told the prescription had expired and would need doctor authorization. "It has NOT expired," she screeched. "The label says, refill as needed until 12/29/2010 !!!!"

Silence. Crickets.

Two other recurring events today:
1. People who were given new prescriptions for all their chronic meds at a doctor's appointment. Some time later they call in and ask me to call the doctor for refills, because "I don't know what I did with the prescriptions."
This is THE biggest freakin' waste of everyone's time, ever, in my opinion. Once again, it is people taking no responsibility for anything. Burns me up.

2. People who allow us to fill multiple prescriptions, bring them to the counter, explain them, package them up, ring them up, and then (and ONLY then) inform us that "I didn't bring any money today."

There's those crickets again.

And the band plays on into 2011. Happy New Year, I guess!

Christmas Potpourri

I've received a couple of calls in the last few days from people asking me to identify some tablet that they found in their kid's room. I can definitely understand the parent's concern but it still makes me a little uncomfortable and I wonder if I am courting any HIPAA violations by doing so -- but I figure if it's a loose tablet and not in a labeled bottle then anyone should be able to pick it up and inquire as to its identity. In one case it turned out to be an Endocet. I don't try to get the parent too worked up ('you don't know who it belongs to or even if it belonged to the previous owner of your house/apartment' etc.) but of course I am not naive enough to suspect there won't be a bit of a confrontation. If it was my kid I would want to know.

People don't seem to be totally in the Christmas spirit this year. For the usual reasons, I suppose -- the economy, stress, fear of what's ahead. I sort of feel it too. Yesterday a customer was very pissed off at his insurance company who apparently told him he was active -- however, when we called them they found no record of him anywhere. As he huffed out I noticed he was wearing a large pin that said "I Celebrate CHRISTMAS." Great..... something else to be angry about.

Another guy was sitting waiting for his prescription and yelling into his cell phone (presumably to one of his employees), 'NOW GO MAKE ME SOME MONEY."
Another guy was signing for his prescription and picked up a stray pen on the counter that said (inexplicably) "The New York Times." Gee, he sneered, "people still read PRINT?"
Rather than assure him that people still did, I let it go.

Finally, a customer called and told us he was out of his narcotic pain medication and needed a refill. He had one tablet left. Oh, and he had NO way to get into the pharmacy to pick it up. There was NO one he could send to pick it up. Did we deliver? Well, no we don't. (Now, at this point we don't even have a refill request in to the doctor, much less a signed prescription ready to go.) Even if we get the prescription immediately and mail it, we're looking at several days, and it's a holiday weekend. WHY oh WHY do people do this? We try to help them out as much as possible, but there's just not a lot we can do in this situation. Add it to the stack of problems. I have no clue how it turned out.

Anyways, Merry Christmas everyone!!! -- hope you get some time off AND enjoy it!!

In Search of the Perfect C.E.

When I first graduated as a pharmacist I joined the organizations, subscribed to the magazines and made every effort to plow through them and keep current with continuing education. Obviously, it is very important -- and not just because CE is required to stay licensed, but to do our job responsibly. I went to the day-long CE events in the hotel ballrooms and convention centers, and the dinners, and the luncheons, and all that.

Gradually I lost interest in a lot of those things --- not because I don't want to learn anything, but because I began to realize how little I was getting out of them. I would plod through some long article and an hour later not remember a single thing I had read. Nothing was relevant to those of us who work not in academia, not in research, but on the front lines of pharmacy. I would sign up to attend a lecture on, say, "Recent Advances in the Treatment of Asthma." I would think great! --- I need to get a little refresher on some of the new inhaled medications and what distinguishes them from each other in practical terms. But alas, what I got was someone who spent 45 minutes reviewing the causes and epidemiology of asthma, which by now we've all heard a hundred times. Then the speaker would realize they were running out of time and hurriedly throw up a slide listing all the classes of asthma drugs, their brand names and refer me to some handout which was no more helpful than any textbook, and bye-bye I'm out of here. Well, I didn't need to waste a Saturday on this.

I can't tell you how disappointing most of these things are to me. No prescriber has ever called and asked me to explain what causes asthma. What they want to know is, "Can you suggest something for my patient who has failed on this-this and this?" or "Which product do you think is easiest to use?" Or, "we need help figuring out some devices to get this recalcitrant 4-year old to use an inhaler."

I know the problem with most of these CE lessons is they have to be objective and not exhibit commercial 'bias.' That's too bad, because I think some kind of bias is what we need. I truly appreciate it when a speaker can relay their own practical experience to me.
Of course I can evaluate it in the scope of my own experience. But the things I remember most are when, say, a pediatrician says "New Liquid Medication X works great and is low-cost, but I NEVER prescribe it because my patients simply won't take it -- it tastes that bad." Now, that helps me. That's something I can USE. I am always desperate for those tips, insider experience, or 'pearls' as we used to call them.

What made me write this post was deciding to give it another shot yesterday and read an article in one of those pharmacy magazines. It didn't go well. One of the articles was on Medication Therapy Management (which used to be called patient counseling, then profile review, then pharmaceutical care -- but that's another story). Another article was on the well-worn topic, "Selecting A Blood Glucose Meter." OK, great, I'm always looking for tips there. It turned out to be a pretty short article:

"A blood glucose meter is an essential tool.... patient should use....blah blah.

Yup, got that.

"Pharmacists play an essential role... selection of meter... key features.. blah blah.

Yup, that's why I'm reading this. Please continue.

"Key features that may be considered.... sample size....alternate testing sites....portability..... memory options.... blah blah.

OK, we're getting closer. Let's get down to brass tacks. Names, specifics please.

"After a meter has been selected, it is important that the patient understand...."

WAIT A MINUTE, THAT'S IT?? WE'RE DONE?? Didn't we skip over the whole 'selection' part? Oh, I see you've ended by providing me with a nice list of all the names of blood glucose meters. Well gee, so that's what all those crazy things are on my pharmacy shelves. Thanks a whole lot.

Well, I'm still searching for the ultimate CE .... good ol' Pharmacists Letter will have to be my lifeline for awhile longer. And no way am I picking up one of those magazines, unless I'm on the cover.

The Wretched Question

Pharmacists often complain that when someone hands us a prescription their first and only question is, "How long will this take?" Sometimes they don't even hand it to us first. Sometimes they themselves have already decided how long it should take (as in, "It's just some cough syrup", or, "how long would it take to just refill an inhaler?") I've gotten used to it, but there are just some days when I hear it over and over again, and it REALLY gets on my nerves. In fact, it discourages and depresses the hell out of me, especially when it is super busy and I am working my butt off to try and take care of people as best I can in a professional manner. Even the customers who don't speak a word of English know how to say "HOW LONG?" And no matter what you tell them, they're back hovering at the counter 5 minutes later. I can't think of anyone else in the health-care chain who gets asked immediately and consistently, "how long will this take?"

It's really impossible to explain to people that putting the pills in the bottle is the least of our worries. The required record-keeping, regulations, requirements of the insurance companies and error-proofing procedures are formidable even without the unintelligible and nonsensical prescriptions that often come our way. And of course there's the simple factor of volume, which is inversely related to the number of staff working. No need to go over all of that again.

Anyways, as part of my 'bucket list' one day I am going to turn the tables.

Patient: I have some questions about these prescriptions.
Me: Sure. How long will this take?

Patient: I have no idea how to use this inhaler. Can you go over it?
Me: Sure. How long will this take?

Patient: Can you recommend something for this gunky cough I have and also something for my kids' acne?
Me: Uh, how long will this take?

Patient: Can you call my doctor and get me something for my migraines and then call me when it's approved and then mail it to my home and then call me when my credit card declines?
Me: OK. How lo-----

Well, you get the idea.

Turkey Talk

I worked Thanksgiving in close proximity to a "Quick-Check-Urgent Care" walk-in clinic type of place ---- surprisingly, most of the patients pretty much needed to be there. Lots of antibiotics were flowing. Not too many people wandered in on Thanksgiving Day to have that rash checked that they've had for 3 weeks, or to get a handle on that blood sugar that's been out of control since last Thanksgiving. So that was a pleasant surprise.

I did get several people who wanted me to 'guarantee' that their prescription would work.
Like, the person getting a Z-Pack (I know, who doesn't get a Z-Pack?) who said in reference to their ailment, "And this will TAKE CARE OF IT, RIGHT?" Or the woman who demanded to know if the phenazopyridine would work IMMEDIATELY for her UTI. As I opened my mouth to answer, she said NO, I MEAN IMMEDIATELY !!!

I can't guarantee that prescriptions are going to work. Prescribing is as much an art as a science. Every so often someone tries to return something because it "didn't work" or they just didn't like it and we have to explain that legally we can't take the medication back and re-sell it again. I had to explain to a customer once that "you wouldn't want me to dispense medication to you that had already been taken home by someone else, right?"

On Black Friday afternoon a customer brought in a prescription for an anti-nausea med for pre-treatment of chemo. The (naturally) expensive medication wasn't covered. We asked when the chemo treatment was scheduled.... "Monday morning." Date of the prescription: 1 week ago. Doctor's phone goes to voice mail. Possibility of getting a prior authorization on Friday afternoon? Slim to none. Moral of the story: bring those prescriptions into the pharmacy ahead of time. I sure hope they figured something out on Monday.....

The Drink

We have a customer, a relatively young individual, who's been through a succession of reflux medications and got rather agitated when his new PPI prescription wasn't covered.
I spoke directly to the prescriber, a younger female physician who actually sounded kind of scared of the guy. "What he really needs to do is put away the vodka," she informed me.

Obviously many of our pharmacy customers have conditions that they have no control over, but others can attribute a lot of their medical problems to things like obesity, smoking, and alcohol. I recently read a small news item in Newsweek magazine that stated,

British researchers find that alcohol is more destructive to individuals
and society than any other drug, including heroin and crack.

Pretty eye-catching statement, but I think it's true. I'm thankful that my parents were only social drinkers -- it was an occasional thing, holidays and special occasions, and no one ever got drunk. I am the same way. I wasn't aware of it as a kid, but I realize now that I have numerous extended family members who are approaching middle age looking back at a legacy of broken relationships, estranged children, shaky financial status and general poor health as a result of the erratic and unpredictable behavior that comes with alcohol dependence.

I work with people who talk about 'going to the bar' like it's a destination in itself. That's their weekend activity. They leave their kids in the care of others so they can hit the bars.
Their kids eventually catch on to this and recycle the behavior later themselves. People describe something to me that happens at home with their (haha) 'plastered' spouse and I think to myself, YOUR HUSBAND IS AN ALCOHOLIC. Why can't you see that? I'm not talking about college students here; these are full-grown adults.

Think about the percentage of police calls that are related in some way to alcohol. (Watch an episode of "Cops".) It's phenomenal. I once heard someone say that beer is the most underrated drug in America.

Unfortunately, smarter people than me don't know what can be done about it. Alcohol is never going to be illegal. Humans are social animals and alcohol is associated with that. We've created a stressful society where people are looking for ways to take the edge off. I believe some people are genetically predisposed to 'addictions' while others will never come close to any kind of problem. But the impact of alcohol on our society really is very dramatic, when you think about it.

Just another observation from behind the counter.....

The Incredible Missing Prescriptions

I know some folks out there who work for big chains perhaps aren't directly involved in the mailing-out of prescriptions. Everybody has to do it now (for free) to remain competitive. But what is your company's policy when the patient tells you they didn't receive it (and it's documented as being mailed, the address is correct, etc.?) People seem to feel it's our responsibility to simply replace it, at no cost to them, and that is regardless of whether we can bill insurance again. We are getting burned on this big-time. I'm curious to know how it's handled elsewhere.... Thanks!

Theater of the Absurd

Prescription medication for customer is being increased from 40mg per day to 60mg per day. Thus, the prescription is written as 40mg tabs, take 1 and 1/2 daily, because there is no 60 mg tablet. Easy -- peezy !!!

Insurance company says no, we will only pay for one 40mg tablet daily. We advise the customer that this medication is inexpensive, and he can buy a month's supply for cash at under $14.00.

Customer says NO WAY and wants it covered under his insurance. Since we're all about the customer service, we send it off to the doctor's office for a Prior Authorization.

A few days pass. A nurse actually calls (!) and says the prior auth is approved. I run the prescription again -- it rejects. I call the insurance company and sit on hold for about 10 minutes. Finally the person on the other end tells me it is approved, but the customer must take three 20mg tablets instead of 1 and 1/2 of the 40mg strength.

OK. I run that through, and the copay is MORE than if the customer had just paid cash for the month's supply of the DAMN 40mg.

Customer comes in later, and when given the two options elects to pay cash price for the 40mg. Customer also is pissy and registers his unhappiness that the insurance company is telling him 'what to do.'

I wish I could total up the salaried time that everyone involved spent on this. Sometimes you just have to laugh in this job. And again, I am reminded of (a) why healthcare is so expensive in this country, and (b) why your prescriptions take so long to fill.

On another note........ we all hate it when management dictates we have to give a spiel to the customer at checkout, whether it be upselling or telling them about a special or asking for a donation to something. I was reminded how much I hate this myself when I attempted to buy a cheap paperback book the other day at Barnes and Noble.

Check out lady: Are you a member with us?
Me: No.
C-O-L: Do you know about the program?
Me: Yes, and no thanks.
C-O-L: Would you like to donate a book to our book drive?
Me: Not at this time, thanks.
C-O-L (now typing into the computer): What is your e-mail address?
Me (silently): CAN I PLEASE JUST PAY FOR THIS GODDAMN LOUSY BOOK AND GET OUT OF HERE ???? AAAAAAAGGGGGGGGGGGGHHHHHHH !!!!!
Me (out loud): I don't use e-mail.


By the way, I TOTALLY lied cause I do use e-mail!!

Can't wait for the Christmas shopping season.

All Tied Up Over Tylenol

Overdosage with Tylenol is the most common cause of acute liver failure, and attempts have recently been made to educate the public that Tylenol (or acetaminophen, or APAP) is not an innocuous drug. People may not be aware that acetaminophen is present in many products other than "Tylenol" leading to doubling-up and inadvertent overdose, and there can be confusion over strengths of different products -- regular strength tabs, extra-strength tabs, chewable tabs, infant drops which are 100mg/ 1ml, and children's liquid which is 160mg per 5ml. For adults, 4000mg per day is the maximum dosage, or 8 tablets of 'extra strength' Tylenol equivalent, and there is talk of lowering that recommendation.

Anyway, the thing that worries me most is the kids, because of the aforementioned strength differences and the lack of faith I have in many of the caregivers who give the doses. You remember when they pulled all those OTC pediatric cough/cold products off the market not long ago? It wasn't because the medications were inherently unsafe, it was because there were too damn many dosage errors to justify leaving them out there. Every time I sold one of those things I attempted to make sure the parent knew how much to give, but they rarely initiated the question themselves.

Getting back to Tylenol, we get a lot of prescriptions for it because it is covered by state assistance for those who are eligible. Pediatric dose, as we all know: 10 to 15 mg per kg every 4-6 hours, maximum 5 doses daily. But after checking the child's weight, we consistently get doses that are written too high. Usually they creep up into the 16-17-18 mg/kg range, sometimes more. Okay, maybe a couple of doses isn't a big deal, but legally as far as that labeling is concerned it's OK for that child to get that dose every 4 hours for the next... well, indefinitely. I'm often nervous about assuming that a non-English speaking parent even remembers what 1.2 mL looks like on that dropper. We always have this conundrum --- should we call and bug the doctors/nurse about it EVERY time and hold up the prescription till they call back? Should we go ahead and change it to a more correct dosage and initiate a phone call or fax back to the office and hope it gets changed in their medical record? Or do we decide we've called them enough times and just tell the parent the correct dose and make sure they know how to give it? Is it worth all the time spent? It happens virtually every day. Are we just getting too wound up about the whole thing?

I'm curious as to how other folks handle prescriptions for OTC items like this.

For the record, I never use those dosing charts that give a weight 'range' and assign a dose for it. I calculate 12mg/kg (right smack in the middle) and then round up or down to the next logical dosage unit (1/2 - 1 - 1 & 1/2 teaspoon, dropperful, etc.) Done.

The Generic-Go-Round

I'm still surprised by how often customers don't understand what 'generic' means. The ones that do understand are the 'prescription pros' whose eyes actually light up when you tell them their medication is now available as a generic, because they anticipate the price coming down. But many people still look very skeptically at you and ask, "But it's the same thing, right?" I feel as though they think I'm trying to put something over on them.

I've tried out a few different ways of explaining 'generic.' Some of them are:

1. It's the same active ingredient as the brand name drug, it just looks different and is made by a different company. (This one doesn't go over that well. It sounds kind of fishy.)

2. It's exactly the same medication as Zocor, they just can't call it Zocor because that's a
protected trade name. (Sometimes this is met with a nod of understanding.)

3. You know when you buy Del Monte Canned Pears and right next to it on the shelf there is a can of "Great Value" Canned Pears? They're both canned pears. One just has a fancier label. (This one is only used when I'm hitting rock bottom.)

People get funny ideas about generics. We all have the customer who swears, "the generic doesn't work for me," (even though there is no earthly reason why it shouldn't) or "I'm allergic to the generic." I don't dismiss these people out of hand. Generic products can contain different inactive ingredients (colors, flavors, fillers) that theoretically someone could have an allergy to. The lack of effectiveness is a little harder to buy, although again, theoretically a person could absorb the generic product somewhat differently which might affect its action. I recently had a customer beg me for a few tablets of Cardura because since he was switched to the generic, "I can't pee." ( I gave him a few and started the prior auth. procedure -- he did look really uncomfortable).

Other times I think people get it in their head that the generic is not going to work and then proceed to enable that very thing by sheer willpower. I took a call from an exasperated nurse who needed to start a prior auth for Duac Gel because the patient would not use its two --- cheaper---- components separately (Clindamycin gel and Benzoyl Peroxide gel) because she claimed that did NOT work. I'd have a tough time with that. I'm glad to see that occasionally docs will refuse to do prior auths for some of this stuff.

Then there's the flip side of the coin, when someone is presented with a higher-than-expected copay for what is a very pricey brand name drug, and their first question is "Isn't there a GENERIC??" I have to answer, "No, not for this one."

And I get that skeptical look, AGAIN............

The Truth Goes Marching On

OK, so the makers of the delicious Sun Chips recently started packaging their product in a compostable bag made of plant-based materials. Better for the environment and a good idea, right?

Wrong. They have decided go back to the old packaging for all but one flavor. Why?
According to news reports:

"But that which makes them compostable also makes them loud. The bags have a different molecular structure from the original packaging, and they're stiffer. So people complained about the noise. Groups on Facebook abound with names such as "I wanted SunChips but my roommate was sleeping..." and "Nothing is louder than a SunChips bag."

Spokeswoman Aurora Gonzalez said the company received complaints about the noise from the bags, although it also received thanks from customers who liked being able to recycle them.

So the decision was made to remove the bulk of the biodegradable line."

Sigh. Some times I worry about this blessed land of ours. Yeah, the environment's important and all, but DO NOT, I REPEAT DO NOT, mess with our salty snacks and our ability to partake of them when the roomie is asleep. There are certain things that are sacred.

Why is this pharmacy-related? It isn't really, except that I often throw a handful of Sun Chips into the pitiful lunch I wolf down back in the stock room. It was a noble try, guys.

I Have Seen the Enemy and It is Me

There are some days (I repeat, some) when I feel like I can really kick ass in this job. Multitask like crazy. Juggle about 15 balls in the air at once. Make snap decisions. Keep things moving. Everything is humming along pretty well and staying in its groove. I've got notes and pieces of paper everywhere but I know where everything is and what's going on with it.

Then, it happens -- that one interruption, phone call or yelled question that somehow upsets the boat. Someone hands me a prescription and asks me to put it on file for them. A few minutes later I realize I don't know what I did with it.

What the HELL did I DO with it? I JUST HAD it in my HAND. Damn it, where IS IT?, I screech.

God, I hate that. Everyone else looks sympathetic but is really too busy to offer more than meek suggestions ("maybe you left it by the register?") I start to empty the garbage cans. I look under every piece of paper, every computer terminal. I am completely thrown off. I get behind and other things start to pile up. The whole rhythm of the universe has completely gone to hell. I fear that my co-workers are secretly snickering and wondering if I am, y'know, losing it.

It's kind of upsetting when your whole workday can turn bad over one misplaced piece of paper. I never did find the damn thing. I'm still stewing.

A Workplace Topic of Conversation Today

There was a news story recently about a mother in Michigan who complained to her daughter's school about the appropriateness of a cheerleading routine that the 6-year old was practicing. It included the words,

"Our backs ache, our skirts are too tight, we shake our booties from left to right."

That's right, SIX year olds. I didn't know they started 'em that young. I guess it's no surprise that in the cut-throat world of cheerleading the end result was that the cheer stayed and the kid left the team.

One of my co-workers was commenting that his very young, school-age daughter and her friends liked to gleefully sing the "California Gurls" song that was popular this summer, including the lyrics "sex on the beach." These are second-graders.

I don't have a daughter, and I'm kind of glad. I'm not sure I could handle it. I'm not trying to sound like the Church Lady here, cause I'm not --- but the messages that girls get about the 'booty', starting at a very young age, has got to be something that is really difficult to navigate. Our kids are totally surrounded by sexual images. We can control what they see and hear to a certain extent, but we can't shield them forever unless we lock them in a closet. I remember an article once pointing out that the U.S.A. has a very schizophrenic attitude towards all this. There's a huge uproar when Janet Jackson has a wardrobe malfunction and flashes a breast on TV, and yet I can't pay for my groceries without an issue of Cosmo screaming "orgasm" in my face or watch any sporting event on TV without the Viagra/Cialis/Levitra hit parade.

I sometimes think that being a pre-teen girl nowadays might be the depth of misery. I see them come through the pharmacy sometimes, and walking to school around my house. Most of them don't look anything like Katy Perry. I know I didn't. I guess those of us behind the pharmacy counter (and in the doc's office) often get to see the consequences of the --uh,-- 'booty', a little too often. Believe me, I bristle at the thought of any Morals Police looking over my shoulder, but sometimes I wish we could just dial it back a little. For the girls, and for the boys.

Same As It Ever Was

This customer comes up to the counter to collect a Z-pack and some codeine-containing cough syrup for what appears to be a respiratory ailment. He seems thoroughly pissed off and grumbles to me, "Why do I get this every month? Why is it when I ask the doctor why I keep getting this, he just says 'I dunno'??"

Well, sir (ran my inner monologue) it might be related to your being about 150 pounds overweight. I don't sense a lot of physical activity here. I sense a general state of unhealthiness exacerbated by a lack of some good air moving in and out of those lungs on a regular basis --- like the ol' cough-and-deep-breathe they make you do in the hospital when you're bedridden so you don't get pneumonia and things like that.

But boy, was he mad at that doctor.

My second thought today has to do with the dreaded Hospital/Nursing Home/Rehab Center DISCHARGE. No pharmacy wants to see this horrendous fax coming because it usually means mass confusion, multiple questions and unanswered phone calls, a long, long list of medications both new and old that need to be filled and a thoroughly hysterical patient or family who don't know what the hell is going on (and are completely OUT of medication). I'm sure there are many places that try to do their best in sending the patient out the door with a clear set of instructions. Most of the time, it doesn't seem to work very well. The medications have usually been copied down by someone who doesn't know what they are writing. Most of the stuff wasn't even meant to be continued after discharge. Doses or medications have been changed from what the person is used to taking, and they don't know why. Some people get really upset by this and when they are elderly or confused to begin with, it's never good.

The companies that provide pharmacy services to long-term care facilities, as well as every hospital pharmacy, should have a Discharge Specialist. Some hospital pharmacists do discharge counseling on a regular basis --- that's good. They sit down with the patient or family, go through that list of medications, weed out the unnecessary stuff and clearly show them THIS is what you were taking before, and THIS is what you're going to start taking NOW.
They also set up a mechanism for them to get those medications filled and deal with the 'refill too soon' because the nursing home has already billed for them. Wouldn't that be great??

"Retreat hell! We just got here!"

It's end of summer/back to school time which means many things for pharmacies (stock up on the lice stuff). Between various friends and family who work at different types of jobs I feel like I've heard a lot about 'retreats' lately -- you know, where a bunch of people from a company or department go off somewhere for a day and talk about their goals, their mission, their overall plan for the upcoming year, whatever.

Everybody hates these things with a passion. Usually they are boring as hell and considered to be a total waste of time. When I worked hospital all of the staff had to endure a bunch of meetings during the 're-engineering' of our department. Giant binders full of glossy flow charts and lists of stuff were generated by some out-of-state consulting firm that just modified the same recipe for whatever company they were hired to torment. People saw their job descriptions literally change overnight and there was a mass exodus of personnel (the economy was better back then so nobody worried about getting another job.) Gawd, it was horrible.

Thankfully, as a mere worker bee I am spared this in my current retail setting, but the pharmacy managers are required to attend gatherings like this and generate a rather fuzzy list of goals and objectives, which mostly just involves changing the order of the sentences from the previous year. They have no problem with WHAT they would like to do, it's the HOW that never really gets addressed.

I don't have anything against group meetings like this, but I'll never understand in a million years why they don't get all the people who DO THE JOB together once in a while to brainstorm on how to make things better, easier and more efficient. None of this ethereal 'goals and objectives' crap. Actual nuts-and-bolts ideas. I work with a lot of people who have some great ideas, but it almost seems like the people who run the place are afraid of us --- they never ask, they never give feedback on a suggestion, and people just keep bitching about the same problems day in and day out. I'll just never understand it. Somebody comes up with a simple idea, like moving a computer terminal, and it takes an Act of Congress to make it happen, if it ever does. This has been such a consistent theme through my entire work life so far, and it still drives me nuts.

OK then, back to school. My mission will be to tread lightly through the Nix and the ADD meds. Oh, and anybody know how I order more paper towels?

What's MY Delta Tau Chi Name?

Congratulations Mom, your son/daughter's in college. I've spoken to many of you in the last few days who need to have their prescriptions filled and mailed to their college address.
No problem -- you simply give me the complete information on where to send it, and it will be done. Invariably though, these conversations usually include the words, "He/she just told me that they are completely out." And, I can clearly sense when I'm talking to a helicopter mom who wants me to work a miracle and get that prescription in to their kid's hands by midnight. It's especially interesting when it's a C-2, y'know, like Adderall.

Now, we all want to help our kids out; be their advocate, give them the tools to be successful. Here's a teachable moment. If you're going to do the ordering for them, they must tell you when they are down to a week's supply. They can put a reminder on their computer calendar, into the iPhone, onto their Facebook status --- I don't care. Better yet, you might want to teach them to call the pharmacy number themselves (it's on the bottle!) and simply tell us what they need and where it is to be sent. And if the kid runs out of Adderall and bombs a test or something --- well, it's a lesson learned and it will probably help them remember the next time, or maybe it will take a few times. We all learn this way.

It's all part of the college experience. Now go make that Dean's List!! TOH-GAHHHHHH !!!

Control-Alt-Delete Me

The pharmacy computer system we have right now has been plagued with glitches and problems from the get-go. In fact, all our technology seems inherently unstable. When it does something weird like kick you off without saving any information, everyone just shrugs, says 'whatever' and starts over.

It just infuriates me that we have the same problems over and over again. I don't know how many people out there regularly have to call their company's computer "help" department, but the fact that these people can't diagnose the SAME PROBLEM we had a few days ago just aggravates me. And of course, the person you are talking to on the other end of the phone isn't even in your own state. I spend the first 15 minutes explaining where I am, who I am and what system I am calling about, and the person I'm talking to seems to be looking at it for the very first time themselves ("Wow, would you look at that screen, huh?") Then they want to give me a reference number and call me back in 15-20 minutes. Yeah, that'll work. Meanwhile, my entire work flow has ground to a halt and I've got a line-up of customers glaring at me and looking like they're about to burn me at the stake.

We are totally dependent on our technology. Believe me, I'm grateful for it even though I am whining here. There's just got to be people out there who can quickly diagnose and then permanently fix these problems, especially the ones that repeat themselves again and again. The face-to-face interactions with our computer people are no better -- they always seem mildly amused by my predicament and start asking me questions about my hardware and my servers until I want to scream HOW THE HELL DO I KNOW? THAT'S YOUR JOB !!!! YOU PEOPLE INSTALLED IT!!

I'm not opening any weird attachments. I'm not deleting programs, pulling any plugs or doing anything I'm not supposed to be doing. Just tryin' to do my job.

Thank you for allowing me to vent. Maybe the heat is getting to me.

This time it's not about the customers' cell phones

So I'm sitting in the tiny 'back room' of the pharmacy eating lunch, surrounded by other employees' purses, backpacks, etc. and several times while I'm sitting there people's cell phones are going off. They can't hear them, so they ring multiple times and go unanswered.

Putting aside the question of why people will call other people's cell phones when they KNOW they are at WORK (??), I at least give these employees credit for leaving their cell phones in the 'back.' That's where I leave mine, and once in a while I might go back and check it, but it stays there.

I've got to believe most pharmacy workplaces have strict policies on cell phones, don't they? Mine apparently does not. Some of our managers are really lax about it, and I'm seeing more and more people working while carrying their cell phone in a pocket or (more often) just leaving it on the counter. Granted, it's generally out of view of the customers, but when I ask somebody a question and realize they are not answering me because they are deep in text-messaging concentration, I do a slow burn. Never mind talking on the damn thing in the middle of the pharmacy.

Is this a problem for anyone else or do I just work in an incredibly lax place? I'm debating whether to ask "upper" management to tighten things up a little and make it a rule that cell phones stay out of the general work area. They'll definitely do it, because they probably don't realize it's going on....but then again I'll be the bad guy if someone finds out.

At Least It's Friday..

After finishing a long session with someone whose expensive, sustained release pain medication was too soon to fill because he had been taking approximately 4 times the dose that was prescribed and didn't discuss this with his doctor so there was no way I was going to tell an insurance company that we confirmed that he HAD consulted with his doctor when in fact he had NOT.... (and this is the kind of thing I love to get on a Friday afternoon)..... I turned to the next prescription.

A beautifully laser-printed, signed document with just the essential information. We'll bang this one out in 45 seconds, I thought, until the technician brings it back and says, "what should I put for the directions?"

Here's exactly what it said:
"1 each 2 times a day 1 tab po qam orally." (quantity, 30).

This was one of those psychotropic meds that could be taken 100 different ways.

A call to the office phone number on the prescription revealed a fortress-like phone triage system finally ending in a voice mail.

This is why your pharmacist is kind of cranky sometimes.

I'm Lovin' It??

Customer drops off Vicodin prescription and says he'll be back in a few minutes. I get 'refill too soon' reject. Hasn't filled the prescription with us recently and the reject doesn't tell me anything else. I get the distinct feeling this customer's going to protest the resulting situation (that being, no Vicodin for you today) and I log onto the new Prescription Drug Monitoring website so I can be armed with the reason. He filled the same prescription (120 tablets!) four days earlier at a CVS in the city. Busted.

He pretends to not quite understand what I'm telling him but very quickly gives it up.

Wow. Something that worked that way it was supposed to . Who knew?

Survey Says........

I admit it, I bury my nose in Vanity Fair magazine every month. The last page is always devoted to the Proust Questionnaire, a 'personality' questionnaire usually given to a celebrity or other famous person. The answers can be serious, creative, funny, or a combination of all. I think my favorite answer was Conan O'Brien's, when asked, "What is your idea of perfect happiness?" he answered, "A walk on the beach with my Israeli bodyguards."

Anyway, I always wanted to try it -- it's a little harder than you think, but kind of fun.
Give it a whirl.

The Proust Questionnaire

What is your idea of perfect happiness?
( Nerd alert! ---)
Being in the middle of a really, really good book that I can't wait to pick up every night.

What is your greatest fear?
What isn't?..... but let's start with making a mistake at work that hurts somebody.

Which historical figure do you most identify with?
Rosie the Riveter.

Which living person do you most admire?
Tough choice. One pair that comes to mind is Bill and Melinda Gates, for using their great wealth the way it ought to be used -- to save lives and try to change the world.

What is the trait you most deplore in yourself?
Reticence.

What is the trait you most deplore in others?
An overblown sense of their own importance.

What is your greatest extravagance?
Expensive food treats.

On what occasion do you lie?
To protect the weak.

What do you dislike most about your appearance?
At the moment?..My upper arms.

When and where were you happiest?
Right after becoming licensed as a pharmacist -- I had a full-time job, my own car and my own apartment... everything I had worked for, and I was happier than a pig in shit.

If you could change one thing about yourself what would it be?
More confidence.

If you could change one thing about your family what would it be?
Make it larger.

What do you consider your greatest achievement?
Being (I hope) a productive member of society.

If you died and came back as a person or thing what do you think it would be?
A career girl, like in a Doris Day movie, in late 1950's Manhattan.

What is your most treasured possession?
My home.

What do you regard as the lowest depth of misery?
Watching a child leave the pharmacy with an openly harsh and uncaring parent.

Who are your heroes in real life?
People who face aging and illness with dignity and humor.

What is it that you most dislike?
Those who celebrate, and propagate, ignorance.

How would you like to die?
Fast asleep. On second thought, scratch that ---- like Thelma & Louise.

What is your motto?
Be responsible for your own happiness.

A Footnote to the Last Post

A couple of comments to the last post made me want to add just a few thoughts. The point I was trying to make (and it's a source of tremendous frustration to pharmacists) is how much time I have to spend some days doing guesswork. I don't mean answering questions or offering advice; I mean trying to get basic information from people whose responsibility it is to provide that information TO ME so I can do my job (and no, I don't think it's the worst job in the world at all). I'm a pretty experienced pharmacist and I can work with some pretty small shreds of information, but there comes a time when I simply can't guess anymore.

There's a subset of otherwise capable people, for example, who will NOT learn the names of their medications. Now, I don't expect them to be able to spell it or even pronounce it that well, but I do expect someone to have a basic idea of the medication's name and what it is for. If you want a written list, please ASK ME. I'd be glad to provide it --- in fact, that IS part of my job, as opposed to the insurance agent/postal clerk/coupon detective/phone operator stuff which is not. I also think people should have an idea of when they need to replenish the supply of that medication (how about when those last few tablets are rattling around in the bottle?) Call the phone number on the label and read me the prescription number. That's it. I will do the rest.

However, if you don't have the bottle you'll need to provide me with a little more information. When I worked in hospital pharmacy we had seriously ill people admitted who had NO CLUE what medications they were taking. Not ONE clue. It was left to someone else (the overworked resident, brand new RN or overwhelmed night pharmacist) to figure out. People who use prescription medication need to know what medication they take. This is not JUST FOR MY CONVENIENCE. IT IS FOR YOUR OWN SAFETY.

And my main point was that we accept this lack of responsibility because it's 'medicine',

it's being sick, it's health care, it's "I'm the patient", it's 'what are they giving me'---- and yet we would laugh at someone who walked into a furniture store and couldn't articulate if they wanted a chair or a coffee table. And the wrong prescription medication has a lot worse consequences.

To the commenter who was frustrated with trying to pick up 6 prescriptions every month ---

I really do sympathize with you. Pharmacy is an over-regulated, very labor intensive business where the human factor takes a front row seat. Most pharmacists I know dislike the 'auto refill' process because it rarely works well for anyone. My advice would be to find a smaller pharmacy with people who will work with you and give you a little more personal assistance. Give them time to work on it and hopefully it will save your sanity.

Thanks for all the great comments!

When Will Other Businesses get their act together and run like a pharmacy?

When you think about it, retail pharmacy is sort of a unique undertaking, and after a long day filled with customers' inattentiveness, strange requests, weird questions, lack of information, non-English speaking interactions, half-believable stories and total guesswork as to what THE HELL they really want I keep wondering what other retail businesses would do if faced with our average day.

For instance, I tried to imagine, the......

TOP TEN THINGS OVERHEARD IN A FURNITURE STORE THAT RUNS LIKE A PHARMACY

1. "I need to get a dining room chair -- well, maybe more of a bar stool or a recliner.... I got one a while ago, it may have been blue or green, but it's some sort thing you sit on, anyway, made by company starting with 'S' or "W".....could you check your computer to see if I've ever bought anything like that before and can I get another one? Go ahead, read me the list and I'll see if anything rings a bell."

2. I talked to someone in your Chicago store who said they would figure out what it was and then call you and have you put it aside for me. I don't know who I talked to . Can you call them?

3. if I describe my dining room to you can you tell me what I might need or what's missing? -- and then how much it (whatever it is) will cost?

4. I have a discount coupon for some kind of chair or table but I didn't bring it with me. Can you look me up on your mailing list to prove that I did get one in the mail so you can give me the discount price? Or, can you call my wife/husband at home and they will read it to you? How long will that take?

5. My neighbor's' going to pay for it. You'll have to call him to get his credit card number.

6. I think I bought a sleeper sofa back in 1989 that was only $200. Why is it more now? It's always been $200.... or maybe it was a desk......anyways I know I bought it here.

7. I'm having company tonight -- can you give me a couple of chairs to get me through the weekend and I'll (maybe) come back next week and get the rest.

8. I need six of them, but once you get it loaded in my car and the paperwork is totally complete I'll probably change my mind and only decide to take three.

9. I lost that lamp I bought 2 days ago... is there some way I can get another one without paying for it again?

10. You know what? ---maybe it's actually a rug I'm looking for......

And remember, furniture can't kill you. I think the average furniture store employee would walk away from this pretty fast, but in pharmacy it's just another day.

And Another Thing........

I remember some years ago picking up a magazine at work that was primarily aimed at family practice physicians. There was an article called "Dealing with the Difficult Patient" and to illustrate the article there was a picture of a guy in a hospital gown sitting on an office exam table glaring into the camera with his arms crossed and looking thoroughly pissed off. The kind of picture that makes anyone want to turn around and run far, far away.

I know there are some people who feel they've always got to be a squeaky wheel to get the results they want, especially if they are fighting some faceless bureaucracy or rude desk jockey who's clearly not doing his/her job. I can understand that... but what bugs the crap out of me are the ones who DON'T PLAY BY THE RULES but get what they want simply because they are such well-known A-holes that no one wants to deal with them.

Like the guy who came in expecting to pick up a refill and was told by us that it was denied. He stared us down and kept saying "that's not acceptable." We went round and round and explained it was the doctor's decision and we're just passing along the information at this point. He finally stomps off to the doctor's office (who is in our building) and 15 minutes later comes back WITH A prescription.

That just bugs the crap out of me. We talked to the nurse later who indicated they had eventually buckled and gave him one month because the guy was always so difficult and put up such a stink. Something along the lines of "we've gotta keep him happy."

I really hate that. And the next time he's just gonna do it again. (Why not? it worked.) He ought to have been told, "Them's the rules, if you don't like it, go somewhere else." Jerk.

The Call-Back

So this customer calls and needs to talk to a pharmacist. She then proceeds to rattle off a boatload of medications that she needs to pick up THIS morning, before she goes to work in the afternoon. I tell her there are many orders ahead of her, and I'm not sure we'll be able to have all of hers ready in time. She pisses and moans, and then asks if we can call her when they are ready. I agree, but then she says, "Well, there's really only one thing I absolutely need today -- I MUST have it, I am completely out."

OK, I tell her, we will definitely have that one item ready for you to pick up when you come in. I can't promise the other things, but we'll prioritize the one item you need and you can pick it up.

Now, imagine for a moment you are this customer. Which of the following do you proceed to do.... DO YOU:

a.) Stop in at the pharmacy on your way to work to pick up the item you desperately need and be glad you were able to get it on short notice.

OR

b.) Call me back at about 4pm that afternoon, from work (and therefore now unable to pick up the prescription before we close) and shrilly demand why NO ONE CALLED YOU to tell you your prescription was ready? When I remind you of our previous conversation (which everyone else in the pharmacy can attest to) you remain pissed off, as it's all MY fault, refuse any alternative I propose (such as transferring the prescription elsewhere) and hang up on me.

I'm sure you can guess which option this customer chose. It's just like those phone calls we get where the customer says, "Why didn't anyone call me to tell me my prescription was ready??? I've had NO medication for 4 days!"

Really? You forgot how to use that telephone, huh? There's really no obligation on your part to take the bull by the horns and give us a call? Huh. I mean for crying out loud, every 6 year old has a cell phone nowadays.

I see Walgreens is now advertising 'texting' people when their orders are ready. Great. We don't quite have that technology just yet, and probably won't any time soon.

If people ask for a call back, we make a note of it and do it. And by the way, if I get no answer, or an answering machine with no identification on it, then the ball is pretty much back in the customer's court. I've got to move on.

But please people, take just SOME responsibility for obtaining that medication you absolutely MUST have today. Since you decided to wait until you were completely out, it would be nice if you didn't blame me for that too.

Drama on Both Sides of the Counter

When you're working long hours in close quarters you learn things about your co-workers in the course of normal conversation and chit-chat. I enjoy these conversations for the most part, although I'm not much of a chatter because I generally can't do that and concentrate on what I'm doing. I don't mind if people want to share stuff with me but I've never been one of those people who shares every intimate detail of my life with the people I work with. I guess I just prefer to keep some separation there -- that's just me.

I've mentioned before how filling prescriptions gives you a bit of a 'window' into people's lives. It's happened to me several times --- I've been working with someone and am impressed (maybe even a little envious) of how 'together' they are --- attractive, smart, personable --- then, I have the occasion to check one of their prescription refills, and I'm looking at a whoppin' dose of Prozac along with a healthy helping of Xanax or lorazepam on the side. Don't get me wrong -- it doesn't change how I think of them and I would NEVER comment in any way on someone's prescription --- but it reminds me that life often isn't as smooth as it appears.

I guess where I'm going with this is that the lives of some of my co-workers seem to be imploding --- divorces, child custody and financial issues being the primary issues. I just read an article entitled "Growing Up is Taking Longer, Economically and Socially." I think it's true. When I hear of someone getting married in their early 20's, I know that the chances of that marriage lasting are not good at all. It particularly bothers me when there are young children involved -- I SO wish people wouldn't have kids when their lives are unstable; I wish they wouldn't think having a baby is like getting a puppy --- but I digress.
I just feel like I'm surrounded by stories of people behaving badly and irresponsibly. People who just don't have a mature foundation and who want to walk away from their responsibilities with no consequences. Everyone encounters some misfortune in their life, but these kinds of things are "eyes wide open" situations that I think could have been averted.

It just bothers me, I guess. I've got the advantage of a few years over them. I'm a pretty practical person to begin with. All I can really do is offer sympathy and listen. I come home from work unsettled, though. Kind of a squishy post here, but it's something I've been thinking about for awhile.

I Lost My Mojo

Jeez, I'm out of practice. Granted, it's been awhile since I took 10+ days vacation, but after being back a few days my knees are screaming, my eyeballs are throbbing and I am totally wiped. I did a lot of walking on the trip, but apparently that means the body is now unaccustomed to just standing all day and staring at computer screens and assorted pieces of paper. I gotta get back into fightin' pharmacist form -- this is ridiculous.

In pre-pharmacy (and I'm sure pre-med, pre-dental, pre-podiatry, etc.) we all have to take stuff like calculus -- get through it, and never think of it again. I couldn't solve a differential equation now to save my life, but I think simple addition and subtraction is perhaps a skill they should emphasize more. We had one course in pharmacy school where we were allowed no calculators -- we had to solve those pharmacy 'math' problems the old-fashioned way, and BOY did people struggle with that course. Even if they knew how to solve the problem they would always make some dumb math error (and there was no partial credit). I bring this up because one of our narcotic counts was way off the other day. Still trying to get my mojo back, I stared at the log, re-counted tablets and rifled through old prescriptions before realizing that someone had received a new bottle of 100 tablets, added it to the 230 already in stock, and come up with a new balance of 490. Sigh. There's 20 minutes I'll never get back.....hopefully I'll get the groove back this week.

Me: 1 Volcanic Ash: 0

I was creating every possible scenario of what could go wrong on my recent trip (as I always do) and of course none of it happened and it was a successful and fun time. That pretty much does it for me as far as summer vacation (till the very end of August anyway) but I figure I miss the biggest crowds this way.

"Across the pond" I am struck by how much people do rely on public transportation -- trains and subways in particular. It seems like there is always a crush of people and the strain on the system has got to be relentless. There's always some sort of maintenance work going on and disruptions in service are an ever-present possibility. Not that we had any problems, but after a few days of being on the move things can get nerve-jangling.

In several of the train stations, as well as at the airport, I took note of occasional signs which read "Abuse of Staff will not be Tolerated", followed by a warning about said abuse and what penalties could be incurred. My first thought was that it's unfortunate such signs are necessary. My second thought was, where can I get hold of one of those signs?.... you know, for those special days in the pharmacy. Yelling at me because your doctor hasn't authorized a refill has about the same result as yelling at a ticket agent to get the trains running on time.

Ultimately, we just have to abide by that other phrase they use over there: "Keep Calm and Carry On."

Back in a Few

Probably taking about a 2 week break here. Having a few virus issues with the computer, plus I've actually got some vacation time! Going out of the country, and again being the nerdy pharmacist I am, looking forward to snooping in the pharmacies to see what they got that we ain't got! (Sad, isn't it?)

Anyways, will return soon!

The Paper Chase

E-prescribing, faxing, and electronic transmission of prescriptions to pharmacies can be ultimately more efficient, and I suppose it's an advancement in patient care, BUT...... sometimes I just can't shake the thought that it's yet another way to relieve people of their own damn responsibility in this going-to-the-doctor thing.

Guy walks in and plops a bottle of prescription lotion on the counter. There is no prescription label on it. He wants a refill.

OK, everybody out there knows the drill, right? --- the detective work now begins (for which I have NO time and even less interest.) Making a very long story short here, he got it when he got out of the hospital in another part of the state. We did not fill it. He can only give us a vague approximation of the doctor's name. We look at his profile and make a crude guess as to who the doctor is from some of his other prescriptions (luckily, there's kind of a "sound alike" name on his profile.) Guy insists we call right then and there. Person on the other end says please fax a refill request. We do, and convince the guy to check back with us later. All other people waiting in line behind him are now very cranky.

Doctor's office calls back a couple hours later...."he was handed a prescription for that with refills. Please ask him for it." OK, fair enough, but we all know what comes next.

We call the guy..... he claims he does not have the prescription (at least, that's the gist of a phone call that again lasts WAY too long.) We fax the doctor's office back again. Later, guy calls back, apparently rifling through a stack of prescriptions he has now found. After keeping my tech on the phone even longer and asking her to tell him what each one is for, he now apparently discovers the prescription. The whole idea that he would need to BRING that IN to the pharmacy seems to irritate and puzzle him.

Total time spent on this entire odyssey: WAY WAY WAY too much.

It makes me furious when I find out that someone was given a prescription and that same person sends me on a wild goose chase because they don't get the whole "you bring THAT to your pharmacy and they fill it" idea.

Is this, like, a totally outdated thing now??

The End of the Day

I was locking up the pharmacy and leaving the medical building one day last week. I think I was probably the last person out. A group of cleaners comes in to the building at the end of the day and works during the evening -- they come in and do some light cleaning in the pharmacy itself before we close. Like a lot of people doing this type of work, they are all Hispanic. They smile and say hello but most of them speak only broken English.

As I was leaving the deserted building I saw one of these young men working in the trash receptacle room. He had some music playing -- it was very lively Spanish / Mexican style music. What I mean is, it wasn't rap or hip-hop or Lady Gaga or country & western or any one of our American mainstays.

It was, I'm thinking, his music from 'home.'

It made me kind of sad. I guess I felt kind of lonely for the guy. I find myself wondering about the path that led this young man from his place of birth to a job in the Midwest cleaning up the detritus from a busy medical clinic (and there's a lot of it, believe me.) Could they find an "American" to do this job? Maybe, especially with the current economy -- but it would be a 'high turnover' kind of job. It's not very attractive work.

I like where I live. It's hard for me to imagine having to pick up and go somewhere else, anywhere else, to make a living. Immigration reform is going to be the next big screaming match, but it's really about time we stopped talking about it and did something. I'm a law-and-order person but there's got to be a civilized way we can provide some opportunities to people who are willing to empty our trash and refill the paper towels and scrub down the exam room floors and work late into the evening after they watch us walk out the door. I'm not saying I can offer up a perfect solution, but I would like to see us work on one.

I'm Sorry........ What?

This past week I can't count the number of people I waited on who had a cell phone pressed to their ear. Now, this isn't going to be another cell phone rant (although I'll say it AGAIN; if you don't terminate that call immediately, you have given the person on the other end of that call permission to hear EVERYTHING I'm going to say about your prescription. And I'm not going to wait one SECOND for you.)

In waiting on multitudes of people all day, I just can't get over how DISTRACTED everyone is.

We're supposed to counsel people on their prescriptions and believe me, I keep it as short and simple as I possibly can. I figure we should talk about the prescription at least briefly, but in addition to competing with the aformentioned cell phone, I've got people more concerned with trying to corral and discipline their kids, juggling their numerous bags and purses stuffed with everything imaginable, digging into those bags for money, credit cards, check books --- writing that check (which is a whole 'nother process in itself -- asking me the date & who they make it out to and then proceeding to balance that ledger), gathering up the other crap they have decided to buy and asking me if I've got it in any other flavors/colors/sizes, questioning the copay on the prescription before anything else and making it clear to me that actually using this medication has long since ceased to be anywhere on their radar screen.

With all the talk about the importance of 'education' in our country my biggest beef has always been that people don't take the time to READ, and if they do read they don't COMPREHEND. "Listening" is another skill that is similarly deficient. I told someone last week to get two doses of their antibiotic in on that day ---" take one capsule NOW, and another one TONIGHT." He calls me up 30 minutes later and says he took 2 capsules at once and is anything bad going to happen? .... And this is the easy stuff, folks.

With all the patient information and med guides we are required to stuff into every prescription bag, I'm honestly kind of surprised we don't get more questions from people.
I'd love to know how many people actually sit down and read through the instructions on that Spiriva or Asmanex or Maxair inhaler before they use it. People don't seem to know how to read and understand things that are right in front of them.

It's unfortunate that most of the children's cough/cold medications had to be pulled off the market recently -- not because they are inherently unsafe, but because too many parents couldn't read the damn directions and give their kid the correct dosage.

I find this worrisome. We can't live our lives in text messages and e-mails and Twitter feeds... but no one seems to have the time or the focus anymore.

The $20 Bottle of Acetaminophen

Fellow pharmacy blogger "Fries with That" recently had a post entitled "OTC products on Medicaid" (http://fastfoodpharmacy.blogspot.com/2010/04/otc-products-on-medicaid.html),
voicing frustration with the time and effort spent having to process prescriptions for cheap OTC medications that are covered under states' Medical Assistance programs.

It's true; the time and labor spent on these things costs way more than the prescription itself is worth -- but they have to be inputted into the computer, filled, counted, poured, labeled and checked just like an Rx-only drug. One of the pharmacies I cover does stacks of these. We'll get entire families of several kids getting Tylenol, Motrin, hydrocortisone cream, petroleum jelly (yes, it's covered)... adults and kids getting generic Claritin in all its forms, Benadryl, assorted topical lotions, vitamin products... you name it. I get really frustrated being buried under piles of these, and having to get them corrected and re-processed for NDC number, or directions, or number of refills, or bottle size, etc..... seems like a complete waste of valuable time.

I say, Medicaid plans should set up an OTC charge. With a couple of keystrokes, we bill them one charge -- and I know, we'll have to fight about how much that will be --- then we pick the product(s) off the shelf and hand them to the customer. Done. Time saved, resources saved. I am more convinced than ever that cutting health care costs is going to involve the little things that reduce people's TIME, and cut out the middle man. We don't always need to cut the service, we just need to do it smarter.

Sitting in the dentist's waiting room I am perusing "Rolling Stone" magazine. I've long since lost track of what 'the kids today' listen to, but apparently one of the most popular college-played bands is "Ted Leo and the Pharmacists." Whaaa??? I listened to a couple of songs online --- they're not bad! I don't think they write songs about pharmacy though... no "My Vicodin was Stolen from my Boyfriend's Car" or "What? My Copay's Always Been Zero."

Random Thoughts While Waiting for the Cable Guy

So we're getting more OTC proton-pump inhibitors on the shelves, and I know people will be confronting me with boxes of Prilosec OTC, Prevacid 24HR and now Zegerid OTC, and asking "Which one is better?" I don't blame them for asking, but I don't look forward to giving my usual mealy-mouthed answer which is, "There's probably no real difference." Then they kind of look at you like... yeahh.....rightttt..........thanks a lot........
By the way, Zegerid OTC (which is Prilosec + sodium bicarbonate) says it contains a "special ingredient" (that's the sodium bicarb, the medical term is "baking soda") that "protects the powerful medicine from acid in your stomach so it can be quickly absorbed." However, there's a little asterisk after that last line: *Speed of absorption does not imply onset of symptom relief." Whaaaa??? I guess the selling point is not really.... a selling point after all.
What the hell, maybe that bicarb will help your heartburn.

I got totally bogged down in a Sudafed transaction last week. Scan the driver's license.... won't scan for some reason...call someone over to help me.... fill out logbook, get signatures, etc. etc. and babysit customer while you walk them through all this. I've concluded that since there's no central database that pharmacies share anyway, our lawmakers should have just done the following:
1. Sudafed products go behind the counter.
2. You can buy ONE package of any available size. No screwing around with logbooks.
3. If you want more, get a prescription.

And if you come back too many times, we'll recognize you. This would accomplish pretty much the same thing as the system does now, while giving me a few precious minutes back.

Someone handed me a prescription for Robitussin 200mg/5mL syrup. Every Robitussin product (brand or generic) I could locate is 100mg/5mL. There used to be an "Extra Strength Robitussin" but I could find no evidence it still exists. This was a computer-generated prescription. Could we puh-leeze purge that system of products that no longer exist? Again, the customer looked at me a little strangely.....

I know what I'm doing back here, honest.

If You Feed Your Toilet Paper UNDER the Roll, Please Seek Care Elsewhere

Dr. Grumpy had a recent post (http://drgrumpyinthehouse.blogspot.com/2010/04/sunday-seriousness.html) about the Florida urologist who posted a sign outside his practice reading "If you voted for Obama... seek urologic care elsewhere." Dr. Grumpy's take was:

"I don't discuss politics with patients. They ask me what I think of the new health care bill, and I give them a generic "We'll see what happens." Divisive discussions aren't good for a doctor-patient relationship."

That's it. That's the only way, plain and simple. Most of the commenters agreed but a few seemed to be on the fence, saying this guy has a right to run his business the way he wants, even though they may not agree with him.

Now, putting aside the fact that this urologist seems woefully misinformed --- like claiming that hospice care will be "cut" but being unable to supply any evidence of that ("I can't tell you exactly what the deal is" he says, when asked) --- I don't buy the suggestion that there's any excuse for this guy at all. Maybe it's not illegal but it is unethical, irresponsible and 100% unprofessional.

In the course of a day we occasionally have patients make comments about the news, current events or whatever, in the course of small talk or conversation. You smile and nod and make some benign remark. It's very wise to stay away from touchy subjects. If someone were to come into my pharmacy and want to engage in loud pontificating about a political viewpoint I did not agree with I would grit my teeth, shut my trap and probably get them out of there as soon as possible, but I would still do my JOB, and I certainly wouldn't tell them not to come back (my employer would take a dim view of that.) It seems to me it's kind of a sacred principle of medicine that people should be able to get medical help from a doctor no matter what their situation. You go to a doctor's office with perhaps some very embarrassing condition and you get non-judgmental HELP. The majority of medical professionals live up to that -- that's what the word 'professional' means. It's the foundation of medicine, isn't it? This Florida guy is just showing himself to be one of the 'bad' doctors if he can't do that.

It's like the cop who deals with a belligerent, abusive drunk and calls him 'sir' the whole time. I admire the hell out of that. It's his job, and he'll do it that way because he respects himself and his profession.

I will never forget when I was a new graduate and was working in the Cardiac Care unit of a hospital, doing chart and med checks. This patient had been admitted who was well known to us --- one of society's cast-offs. He was homeless, obese, had multiple medical problems and was not exactly the most attractive human being you've ever seen, if you get my drift. The med students and residents were tired of him, and here he was back again with some new problem. I sat down and looked at his admission note. The admitting cardiologist had HAND written the most elegant, thorough, organized and complete 5-page note I've ever seen, before or since. I remember thinking, this is the doctor I want. This is the doctor I want advocating for ME. He's going to do his best for this patient, no matter what. Mr. Florida Urologist couldn't even pack this guy's lunch.

In our blog world we often complain and vent about the quirks and weirdness of our jobs and our patients. It's an outlet that everyone needs. But in the end I think most of take it very seriously that we do our jobs for them the same as for anyone else. The day I stop doing that is the day I KNOW I'm finished.

I only hope another urologist arrives in the area and posts a sign on his door that says "I'm a doctor, come and see me."

Are We a Pharmacy Today or Not?

One of the pharmacies I work at is a small store with a pharmacist-in-charge who is very stingy with inventory. You'd think the purchasing money was coming out of his own pocket. Part of this is probably a personality quirk but I'm sure he gets a pat on the back from the head honchos for keeping inventory costs low.

Of course, he's not there on the days I work, and one of my biggest frustrations right now is not having drugs in stock & having to constantly fill partial prescriptions and 'owe' people the rest. I feel bad enough that I usually offer to mail it to the customer (IF it's an item that can be mailed) --- so, we get hit for mailing costs anyway. Seems it would be cheaper to just have enough in stock. I can almost tell just by looking at a prescription when it's handed in that we're unlikely to have enough (TWO bottles of Peridex??? -- ha, you wish). And yes, we've got the computerized inventory system which is supposed to replace what is used, but when he's got the par levels set ridiculously low it doesn't work so well. Plus, as we all know, you cannot rely on people to call in the day before to order their refills. We lost that battle a long time ago.

People get annoyed when this happens constantly. They're coming in every month for the same damn thing and we're always short. I'm mailing one tablet here and two tablets there. People claim they didn't get the balance of their prescription, or dispute the amount they were owed. What a headache !! Just KEEP SOME DRUGS on the shelf !!!!!!

Oh, and by the way, maybe the 4th or 5th time somebody asks for an OTC product we don't carry, maybe we could, y'know.....CARRY IT. I have no business training at all, but this seems like a swell idea to me.

Oh, Baby

This couple came into the pharmacy last week with a newborn baby. Now, I think it's safe to assume that they were the parents, and I swear the Dad looked about 15 years old.
Mom didn't look much older. I've got professional co-workers in their 30's who just had babies and are overwhelmed and exhausted. I can only imagine how these kids are feeling.

I also worked with a technician recently who I was meeting for the first time. She was telling me how she had been admitted to a very competitive college program a few years back, but didn't like it and dropped out. I'm not sure what happened in the interim, but today she has a school-age child and infant TWINS. She is a single mom, and drawing some state assistance.

I'm sure the kids are all real cute, but I'm a practical person. I can't help but think of the struggles ahead for people like these. I can't quite figure out how people find themselves in these situations. Life can be messy, I know, but........??

In my view, birth control is an essential part of public health (and public economic health, too). I get really irritated with old-guy politicians and other morally-superior folks who want to make birth control sound like merely an excuse for wild women everywhere to have promiscuous sex. And the issue of pharmacists who won't dispense birth control because of a moral objection has always exasperated me. I most certainly understand the differing views on dispensing something that interferes with an established pregnancy, but that's clearly not what we're talking about here.

If a pharmacist has a problem with the idea of birth control, they cannot work in a retail/community setting. There's just no way around it. They can work in other areas where they will never need to come in contact with birth control, if that's their issue --- hospital, pediatric, long term care pharmacy, industry, academia --- and they will suffer no loss in income, prestige, or opportunity for advancement -- so there's no need to cry discrimination.

I must admit I don't get it -- how someone can go through all the training that pharmacists must endure without understanding that birth control is part of public health. When women control their own fertility it has a demonstrable effect on poverty rates, the workforce, and the economy. I'm not saying don't have kids, I'm saying have them when it's the right time in your life.

I know it's a complicated issue. But WOW, did that baby's daddy look young.

Feeling Sorry for Myself.. Waaaaaa

I'm trying to focus enough to write today, cause I am totally incapacitated by allergies!
What the heck is doing this to me I don't know. I'm going to start sounding like one of those customers that gives the litany of disgusting symptoms I don't want to hear about -- post nasal drip that causes a sore throat and that tingly, itchy sensation in your nose and on the roof of your mouth. My usually reliable Allegra isn't working. Zyrtec isn't working. I take Benadryl at night and in the morning I feel like I had 12 martinis. I'm now going to move into the hard-core cold medications and keep piling on till something works.

Cripes, I'm actually woozy. Okay all you allergy customers, I'll join you (just for today) on the WAHHHH--mbulance........

Waste Not, Want Not

I am glad to see "waste, fraud and abuse" being talked about in the debate on health care reform and I think addressing it is something everyone can agree on. I certainly know there are vast amounts of prescription drugs wasted every day by people who don't use them or don't use them properly. Pharmacy staff are all too familiar with the customers who believe that if their copay is $10 then that must be what the drug costs. We also know lots of people will take a few doses of something, decide it doesn't work, and never touch it again. I was reminded of this the other day when I watched a 3-month supply of a prescription leave the pharmacy --- cost, over $800, copay, $3.

A few months ago I saw a "60 Minutes" segment on Medicare fraud --- a guy talking about stealing millions from Medicare by submitting fraudulent claims for wheelchairs, artificial limbs, etc., through a fake company. He said it was like taking candy from a baby. Estimates of Medicare fraud go up as high as 70+ billion dollars a year (that's BILLion). And of course fake 'pharmacies' are right in there too. The report mentioned certain areas of the country, like south Florida, where it's a huge problem.

I think our government should make it the highest priority to go after this stuff. Talk about creating jobs, too --- lets get armies of field inspectors out there! They would pay for themselves in one day. They wouldn't even need a whole lot of training; in fact, people could work out of their homes, couldn't they? They could screen suspicious claims or concentrate on certain areas of the country. They could call up the person on whose behalf the claim was submitted...."Say, did you in fact receive that $7000 customized wheelchair from FakeIt Medical Supply?" If they say no, well ---- boom, that's money straight back in to the Treasury. We're talking about saving billions here. Am I oversimplifying this? I think it would be a blast!

And Then He Jumped Off the Couch, and................

I've indicated before that I'm not a very good conversationalist when I am working. I have to concentrate... that's just me. When there's nothing going on of course, I am happy to do the chit-chat. Either way, there are some people that insist on keeping up a steady stream of conversation even when they MUST know I CAN'T listen to what they are saying.

Lately I feel like I've been bombarded with people who want to tell me stories about something their pet did. Long, detailed stories, just as if the animal is a person. Now, I like animals just fine. Listening to stories about someone's 2-year old kid can get pretty grim, but listening to the 15th accounting of that darn cat's antics is really putting my teeth on edge.

Kind of crabby, I know. It's been a long winter.

I Hate Being Forced to Sell Crap

There are still a lot of snake-oil remedies out there in the big-box chain pharmacies. In my job I don't usually have to deal with people asking if the Chaser hangover remedy really works, or if they should use some weird de-toxifying thing that is prominently displayed on our shelves. I can vouch for most of the OTC items we carry. Sure, there are some that I don't think are very good, like the sub-therapeutic-dose multi-symptom cold products, but for the most part I wouldn't tell someone "it's useless, don't throw your money away."

I don't have any real training in marketing or business, but I do know there is a sucker born every minute. The same people who loudly protest a $25 copay will gladly fork over that much and more for a 'natural, homeopathic' remedy. I take a dim view of that stuff. Sorry, but the placebo effect is very strong, and these are some really expensive placebos.

Unfortunately, some of these products are starting to creep into our inventory. Some non-pharmacy, remotely-situated retailing geniuses apparently think they will be a moneymaker (and they probably will.) We don't have a 'front-store' and a 'back-store' --- it's all one store, which means not only will I have to ring the stuff up, I will get asked what I think of it.

I'm going to be honest. But even if I nicely suggest another product with some true pharmaceutical evidence behind it, the customer is left wondering why we carry the first item at all. I hate being put in this position. I 'm not going to pretend I am happy to sell this stuff. But if I say what I am really thinking ("somebody who I've never even met has decided we need to carry this junk") I come across as .... well, a disgruntled employee?
I need a way around this...... know what I mean?

My Phone Avatar

There are many times when I pick up the phone during a really busy day and instantly regret it. I wish I could time-travel back 10 seconds and not pick it up. I wish I could instantly change places with a virtual representation of myself, who had plenty of time to take the call -- an avatar, if you will. I want my avatar to handle the following calls:

The historian. Someone who wants to give me a long, leisurely story about anything that pops into their head -- long-ago prescriptions, surgeries, doctor visits, family issues, etc. etc. leading up to ( I assume) a question, if they would ever just get to it.

The number reader. Someone who just wants to give me a list of prescription numbers to refill, perhaps with a little extra information about each ("You'll have to call the doctor on that one") in case I am unable to figure that out for myself. They don't want to use the automated refill line, which was created specifically so I would have time to actually fill those lists of prescriptions and not have to be on the phone all the time.

The non-English speaker. After about 10 minutes of back-and-forth on the line, I've been able to ascertain your name and date of birth. Now we're gettin' somewhere.

The salespeople. This one really gets me. What in God's name makes you think I have time to listen to you?? Without identifying themselves, they ask to speak to the 'owner.' When was the last time you worked in a pharmacy with an owner ??? For me, I think I was in pharmacy school and did a rotation in the last independent pharmacy left in the state. Then, they ask to speak to the administrative assistant (??) or whoever does the buying. Strike three, buddy, can't help you. Or it's some drug company rep wanting to give you a long scripted spiel 'just to let you know' about some product and what tier it's on with such-and-such insurance and would I feel comfortable now recommending it? I hate being rude to these callers, but have any of them been in a pharmacy lately? Do we look like we can deal with these calls?

Please hold for my avatar.

Groundhog Day, Again

I know there are people way worse off than me right now, but I'm gonna complain about stuff anyway. It helps to get it off my chest. Maybe it's just the cabin fever talking.

1. PIGSTY PHARMACIES. Half eaten food, water bottles, pop cans, dirty dishes. Make it go away.
2. ENDLESS CHIT-CHAT. Worked with someone last week who wouldn't stop talking. Stop it! I can't think. I can't concentrate. No problem, I'll just do all the work while you are chatting. Why are you here again?
3. FAILING TECHNOLOGY. The computer system is slow. The computer system is down. The register is down. Why don't we just hang a sign on the door: Go Away, We Don't Want Your Business. How's that for a business model?
4. FOREIGN NAMES. I'm sorry, but you're going to have to spell it. Rattling it off and staring at me defiantly isn't going to get us anywhere.
5. GIVE ME YOUR NAME. Speaking of staring, announcing you're here to pick up a prescription and then staring at me silently isn't getting us anywhere either. I'm gonna need your name. Think about it, you'll catch on.
6. FLEX SPENDING CARDS. What a pain in the ass these are, and I know they make them that way on purpose.
7. ASKING ME HOW LONG IT'S GOING TO TAKE. Did you ask the nurse that question? Did you ask the doctor that question? Did you tell the doctor to hurry up because you have to get back to work? And when I give you my best-guess answer, don't argue or try to bargain with me. Believe me, this is no fun for me either.
8. AND OTHER THINGS THAT JUST IRRITATE ME RIGHT NOW. The main selling point for a pregnancy test is that it's the "easiest to read." What a great start in life for the kid who's mother is too dumb to read the test....
9. THE WINTER OLYMPICS (and the summer olympics) cost too much money. The Beijing Olympic stadium is sitting in disuse and rotting. What a waste.

I can't wait till spring.

The Meaning of an Expiration Date

We get a lot of calls from people asking if some prescription they had filled a couple of years ago is 'still good'. I guess I can understand that question, but why does somebody call and ask if they can still use their bottle of vitamins that expired in March of 2007? I've had a string of these types of calls lately.

The fact that they have even looked at the expiration date indicates they have some idea of its significance. So I'm not sure what kind of answer they are expecting from me. Back in good ol' pharmacy school we were taught that for most pharmaceuticals under proper conditions, the expiration date is when they may have lost 10% of their potency. I know there were some studies recently that found many pharmaceuticals maintain potency well past the expiry date, especially if the packaging is unopened.

So yeah, if someone's in a really tight spot and they need to use a product, depending on what it is of course, I might say go ahead. But I get the impression some of these people just don't want to be bothered to buy another bottle, so they'll wait 10 minutes on hold for me until I can finally come to the phone and say, "Naw, I would probably discard it."

Just another puzzlement in the world of retail pharmacy......

Me Want Cookie

The neon sign on my local "Pharmacy America Trusts" reads "Dr. Siegal's Cookie Diet $59.99."

Say what? They sure have some wacky products in those WAG stores, don't they? Apparently on this diet you eat 6 of these cookies during the day, and then you're allowed to have, y'know, a 'sensible' dinner. I imagine anyone who could actually stick to this would indeed lose weight. That 59.99 price buys one week worth of cookies. Seems a little pricey to me.

I bet they're selling like crazy -- that's why it's up in lights.

By All Means, Move at a Glacial Pace

On a day last week at one of our smaller pharmacies (one pharmacist, 1 & 1/2 techs) we seemed extremely busy all day. Between the phone, cash register, new scripts and continuing January insurance issues there was no time to spare. At the end of the day, I look at the prescription totals, and I can't believe it --- you know, it says 110 prescriptions and if feels like 500.

What's frustrating is that the people at corporate look at JUST that number when allocating staffing and resources. You can't explain to them that it's not a true representation of how 'busy' you are. One of my 1 & 1/2 techs is lost to me on the cash register much of the time.
Endless phone calls are taken and made (mostly to insurances) and this eats up SO much time. We are bogged down in ordering procedures and the labor-intensive process of preparing mail-out prescriptions and calling people when their credit cards decline, etc... stuff that has nothing to do with filling prescriptions.

I can handle all that, but I can't change a staff member who is just inherently SLOW. This, I've realized, is probably our biggest problem. Somehow a simple, run-of-the-mill Vicodin script takes 10 minutes to produce in a finished form. I've got other techs who can enter/count/fill/label it in literally 90 seconds. In pharmacy, that's the way it has to be. You've got to be able to MOVE faster. And I mean physically, too. There are some people that just saunter around at the same pace all the time, completely oblivious to the situation crashing down around them. There are times when I want to holler, Come on, LET'S GO !!!!!! WHAT ARE YOU WAITING FOR ??????

Believe me, I don't believe we all have to run around like little jack-rabbits all the time.
But have you ever been waiting on a bank teller, or a receptionist, or a sales clerk who's moving at a glacial pace right in front of you? Just makes me a little crazy.

I Like Simplicity

Little hiatus there...... some family obligations over the holidays and then attempted to go someplace warm for a week. It was NOT warm. I'm actually glad to be back to the normal routine..

Anyways, the other day I was faced with working at a pharmacy where most of the 'regular staff' were off for the day. Even though I know the place fairly well, I absolutely DREAD this.

It never turns out well. Invariably, something comes up that only one of the 'regulars' knows about. Or we really need to find something and no one knows where it is. The fill-in staff will 'kind of' know some of the procedures but there are some serious gaps, or they just don't know how it's done at that particular store. I can't help them, because I never do those tasks -- it's always done by the regular technician and I am rarely involved in any way. Now all of a sudden all those people are off, and everything is supposed to run smoothly? Never. It's always a disaster. Even if the prescription volume is totally normal, everything is a struggle.

On a day like this, you can count on some customer coming in to follow up on a conversation they had with an (absent) staff member 3 weeks ago, and expecting all of us to be instantly familiar with what they are talking about.

"He said he would order that soap for me and put it aside. I always get it here."
"She was going to call my insurance and then run everything through."
"He was getting a vacation override for me and mailing my meds, but I didn't get them yet."

I find this incredibly irritating because I just don't have time to figure out what someone else might or might not have done. And maybe the person actually DID do what they were supposed to, but they don't leave a paper trail, a note in the computer, ANYTHING. They special order something for a customer and leave it in the LAST place I would ever think of looking. Or they don't bother calling a customer and saying, "All those meds you ordered are too soon to refill, so DON'T COME IN."

A customer will come in claiming they are owed a big refund after an insurance re-bill. We waste 15 minutes scouring the pharmacy for evidence of this and finally find a barely legible 2 X 2 post-it note stuck to the side of the pick up bin. There's GOTTA be a better way.

But it's not always the staff's fault. Some of our procedures have become so freakkin'
complicated (drug order, closing the register out, various 'logs', etc) that unless you do it EVERY single day you are literally pulling out the Manual and starting at square one.... if you have a manual, that is, and it's not written in total gibberish.

I desperately wish we could simplify things and keep procedures uniform across all our pharmacies. I wish people would do things knowing that someone else has got to be able to understand what they did. If there's some weird thing with a customer's insurance or some other crazy thing that only one staff member knows about, for God's sake put a note in the computer! It will save us so much time and aggravation. There's a lot of automation in pharmacy now, but so much of it is still human-being labor-intensive, and the human beings keep a-changing.