Operation Baby Ejection has Begun!

If you're reading this post, it means that little Mason (yes that is his name) has decided to claw his way out of the wife.

I have no idea if I'll be gone from this site for a week or a month. As you read this I am stepping into the great unknown, only without my trusty flask this time.

Wish me luck.

The Real Point of Pharmacy School

Time is elusive... an almost mythical component of life. Often it seems as if it is plentiful, yet quickly it evaporates. Confused, you scramble around attempting to make up for it, but often it is too late.

Such is the life of a pharmacy student. Walls routinely collapse around you and part of the test is being able to survive and climb out of it. All the while you chase time... more and more time.

It seems as if we're being tested on our mental toughness as much as the material. And this makes sense, in the real world you do not work within nicely defined borders. Being adaptive and able to cope with stress in the face of adversity is one of the best skills you can develop.

Often I tell people the best thing you can ever learn is that you are can be wrong. For many it is a hard fact to accept as in order to reach this level of education you have to be egotistical and believe, to an extent, that you are mentally infallible.

Yet the opposite is true, we're all mentally infallible and in fact we may be more prone to it. Over confidence is predominate among myself and many of my classmates as a byproduct of the process in arriving here.

This makes it very, very hard to look yourself in the mirror and admit your faults.

I argued during my interviews that I was apt to not only be an excellent pharmacy student, but an excellent pharmacist because I have failed numerous times. Due to those experiences, I know how to control my emotions and develop a train of rational thought to overcome that failure. It is, at least in my mind, one of the best skills I possess.

Pharmacy school is about failure, whether they want to admit that or not. It's about not having enough time or struggling with material or actually failing an exam. We are not only learning mountains of material, but we are developing a mental toughness and agility which will be essential in our daily professional lives.

I wish there was someway to adequately explain this to many of my classmates. I know, and see, so many who are overly stressed out to the point where I wonder sometimes if they'll survive the next few years. Ironically enough I am almost certain one of my classmates regularly reads this little blog, so at least one person may be aware of it.

One test does not make a person any more than it breaks one. The light at the end of the tunnel, however faint, will eventually arrive, probably more quickly than we imagine.

So to all of you fellow first year pharmacy students who find them struggling throughout this initial year, heed this advice. Learn from your mistakes, but don't dwell on them.

Lastly you're not alone. We're all struggling in our own ways, even if we don't outwardly show it.

I will gladly crack a beer for anyone who needs to have a drink after this semester. Trust me on that.

Breathing, Peeing and Pooping, Oh My!

Depressing notion for the week... Walked into the library today and the librarian who's working the desk looks at me and goes:

Well hello! So nice to see you again!

I think that's a bad a sign. Or a good sign. Or... I don't know what the hell it means.

Alas, this is the fifth straight night I have been in this wretched little library. Tonight I am learning the intricacies of breathing, peeing and pooping.

Who said there's no glory in studying the human body?

Three more days and freedom awaits me... at least until the little bugger makes his initial appearance. As I sit in the study at night going over material, every time I here her move in the bedroom my blood pressure shoots up as I prepare for her to walk in and say, "It's time."

It's like a game of Russian Roulette, only instead of a bullet it's a small child.

Before one of our finals on Friday, a classmate of mind was bitching to me about how 'stressful' it has been studying for the exams this week.

Really? My wife is about to eject a watermelon from an area which seems like it does not have the space to eject a watermelon. Every time my BlackBerry flashes the LED colors signifying I have a message from her (BTW: if you have a BB, look up the app BerryBuzz. You'll thank me later) my heart flutters a little bit.

Pretty sure when it actually does happen, I will either hyperventilate, piss or shit my pants. Maybe all three, who knows.

At least I know now how precisely each process works. Although we never did cover birthing...

Because God Said So

I'm man enough to admit not only do I not know everything, but that I continually learn new things almost every day. About a week ago there was a note on a patient's prescription asking if she had new insurance coverage for her birth control prescription.

Her response was that since she worked for a 'really religious' organization they had decided that certain medical treatments defied the will of God and that they would not pay for these items. In this case, one of these 'treatments' was birth control. There were also other 'treatments' that were not allowed, but she didn't really wish to discus them.

And no, the organization was not a church or anything similar to that.

In my mind there is no point to delve into a debate on personal beliefs because we each have our own. Mine is no more superior to yours than yours is to mine. We believe what we believe and leave it at that.

This, however, I do have a problem with. How can you deprive someone, specifically an employee, medical coverage for something because of someone else's belief? How is that fair to others?

Furthermore, how is that deemed acceptable in modern health care? What's to keep the CEO of company from deciding, "Ya know what, I don't believe in warfarin therapy because of my God the Flying Spaghetti Monster and I don't want our health insurance to cover it anymore."

Ridiculous? Sure it is, but the scary thing is that that instance really isn't terribly far from what has happened to this poor woman. She seemed like a well educated and well adjusted married adult woman who simply does not want to have children at this time. And yet she is being punished, in a way, for being responsible.

Sure she could just leave her job, but who is really willing to do that in this economy?

I'm all for expecting and honoring every one's beliefs. But when your beliefs deprive an innocent person medical coverage, then I have a bone to pick with you. Push your beliefs through pamphlets, mass emails, televisions ads, whatever pleases you.

But for the love of God, don't deprive people of their right to health care.

Pun most definately intended.

Big Fish in a Huge Pond

Pharmacy school, much like starting any new school, is all about adjustment. For the most part, you roll with the punches until you find your new equilibrium. It's a struggle at times, but eventually you come to peace with the new situation.

Only after that do you realize you see the elephant in the room and discover what is, for most, the biggest struggle to cope with.

Let's face it, if you're in pharmacy school you're highly intelligent. Chances are you did very well in grade school, very well in high school and very well during undergrad. You were the proverbial "big fish in a small pond."

Some people relish this fact and will consistently remind you of how smart they are on a regular basis. These are the people who came very near death during many of my undergrad courses. And I say that with utter and complete certainty.

In pharmacy school it's different. Everyone here is intelligent. For many the pond has grown so huge that not only are you not the big fish, but you very well may be completely insignificant. It's a fact which sneaks up on as you are completely unaware of this change.

In actuality, this alone may explain so many of the frustrations we feel during this first semester. When you're used to getting high As and being the prized jewel of the class, but instead you're fighting tooth and nail merely to get a C... well it's a sobering experience.

I imagine for some this new hierarchy will be exceeding difficult to follow. Already I have noticed some personalities within my class changing ever so slightly. Whether this is attributed to the Big Fish Syndrome or whether it's related to something entirely different I do not know. Yet it is there, clear as day.

So I sit here in the medical library and proudly exclaim that I am a big fish in a huge pond. Except I'm not just a fish... I'm a shark. And I'm gonna come back and bite some ass in the future.

Something To Read

Blogging is such an intimate endeavor. Many people bare the inner workings of their soul to complete strangers on a daily basis. I cannot ever describe how immensely therapeutic it is to have a site like this.

That being said, occasionally you stumble upon something that is rather powerful. I'm not a huge fan of posting things from other sites, but this is something worth a read. I highly doubt I could ever share something of this nature, and to say what I respect what is written here may be the understatement of the month.

Enjoy.

Edit: When I originally composed this post, there were no recent posts other than the last link I've posted. If anyone has any words of encouragement or anything of solace to offer, I encourage you to leave it.

My Life Exploded - Part I
My Life Exploded - Part II
My Life Exploded - Part III
My Life Exploded - Part IV

The Man With the Itch

It's dusk in the pharmacy, as the last commuter comes through the drive thru. As the last rays of sunlight streak through the window, a man steps up the counter.

"Hey," he half-whispers, "I can I ask you a question?"

I stroll over to the counter and he leans in, "I have an itching problem. Do you have anything I can... put on it?" Half-exhausted from the mid-afternoon rush, I bring home over to the first aid aisle and show him the Hydrocortisone products.

"Hey... does this stuff like... stay on?" he inquires.

I assure him that it does and depending on where he's applying it dictates whether or not the cream or the ointment would be best suited.

"Well... what about for like under clothes?"

I then tell him that in that case a cream is usually best as it doesn't leave the oily residue on clothing that so many have a disdain for.

"Well... can you... I mean would you.. have sex with it?"

For the first time in months I am held speechless. I inform him that you shouldn't be using it as any type of lubricant for intercourse.

"I've got this like.. like a rash on my johnson... and it itches and burns real bad."

Then to kick it up a notch.... "Do you want to see it?"

It is at this point, I pull the student pharmacist card and mention that I will have to get the pharmacist to help him further. As I stroll back to the pharmacy, suppressing a grin, I kindly tell our pharmacist a gentleman in aisle 4 needs help.

He asks which mean and I point and say, "The man with the itch.."

No One Can Change How You Practice But You

Today a woman in her mid-70s made her way to the out-window of which I was manning. As I brought her name up on the work queue, she started by saying that she recently transferred to us from Walmart due to "those swarmy bastards."

I liked her already.

Since she was a new patient, I went through the usual round of intel gathering to update her file. It was when I arrived at the question regarding insurance that things became interesting.

She initially stated she would be paying cash for her prescriptions. I asked her if she was sure because her prescriptions totaled nearly $900 at the cash price. She was taken aback at first, but reiterated that she was paying the cash price.

After a minute she pointed at one of the scripts and said, "This isn't right, Walmart's been selling this one to me for just $373, not what you have listed there."

Now one of the drawbacks of WAGs system is that you cannot override cash prices, at least from what I've been told. The price we had was, to say the least, ridiculous in it's own right and I wasn't going to make this elderly woman fork over hundreds of dollars extra because of it.

I turned to my pharmacist and said I was going to take her over to our consultation area so I could work with her and see if I can find some way to fix this. He looked a bit perplexed at first, but allowed me to continue on.

I begin to try various filling combos to fix the price. There was changing it to two different prescription strengths, halving tablets, taking more of a smaller dose, etc. I had gotten it knocked down to just a shade over $400, and she was content with that.

It was then that she began fumbling around in her wallet for her credit card when I noticed her Medicare card. And it dawned on me; she has to have Part D coverage and, if she doesn't, she has to have some sort of supplement.

I ask her if she's enrolled in Medicare Part D and she replied yes. Next I ask her why she didn't mention she had any coverage at first and she said it was because she had lost the card several weeks ago so she didn't know how to get us the information. Naturally she was surprised when I said I could look up her information simply by using her Medicare number.

As she hands me her Medicare card she then states, "I don't know how much good this insurance stuff is gonna do me." I ask why and she goes, "Well they don't cover that spendy one right there cause I've been paying cash for it all year. And I'm in the donut hole so Walmart told me it's better to just pay cash for everything."

Are the alarm bells going off in your head? Because they were going off in mind.

First, I explained to her that I would be very surprised if they did not cover the drug in question. It's not an uncommon generic drug and I'm not sure if I've ever seen someone not pay for it since it went generic.

Second, I then explained to her that when you're in the donut hole you don't really pay the 'true cash' price. The price given, if you will, is more of a discounted cash price and is usually less than what WAGs or Walmart can match.

Of course she asked why her Walmart pharmacy had never explained to her, of which I had no answer.

I proceeded to input her Part D information and rebill. Suddenly that almost $400 medication she had been paying for at Walmart was now just $40.

She was shocked. Utterly and completely shocked. By the time I re-ran everything, the total bill was around $280, down from the $900+ originally. She thanked me several times for helping her as she left, while I sat wondering how in the world another pharmacy could be so inept at helping a patient.

Then I remembered that Walmart employs more of a profits before patients policy, similar to what I alluded to in my last post. Their pharmacies are often overworked and understaffed. A corollary to this is they have a tendency to hire 'cheap' techs who may not know as much as they could otherwise.

To make things even more interesting, my pharmacy manager pulled me aside and said he hadn't seen anyone do anything like that here in the eight years he's been working at WAGs. It reminded him of working in his pharmacy back home.

I told him there's no reason you can't practice like that, even in a WAGs-type setting. It's how I decided to practice long ago and where I work won't change that.

Ultimately, I think this is the moral to the entire story. It doesn't matter where you work, what you do on a daily basis or what corporate wants you to do. We still have an opportunity to take some time with our patients to help them.

We choose how we want to practice, no corporate decree can change that. It doesn't matter how busy or how swamped you are, I did this entire exchange during the 5pm rush on a Friday afternoon.

And if I can do it, so can you. All I ask is that you try...

One Semester (Almost) Down

I sit here plotting out my schedule for the next fourteen days. Finals are approaching and I need to develop a battle plan to not just survive, but conquer my upcoming finals. It's hard to believe the the first semester has almost come and gone. The excitement of being in pharmacy school wore off weeks ago, and now I find myself aching for finals to end.

To everyone who said I couldn't do all of this this semester, I have but one phrase for you: Go to hell. This includes my school's Academic Office and our class adviser.

My schedule for the vast majority of this semester consisted of:

7:20am - Crawl out of bed
7:50am - Drive to campus
8:20am - Hop on the campus bus
8:50am - Class
11:45pm - 20 minute break for lunch
2:25pm (5pm on Tuesdays, 6pm on Thursdays) - Class ends
3pm (5:30 on T, 6:30 on R) - Go to work
11:30pm - Get off work
11:45 - Get home, say hi to the wife
12:00am - Burst of studying
2:00am - Bedtime

And this doesn't include the 9am to 11:30pm shifts I would work on the occasional Saturday. Yes, for the first two and a half months of pharmacy school I averaged working 50+ hours a week.

Did it suck? Damn straight it did. Did my grades suffer? Not really. Am I glad it's over? Hell yes I am.

This semester has been hell. Luckily my wife has been awesome throughout this, which I mentioned a few weeks ago, and we have everything ready for the arrival of Phathead Jr in about a month.

I have cut back to a mere 33 hours a week, which is roughly what I'll be maintaining next spring. I've tested out of one class, possibly two, so my schedule will be a little lighter. There will be no rest during winter break with a newborn in the house, but I like a challenge.

People in my class and online ask me all the time how in the world I do all of this. Truly, I do not know. I think I've conditioned my body to get used to this sort of thing over the past few years. I'm probably one of the least stressed out students in my class namely because I've been through much worse.

In 2-3 weeks time, this semester will end and I can prepare for the spring. I will be a much, much better student than I was this time around, namely because I know what to expect.

Plus, look at it this way, only 1255 days to go!

Taking On Walmart: Lawsuit Style

Over the top post title? Perhaps, but hear me out.

Every one within the pharmacy world agrees that Walmart pharmacies are the cancer of the profession. They are mostly detrimental to the profession, to the point that something needs to be done about it.

In the Walmart I recently worked at, my store manager told me the pharmacy is responsible for 4% of the yearly revenue of the store. Think about that, just 4% of the entire store. In the great scheme of things, the total profit brought in by the pharmacy does not have a high priority. What a pharmacy does accomplish, though, is to drive more people into the store. And that's where the problems arise.

It's not difficult to imagine that twenty years from now we will see the final death blow for true small town, rural, independent pharmacies as the four dollar generic program that Walmart began a few years ago. The effects from this program will begin to become more evident as the years wear on (I personally believe it will, or maybe already has, trickle over to the reimbursement side of things). It's a program which is great for consumers, but utterly terrible for pharmacies and pharmacists.

Previously I have covered how we are routinely underpaid by insurers for the services we provide. Here is how Walmart, in its revenue based mindset, gouges the profession using poor, and unethical, business practices.

In the state I am in at the moment, the average cost of a prescription, prior to the addition of the cost of drug, was $10.28 as of 2006. This is the most recent data we have and does not take into effect the legal changes since then which have significantly increased overhead labor costs. If you consider that the most of the drugs listed under the $4 generic program actually cost roughly $1 per 30-day refill, we're looking at a total cost (in this state) of $11.28 per 30-day supply.

Using a bit of simple math, we can see that Walmart is selling these $4 generics at 64.6% below true cost. Sure they're making a "300%" return on the cost of the drug, but we're a service based profession and you cannot quantify cost in that manner.

Here is where the lawsuit would come into effect; there are laws in place to prevent businesses from undercutting competition by ensuring that they cannot price their products and/or services below a price floor, namely the cost of the product/service. It a byproduct of the monopolistic tendencies of big business at the turn of the 20th century and the anti-trust laws that followed.

This is called predatory pricing, and it is usually intended to drive competition out of business. In Walmart's case, they are doing so to drive more consumers into their store and not so much to rid them of competition.

However, one of the key components of predatory pricing is a high market entry barrier. By pricing their prescriptions so low, and under cost, they are in effect presenting a high market entry barrier. It is one thing for a new, or small, pharmacy to be unable to offer all of the insurance plans offered. It is a completely different problem when they cannot come close matching the cash-pricing policy of Walmart.

Under the Sherman Antitrust Act, this is considered monopolistic business practices and is unhealthy for both the market and the consumer. And, at least legally, you could file a class action lawsuit claiming as such.

The thing is, you would lose the lawsuit. Walmart is far too big, far too powerful and with far too many attorneys. Also, it has proven difficult to adequately argue for monopolistic business practices, although I concede we could develop at least a moderately successful argument.

But here's the best part... we wouldn't have to win the lawsuit.

Really what we need is consumer awareness of what is happening within our profession. It's been shown time and time again, especially when it comes to Walmart, that when the public is presented with an injustice they will move on their own to attempt to right it. People like a good deal, but only to a point.

We have the data, we have the facts, we have the manpower, so why not? What's stopping a group of us from standing up and actually doing this? It isn't about increasing pharmacy profits, about maintaining the integrity of one of the most important health care professions in existence. We an argue convincingly that we have been put on a dangerous path and, if it is not righted, in a few years we will be presented with a very serious problem.

Cost/revenue cannot be the sole driving force for the profession, yet Walmart, and to a lesser extent the other large corporations, have decided to take that route. It will continue to harm us, the market and, ultimately, the patients. The last part of that statement is what we have to proclaim most loudly.

Let's rile up the consumers, let them see how big business is harming one of the essential health care services in this country. It can only go up from here, right?

How You Can Touch A Life In A Pharmacy

It's hard to imagine that I have been in pharmacy for nearly ten years now. When I was started I was a bright-eyed fifteen year old, fresh off his first year in high school. Now I sit here awaiting the birth of my child and stressing over the possibility of pharmacy residencies and MBA programs.

I'm not sure if you can quantify one particular point in my life that drove me to pharmacy. Rather it is more a collection of experiences spread over the first handful of years working in a pharmacy.

In the past I've written about the steps I have gone to help a patient and what it's like dealing with the death of a patient. But the first time a patient I had known well died is really what sticks out in my mind.

I was seventeen at the time, still young enough to be oblivious to the actualities of the real world. The patient was a captain in a branch of the military, which one though has forever escaped my memory.

He was a rather fun guy to be around. A doting husband and father, he always had a legitimately funny story to tell when he came into the store. One of the few patients who makes your day a little better when you see them walk through the front door.

At this point, I was seriously mulling pharmacy as a career and he kept encouraging me to go that route. His thing was to always challenge yourself and to not become overly lax in your daily life. It's a motto I have since adapted as my own.

One day while preparing to fly out for an assignment he was stricken with a massive headache. He was taken to the hospital on his base and after a serious of tests they determined that had a brain tumor.

A terminal brain tumor.

He was then discharged to begin treatments and to spend time with his family. Over the next several months this kind and gentle man devolved into a bitter and angry one. He would come in, snap at his wife, yell at us and say things that I do not wish to repeat here.

It was difficult at the time to process. I had never dealt with something like that and wasn't sure how to think, yet alone respond to it.

Just a few months after that initial headache he passed. A few weeks after that his wife, came in to pick up something for herself. As she was leaving she put her hand on mine and said that her husband began to revert to himself during his final days. He wanted to apologize for all he said and had done to us during that time.

And that he wanted her to make sure that 'pharmacy kid' stuck with pharmacy as a career as communities need people 'like him' in that sort of position.

I never saw her much after that. I suppose she really didn't have much of a reason to visit us anymore. A year later I went off to college and the rest, as they say, is history.

It's something that's stuck with me over the years though. The fact that even when a patient is near death, their thoughts can turn to us and what we have done for them. Whenever I crawl into my personal pit of despair, that memory usually acts as my ladder to climb out of it.

I guess in some way I'll always be that 'pharmacy kid.' And I'm perfectly okay with that.