Twas A Pharmacist's Night Before Christmas

Twas the night before Christmas, when all through the pharmacy,

Not a patient was stirring, not even a proxy.

Prescriptions were hung by the window with care,

In the hopes that tomorrow will bring no despair.

While the patients were nestled all snug in the beds,

The goods one that is, likely not the hotheads.

And the PBM in their castle, and we in the moat,

The pharmacist is left, unable to emote.

When out of the gate, there arose such a clatter,

"Fuck," goes the pharmacist, "Now what's the matter?"

Away to the window he peers, eyes scanning with a flash,

And out jumps a patient, smiling, yet brash.

"I need some Norco," she states, wearing booze and glitter,

"Goddamnit," mutters the pharmacist, cold and bitter.

"We're closed, nearly Christmas and now you appear,"

"Drunk, disorderly and covered in beer?"

"But my night, kind sir, it all happened so quick!"

"And my Oxy was stolen, just ask my clinic!"

He starts the computer and curses the name,

Looks and wonders and says with an exclaim.

"Miss this was filled a mere four days ago,"

As her eyes quickly dart back to and fro.

"I told you once, kind sir, it fell in the trash,"

And now the lies are dealt, all coming with a crash.

"Stolen or the trash, where has it gone?"

Knowing the answer was to long foregone.

"I just need it," she says, her voice a quiver,

A junkie she be, veins a pulsing drug river.

"It is to soon to fill, you'll have to come back,"

And it is then it arose with so much of a crack.

"Fuck you, kind sir, who do you think you are?"

"Do I look like a hussy from the local bar?"

"I know my laws, have money and  know my rights,"

"And I know my doctor who will put up a fight."

"Give me my Norco asshole, or for I won't hesitate"

"To call the state board, take your license and castrate."

She paces and races and screeches aloud,

"Give me my drugs, right fucking now!"

The pharmacist steps to the window, mouth slightly agape

Waiting for his words to slowly escape.

He spoke not a word, but looked straight in her face,

How much more can we live in disgrace?

"Christmas it may be, the season of giving,"

"But to be a junkie is really not worth living."

"Bitch if you want, go throw and yell,"

"But don't you dare give me such hell."

"I am a professional, trained in health,"

"Not here to be your pimp despite your wealth."

He sprang to the gate, to her face gleaned anger,

"I'm sorry for your problems, but I care no longer."

As the gate slams down, the junkie shouts loud,

"Happy Christmas to all, and enjoy being plowed."

Where Is The Passion in Pharmacy?

While struggling through my undergraduate years, what stoked the fires of my soul was pharmacy. I loved every minute of being in one and would do everything I could to absorb myself in the profession. My desk was littered with trade magazines, my computer flooded with pharmacy websites and even this little site here was born out of this fit of passion.

And while time was worn on and I find myself questioning that passion at times, it nonetheless is still flickering. The new fire in my life is my family, but becoming a pharmacist is ingrained in my being after my experiences these past ten years. It is, in many way, what defines me not only for myself, but for many of the people who know me.

So why do I not see this in my classmates? Why do I not see this in my co-workers? Why do I not see this in the majority of pharmacists, 63 and counting, that I have worked with over the years?

Where is that passion in others that drives me each and every day?

It is out there, fleeting as it may be. No matter where I have found myself, I have always had a pharmacist near by who truly cared about the profession. They saw what I saw, yet felt our hands tied in numerous situations.

My classmates seemingly go through the motions of school, jumping when professors say jump and barking when they say bark. Excitement is extruded over cute little informational clinics, the next frat get together, or the idea of an exam being over. We are tested on regurgitating classes of drugs, signs of a disorder and how to dictate a therapy.

Yet there is no passion in these discussions. For many, it's just more school... a means to an ends if you will.

Again, there are those who feel this passion, who want to see change or wish to envision pharmacy as something more than it is right now. Perhaps it is not as surprising that those of us have found each other to varying degrees as we, more or less, stand out within the class.

But we need more passion.

The disillusion in the profession still astounds me. Retail pharmacy is slowly devolving into a profession of puppets, only doing what corporate lays out for them to do no matter their desires. It is almost as if we are living in a George Orwellian 1984 and information is relayed in pharmacy doublespeak.

"Give more flu shots! Push for 90 day supplies! Obtain new patients!.... But we're going to cut your hours by 20%"

"Patient's are of the utmost importance to our business!... But you're going to be understaffed, only allowing you to spend a brief moment, if at all with them."

It is as confounding as it is frustrating. And I can completely understand why those who say they came out of pharmacy school ready to change the world, only to have their hopes and dreams squashed by reality.

My question is why give up? Why let that passion die? Why must so many pharmacists and students be so apathetic?

"Time is the fire in which we burn." - Delmore Schwartz

Above is one of my favorite quotes that I use as a reminder that our time is ultimately limited and that we need not waste it with frivolous activities. Live life and have fun, but do not waste it away merely doing what corporate says.

Find that passion. Fuel it and stoke its fires. Take that extra second with your patient not only to show you care, but to show yourself that you can do what you want.

We do not have to be pawns in a corporate game. We are professionals and we deserve to be treated like so. Stand up for what you believe is right and where you're passion for pharmacy proudly. After all, they can only ignore it for so long...

Be A Proactive Pharmacist

We are all disillusioned in the profession. Considering the majority of individuals do not believe in our national professional organization, I think it is fairly safe to use the term "all."

After talking with APhA for the last month, it is clear that they are aware of the problems we all face. They do, in fact, have some reasonable ideas on how to address them. What they lack though is the solvency to actually act upon them.

One of the most oft repeated phrases is, "Why don't the disillusioned pharmacists show us that they care?" and to be honest it is a valid point. So many have taken such a long drive down the cynicism trail that it's hard to look back.

After all, why put forth a concentrated effort only to have it soundly defeated? I know I feel that way on a regular basis.

But why don't we put for some sort of effort? If not to show to APhA and others what they're missing out, but to give us some pride within our chosen profession.

What I am about to ask is simple... actually it's borderline remedial. We are all extremely busy during our work days, some more than others, but this would take just a minute out of what little free time we do have.

Ask a patient what they think of pharmacy. Ask them if they know what a pharmacist does for them on a daily basis. Ask them if they've ever heard of something called Medication Therapy Management or outline services we could, but cannot currently for financial reasons, provide.

See what they know and see what they want to know. I venture that the answers may surprise you as they certainly have surprised me when I have done this.

As much as the countless pharmacy rants have bound us together over the last few years, perhaps this could do the same. We need hope... the profession needs hope in order for us to continue to succeed.

If you choose to do this, feel free to come back, or E-mail me, and share your response. As cheesy as it sounds, maybe we can make our voices just a little louder and a little more substantial.

It cannot hurt to try now, can it?

The Death of Angry Pharmacy Rants

No, The Angry Pharmacist is not dead... okay well maybe his soul is dead, but his body is still kicking out little amber vials at an inhumane pace.

I started this blog over four years ago partially to centralize my interesting stories from work and partially to partake in the large amount of pharmacy bitching that was present on various websites. I'll never forget the day I first stumbled upon TAP and Drug Monkey's website. The feeling of "You mean I'm not alone?" spurred a smirk as I realized others had the same thoughts as I.

And I loved it.

Finally pharmacists, technicians, students and any one else related to pharmacy had websites where their frustrations could be viewed in colorful and often humorous tones. Many others tried to emulate the original sites, while few truly succeeded. As a profession, a proverbial bitchfest took place day after day on the internet as a means to vent.

And we all loved it.

Four years later though, where are we? The tone of this site has changed dramatically over the years, and something similar is seen on other sites. While the frustration and bitterness is still prevalent through blogs and other outlets like Twitter, it's nowhere near as resonating as it once was. The knowledge that we are not alone is no longer a source of relief, but a part of daily life.

And we all became used to it.

The question becomes, what now? Witty and spiteful posts are often been replaced by more demonstrative and action-oriented posts as shown by Eric, Pharmacist and The Readheaded Pharmacist. One could say that substance is slowly replacing style and it seems as if there are the beginning flickers of a collective voice for the profession. Something APhA, which has been covered numerous times, lacks the ability to do so.

And we all want more.

Perhaps the next step is providing substance towards are frustrations. To focus it into something productive and produce actual change. Many pharmacy bloggers are attempting to do just that and, if the conversations I have had from APhA are accurate, they are beginning to be heard. The time for angry pharmacy rants is ending, being replaced by something which may ultimately be even more fruitful.

And we all will love it.

It is a scary thought how a few late night, profanity laced tirades could propel a, perhaps, legitimate push to change our profession. Evolution often takes a winding and unpredictable path, yet usually leads to a superior result. My hope is that our current trend continues because it holds the promise of yielding true change in our profession, albeit in small amounts at first.

And we will all finally be happy.

A guy can dream after all can't he?

Does APhA Really Represent Pharmacists?

Tonight I was playing with my son with the TV on in the background when a commercial splashed across the screen. Immediately I stopped what I was doing and watched, jaw slightly agape, at what was on the screen.

What was it you may ask? Take a look for yourself:


Beautiful is it not? Even more so when you go to the actual YouTube page and read the purpose of the advertisement. It truly is great to see a professional organization be assertive and stand up for their profession. Clearly the AMA will not sit idly by and wait for change to come to them.

Bravo for that.

Now wouldn't it be great if APhA did the same? Between the health professional organization trifecta of the AMA, APhA and ADA, the APhA is often the silent partner. Whereas the AMA and ADA are very active outside of their practitioners and have a very broad public awareness, few outside of our immediate profession even know what APhA is.

It's one of the topics I have pushed several times on this site in the past and will continue to do so until someone actually listens. Recently I discussed the distressing notion that a business oriented enterprise is, in effect, leading our profession to change for their own selfish reasons.

It is something which has even been brought up in publications like the Wall Street Journal. Interesting how those even within the profession see the massive amount of benefit of the idea I laid out, yet APhA does not seem interested in actually following through with it.

It is this which is the most distressing aspect of pharmacy as a whole. In school and by APhA we are repeatedly told about the "future" of pharmacy, but in reality there does not appear to be a realistic path towards this future. Progress by APhA can be measured by the speed of a sloth, and we run the risk of being bypassed by other health care profession as the system evolves.

For instance let's look over the Strategic Issues on the AMA website which describes who they are and what they are fighting for. It is rather all encompassing while being concise and plotting for the future, wouldn't you agree? It's something even the lay person could read and instantly understand what AMA, and physicians as a whole, stand for.

Now let's look over what APhA has listed as their Advocacy Issues. One of the first things you notice is a lack of an adequate summary to the overall goal of the organization. Line by line and link by link they list specific issues, but there is no connection between the issues and what they mean for pharmacy. The AMA does a spectacular job of presenting their main goals and then diving into the specifics. Here, the APhA merely presents the specifics without any cross-linking to form a cohesive idea. In the end, the problem lies not so much with the issues themselves, but more with how they are presented.

Clearly the AMA's website is focused towards both their providers and their patients whereas APhA's website is tailored to its providers. There is already a disconnect of perception between pharmacists and their patients, and this does nothing but further that divide. If anything, the APhA website continues to make it's self inaccessible to the patients they so often tout as the focus of their work.

Why is this? Why is it the organization, which is financed partially through the dues of pharmacists, seems to ignore this crucial ingredient to the long term success of the profession? Why is it that pharmacists across the country feel like they have no voice?

There was no immediate response to the disparaging remarks by the CEO of Medco from APhA. For those unfamiliar with the situation, this link provides a good summary. How is it that our so-called voice of the profession remains eerily silent while one of the most powerful individuals in health care obtusely insults our profession?

What are those dues good for then? Several times it has been reaffirmed that the APhA can only reflect the views of those members who participate, and pay, through their membership. Granted I see the logic in this, by why is membership required to represent pharmacists as a whole? Why is it that none of the 70+ pharmacists I have worked with over the last ten years are active with APhA? Why is it that rarely do you find a community pharmacist, who just happen to make up the largest constituents of the profession, that considers the APhA worthwhile?

Because they have no faith in it. APhA is viewed as a lion with no teeth and no roar. Why devote time to something which is ultimately fruitless? As pharmacists are pushed around year after year with little light at the end of the tunnel, of course they become disillusioned. Who wouldn't?

So why doesn't APhA throw up a hail mary and start to regain the trust of the pharmacists it represents? Why doesn't APhA consider educating patients on who they are to overcome the biggest obstacle the profession faces, a lack of understanding of who and what a pharmacist is. Why doesn't APhA maintain a daily, strong active voice for the profession which can readily respond to comments from individuals such as David Snow?

Why doesn't APhA model itself after the AMA and actually represent the profession?

Give me a reason to want to be a member of APhA. Give me a reason to want to be extraordinary proactive within the profession. Give me a reason to stand up for what pharmacy stands for. Give me a reason to have faith in APhA.

Is that too much to ask?

Will You Remember Me?

Every day we cheat death. It is not something we readily acknowledge despite its prevalence.

We choose to eat a low fat salad for lunch. We choose to drive just a little slower on the freeway after a scare.We choose to go for that three mile run when all we want is to drink a beer on the couch.

Jusitifying it as a desire for "healthy living" we go about our lives without acknowledging that what we are really doing is avoiding the inevitable for just a little while longer. Each person has a differing reason for following such a winding, and often difficult, path.

Many years ago I realized I didn't want to just live my life as a mindless drone in a dead-end job. I did not want to be the person who merely went through the motions of bringing home a check, driving the kids to soccer practice and then hit repeat every day. I wanted to do something different, something unique, something... special.

It is one of the reasons I chose pharmacy. Hell, it is one of the reasons this site exists.

I have few selfish desires in my daily life. I put the vast majority of free energy towards my wife and son because... well they deserve it. For many years my main daily goal has been to make people happy. For my wife it may be a simple massage at the end of a long day, for family and friends it is my intentionally hilarious comments on Facebook or Twitter.

Ultimately though I begin wonder if I will be remembered.

I have always wanted to do something truly great, something that makes people step back and be amazed. I always said one of my goal's in pharmacy was to change the world in some way before my time was done. How I will accomplish this remains a mystery, yet a part of me feels that this particular time will come.

Yet a small part of this desire was born in spite. Far too many times in my life, especially my "school yard" days, I was dismissed or told I would not amount to much. Since that time I have always been driven to not only prove them wrong, but to make them feel humble in their judgements.

As the years have worn on and I have continued on this process, my ultimate desires have become more  personal. Today I would be very content just knowing my son, wife and family were proud of me. Everything else is secondary to this point.

And yet, there is still that desire to attain greatness... the ability to look back on my life many decades from now and smile knowing that I am going to leave this world a better place.

I guess the ultimate question is... Will you remember me?

Voodoo Pharmacy

This is, hands down, the oddest spam comment I have ever had on this site. And yet, after a stressful day at work it oddly starts to make sense...

I am melinda,from what I can read. It has been sad news and scam to everyone about Voodoo casters or so. But to me they are so real cause one worked for me not quite two weeks. I traveled down to where his shrine his and we both did the ritual and sacrifice. and now me and my ex are living very ok now.I don't know about you but Voodoo is real;love marriage,finance, job promotion ,lottery Voodoo,poker voodoo,golf Voodoo,Law & Court case Spells,money voodoo,weigh loss voodoo,diabetic voodoo,hypertensive voodoo,high cholesterol voodoo,Trouble in marriage,it's all he does. I used my money to purchase everything he used he never collected a dime from. He told me I can repay him anytime with anything from my heart. Now I don't know how to do that. If you can help or you need his help write him on (nativedoctor101@live.com) Thank you.

Wait, Is That Walgreen's Leading The Way?

Past writings have been evident in showing that I greatly disagree with how Walgreen's conducts their business in the profession. With firsthand experience, it is quite obvious that patient care is not necessarily their primary focus. Clearly I am not alone in this feeling as it is often perpetuated by vast number of other individuals within the profession.

Then how is it that, at this very moment, the pharmacy organization that is finally standing up for, what can best be termed, the unalienable rights of pharmacy is Walgreen's?

Who is challenging one of the largest PBMs in this country and their ridiculous reimbursement rates?

Who is seeking to educate the public as to what a pharmacist truly does in the retail setting?

It's not APhA. It's not the various pharmacy schools around the country. It's Walgreen's of all people.

Actually it speaks volumes that an organization who's ultimate goal is really to increase their revenue is taking this stand rather than the professional organization that is supposed to represent us.  Walgreen's is not attempting to be the torch bearer for the profession, they is just a byproduct to increase their own market share.

There is some irony in that due to Walgreen's inherent greed, they are inadvertently pushing forward a movement that could actually change the profession. The spat with Express Scripts will invariably continue to grow more ugly as they both stare each other down like two bullies on a playground. It's about damn time someone stared them down though... even if it is another bully.

Walgreen's has also been focusing on an advertising campaign regarding their ten point checklist for patient's safety. It may seem trivial to us, but when you consider many people believe a pharmacist merely puts pills in a bottle, this may help to show that we are actually a dispensary of knowledge.

I have been saying for a long time that the profession needs to step up and show the public what it is we are doing. Not only to better facilitate understanding of the profession, but to reveal how much more integrated we can be in the health care system. We can't do it on our own, that has become blatantly obvious, so why do we not have our patients become involved?

And Walgreen's is attempting to accomplish it in their own battles. It really is perplexing as it is intriguing and if the outcome is successful it may prove to be a blueprint for future change.

Who would have thought that Walgreen's would be the first one to take the first step on a national scale? Wonder if APhA is even paying attention...

Health Literacy and Increasing Patient's Decision Making

Health literacy has been a buzz word in health care for several years now. It is an obvious idea when one thinks about it, but may not be overly apparent. Often we take our intrinsic knowledge for granted, and do not consider that a patient may not have basic reading skills yet alone basic science knowledge.

Because of this in class we talk about open ended questions, talk-back guidelines and reading level of materials. All very valid points, but they all underline a common theme. There is way too much unfiltered information out there for patients now.

Think about it, with the internet and sites like Google, the average patient has ready access to nearly the same medical material that health professionals have. This post does not even consider the large amount of misinformation present. I'm more concerned with the sheer amount of correct and pertinent information related to a patient's health.

Think about it, what if you had immediate access to, say, the building plans of your workplace.  The next day you come in and talk to the owner telling them you think this wall should be moved back another five feet or so to give us more room. In looking at the plans, you say it doesn't appear to be doing anything other than partitioning the floor space.

You know what would happen? The owner would laugh his ass off and walk away as you unknowingly want to move a load bearing structure.

Yet this is what we are forced to deal with in health care each day. Patients log on to WebMD or watch Dr. Phil, are presented with information that they do not have the neccessary background to fully understand. They then take this information, come to us and decide to make decisions about their health care without considering our own expertise.

At best it is ludicrous. At worst it is deadly.

I know, I know, you are all screaming. "But a patient has a right to know this information and participate in the management of their health!" And this is true... to a point.

Consider when the negative press about Avandia came to light. One particular patient of ours immediately stopped taking to the medication due to fear of "heart problems." Never mind the fact that the liklihood of this problem was not all that great, we cry wolf far too much in protocols now but that's another discussion, she did not want to die from a heart attack.

The pharmacist looked her straight in the eye and said, "Well you can possibly die from a heart attack or for sure die from diabetes. Your call."

Good for him.

As much as we do not wish to think of our profession in this way, pharmacy is really the management of poisons for positive health purposes. There are side effect whether we like them or not almost solely for this reason.

Many people simply do not understand this part. Life is full of risks, you speed on the freeway to make an appointment or start smoking to look cool with your friends. But when a drug can benefit a patient, but they don't want to take it due to a minor chance of a severe reaction that's okay?


Solutions to this problem can be insanely simple. For instance, when we hand out drug monographs, or when they are posted online, side effects are often listed under categories like 'common' or 'severe'. Dizziness is often listed in the same breath as heart palpitations... but does that mean that the probablity of both are equal? Actually, how often do these side effects occur?

As pharmacists, we know these answers. Patients do not.

So why not add odds of occurrences to all side effect listing? Or perhaps list them in the order of occurrence? I'm sure a few more patients will panic by seeing the exact numbers, but I'm sure many more will have their minds put at ease when they see how rare these 'common' side effects are.

A simple change like that mitigates one of the problems with health literacy and compliance. We have made information a little more digestible and give them a stronger base to make a decision about their health.

We talk about white space and reading level, but not how to relate the information to patients. Honestly, that should be the primary goal of health literacy. It doesn't matter if the material is at a fifth grade level if there is no way for the patient to relate the information in order to make a decision.

And that's ultimately what this is all about, making sure the patient is properly informed so they can make decisions about them selves. We cannot rid the world of WebMD or Oprah, as much as we may want to try, but we can certainly organize the information we give out in a better manner.

Seems simple enough, right?

The 'Nevers'

Fewer singular words are more difficult to comprehend than the word never. We live our daily lives looking towards the future and under the assumption that we can do whatever we set our minds to.

There is no 'never' in this mindset.

We teach our children that they can grow up to be a world famous scientist or the president or a star football player. As we enter young adulthood, we are told we can be the next great business person or a well respected health professional.

There's always more in life to attain and time appears to be limitless.

But the truth is, the older you get the more 'nevers' become apparent.

For instance, I will never be an astronaut. Surely this was a fantasy in the most literal sense, but I am now officially beyond the most basic requirements. Even if I were to set every ounce of energy towards attaining this goal, I can no longer attain it.

As the number of 'nevers' increases over the years some choose to ignore them while others choose to embrace them.

Namely because when you start thinking about the 'nevers' a wave of sadness floods over one's self. We do not like the term because never is ultimately connected with one of our most feared words... death.

For instance, I will never talk to my good friend again. Never again will we meet up yearly in my hometown for a local event, drink beers on the deck of my home and laugh at those who doubted us in high school. It's a difficult and bitter pill to swallow, and it is intrinsically laced with the word 'never.

I will never recapture the sheer amount of unbridled fun of the first year in college. There were minimal stresses in life and when all of your friends live on the same wing of your dorm you ultimately form daily unforgettable experiences. Today, we're lucky if we can all gather but one time a year.

Not all 'nevers' are negative in nature.

Never again will I not know what it's like to be a father. Who knew someone so small could brighten even the darkest days?

Never again will I have to worried about being loved in the last few years I have found more people who care for me than in all previous years combined. For someone who has found the deepest of depths of despair, it is reassuring to know this fact.

These are 'nevers' that I can live with. And they make the less enjoyable 'nevers' a bit more barable.

So on days like today, remember what we may never be able to change the past. We may never be able to change how we feel. We may never be able to get over our own personal pain.

But that's okay. It makes us stronger, more resilient and ultimately a better person.

And in the end, that is what truly matters.

No iPhone For You!

"I was wondering if you could possibly spot me enough of my meds for a week cause I won't have the money for my co-pays until I get paid next week."

An innocuous question, no?

I'm sure most of you are thinking that it is a completely unreasonable request and, as pharmacists, we should see no issue with heeding her request.

Which would be true... unless you had a bit more information.

First, the total amount on her seven medication was $1. I'm pretty sure there is enough change in my couch to total a buck.

Second, she asked this while her blinged-out iPhone 4 sat on our counter. A quick glance at said phone showed numerous pages of apps and, from what I could see on the page showing, numerous paid apps.

Knowing this, does your answer change?

Apparently this person, and many others, can fork over money for a pointless app which makes a farting nose for their phone, but they don't have the dollar for the medications which help keep them alive?

Does anyone else see the issue with this?

Look, I know what it's like not to have money, I live with it every day. I put off buying new shoes for over year until I could not glue or tape them anymore. Why? Because we needed that money for bills, diapers and other necessities.

It was not absolutely required to live, so I did not purchase it. Being able to provide basic needs should supersede any other frivolous spending at all times.

I don't care if someone splurges on themselves every once in a while and, in fact, it can be a good thing. But when you do so at the expense of your basic needs which may harm you, or others, what the hell is the point?

The better question is how we can let low-income individuals, whom for various reasons the public is supporting, be allowed to sign expensive phone contracts or fill said phones of paid apps? How is that fiscally responsible? They can't pay more than a dollar for their medications, but they can pay over $100/month for their iPhone.

Too often in today we rely on others to fix our own problems. We "pass the buck" far far too often and do not take responsibility for our actions.

And it's sad to see.

Ultimately the pharmacist decided not to spot her any of her medications partially for the reasons I mentioned and partially because this is a regular occurrence with said patient. There is only so much charity and hand holding we can do before the patient needs to stand up for themselves.

Cruel? Perhaps. Unprofessional? Maybe. Except for when she came back an hour later and paid with a crisp $20 bill.

Funny how that works.

Who Am I?

For various reasons I decided it would be best to take the summer off from using my brain. This is the first thing I have written in over two months and, for the most part, I have remained as distanced from pharmacy as I can be right now.

After the last year, I felt a need to simply relax and spend time with the family. And as I look ahead to second year starting in a little over the week, I find myself asking, "Who Am I?"

One year ago I was overly ambitious, hell bent on changing the pharmacy world upon graduation. I felt as if I was here to right so many of the injustices we all live with every day in the profession.

Then class started... and work become overbearing... and the baby came.... essentially, reality set in. I'm still bitter towards my school and the profession after how the first year panned out. Honestly, I'm not sure if I'll ever get that taste out of my mouth, no matter how much I try.

And if it wasn't for the wife or Lil Man, I doubt I would have survived.

But who I am now? All I want right now is to finish school, have enough money to provide for my family and spend time with them. Whether that's as the director of pharmacy for a large hospital or as simply the RxM at Walgreen's, it truly does not matter to me at the moment.

I would love to be able to find enjoyment in pharmacy again, to find that fire that used to burn so strongly inside of me.

And to find out just precisely who I am now... because I really have no idea.

The Pharmacy School Depression

You slave through several years of undergrad, study for hours and hours for the PCAT and finally earn your pharmacy school acceptance letter. To yourself you think, "I know pharmacy school will be hard, but at last my stress will be reduced because I've finally made it, I'm a pharmacy student!"

Alas this is not the case.

Sure, for the first few weeks of class you ride the wave of accomplishment, taking pride in earning admittance to a school few others enjoy. It's a wonderful feeling and ultimately you feel pretty damn good about yourself.

Only it will not last.

By December that stretch of unbridled joy will seem but a distant memory. Replacing it will be stress-induced insomnia coated with a bitter taste of self doubt.

One of the things that your school will not tell you, nor your friends, is how emotionally and mentally taxing pharmacy school is. If not for the material, than for the expectations of the school or the manner in which courses are taught.

You find yourself sitting next to a dual Ph.D. on one side and on the other sits the wiz kid who powered into pharmacy school riding a 4.0 after two years of undergrad. Suddenly you are no longer a big fish in a small pond... and you come to the realization that there are individuals, perhaps several, in your class who could mentally wipe the floor with you.

The first round of exams come and... they're not what you expect. Maybe you do well, maybe you do not, but you quickly realize these are not the same type of exams from semesters past.

Dozens of hours of studying and sleepless nights may yield a mere sixty percent on an exam. Material you thought you knew like the back of your hand vanishes under the complexity of exam questions.

Doubt sets in.

"Do I belong here?" you begin to wonder. "Did they make a mistake? Maybe I shouldn't do this... maybe I can't do this."

You moods became more variable as your patience wains. It's not common for you to suddenly snap at someone under even mild stress. Self-doubt clouds your mind from exam to exam as you scrape together the will to continue.

At times you do not think it will get any better. Friends speak of struggling during studying and exam taking, yet they proclaim earning an "A" while you quietly mumble about your "C". Socially you distance yourself as you internally chastise your inability to maintain pace with your friends.

You have the Pharmacy School Depression. Mentally you have been broken... perhaps you are merely a shell of who you once where.

The semester draws to a close and you feel as if you are on your last bits of sanity. Suddenly the tough facade that everyone else has erected begins to crumble.

The dual Ph.D. you sat next to? Barely scraping together Cs in a class... and wondering if pharmacy is for him.

The wiz kid? Can memorize the material, yet cannot figure out how to apply it in several courses.

One friend mentions how they almost withdrew from school towards the start of a spring semester. The other mentions that they scored well below you in some exams... only never mentioned it.

You come to realization that you are not alone. No matter what someone's intellectual pedigree may be, no matter how enthusiastic or how cocky someone will be, at some point they will have to face this bout of Pharmacy School Depression.

There is no escaping it. There is no denying it. For some it becomes encompassing and they do drop out. For others it becomes even more serious requiring hospitalization.

Yes, it does happen.

For those who survive, it is almost as big of an accomplishment as being accepted into pharmacy school. And as you walk out of an exam room for the last time, you look back on what this year has brought upon you.

Are you the same person? Are you better off? Or worse off? Can you still do this?

The last question is an easy answer... Yes. For you are not alone, and actually never were alone. We all suffer for with it, but few speak out.

So upcoming first year students, when you are in the greatest depths of self-doubt and despair remember that you are truly not alone.

We've all been there... whether we want to admit it or not.

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So pour yourself a drink, turn off the internet porn and let the anger flow out of you like a colon after four liters of a PEG solution!

The Battle of the PPIs

The remains of the fallen solders from the Prevacid tribe

In the annals of historic battles there are Gettysburg and D-Day, but never before has there been a battle as epic, or as dramatic, as the Battle of the Proton Pump Inhibitors this past evening.

On one side sat the old guard, the Tribe of Prilosec led by General Astra Zenica. As one of the oldest tribes in the PPI realm, Prilosec had felt the increasing pressure of the Prevacid Tribe as they first encroached on the Prescription Peninsula and then eventually OTC Island. Using shimmery, metallic purple colors they attempted to outshine Prevacid Tribe, but in recent months had continued to be besieged by the upstart tribe. Now they felt their livelyhood was immediately threatened by its racemic counterpart.

Prevacid Tribe, led by the venerable General Takeda, had surpassed all expectations and supplanted themselves as a force on PPI isle. A more multi-racial tribe composed of equally mixed pinks and aquas, Prevacidians found themselves ambitious and eager as they attempted to topple the mighty Tribe of Prilosec.

At 7:04 PM on Tuesday the 31st of May, the General Zenica gave the order which would alter the history of the PPI isle. A surprise attack on the capital of Prevacid Tribe, Novartis, sought to finally rid the world of the too-similar Prevacidians.

Using intimate pharmacologic knowledge, Prilosec leaders used optical attacks from the left and right to decimate the Tribe of Prilosec. Capsule and capsule parts lie strewn across the land, with the innards of Prevacidians coating the counter-side.

By the end of the battle, the Tribe of Prilosec stood victorious over their nemesis, and found themselves the reaffirmed King of PPIs... for now.

Realistic Professionalism in Health Care Practice

Inspired by the following post over at 33 charts

Barely an hour into the first day of orientation for pharmacy school we were given the first, of what would be many, lectures on professionalism. We were told how our daily actions, both during and after work/school, would reflect both the image of the school and of the profession. Due to this, we were to maintain professional decorum at all times.

There was also some insinuation that our actions outside of school could be used as a reason for dismissal.

Think about it though, how realistic is it to expect an individual to maintain professional standards at every waking moment? Am I not allowed to see movies with an R-rating in case a patient sees that I may be viewing something inappropriate? Am I not allowed to consume a beer at a restaurant for fear of a patient judging me?

Where precisely is the line?

For whatever reason, too many people today expect perfection. In the mind of the public, there can be absolutely no errors in dispensing or prescribing or diagnosing without an immense amount of retribution. Life is, of course, immensely precious and people feel wronged when something goes wrong. So-called 'News' shows such as Dateline NBC feed off this fact and help propagate the incessant need for perfection.

However as Alexander Pope once said, "To Err is to be human." We are not machines designed for perfection, we are human beings. We have faults, we make mistakes even though we may strive to mitigate them as much as possible. It's one of the reasons why I repeatedly say here that failure is our greatest strength. Perfection is a wondrous illusion, namely because of the impracticality of it.

Humans, well most humans, cannot restrain their emotions every hour of every day behind a professional facade. In fact, it has been shown in numerous studies that bottling up one's emotions has negative consequences. Health care professionals have one of the most mentally taxing daily jobs, yet we are all expected to maintain professional composure at all times.

Due to this, many choose to vent their frustrations not only for their own mental sanity, but to be able to continue to effectively practice. We all have to let that facade crumble at some point or another, and the majority choose to do so outside of the public realm. Whether it is through a blog, Twitter or even a friend, it is where we are able to let our guard down and shed our concerns, fears and worries.

The evolution of devices like blogs and Twitter may prove to be one of the most beneficial outlets for health professionals in their history. It now only spurs new and creative ideas, but let's professionals bond across state and even national boundaries if only to reassure all that they are not alone in your frustrations. Pharmacy blogs like Your Pharmacist May Hate You and The Angry Pharmacist have quite literally helped to relieve the immense amount of stress felt in pharmacies across the country.

For those of us who may be shy when discussing our most personal problems, professional or otherwise, the fact these devices exist is a godsend.

While those popular blogs exist as a source of venting for the profession, it has lead to the creation of other blogs with slightly different focuses such as Eric, RPh and The Redheaded Pharmacist that exist to help better the profession. And this example is just describing the pharmacy blogosphere, not even considering the countless medical blogs in existence.

Yes, some of these blogs and Twitter accounts are crass, using language that would never be used in an actual professional setting. Yet they speak more truth than any professional document you may see coming out of organizations like APhA or AMA.

Why is this?

Because professionalism is self-limiting in that we are all expected to maintain the same methodologies and persona to standardize patient care. In itself, there is nothing wrong with this, but outside of a professional setting how else are we to spur innovation? How are we to explore the good, and bad, of our profession? How else are we to relieve the stress we all feel and actually enjoy life?

We all carefully consider federal and state laws, often artfully crafting responses to ensure the innocent are protected. Every work place has similar gossip-style discussions, and yet similar health care professional discussions are draped in anonymity in comparison. This is a fact even more impressive when considering the amount of venting we all do.

And venting is just that, an outpouring of frustration. What is said during this time should not be construed as a representative of who they are as a person and a professional. The majority of the time if someone stubs their big toe, their first reaction is to spout off a slew of words that would make a sailor blush. Does this mean that we should judge their response and formulate that they are crass and unprofessional?

Of course not.

Expectations are a wonderful device when used properly, but only when they are based in reality. Today the expectations for not only health care professionals, but for individuals as a whole are unrealistically high. Before you decry what and how they say something, consider the benefits they earn from doing so.

Would you rather have a practitioner who is constantly uptight, concerned with ensuring that they abide by all expectations and standards while they treat you? Or would you rather have the practitioner who is able to release their frustrations outside of work and remains relaxed and clear headed?

Before you judge and before you point fingers remember that you are not speaking about a device spouting off medical advice, but a person with a personality and emotions. They have the same needs and desires as anyone else in the world.

If anything it's a good thing others can see these frustrations under the premise that they realize we are not as infallible as they assume us to be. Because of they see that we are not infallible perhaps, just perhaps, they will no longer operate under the guise of perfection.

One can dream, can they not?

10 Year Anniversary

My first day of work in a pharmacy was June 1st, 2001. It was my first job, and the ultimate goal was to make enough money to buy some bitchin' clothes for my sophomore year in high school.

Fascination grew while learning terms like "Stool Softner" and the fact there were medications that made you pee. In fact, the "pee pills", HCTZ and Furosemide, were the very first drugs I learned. By the end of the summer I found myself enjoying what I was doing, but still had no idea that it would transform into my lifelong profession.

Now, I'm staring down at my ten year pharmacy anniversary. Changes over those ten years are too numerous to count, and too minute to elaborate upon. There has been different cities, different schools, different states, and yet I ultimately have not wavered in what I want to do.

Well, until actually starting pharmacy school.

I remember the Bextra and Vioxx recalls, the birth (if you want to call it that) of Medicare Part D, the proliferation of e-Rxs and the rise of $4 generics. I have seen way more than I ever intended to and sometimes I feel like I have more knowledge and experience than I deserve.

The question now becomes, do I celebrate this milestone? Do I look upon it with befuddled curiosity and continue on with my day? Does it even matter in the grand scheme of things?

I am 25 years old and have spent nearly half of my life in this profession. I venture that there are very few others out there who can lay claim to such a fact.

Who knows what will happen in the next ten years? Who knows if I'll even still be optimistic after another ten years.

If one thing is evident, I feel I should at least raise a beer when June 1st arises. And then hunker down a prepare for a day of work in the battlefield that is pharmacy.

Because right now, that's what pharmacy is, a battle. A battle between the desires of the profession, between PBMs, between what our current health care system says what pharmacy is compared to what it should be, and between our own shreds of sanity.

And at least I'm young enough to still have my sanity.

For now.

Year One: Complete

First year has been over for about a week and it's only been in the last day or two where my mind is finally able to unlock from the "Study All The F'n Time" gear. Hell it wasn't until the third day after my last final before I was finally began to feel as if the stress of school was subsiding.

Funny how that works.

To say I am ecstatic for this year to be over may, in fact, be the understatement of the year. I have neglected this site for the same reason I have neglected everything else the last six months, I felt I had to. Without going into too many details, my school managed to completely rip apart who I am as a person and how I conduct myself both academically and personally.

It wasn't until very recently that I was able to shake off the scratches from that meeting prior to the start of the spring semester and finally be able to feel comfortable once again. Only time in my life I have ever truly doubted it and it frustrates me all to hell that it was induced by others.

So to those deans and profs who said I was unprofessional and would never survive pharmacy school, you can take my As and Bs from this semester and shove them up your ass.

As bad as it sounds, I have resorted to steering people away from my school on the basis of how I, and others, were treated in the past years. Call it my first taste of reality in dealing with egos if you will.

That being said, this place should become a bit more lively in the coming weeks. With rediscovered confidence comes a new-found desire to post nonsensical ramblings. Because honestly, that's what everyone comes here for right?

It's going to be one helluva a summer. And I can't fucking wait.

I Have A Question… A Lesson for the Profession

It is not very often that my mind is blown while working a pharmacy. After doing this for as long as I have, even the unexpected, to a certain degree, has become expected.

So yesterday when a patient turned to me and said as they were leaving, “I have a question before I go…” I thought little of it. The cynic me expect some inane question devoid of common sense, as typically that is the question you receive in this stage of a pharmacy visit.

Instead what followed damn near caused my jaw to hit the pharmacy floor.

“I was reading up on health care legislation and kept coming across something called therapy services by pharmacists and how helpful it was for the patient. Wouldn’t it make sense for you guys to help out with my drug management instead of just my doctor?”

After pinching myself and realizing that the patient, indeed, had said what she had just said, I quickly began to formulate a concise way to explain what she was talking about.

First, I mentioned that the majority of what she was talking about would be covered under the term MTM. I went over how it works and how it is integrated into current health care. We then glanced over some general cost savings associated with it that could be had, to which she replied,

“So, what you’re saying is that everyone could save money from doing this simply by catching problems before they get worse and making things more efficient? And patient's health could be better? Why aren’t we doing this already?”

I then mentioned some of the studies that had attempt to do this sort of thing, and she wrote down information about The Asheville Project to do a little more research on her own. Lastly, I explained the difficulties we are facing in wide spread implementation of MTM services from the patient, provider and insurer prospective.

It was a conversation which lasted a mere 15 minutes or so, but nonetheless provided a wealth of information for her.

By the end of the conversation, I realized that she was just a typical patient who had stumbled upon what we are all striving for. Inquiring with the normal pharmacy staff, to find out if she was someone with extensive education and/or health care experience, they confirmed that she was none of the above.

And it was the closing statement she made that offered the most telling benefit of our conversation.

“Well pharmacists need to start getting more involved with this. I’m going to talk to someone at my insurer to see why they don’t insist on something like this for everyone because it seems stupid we’re not doing it already.”

The patient gets it. A simple conversation explaining MTMs and the future role of pharmacy, and the patient gets it. And all it took was a little conversation during a slow afternoon in the pharmacy.

Are you listening APhA? This is exactly what I have been saying for the last year. If you want to proliferate the next generation of pharmacy services, don’t go after providers or insurers. Go straight to the source and start educating patients to the benefits of them.

It's a simple supply and demand problem. You can't create something without showing the demand for it. Recently I discussed with the Director of Pharmacy for a, somewhat, rural hospital on how they were implementing MTMs into their patient care for employees. Her, and the hospitals CFO's, idea was to force employees to use MTMs services combined with their own PBM. The plan then was to show the benefits of said program to local employers and attempt to show them the benefits that could be had.

Naturally this will work in their area, due to the small population size. On a larger scale, we need more grand ideas to challenge the status quo.

This little story could prove to be the catalyst that finally gets the proverbial ball moving. If this patient is as interested in MTMs as we are, why aren't we more vocal about it? Why aren't we casually mentioning it to patients who are waiting on slow days? Why aren't we pushing fliers and educational materials to show them what we can accomplish?

Why aren't we standing up for the profession on a daily basis to ensure that we reach our full potential?

APhA, are you listening?

Need Some Medicaid for your Escalade?

A lively Twitter debate has sparked a collection of data, formulated into a highly non-scientific study. The results are as follows.

Note: To curb some of the hate mail I've been receiving, I encourage you to check out this link. It may prove useful before getting one's panties in a bunch.

Abstract

There is a direct correlation between the drivers of Cadillac Escalades, especially when they are black and possessing rims, and their reliance upon state sponsored Medicaid when visiting a pharmacy. That correlation provides an example of not only the faults of the system, but the manner in which discretionary income is disproportionately spent on frivolous purchases, like an Escalade, over supporting their family.

An example of the type of vehicle in question

Introduction

First, we must clarify some otherwise stereotypical notions regarding individuals on Medicaid. This is not intended to judge those who use the system as it was designed. Individuals who are disabled, in the midst of transitional phase in their life or simply hard on their luck are not sought by this study.

Additionally, this does not seek to single out the Medicaid patient who may have given themselves the rare gift of a nice manicure or any other small piece of joy in an otherwise stressful life. Every person is entitled to spoil themselves at least occasionally.

No, this study seeks to identify those patients who appear to be abusing the system. Those who come to the pharmacy in repeatedly extravagant purchases, often times owning items beyond the means of the people who work in the pharmacy.

Data

Data was collected across a six day period over two separate pharmacy locations. Each location possesses a high percentage of Medicaid based clientele and a propensity for playing extremely shitty music overhead.

As such, fourteen (n =14) Escalades were either noticed at the pharmacy’s drive-thru or were noticed as being the patients vehicle at the pharmacy. A careful analysis of this number of data points combined with noted actions while in the store, including their insurance, provided the following results.

• Number of Patients meeting criteria: 14
• Number of said patients driving Escalades: 14
• Number of non-Medicaid patients driving Escalades: 0

Further analysis concluded that there is indeed a 100% probability of a patient being insured by Medicaid if they drive an Escalade, even truer if it is black in color with blinged out rims.

Every study needs a complicated graph. Look at the pretty colors!

Discussion

In noting these patients it became abundantly clear that there were other useful bits of information to be gathered. On average, the patient would bring three unruly children into the store. There was almost always an excessively jeweled up iPhone in their hand, the majority of which they had pressed firmly to their ear while at the counter.

In three instances the phrase, “My baby’s daddy…” was heard uttered during the conversation. The phrase, “I ain’t got my check for the month,” was used twice as a reasoning for not wanting to pay the one dollar copay.

While it is impossible to delve into the specifics of each individual’s personal and financial situation, it is possible to derive a perhaps improper spending of funds based upon their visible purchases. Not having a dollar for your son’s asthma medication could easily have been avoided if you were not driving around in a vehicle which most likely costs twice what you earn in a year.

Other high priced vehicles, Lincoln Navigators, BMWs, etc, were noted but did not meet any of the criteria sought in this study.

Conclusion

This non-scientific study has confirmed that if a patient arrives at a pharmacy in an Escalade, they will be an irresponsible Medicaid patient. Little can be done with this knowledge other than to provide an example as to how to not use the system. In addition, pharmacists and pharmacy technicians can use this visual cue to prepare for the highly probable flood of bullshit that will gush from the patients month.

One of the god fathers of the blinged out Cadillac Escalade phenomenon

A Collection of Disdain

Oh woe is me.

That simple statement is the underlying theme of pharmacy school, at least if you ask people who are either in it or have recently escaped it. Little variation exists from person to person as while the verbiage may change, the tone does not.

As I slowly begin to rediscover my pharmacy mojo and climb out of this funk from the last few months I am discovering just how truly unhappy the vast majority of students here are. It is such a collection of disdain and frustration that at times it is almost overwhelming.

Even those who put on the most stoic of faces, are internally crumbling. Many are too proud to admit their struggles or to admit their frustrations. After years of being used to academic success, it is a bitter realization that one may be forced to struggle to earn merely average grades.

Nor will it become any easier. At least not yet.

And one has to wonder when this feeling will ever end. Honestly, I think the majority of success one has in this program is learning how to mitigate these feelings. Despite the pamphlets and the emails and the meetings, they never tell you one of the important tests you'll be faced with over the next four years. That is the fact that you will be mentally broken down and slowly rebuilt as the curriculum wears on.

It's the equivalent of academic boot camp.

But we mustn't feel sorry for ourselves. We mustn't drown ourselves in the almost sweltering pressure that at times seems unending.

For we are not alone. No matter what the surface may show, beneath it there is little difference. We're all in this hell-hole together, and we're going to be buried under it for a few more years.

So to hell with it I say. To hell with being overly stressed to the point of exhaustion. To hell with trick exams and impossible objectives. To hell with letting an academic program attempt to break me.

The worst may be yet to come, but I say bring it on. Because I'm taking this bitch on head on from this moment forward.

Who's with me?

When False Facts Are Factually False

As I walked into the pharmacy school building on the first day of classes, I was keenly aware that the next four years would be difficult. I knew that it would test every ounce of mental and emotional fortitude that I housed in my geeky little body. In the end, I would be challenged to grow beyond myself into something, hopefully, resembling a health care professional.
Heading to the first day of pharmacy school, I knew that the next four years would be difficult.

What I did not expect was for this road to be made so astonishingly difficult, almost in a sadistic manner.

You see, no one had informed us that professors routinely trick students in lectures and/or exams. That they'll present something as fact, but carefully phrase it in a way that means it is actually false.

Kind of like using a triple-negative to explain something.

When you use said fact and are told you are incorrect, they reply back that we must be acutely aware of how and what it is they say. Phrasing this way is to help develop a higher sense of thinking on our part.

Now how in the hell is that supposed to work? I busted my ass for six years only to be forced to endure another four years of deceptive learning? Leading up to a recent exam, our professor routinely exclaimed that we were over-analyzing material and that, "it will be incredibly straightforward, not requiring overly analytical techniques."

I'll let you guess what the exam was truly like.

And I don't get it. How are we supposed to adequately learn for patients if some of the professors derive some sort of sick pleasure from tricking us? Granted not all of the material is presented in this manner, but enough of it is to make you wonder how we can be taught in such an environment.

Now maybe I feel this way because I am an ardent believer in equality or maybe because I'm still young and relatively un-jaded about the world

Or maybe it's just because it's a steaming pile of bullshit.

I think I like that explanation better.

To Post or Not To Post

As I sit here gazing out the library window as the wisps of spring begin to enter the air, I have been contemplating the last few months of my life. They have been a roller coaster of triumph, failure and exhaustion. With the light at the end of the tunnel slowly growing brighter, I am left in a bit of a quandary....

...Namely whether or not I shall continue this blog.

For almost four years and 503 posts I have documented my journey as a discouraged undergrad to successfully adapting to pharmacy curriculum.

I have gotten married, become a father, moved hundreds of miles and lost a good friend along the way. This site was originally designed as a centralized database for my adventures at work, but over the years it has evolved into something more.

Now I am left wondering where to take it from here. I do not have the time, nor the confidence or experience, to take it in the direction of Eric, RPh or The Redheaded Pharmacist. I cannot compete with the artful and hilarious writings of Drug Monkey or TAP. Nor do I want to emulate any other pharmacy blog in existence.

I always told myself that I wanted this site to be something slightly unique and different. Everyone can yell and complain about the profession, I had decided long ago to delve onto a different path.

Today, when I wish to write I find myself writing more about my other main interest rather than pharmacy. I am not sure if it is that I am burnt out on the topic due to the trial and tribulations of the first year of school or if it is something more.

Call it writer's block if you will... except there is no actual block. It's merely a nonchalant feeling when it comes to discussing daily aspects related to the profession.

That, and the pharmacy I work at is incredibly boring to work in.

Earlier this week I toyed with the idea of possibly calling it quits. The response I have received since then has kept me open to the idea of keeping open... at least until I can decompress over the summer.

In short, the tone of this place may change a bit in the coming weeks. As to what that one may be, I cannot say, but it will be different nonetheless.

Whether its for the good or the bad... well that's up to you to let me know.

The Oxycontin OCs: Dedication to Live By

If you haven't received a phone call in the past few weeks of someone asking if you have "any of the Oxycodone tablets with the OCs on it." Then you're probably not working in a pharmacy. It's most likely a Radio Shack. Or maybe a Wendy's.

Probably should check on that.

Earlier this week though, the one OCer took this dedication to a whole new level. This person, for some unknown reason, asked the pharmacist the following question.

"Yea I uh... I threw up a little while ago and uh.... well I threw up my Oxycontin and they're the ones that work with the OC on them and uhhh... is it okay if I take uhh... if I take them again?"

Ya know what, if you're willing to re-ingest your freshly vomited Oxy, you go right ahead. Hell, while you're at it, there might be some left in your shit so why don't you make a sandwich out of that too.

Who says addicts can be dedicated to their trade? I felt like I should give her a freakin' award first for the mental capacity to even come up with such an act, and second for the desire to complete it. It's truly an astounding feat, much like this video.

Actually, I take that back because at least the monkey didn't lick the finger...

Roads... Where We're Going We Won't Need Roads... But We Will Need a Prior Auth

Is there any other rejection phrase I dread more than:

DRUG NOT COVERED; STEP-THERAPY/PA REQUIRED. CALL 1-800-JACKOFF

Seriously, that simple string of words is enough for this normally calm little pharmacy student to erupt in a fury of rage reminiscent of taking a cake away from a fat kid.

What makes it worse is that it happens when you least expect it, eerily similar to a herpes outbreak. Kind of like when someone brought in a new prescription today for loratadine.

"But Phathead," you're saying, "The smidgen of glue that holds the label on the bottle costs more than the number of tablets in the bottle. Never in a million years would a PBM require a PA on it."

Well that would be true... if PBMs were run by human beings with a lick of logic.

This particular plan, cough Medco cough, decided that cetirizine needed to be first line and that, for some god forsaken reason, loratadine would only be paid for after a PA and step-therapy.

Way to go Medco, you just saved yourself a whopping two cents by denying the initial fill. Glory be to you for such a wise financial decision which will ultimately bring troves of riches to your CEO. And by troves, I mean one or two extra Tootise Rolls after lunch.

Long time readers may remember that I have a particular hatred for the sadists that call themselves Medco. If anyone deserves to have bamboo shoots shoved up their urethrae and then forced to watch Glee for 24 hours straight, these guys are the unanimous winners.

After the pharmacist stopped laughing at the ridiculousness of the rejection, we kindly pointed her to the allergy aisle and told her it would only be a few dollars more to bypass this lunacy and receive the same treatment. She agreed, the gray skies parted and for a brief while peace and tranquility returned to the pharmacy.

Until the next PA rejection. About two minutes later.

Damnit.

Rite Aid: Cheapening the Profession $5 at a Time

The majority of us are aware of Rite Aid's guarantee to patients that their prescription will be ready in 15 minutes. For the most part, I don't have a problem with that. I give our guarantee to our patients that if you fill your Norco on time, a Spanish speaking Monkey will fly out of my ass and make you a denver omelet.

See, I can promise things too.

Apparently, this wasn't enough. Oh no, in an age where a Dateline special lurks around the corner for a worn down, exhausted pharmacist to make a mistake, Rite Aid decided to kick it up a notch. They decided to offer a $5 gift card if that 15 minute guarantee is not met.

Bravo Rite Aid, bravo. Way to aim yet another shotgun blast to the image of pharmacy.

We live in a world where pharmacy is viewed as a product based business rather than the service it truly is. That's how PBMs reimburse us, that's how the public views us and that's how we are treated on a daily basis. If we are to truly reach the goals laid out by APhA and other organizations, we must truly remedy this fallacy.

But then there is Rite Aid, making sure that for every step forward that we are shoved back another five.

A few weeks ago I questioned why national organization such as APhA did not denounce WAG's creation of Wal-beer. Again, I ask, how can APhA allow such a cheap attempt to attain customers without disparage?

It doesn't so much matter that the 15 minute guarantee is a game of Russian Roulette as it is. Rite Aid just made sure that the barrel is loaded with five bullets instead of just one.

Rarely are we complemented for the work we do in fixing errors by doctors, solving various insurance issues, keep track of interactions or offering simple advice. We are chastised when their doctor takes one day too long to fax back a refill authorization or when the four different C-IIs they drop off take a bit too long to fill.

The public already treats us like we're the bitch of the health care system, there's no need to give them another whip to play with.

People need to start realizing that in pharmacy the customer is not always right. In fact, they are not a customer at all, they are a patient and we are a health care provider. This is not a Jiffy Lube where we'll top off the washer fluid just for the hell of it.

And with ridiculous programs like the one Rite Aid is employing, we'll have a damn hard time trying to convince anyone otherwise.

It's just too bad they can't use their $5 to buy a six pack of Wal-Beer. Oh wait, I think I just gave someone an idea...

Hello Reality

This semester we have moved past the regurgitation of pre-reqs and are slowly delving into actual pharmacy material. It has been an enjoyable experience, for the most part, to start learning the information that I have been aching to yearn for several years.

Suddenly last night I was introduced to a small bit of reality. In discussing a question from our most recent drug delivery exam, one of the people in our group exclaimed it didn't matter if he didn't understand a particular type of question because it was just one exam.

I thought about that statement later that night, and about the question in general, and came to a startling dose of reality.

What we learn now truly does matter.

When you're an undergrad sitting in philosophy or British lit, you realize that what you are learning is really immaterial to your future. Sure it's good to learn about Socrates and maybe you can apply some of those learnings to your daily life.

In reality it does not matter if you remember who did what and a certain act. Call it disposable knowledge if you will.

Last night came the realization that, for the most part, that disposable knowledge is now gone.

The question the person in our group claimed to not care if he understood had to do with renal clearance for certain drugs. It's a piece of information that, may very well, prove to be highly important at some point in your professional life.

What we are learning now is the opposite of disposable knowledge, it is highly intrinsic knowledge that we will in some form be using for the rest of our professional lives.

It may seem like a meek or unimportant realization, but it's a stark one nonetheless. That thought provided the first feeling that this was more than just exams and labs... that we were actually learning something with a purpose.

And it was a pretty damn good feeling.

The Problem With MTMs

Judging from what we're told at school, MTMs are the second coming of Jesus. It is "an example of the future of the profession" or "identifies the new role of the pharmacist in the health care community."

That is entirely true... to an extent. The problem though is that everyone, and by everyone I mean those in power, realize what MTMs can do for the profession... yet choose to ignore the relevant problems of adopting it to our current business model.

We all know the benefits of a service such as MTMs. Physicians are even conceding to the benefits of MTMs, a fact which is more groundbreaking than most realize.

The problem is the consumer does not know the benefits of MTMs. Hell, they don't even know what MTMs are for the most part.

I covered this fact earlier last year and it is something I have been pushing APhA to look into for the last few months.

Essentially we are telling the various insurance providers that we can offer this service which will, ultimately, save them money but will do so in a novel approach. Herein lies the bigger problem... there's no demand for these services.

Really, there's not. Name one time a patient came up to you asking for something similar to what MTMs do? I bet you cannot name one specific instance can you?

That all comes back to the fact that the public is blissfully unaware of what a pharmacist can do. We have to create the demand if we want to take this next step. Some pharmacists, namely Eric, RPh, are already taking the brave first step into this new world.

If we're so intent on moving in this direction, we have to tackle the business aspects that we have so far been ignoring. Pharmacists, in general, have been the passive members of the health care community and in many ways this has become an ingrained trait. It is time to step out side of this self-induced funk and reassert ourselves.

And if not for ourselves, for the future of our profession.

Would it really be so difficult to devise a system for billing for time spent monitoring a patient? We already have ICD-9 codes and DURs to classify what it is we're doing, would it be so difficult to add one more field classifying some time scale? This wouldn't require a complete rewrite of how we do our every day business, merely a small adjustment.

Honestly, I think that is the biggest hurdle places like WAGs, CVS and the likes have with pushing for these services, successful implementation of billing. Sure there would be some trust involved, but it's there are ways to self, and externally, audit times.

And for the business minded folks, the sheer dollar amount that is available out there is astounding. It's almost as if we're sitting on top a giant field of oil, yet we're too scared to drill some test wells.

Ironically enough, the exact same could be said in terms of benefits for patients.

Really, what on Earth are we waiting for?

Useless Term of the Day: Generic Utilization

Last week at work one of our newer tech's asked me what the phrase "Generic Utilization" meant. He had seen it on a memo from our DM and couldn't quite grasp what it meant.

The more I thought about it and tried to explain it to him, the more I realized how utterly ridiculous the term was.

The memo itself was telling us that we needed to increase our generic utilization. How though? 95% of what receive is filled as a generic (if one exists) right off the bat. The remaining 5% are either on a brand for a specific reason or are anal retentive and refuse to switch.

So how precisely are we to effect that? Why waste time and energy focusing on something of which we have very little control.

Can someone out there with a bigger and more developed brain explain it in any better fashion?

To Speak or Not To Speak

This may not surprise most of you, but I apparently already have a reputation among the other classes at my school.

Shocking, I know.

Through the grapevine I have discovered that I have been referred to as the "guy who doesn't take shit from the professors" or "the guy who brings the real world into class."

Kinda cool, wouldn't you think? Except I've noticed a slightly perplexing side effect to this. It seems, almost, as if I'm being blackballed by certain professors.

That big multi-year research project I had mentioned a few months ago? It's suddenly vanished, along with the regular emails from the related professors. In one of my classes, management class, I am regularly ignored when my hand is raised.

It's frustrating.

Which leads me to this question, should I continue to speak up? Should I continue to push the envelope in our classes in order to ensure my fellow classmates, and future pharmacists, have a truthful view of the pharmacy world?

The me of 2-3 years ago would keep at it. Now that I have a wife, a child and a burgeoning career, I wonder if this is the best course of action. This isn't a small, unknown little school and I certainly do not want to create a negative perception of myself as I enter the pharmacy world as a pharmacist.

And since my plans have changed in the hopes of attaining a particular residency, I really do not want to shoot myself in the foot anymore than I have to.

So do I speak up at every inane situation presented, at every fairy-tale story told, at the incorrect information we're fed? Or do I pick and choose my battles and straddle the line of appeasing both sides.

Truly, I do not know. It's part of the reason why I have been "freakishly silent", as someone told me, the last few weeks.

What good is having a voice if it only spouts negativity?

I suppose that is the ultimate question I have been asking myself. And honestly, I do not have an answer.

Ten Years Ago Today....

Yearly Repost:

That being said today is a special day, although not in a good sense. Nine years ago today my sport lost its leader, its champion and by all rights its greatest driver, Dale Earnhardt. After nine years it still kind of feels as if a family member is gone, which is rather strange. Then again those of you who did not follow the sport prior to that day will never quite understand. But if there is any of you out there who does read this blog and does understand what this day means... well then you'll understand the accompanying video as well.

A Cavet of Knowing the Inner Details of the Profession

I have an exam later tonight on pharmacy systems. When we first started these classes I was ecstatic because, as some of you may have gathered, between my business background and my experience, I know how and why pharmacies work and function quite well.

I've studied CQI, the various ISOs and I've seen every flavor of community pharmacy (the main focus of the course) that there is. It should be a cinch right?

Nope. Not at all.

You see, I know too much. How can that be? I shall explain.

The first exam we had in this type of course way back in September was about the economics of pharmacy. I had taken many Econ classes during my undergrad and feel like I have a rather good understanding of the topic. On the exam though... that was another story.

I lost numerous points because either my thought process went beyond the scope of the problem, even though it was completely correct and that they did not define the scope, or that I understood the topic better than the TA who did not understand what I was saying.

It was immensely frustrating, and alas that has been the theme for the rest of the course.

Tonight's though could be far worse. You see, the material we have been given is, at best, five years out of date. Our text talks about the 'new' use of PDAs in health care, or how eRxs are going to take off.

One of our readings is an analysis of the functions of the pharmacy... only it states that one of the problems they recognized is that pharmacists do 95% of data entry and 50% of filling. The article is twenty years old.

For the most part, this isn't the fault of the course or the professor. It is such a fluid topic, that it is hard to devise a textbook or lecture set that is current. I completely and totally understand that.

But I will be going into a test today with the knowledge that I need to dumb down my answers. I can't sit down and study a lot of this information because I know it's wrong. It's a very unusual position to be in, and a very frustrating position to be in.

To state a quote that my wife hates, it is what it is... isn't it?

Improving the Pharmacy Profession… One Wal-Beer At a Time

Walgreen’s bills itself as “The Pharmacy America Trusts.” With that trust comes the responsibility of an honest and ethical management of their patient’s health care. If America trusts them as they suggest, and honestly it’s probably hard to argue otherwise, due to their size they are the public face of pharmacy.

It’s not preferable that one, generic entity represents the varied world of pharmacy, but alas that is what we have to live with.

Imagine the shock pharmacists across the nation had when a little nugget of news appeared, even as it was clearly attempted to be brushed under the rug. That nugget? The creation of Wal-Beer.

We live in a massively evolving health care system in which pharmacists are fighting to rightfully assert themselves as a respected and educated member in modern collaborative practice. For too long we have been either dismissed or ignored, but in the last two decades have seen the profession begin to shred itself of those shackles and become an integral part in the management of a patient’s health.

And it is something to be applauded.

The bigger issue, something which I have touched on in the past, is that while those within the medical profession now readily acknowledge our presence, the public has a complete lack of understanding of our abilities. It is a fact that, at some point, will need to be addressed if we are to reach our full potential.

Now, the public will have Wal-Beer.

How morally and ethically responsible is it for the largest pharmacy chain in this country to create a beer label, with a low-ball price point, in the midst of this change? Pharmacy’s across the nation are refusing to sell cigarettes and alcohol in their pharmacy, yet Walgreen’s has decided to not only ignore this but to instead take it a step farther.

And don’t tell me that it’s okay to sell cigarettes in a pharmacy as the pharmacist can consul a patient on the negative aspects of smoking. The day that truly happens is the day the cigarettes are kept behind the pharmacy counter.

Fat chance of that.

Instead, “The Pharmacy America Trusts” is undermining everything we have fought for these past decades. In class we are preached “Patient Care, Patient Care, Patient Care,” and that our generation of pharmacists will be focused on this for our entire career in new and novel ways.

So how does Wal-Beer fit into that? How is what Walgreen’s doing an attempt to not only further the profession but increase the health of their patient population?

I realize that chain pharmacies are more profit driven than others, but this is a deplorable step even by those standards. Every day we deal with shrinking reimbursements and the lack of an ability to bill for basic services. This is what Walgreen’s should be focusing on and standing up against, not creating its own line of cheap beer.

The better question is, what will organizations like APhA say about it? Will they ignore it? Or will they stand up and denounce the creation Wal-Beer and what it means for the profession? A dare not to be overly dramatic and overstate the importance of doing so… but I’m not sure that would be overly dramatic.

Surely Walgreen’s isn’t the first pharmacy to attempt something of this nature, but as the face of the profession they should be held to a higher standard. If not by the public, then by their employees and the profession itself.

There are bigger fights on the horizon and many will dismiss this as something trivial. It is far, far from trivial however, and represents a dangerous tipping point for the profession. If we wish pharmacy to be properly understood and respected among not only our peers, but the public, we cannot condone this.

Until then, Walgreen’s shouldn’t be the pharmacy America trusts. Hell, they shouldn’t be the pharmacy pharmacists trust. Should they?