Paranoia

 

The voices start to grow louder in the back of your mind.

At first they are mere whispers in fog of information overload, but as time wears on those whispers amplify more and more, before resonating as a shriek.

In starting pharmacy school it seems as if the world is yours for the taking. For years you followed the predefined path, reading the likes of Socrates and learning the detailed psychology of the human mind. And in arriving in pharmacy school, you feel as if you are finally about to reach your life's true aspirations.

And then a funny thing happens. That hopefulness, that strong desire for learning is slowly chipped away like waves crashing against a cliff. Eventually you become a shell of yourself, merely moving through the motions and responding to questions when asked.

Someone once drew a parallel to boot camp in the army, where we are all broken down in an attempt to rebuild our minds and internal processes as professionals.

But at what cost?

Those voices mentioned at the start of this post are the voices of paranoia. The overwhelming sense that, at any point, you will be labeled a failure. Not just in your mind, but in the minds of your family and your peers. For every professor that is there to support you, there is always one or more who seemingly relish in making you squirm.

So your paranoia grows. It consumes you. It dictates your actions in every aspect of your life.

Did I put my shoes on the correct feet this morning? Did I shut off the light in the kitchen? Did I sign my name correctly?

The latter may sound silly to some, but when your hounded about signing with proper credentials every week it is something you become acutely aware of. It is at this point that you realize you have been broken, reduced to merely a puppet in the confines of pharmacy school.

But it is at this point where you rebuild. The light at the end of the proverbial tunnel begins to grow and what was once seemingly impossible seems tantalizingly tangible. A question is asked about why oxybutinin causes dry mouth and, without thinking, you start describing it's anti-cholinergic properties.

Maybe you can do this. Maybe this seemingly unending and unnerving mount of information you have been presented with has, in some way, become ingrained in your mind. Maybe once you were broken, but now you have become what you have always wanted... a healthcare professional.

And slowly those voices begin to quiet, first down to a whisper before ultimately vanishing completely. In some ways you are finally mentally at peace.

Yet... you still feel incomplete. As if the sacrifices made you into a new person at the cost of who you were. Whether that is a good or bad thing remains unseen, but it leaves one with a tantalizing question.

Are we better off?

Lo Chi Pride

 

For the uninitiated, Rho Chi is the organization that rewards those who academically perform well in pharmacy school, and then grant them with acceptance into their prestigious organization.

When starting pharmacy school, it is presented to you as one of the crowning achievements of your academic career. It is only when you finally become buried in the life of a pharmacy student that you realize what an actual farce this is.

In my experience, those who are in Rho Chi typically don't know what the hell they're talking about in practical situations. Sure they can recite every side effect of lamotrigine and they may know proper UHF dosing guidelines in a patient with VTE or ACS... provided everything is answered on a scan-tron form.

In a real world setting, most often emulated via our case studies, these successful "methods" no longer apply. Therapeutic suggestions are aimlessly justified because of what it said in a slide. Or, even worse, they won't know what a specific agent is or does, as they merely memorized it for the exam.

These are the "elite" pharmacy students we are told we should strive to be. It is the first of many seemingly unimportant carrots that are dangled in front of us as burgeoning pharmacy students.

Yes, this is a generalization and there are several Rho Chi members who do not fit this mold, but it still does not change my belief on the illegitimacy of defining success in this manner. As practitioners, we will not see success because of our ability to remember minute details, we will see success based upon our ability to logically apply our knowledge in practical situations

So you know what, I'm damn proud to be part of Lo Chi.

I may occasionally meet the average for exams, and even more rarely exceed it, but at the end of the day I know that I will still be a damn good practitioner.. perhaps one better than those Rho Chi members.

For the rest of you exhausted pharmers, aching for the end of the semester I say raise a glass of your favorite booze/caffeinated substance and toast the recognition of the most truly glorious organization in pharmacy school.

Lo Chi Pride!

Dispelling The Myth About the Second Year of Pharmacy School

There are things that we are told growing up that make our skin crawl. Our parents speak of the boogey man hiding in our closet. Our friends speak of ghosts hiding in an old abandoned house in town. And our counterparts in pharmacy school speak in dire tones when discussing the second year of pharmacy school.

One person will say it's the most terrible experience of their life. Another describes endless nights of not sleeping in order to memorize materials. Professors will warn you that it will shake you to the very core of your being.

I'll let you in on a little secret... it's not as bad as they say it is.

Don't get me wrong, the amount of material is daunting, the wealth of examinations can be overwhelming.

At the end of the day though, it's not any worse than first year. Actually, I have found second year to be easier than our first year.

Part of the reason is that you cover topics in multiple courses. Med chem will talk about SSRIs, SNRIs, and TCAs, and then pharmacology will discuss those and then we'll have a lecture on the same classes in therapy. You are, in effect, exposed to the material in three, or more, separate courses, often with a slightly different perspective.

In a way, you are being tested on the material three different times and, eventually, you realize that you have actually learned said material.

Yes, there are shitty lectures that will leave you confused. Yes, kinetics is the STD of pharmacy school which seemingly does not go away. When you part the clouds and look at the year as a whole, it's truly not that bad.

Granted I have had to learn how to budget my time due to working and having a child. I'm not "missing out" on getting wasted every weekend like I have heard so many classmates claim so far. But with a little organization and a little budgeting of time, it is completely doable.

So for you first years looking forward to next year with a sense of dread, heed my advice... it's really not that bad.

Just be sure you stock up on a little Red Bull. Just in case.

Walgreens, Express Scripts and Pharmacy Economics

Much is being made about the spat between Expess Scripts (ESI) and Walgreen's (WAG) over their latest contract. While privately many in the industry appear to be siding with Walgreen's for finally standing up for the profession for reasons listed here, pubically it appears a more even split.

Many decry the terrible burden this is for patients, as they are left to be pushed around by big business when it comes to the management of their health. Others are screaming that it is unfair for the pharmacy employees, as they are merely overworked pawns in this mess.

But with change comes sacrifice, does it not? No one will argue that the business side of pharmacy has been on a dangerous downward spiral for the last 10+ years. So why is it that when an organization is finally starting to stand firm against this spiral, that so many are speaking out against it?

Perhaps we need to simplify what this argument is all about and explain some of the numbers behind it and what they mean.

For a quick overview of the Economics of Pharmacy, check out the associated link. No, it is not college level macroeconomics, but for many who have not directly experienced it, it  does describes what the business environment is like. And, if you'll note, I have a rather accurate prediction in my closing statement.

How pharmacies are paid is quite simple, you are given an amount for the cost of a drug and a "filling" or "service" fee for actually filling the prescription.

Note that the average overhead cost of filling a prescription, before the cost of the drug, is roughly $10. That includes wages, supplies, building expenses and so on. Again, that's $10 for every prescription, irregardless of the cost of the medication.

When it comes to how pharmacies are paid for the cost of the drug is where it becomes tricky. Essentially there is a fictitious average price called the Average Wholesale Price (AWP) that is set as a standard for a drug nationwide. This fictitious price typically is not line with the actual cost, so a lot of times you'll be paid what's called AWP - 10%, which is 90% of the AWP price.

The percentages vary and there are additional systems involved, but this is generally how pharmacy economics function. Now let's run some numbers on a fictional script.

Drug A (Generic)
Drug A AWP: $13.00
Pharmacy Cost: $10.00
Overhead Cost: $10.00
Total Cost: $20.00

PBM Cost Payment: $11.70 (AWP * 0.9 = $13 * 0.9)
PBM Dispensing Fee: $1.50
Total Payment: $13.20

Now you'll notice, due to the AWP, that the pharmacy is actually paid more than the cost of the drug on this prescription. You'll then notice that the pharmacy was only paid $1.50 (15%) of the total $10.00 it costs to dispense this drug.

Believe it or not, this last fact is very common, something which pharmacies have been lashing out against for years now. And, from what I've heard, it is this sticking point which is at the heart of the ESI/WAG stalemate.

Various reports have stated that ESI wanted to decrease their dispensing fee to $0.40, that is 4% of the total cost to fill a prescription.

Now your first question is, "How do pharmacies stay in business if they lose money like this?" With some prescriptions, namely branded drugs, the prices used to calculate cost are somewhat more accurate and they have higher margins due to their higher cost.

The last article I read placed the average cost of a generic drug, for a month supply, at around $10.00 while the average price of a branded drug, for a month supply, is around $80.00. A higher cost allows more wiggle room if you will, and it is these drugs which subsidize the losses on other prescriptions.

The second question then becomes, "Well the fee is already low, you subsidize the cost with other prescriptions and it's only dropping a $1.10, what's the big deal?"

One of the ways in which pharmacy is evolving is that the percentage of generic drugs being used is increasing. The new drug pipeline has dried up considerably in recent years and blockbuster drugs like Lipitor, Prilosec and Claritin probably will not be seen again for quite sometime... if at all.

If you are dispensing fewer and fewer of the name branded products which counteract your losses on other drugs, it becomes increasingly important that you try to mitigate your losses on those other drugs. Pharmacies have been able to survive thus far on the backbone of strong, brand name drugs, but clearly this will not last forever.

Granted, this is a greatly simplified view of what the entire disagreement is all about. One could talk about the effect of the Walmart $4 generic program or government regulation or consumer indifference to the profession itself, but quite simply this is what it boils down to.

You cannot fault Walgreen's for being the first to finally stand up to one of the monster PBMs in this country. The fact of the matter is that Express Scripts needs Walgreen's more than Walgreen's needs Express Scripts.

ESI has no equity with the consumer aside from whatever experience they may have with a help line. Walgreen's has a face, a voice and a place to visit on a daily basis. It is as big of power move by Walgreen's as we may perhaps ever see.

While it's competitors enjoy the new business and take advantage of the situation, I'm sure deep in their corperate offices they are secretly cheering WAGs on as they could be next in the lines of these cuts.

This isn't about lining the pockets of the Walgreen's CEOs or it's investors. This isn't about making a pharmacy a cash cow. It is about taking a stand for what is financially right not only for pharmacy as a profession, but for patients as well. If we want optimal, efficient healthcare, we have to be paid a fair price for this service.

Remember this is not about making more money, this is about saving what little money they are making... if any.

And that, my friends, is why Walgreen's and Express Scripts are in a stand off of historic proportions. Perhaps it's not so bad after all...

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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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.