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...