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!

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...

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?

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?

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...

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.

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?

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.

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?

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.

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?

I'm Lazy

The overwhelming theme of this winter break? Sheer laziness.

I had a decent sized list of things I wanted to either do or complete over winter break. As spring classes now loom over my head, I have looked over that list and discovered I have accomplished little, if any, of them.

And honestly I don't really care.

The only thing that is mildly disappointing is not finishing the article I had started working on at the start of the semester. I think we can place the blame of not finishing that, and other things, on being a new father no?

I've been enjoying this funk of not wanting to think. I'm not really sure why as the fall semester wasn't overly mentally taxing, but hey I can sit on a couch and stare at a tv with the best of them now.

Of course the last two weeks has been, more or less, late night after late night staying up with the little guy which only propagates more laziness. It's impressive in the most disheartening sort of way.

Disheartening in that I hate being lazy. Channeling my inner nerd, I'm mildly excited for classes to start up again. I like being challenged on a regular basis, even though it may eventually frustrate and exhaust me.

Naturally this is a huge unknown as to how this will work with the baby and I do have an incessant fear of relying far too much on the wife. I really don't want to have to be a regular absent father during the semester, but I feel at some points it's going to be required.

In any case, in just a few days the laziness ends and the grind begins once again.

At least the wife will be able to drink with me this semester. Thank God for that.

Breathing, Peeing and Pooping, Oh My!

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

Well hello! So nice to see you again!

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

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

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

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

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

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

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

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

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

No One Can Change How You Practice But You

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

I liked her already.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Taking On Walmart: Lawsuit Style

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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