Tuesday, September 28, 2010

When A Medical Professional Turns Into The Patient...

I woke up the other morning with pretty badly irritated eye. Apparently I forgot to take my contacts out before going to bed. WHOOPS! I walked into the bathroom and looked into the mirror just to see how seriously red my eye was. I decided to take my contacts out, not sure whether it would make the situation worse or not. It made it worse, much worse! My eyes had a sharp stabbing pain whether it was open or shut. I continued to cover and wipe my eyes of drainage and decided to lay down and see if it passed. This did not help very much so I got the idea to put some contact solution into my eye in hopes it would bring some relief. It only stung more.


I guess I had to go to the pharmacy to see if something like Clear eyes or Visine would help. I figured that if this didn't do the trick, I might have to get some further medical attention that was above my own skill as a pharmacist.

The pharmacy I went to was the one I currently work at. I called a friend and he went with me in case my eye really bugged me. I made it to the pharmacy, picked out the eye drops I had in mind and left. My friend drove me home and stuck around to make sure I was alright. Thank God for good friends. The eye drops burned and did not seem to help much. I waited awhile and tried them again still to no avail. It was time to seek further care.

My friend drove me to an Urgicare which I used to know some nurses at. When we got there I had to fill out 4 forms and give them my insurance and identification. Filling out forms with one hand over your eye is not the most fun, especially after a 20 minute car ride which simply looking out the window makes you nauseated. I turn in the forms and waited to be seen. I waited about an hour and fifteen minutes in the waiting room before being called back to an exam room. Finally!

Once in the exam room the nurses came and asked some basic history and pain questions. They also took my blood pressure and they took it wrong. They raised my arm just over shoulder height and took it. Blood pressure readings should be done at heart level, at least that's what they taught me. I then continued to wait 45 minutes for the physicians to come into the room. He explained what he thought it was (since I gave a very detailed explanation he probably could have diagnosed it without even seeing me) and what he was going to do to examine it. Overall, he was very professional and I was pleased with his work. He then explained he did not see anything serious but was going to give me and antibiotic just to be safe. I then told him I was a pharmacist and wondered what he was thinking for an antibiotic. He said I should have mentioned it earlier and said he was going to write for Vigamox.

Wrong answer.

I knew Vigamox is over $100 a bottle and requires a prior authorization for every insurance I have every dealt with including my own. I suggested tobramycin and explained to him what I knew. He agreed and appreciated my knowledge then left to write the prescription. He came back and gave me follow up instructions if needed, including an ophthalmologist he knew personally, as well as the prescription for tobramycin eye drops, then showed me out to the nursing staff to sign one more item.

When I saw the nurses and signed their document, I asked them to call my prescription into a pharmacy near by that was part of the chain I work for. They were hesitant and said they do not do that.

Wrong asnwer.

I told them I am a pharmacist and that I knew the pharmacist they would be calling it into. They checked with the physician who literally said, "Ya, why wouldn't we call it in?" They agreed and I left with my friend to go to the pharmacy.

We got to the pharmacy 30 minutes prior to close and to no surprise my prescription was not ready. I asked how long and the intern, who I knew, said that the pharmacist did not take it because they were out of stock of it. Personally, I would have still taken it and then offered the patient to transfer it, but to each their own. The pharmacist said the Urgicare was going to call me to call another pharmacy with it or to preferably to pick it up. One problem, my cell phone was dead. Thankfully, my friend let me use his phone to call the Urgicare and call it into the exact pharmacy I work at, to which the Urgicare nurse obliged.

We drove to my pharmacy, speeding a little since we know we would be getting there with in 5 minutes of closing. I called ahead as we pulled off the highway and my pharmacist partner said it was ready and he would stay open until I got there and that he rushed it since he knew it was mine. Again, I am thankful I know how the medical system works and some people in it, which allowed me to get my prescription in a fairly timely manner.



As I was rung out by my cashier, I thought to myself, "What if I wasn't a pharmacist?" This would have meant that the doctor would have written for an expensive prescription which my insurance wouldn't have covered. I would have gotten to the first pharmacy and been pretty frustrated since I had spent 2 hours plus at the Urgicare and still had a sore eye. If the pharmacist would have called the Urgicare to change the prescription, she would than have not had the antibiotic in stock. I then would have to go to another pharmacy to get my prescription. I also would not even be able to stay with the same chain to get my prescription that night since they all would have been closed. I may have even not gotten my prescription that night. On top of all of this the antibiotic I did receive needs to be applied every 3 hours while awake. This is fine by me, since it was $4 instead of over $100, but even as a medical professional applying an eye drop every 3 hours is hard to remember. Imagine if I were a patient again, I would probably be annoyed and not understand why the drop needs to be used so often.

This whole experience really did make me think differently about patients who come in last minute. Ironically enough I had a patient about my age come in with an antibiotic 5 minutes prior to close while I was already busy the night prior to my eye injury. I told him to stick around as I would make sure he got it before he left. The man was grateful for my services and that I took care of him despite being busy. I now fully appreciate his appreciation for me taking care of him despite the fact that I was closing really soon. Thankfully, karma must have paid off and taken care of me when I needed it. I can definitely say I look at the last minute patient with a little bit more respect considering what they might have just been through. If a last minute patient just hurried to make it in, I will definitely take care of them as long as they are in a true urgent need and not just filling a prescription they had for 2 weeks. This is especially true if a patient has an antibiotic or is from an Urgicare!

Thursday, September 23, 2010

Pain Management For Sale


This picture was sent to me by a reader. This scares me. This is what is wrong on so many levels. If I had seen this, I think I might have stolen it to help fight abuse.

Why Herbals Are So Popular

"Is there anything over the counter I can take for my menopause?"


"Where's your glucosamine at?"


"Can you recommend something natural?"

These are some very common phrases around most retail pharmacies these days. Many consumers are turning to herbal supplements to help them improve their health or to aid them in other ways. This boom in herbal remedies is due in large part to the amount of information available on the internet and the ease of access it provides now more than ever.

On a daily basis I have handfuls of patients that ask me question pertaining to a variety of health issues and remedies for them that they have researched on the internet. In many cases, these patients come to me asking what I think about specific products and "do they work" or "how well do they work". With the availability of information many of my patients can filter out their symptoms and essentially find their "diagnosis". I use that word loosely since only limited medical professionals can actually make a diagnosis.

To be fair to lay people, I put myself in their shoes...

I am sitting at home with knee pain and wondering what I should take? Should I take the Celebrex (celecoxib) the physician prescribed for me? I just saw a commercial of which half it was the risk of side effects including possible heart issues (by law 1/2 of all prescriptions advertising must be focused on things such as side effects, just look at the next printed medication ad you see in a magazine). Well that seems a little bit serious. I remember there was a commercial for Osteo-Bi-Flex when I was watching the price is right and it didn't list any side effects. No side effects must mean that it's safer, right? There was also a commercial for One-A-Day Energy which said it would give me that little kick I needed. I am going to go the the drug store...

After arriving at the drug store, I grab a generic pain reliever (that is similar to Celebrex but cheaper as my pharmacist said) and what appears to be a generic for Osteo-Bi-Flex. I look at the labels...

First the herbal supplement...

Just like I thought, there aren't very many warnings. Now let's look at the over the counter (OTC) pain reliever...



WHOA!! That's a lot of information on a bottle about the same size. I think I am going to try the herbal instead. Let's look at the energy vitamin. It looks like the rest except it has guarana with an asterisk by it. It's probably alright...

Now this is in now way an all encompassing example. Many of my patients will actually listen to what I recommend for them, especially if I tell them it's what I would take if I were them. However, there are also several patients a day that now matter what I say they believe that the natural is better. I do what I can to help all but sometimes, they will not simply listen.

With such strong FDA restrictions on prescription and some OTC medications while have little to no regulation over herbals it is no wonder why advertising and the billion dollar herbal industry has lead consumers to think they are much safer than FDA tested and regulated medications. Many patients, even when they look up herbals on the internet, are not aware of the side effects or drug interactions of many herbal medications or that many of the herbal products are not tested and in many cases are not regulated for quality.

Just to highlight a few common areas I see in a daily basis I will keep this herbal review short. VERY SHORT. Here are some herbal basics:
1. ALWAYS consult a pharmacist/physician before taking them. At the very least do some homework and look up possible indications and directions for use as well as potential side effects.
General Rule: Beware of the G's - Ginseng, Guarana, and Garlic. These have the most interactions and the first two can increase blood pressure signigicantly. Glucosamine is generally safe but may interact with Coumadin (warfarin)

2. If it makes some cure all or miraculous claim, it's garbage and will not live up to the hype

This includes: most weight loss remedies (Alli will work but with proper diet and exercise only minimally), male enhancement or erectile dysfunction (ED) herbals (some with yohimbe or horny goat weed may work but all of them I have seen have ingredients that will raise blood pressure which may worsen ED), and colon cleansing products to name a few.

3. A lot of the herbals have some basis as to why they work. However, many may only work mildly if at all. They are not replacements for prescription medications.

4. Look for the USP or ISO certification stamps. These mean these herbals where tested by an independent third party and actually have what they claim in them. Thus these are safer than most.

5. Do not ask advice at a store that strictly sells these products. Many of the employees have numbers they need to reach and will sell you a variety of things to meet THEIR NEEDS, not yours. Instead ask a health care provider, like a pharmacist. We must be able to legally back up what we recommend. Would you trust someone who must back up their recommendation in a court of law or someone who was hired last week and is still in high school?

With all of that being said herbals are not always a bad thing and can actually help many people live better lives. They are not cure alls but should be used with the same discretion as prescription medications. Everything has side effects even foods. If a person eats too much fat, they gain weight. BOOM! Side effect! Always ask advice of a professional. Yes, they may make a little bit off of selling you something but they are held accountable for what they tell you. That's why they are PROFESSIONALS!

Wednesday, September 22, 2010

15 Pharmacy Rules for Patients

Pharmacy Rule #1: If your name looks like a set of Scrabbles tiles don't yell at me if I butcher it.

Pharmacy Rule #2: I can only explain your insurance only covers 30 days worth of medication instead of 90 in so many ways before I give up. I am not bad at dumbing things down, you may just not be that intelligent.

Pharmacy Rule #3: If you don't know the date of birth or address for the prescription you are picking up, I do not know how to sell it to you. Double checks are there for a reason.

Pharmacy Rule #4: If I tell you your refill is too soon and you try to have it transferred to a different pharmacy, I will make sure the other pharmacist knows it's too soon and that you are a current problem for me. Therefore they won't fill it either.

Pharmacy Rule #5: If you try to get you pain medication filled too early repeatedly you will get a nice note in your profile that will let other pharmacists know this.

Pharmacy Rule #6: Respect. Respect the pharmacist and the technicians. Respect is mutual and if you don't respect us, we will not respect you.

Pharmacy Rule #7: If you do not think something is correct please feel free to ask. If you do I will look into it and try to correct and problem willingly. If you yell and make a scene, I probably will not go out of my way (unless it's truly bad).

Pharmacy Rule #8: If you simply say thanks or show that you appreciate my work, I will bust my hump for your gratitude and take care of you.

Pharmacy Rule #9: If I can't read it, I can't fill it. I will try to clarify any issue, unless you act indignant towards the fact that my effort and care may take a few more minutes to ensure YOU get what YOU need.

Pharmacy Rule #10: Your physician isn't always right. Neither am I and neither are you. Everyone's human, so there is no reason to go crazy about something if it's small. If it's big bring to my attention as politely as possible and it WILL be resolved.

Pharmacy Rule #11: Controlled medications are controlled for a reason. This is why I can not fill them early. Drug abuse is real and very serious. No early controls. Period.

Pharmacy Rule #12: I see more patients than any other medical professional and do it fast and accurate. If I need extra time to ensure something is correct, please allow it. It is YOUR health.

Pharmacy Rule #13: If you think my hold time sucks, feel free to call your own insurance company. I do it all the time for YOUR gain, not mine. Trust me it sucks 5 times worse.

Pharmacy Rule #14: There are many pharmacies and pharmacists out there. If you and I don't get along or see eye to eye, feel free to venture elsewhere for BOTH of our sanities.

Pharmacy Rule #15: I became a pharmacist to help people. I did not go through 6 years or more of college, stay up countless hours studying and busting my hump to be a pain in your side or to play God as some may accuse me of. I use knowledge, legalities and logic to ensure what I am doing is the best for my patients and others. This is why I am a pharmacist.

That is all of my pharmacy rules for patients.

Until I can think of more.

Saturday, September 18, 2010

8 Quick Rules All District Managers Need to Remember

I decided to send my district manager an email of pharmacy rules. They are as follows:

Rule #1: If I am not the store manager, do NOT call me on my days off. I earned them by working on my days ON.

Rule #2: When you pay me real overtime, then I may not mind working 60 hours a week. An extra $3 an hour isn't gonna make much difference in my pay check, it just increases my taxes.

Rule #3: I can actually affect how much your bonus is, so treat all of us pharmacists better. Or else there may be an "accidental" order for some high end medications just to throw off you days supply and inventory demographics

Rule #4: If you won't fill in for me or my technicians, do NOT tell me that I am NOT understaffed.

Rule #5: Don't tell me to improve my numbers when all pharmacists should focus on patient care FIRST and foremost.

Rule #6: I stand all day and take heat from patients, physicians, technicians, random others and you. When complaint calls make there way to you get my side first before doling out a gift card. This will only infuriate me more and reinforce the patient's entitlement complex.

Rule #7: All pharmacists have some anger inside (see Theangrypharmacist.com). Remember this when you think how we might react to something!

Rule #8: I have mastered the skills and many uses for the spatula. Again, remember this!

That is all.

For now...

Friday, September 3, 2010

Blondie Gets Plan B

Fried Chicken with a Side of Diabetes

Any time I see a patient in motorized cart headed towards my pharmacy, I can usually see some sort of odd problem on the horizon. When the patients pulls up in a motorized cart, is over 100 pounds overweight and eating fried chicken straight off the bone (grease all over the prescriptions of course), I know it's going to somehow cause me a headache!


A morbidly obese patient slowly heads to my pharmacy in a motorized scooter because they are probably too large to walk any distance. They hand my technician several prescriptions with one hand while eating a few pieces of fried chicken in the other. My first thought is that that all of these prescriptions are probably for diabetes and hypertension and of course they were. Clearly this patient is not trying hard to control either by eating fried chicken for a snack (it was mid afternoon and I am sure she does not miss many meals) and not even trying to do simple exercise like walking.

The technician tells the patient that it will be just under an hour to get their prescriptions ready because there are so many of them and it is the first week of the month, so we are swamped. The patient scolds the tech with, "I can't believe this I need my medicine and I have to wait and hour!?! I am gonna go over there and I'll be back in half an hour they better be ready!" The tech tells the patient that she is welcome to come back but it will be closer to an hour. The patients scoots aways with the drumstick still in her hand.

Twenty minutes later, I finally am able to initially check the prescription before the techs fill it. I do so and then my computer tells me that her insurance won't cover the medication because the physician did not put clear and precise directions or a diagnosis code on the prescription. Although forgetting this legal bit of info to bill a government insurance, which the physician knows the patient is on, she did put her hemoglobin A1c which is 11.0. This measure is explained here. Despite being on high doses of every medication possible this patient's diabetes is still through the roof! Again, reinforcing my previous opinion that she really does not care but is rather riding this for what she can get out of the government.

Like any good pharmacist, I pass the task of calling the physician's office on to my intern. My intern calls and actually gets a hold of the physician. Odd, why can I never reach anyone of knowledge when I call that office? He explains to her the situation and the response by the physician is appalling. "This has happened before and your pharmacy always prevents my patients from filling their medications! It's only you guys! Just give her the damn medicine and don't bother calling me back! I have other patients who need help too and I am sick of you calling me on technicalities!" My intern looks at me with a look of disbelief, he knows I heard the whole conversation because it was that loud.

Now I am angry. People don't like me when I am angry...

I call back and get the office secretary and ask for the physician while explaining where I was calling from. "She's in with patients can I take a message for you?" I explain that I can hold it's that important. After several minutes on hold the physician picks up the phone. "How can I help you?" It's go time! "Hi, is this Dr. (protected so I don't get sued over slander)? It is? Good, I have to tell you to NEVER treat an intern, or pharmacist for that matter, like that again! We called you because you did not fill out a prescription in the correct and LEGAL way so we can help one our mutual patients! I heard what you said to my intern and am tempted to report this further to the institution you practice under. Are we clear? GOOD! Now can you get me the diagnosis code and the precise way she is taking her medicine so I can give her the DAMN medicine you prescribed? Uh, huh. OK. Thanks! I appreciate you giving me that LEGAL information. I hope when or if I have to call your office again your are more appreciative of what I do. Without my knowledge and skills your patient would not get their medicine and good medical care could not be provided. Have a great day!" **CLICK**

At this point my ears are red and my intern is in hysterics. It is sad how some people, particularly in medicine, have such a God complex. Now the patient is at the counter and asking why her medicine isn't ready. My intern quickly walks over and informs the patient who promptly starts into a fit of yelling. My intern is calmly explaining the situation to the patient but the patient is not listening. I don't expect patients to fully understand everything but I do expect that they listen to me or trust what I am doing is correct. They can even question me but there is never any reason to yell unless something is really messed up.

I scurry over to bail out my intern. As I start to tell the patient what all we had to go through to ensure that they get their medicine they shouts this, "I don't care! My doctor gave me those scripts and there is always some problem! I ain't waitin'! Let God figure it out! If he wants me, he'll take me! If he wants me to live he'll fix my diabetes!" Now I am fuming! For better or worse I was "blessed" with a sharp tongue and quickly state to the patient, "God only helps those who help themselves." The patient continues to raise a scene and putts away in her scooter (which is now leaning to one side as she has been rocking back and forth in it). My intern looks at me with disbelief, I tell him "Some people just don't care."

This was an extreme case of ignorance on multiple ends. However, this could be avoided by one simple way. Put a pharmacist in a physician's office. I understand this has some high costs with it as most pharmacists in my area get paid right around $100,000 a year. With the cutbacks by government programs, which are the biggest payer of health care, this can really strap physicians and their practices.

Here's my justification and solution.

If it takes me 10 minutes to get a hold of someone at an office who can help me, that's $10. Include the office help time and the nurse or physician's, that number jumps to ~$25-$30. This is assuming an office person spends 10 minutes at $20-$25/hr and that the physician only gets paid double what I do and spends 5 minutes on the problem. Multiply this by the number of calls I make daily for things like this, about 10-15, that's easily $250-$450. Extrapolate that number to all of the pharmacies in the metro area in which I work in, according to Google is 2,676, that number booms to $669,00 - $1,204,200. This number represents wasted time for pharmacists, physicians and office staff. The scary part is this number is probably low since most office staff have to hunt for answers after I leave them a message. Physicians have to go and look up more info and spend more time, which is more money. This number may also be low because my pharmacy is slightly below average for volume as well.

So what could reduce this cost?

If a pharmacist was to work one day a week in a physician office and work for 5 offices, that would only cost and each office ~$20,000 a year, which is less than they pay most, if not all, of there staff. Most practices have multiple physicians so they have higher patient volumes. A pharmacist could work with the staff and physician to review charts and ensure patients are getting correct prescriptions that can be filled by pharmacies easier thus resulting in less money being spent on wasted time. This would also result in the staff and physician being better educated on what it is pharmacies need to get patients their medications easier and possibly cheaper. I have no way of measuring the statistics of how much this could save patients and thus insurance companies as well as government programs but with my experience, I am sure it could easily be millions in just the one metro area I work in. This could be another benefit and cost savings which a pharmacist could help greatly reduce. Maybe the government would be willing to pay a little bit more to physicians if they saw a decrease in the back end of prescription costs. They may argue this is what their prior authorization process is for but, honestly, that just costs physician's offices and pharmacies more time. Most patients have more time untreated and end up frustrated or not getting their medicine. This problem can from here just snowball, but could have been prevented with a pharmacist on the physician staff. With the loose math above, this means that roughly 12 pharmacists could cover 60 physician offices! If you had several head pharmacists and made a residency program out of it you could cover even more!

Maybe I am aiming to pie in the sky, but to me this make to much sense financially and medically. Why not try to save money, decrease government spending and improve medical care. Many studies out there already back these claims up, so why are we not seeing more of this? I wish I knew, but until that day I feel that it is too many times we are, figuratively, just giving the fried chicken to the diabetics and only creating a worse situation for everyone involved.