Why Listening Goes a Long Way

Some days in the retail pharmacy setting can be tough. We see patients who are frustrated that they have to be taking medications that they may hardly see the benefits of or must take just to survive. Sometimes these frustrations boil over at the pharmacy, particularly when there are insurance issues. Then there are those patients that are just down right disrespectful and rude to everyone, yet for some reason they always come back to the same pharmacy. I have yet to understand what drives these people to act this way and then return time and time again. Maybe it's trust without respect. Maybe it's convenience or price. Maybe it's just a routine. Maybe it's something deeper...

During the holidays it can get a bit busy around a pharmacy as everyone prepares for weekends of travel or for the pharmacy to be closed. A few days before Christmas was a normal pre-holiday rush at the pharmacy when I saw a familiar gentlemen and women come up to the counter. I waited on them as I would any other patient and saw that the 12 prescriptions they were dropping off were for one of my patients that is a real pain in my backside. Every time this patient comes in he is always cursing at the pharmacy staff and yelling about how incompetent we are, even going as far as to yell at us about his "outrageous" copays. The only outrageous thing here is the utter disrespect this man has for people who are trying to help him, including his physician he commonly lets a tirade off about.

I politely tell the man and woman that it would take a little bit to get these prescriptions ready as we were fairly busy. They asked how long and told them to give me about an hour. I hated to tell such polite and courteous people this long of a wait but there was no way it could be done any faster given the amount of prescriptions that needed to be worked on. The couple said that would be fine and they'd go look around the store.

2 hours later....

The couple comes back to the pharmacy counter and asks if the prescriptions that they dropped off were ready. My technician quickly informs them that I am finishing the last one and if they step to the side he'd be with them as soon as they were ready.

To be honest the prescriptions were not done at all. I had gotten tied up on the phone with an insurance company that killed my wait times, even though I was still checking and filling prescriptions while I was on hold or talking to the insurance agent. Nonetheless, I quickly finished checking the medication for the couple, knowing it was very important for them as well as VERY expensive. Add to this the fact that they were so patient despite the fact that it took me twice as long to finish the prescription as I had told them and I truly owed it to them to expedite the process of finishing their prescription.

After I finished the prescriptions and was printing the leaflets, I took note of the relatively high copays. The copays were somewhere in the range of $350. That's roughly a $30 per prescription copay and some of the medications weren't very expensive. The catch was the copay on the medications for the kidney transplant the patient just received (tacrolimus and mycophenolate mofetil) was rather high. I assumed these high copays were correct given the actual retail cost of this medicine was around $4,000 and just told the tech to mention this to the patient. It wasn't like they could really say no or not take this medication for the patient, he needed it to accept his kidney and go about life!

The patient couple was called over and informed of how much their medication was. Immediately the woman looked at her husband and said, "We can't afford this! I don't have this much in my checking account. (Insert real patient name here) only gave us $25 and said that would cover it." The husband responded gruffly then called his credit card company to make sure he had enough credit limit left to charge these medications.

At this point I couldn't help but feel for these people. They were going above and beyond to take care of a patient who I knew full well was a handful. I could only imagine what they were going through and how he was treating them. I quickly walked over to the counter and explained the actual cost of the medication to the women, as well as why the patient needed them.

This is when the water works started...

"I know they're expensive and I know it's not your fault, but it's just we are here from out of town to take care of my brother who just got a kidney transplant. We found out a few days ago that they found a donor for him and that he would be getting this kidney, so we drove up here on a moment's notice and helped take care of him and his house.", she said through what was beginning to be a full on tear-fest. "We have been up here several times over the past year, each time dropping what we were doing to take care of him when he got admitted to the hospital. We just want him to be healthy but all he does is shit on us!" The tears were really coming now.

Knowing how verbally abusive this patient can be I try to calm the woman down, "Well, ma'am I know how he can be. He has given us a tongue lashing or two in our time with him." as I nudge my tech, "However, ma'am you and your husband are doing the right thing. You're trying to help someone and if no one else tells you that, trust me, you're doing the right thing and that's all that counts."

The woman leans over the counter, still sobbing, and hugs me (a little awkwardly as the counter is at least 2-3 feet wide). "Thank you so much! It's just we have cleaned every inch of his house! There was rat turds and trash everywhere! We scrubbed the grout with Ajax and bleached everything! We are constantly funding his healthcare and trying to work with him and he won't even quit smoking! He lied to them and said he stopped but he even still drinks a couple beers every day! Now I'm stuck here thousands of miles from home with my brother who doesn't give a shit, no money and all I want for Christmas is to be able to go home!"

I couldn't stop hugging this poor woman. I was so backed up that I probably wasn't going to leave for at least an hour after my store closed but I couldn't stop. This woman wasn't even my patient but after seeing how a similar situation occurred in my family a few years back, I just couldn't stop hugging her. She needed it. Even if it was from a completely random pharmacist.

She sobbed some more and went on how she doesn't want to lose her brother because he won't follow any of the medical advice and he is even thinking about getting some puppies to make himself feel at home (this is kind of a big no no if someone just got a transplant seeing as how dogs are the cleanest animals). She went on and on for a while even her husband, who was clearly the rock in this relationship, was getting watery eyed as he saw me start to tear up knowing exactly what this family was going through.

After a few more minutes of sitting with this woman on the bench in my waiting area while her husband paid for the prescriptions, I counseled them on what each medication was for, how to take it and gave them a complimentary pill organizer that would help them organize her brother's medications while they were there and hopefully afterwards.

Mind you I was in my lab coat and in full view of other patients who were waiting. Not one of them said anything or even huffed over having to wait a little longer as I worked with this woman and her husband.

After counseling it dawned on me that there was a local kidney center that could help take care of patients like this woman's brother. I looked up the information on my smart phone and put it on the back of my card, that way she or her husband could put it in their wallet to call later and help set up care for her brother. I explained that maybe this could save them from having to come back so much or even at all. This is when the woman blurted out through the slowing tears, "Thank you so much! My brother always says how good you all are here. I just feel like you're an angel that was sent to help us get through this!"

Whoa! I have been called many things as a pharmacist but an angel is NOT one of them!

I jokingly played it off, thanking her and telling her "That's funny you say that because you brother has called me every four letter word in the book before, it must be how he shows love." The woman laughed and hugged me again. Her husband firmly shook my hand with both of his big callused hands and said, "Thank you so much for listening, it really means the world to us."

As they left they took my name and asked for the name of my district manager, as they wanted to call to tell him what I had done for them. I gave it to them (as these calls NEVER happen) and said I appreciated it. The woman replied, "Well we appreciate everything you have done for us. It's the least we can do since you gave us a Christmas miracle."

I was able to help 3 people, maybe more. And all I did was listen...

When Are Cuts Simply Too Much?

For the longest time pharmacists have talked about numbers. Hospital pharmacists brag about the how many beds their institution is. Retail pharmacists brag about how many scripts they do per day. Some pharmacists also brag about how much profit their pharmacy made and how big their personal bonus was.

When do pharmacists brag about cutting hours?

This is where my usually funny and quirky self turns dead serious.

Let’s face it, in the current economic situation hours and employees seem to be getting laid off or cut everywhere. The once secure job of working in a pharmacy, which was once thought to be an untouchable industry, is not immune either. Pharmacy technicians are especially susceptible to having their hours cut because a pharmacy can run without them but it MUST have a licensed pharmacist.

Over the past year or so I have seen the hours at my own store cut. It was no sooner that we got a new technician hired (based on old corporate staffing guidelines) that we had to cut them 3 weeks later. In addition to this cut of 30+ hours, we had to cut every other technician down from 40 to 36 hours, for a total savings of about 50 hours plus one persons benefits. At the same time, our volume remained unchanged.

Who runs the pharmacy?

These cuts started taking their toll. We had increased wait times for prescriptions to get filled, we had a decrease in our patient satisfaction and increase in complaints, and we had technicians who were getting more and more stressed out as well as an increase burden on the pharmacist. Some people would call this “being more efficient”, which translates to the almighty stock price and analysts as “increased profits”. This is the major downfall of all corporate pharmacies, the stock price.

Notice a few piles going?

I know this isn’t just the company I work for cutting their hours either (example 1, 2, 3, Canada) Almost every one of my friends who is a pharmacist, in both retail and other settings, have seen hours cut. Part time and floater pharmacists are having hours cut or are being phased out, older pharmacists are being forced to retire, and pharmacy technicians are having their jobs cut like the woman in the shower scene of Alfred Hitchcock’s Psycho! To be fair we should have seen this coming. When automation was put into pharmacies it was for 2 reasons, to reduce errors (which I feel it has depending on circumstances) and to REDUCE COSTS.

From others I have talked too this is an issue affecting more than pharmacy. Physicians are having to see more patients or staff longer hours, nurses are taking on more patients as well and not to mention the increase in scripts I see from physician assistants and certified nurse practitioners. For now I will just focus of pharmacy as that is my own profession and what I know best…

So from the outside looking in, it is easy to say, “Well if there were hours to cut, that makes sense. You have to increase profits and productivity as a company. These times are tough.” That argument does make some sense, however with an increase burden put on pharmacists, as with any medical professional, the chance of error goes up, dramatically. According to the Institute for Safe Medication Practices (ISMP), there are 10 key elements that affect medication error rates. Of these 10 key elements, I can see an overworked or stressed out pharmacist being affected by these: Communication of drug information, Drug labeling, packaging and nomenclature, Environmental factors, Staff competency and education, Patient education, and Quality process and risk management. Realistically I can extrapolate scenarios for all of the others but these are probably the biggest areas that would be impacted or would impact the pharmacists’ ability to do their necessary duties to acceptable standards. I do not feel that acceptable should be the goal in healthcare, the goal should be the best possible but cuts have lowered that standard due to an increase in workload.

Now this picture is probably taken out of context but what if there is no one working but one pharmacist? Expect good service or them to be stressed?

Then you have stories like this… “Pharmacist Gives Pregnant Woman Wrong Prescription”

Please watch this video. It does have some media extravagance BUT it should never have happened. I cannot say if pharmacists or technicians here had recent cuts or are overworked but it is an omen to what could happen if cuts continue.

Before people say this is just another pharmacist ranting and venting under an anonymous blog, let me explain something. I am doing this for patient safety, I pray to never make a mistake but realize that is impossible. I would like any possible thing done to avoid mistakes so patients do not get hurt or worse. Yes, I would appreciate less stress at work, but where I work, that is unlikely to happen too much due to the clientele in my area. I am pushing against these cuts because I feel it does not allow pharmacists to use their full ability to help patients. It also does not give patients the best possible healthcare they would like. Therefore, this is as much a patient issue as it is a risk management issue. These are two things that most corporations care greatly about but are blinded by the almighty stock price and perception of their company. I think this quote from the recent movie Wall Street: Money Never Sleeps sums it up very well:

“Is greed still good? Somebody reminded me the other night that I once said ‘greed is good.’ I swear I don't remember it but it sounds like something I would say in the eighties.”

– Gordon Gecko

This leaves the question of, “So what can we do now?” The answer is not very simple and does involve some work but is more than reasonable. LET CORPORATE HEAR IT! In the wake of hour cuts and customer complaints I have taken an active role to ensure my store gets back to having improved staffing. Any time a patient complains or comments of how short of help we are I am always quick to point out exactly where they can go online to let my company know about how they feel and offer them the corporate service hotline. So far it has worked a little in corporate let all of the 36 hour technicians back up to their gull 40 hours. It’s not world changing but it is a start. Since increasing our hours, the district manager has noted that our complaints are down and that our volume has picked up a little bit. Hence the increased staffing has worked to his advantage and to that of my sanity as well as to the benefit of my patients. I wouldn’t call it protesting but the two most powerful things a patient has is their voice and their dollar.

I really hope to see them both used wisely.

The Scary Future of MTMs

If you have been listening to the recent news and trends in the pharmacy industry any time in the past few years the chances are that you have heard of medications therapy management programs (MTMs or also called MTMPs).

"Medication therapy management, also referred to as MTM, is a term used to describe a broad range of health care services provided by pharmacists, the medication experts on the health care team." - APhA

MTMs were first mentioned in the Medicare reform under President George Bush and have shown to decrease healthcare costs significantly as well as show increased patient compliance and overall improvements in healthcare quality. MTMs have a big role in the future of pharmacy and could really develop a new face for the profession.

There is one key thing to all of this, however. MTMs must be performed in the right way, with physicians and patients who are open to the concept. This way the programs can have optimal results and show other professional and members of the public the benefits of having a pharmacist perform such activities.

I recently found out, through a source not to be named, that a major chain pharmacy is rolling out an "MTM" program. This program however is being done in a very poor manner. The chain is trying to force all of their pharmacists to participate, even those who are older and not fully up to date with current practice guidelines. This chain is also having pharmacists call physicians office and recommend adding/changing medications, which may sound like a good idea however, these pharmacists are doing so with no lab work, no practice agreements with physicians or with patients and nor formal training in how to run or operate and MTM program!

The practicality of this chain's "MTM" setup is just atrocious. How many physicians are open to a pharmacist (or anyone) calling them and recommending they put their patients on more medicine or changes in dosages, outside of the normal calls that occur already? How many patients really want to be on more medications? From my own experience both of these issues provide serious obstacles that I do not see going over very well for the pharmacists involved.

The main problem here is greed. This chain is not reimbursing their pharmacists any more for their time spent performing MTM services. They are forcing them to do all of this on top of giving flu shots, filling the same number of prescriptions (if not more caused by the calls they will be making), answering phone calls, counseling patients and any other duties that need to be performed. This chain has held stagnant is sales while others have increased over the same time period, thus they are trying to increase business by forcing pharmacists to make more phone calls. I am curious to see if the chain will also try to bill insurance companies, particularly Medicare, for these MTM services and how successful they will be in doing so. Let us not forget that all of this is also occurring after this chain cut both pharmacist and technician hours. YIKES!

Another thing that worries me here is the lack of cohesion that this may cause in the pharmacy industry. Accrediting bodies have fought long and hard to get these type of programs set in place and reimbursement for these services, which is great! They have also established residency programs with the specific focus of MTMs and have recently established a board certified program for these types for these types of positions. This chain is single-handedly degrading everything these bodies have worked for by having under qualified professionals perform these duties.

Now, before everybody thinks I am demeaning MTMs I must say that I am in full support of MTM programs and really believe that they are a great thing for pharmacists to be involved in. The provide a great benefit to both the patient, the payer and the healthcare system. That being said, they should be done correctly and rolled out in a manner where all participants are accepting of it. It should not be forced on pharmacists, physicians and patients like this chain is essentially doing.

The problem here is a simple one to me. Too many under qualified pharmacist will be forced to execute MTM services in a poor manner. This could potentially lead to resistance to it's acceptance and eventual adoption into the healthcare system. This would be greatly disappointing because of the potential delay in improved healthcare, education and substantial money saved. I would love to see these types of programs rolled out over the whole U.S.A., I believe the way to do it is start in a manner that will be better accepted by all participants. A suggestion of mine would be to start in smaller areas where pharmacists, physicians and patients all, generally speaking, know each other a little better. This much has already happened to some degree, seeing as how many independent pharmacies currently provide these services. The chains need to start in a similar fashion and be sure to include such services in a manner that takes pressure off of the pharmacist so they are performing these services while prescriptions and other duties are piling up on them. This may mean that one pharmacist has to cover a few different stores until the program is more widely accepted but at least a properly trained professional will be focused and undistracted from what they are to do. This is an idea the previously stated chain is clearly not concerned about.

The biggest thing here is that pharmacists need to step up and show what they can do, but stop trying to be Superman and do everything all at once, which sadly is what we are known for doing. I would love to see MTM services rolled out in a greater scale but I am afraid if not done correctly it could cause years of delays in acceptance and costing this country a lot of money in several different ways. I hope this chain realizes their soon to be potential misstep and really thinks about what they are doing. The problem is stock prices and greed may win out.

(Note: I have left out several citations for fear of fully divulging which chain this is. Any comments left after this are not mine and that of individuals who do not speak on my behalf.)

Weight Loss Clinics, Marketing at It's Finest!

America is obese.

This we know.

Because of this people are looking to others for help them lose the weight. I see a great deal of people who ask questions about what works best for weight loss. Many of these patients want to try a quick fix pill or a trendy diet and see results in a week or two. Lots of questions have recently focused on the Jillian Michaels line of diet pills or Hydroxycut. Both of these medications are choc full of stimulants like caffeine that may help in weight loss, but also can raise blood pressure increase, affect sleep patterns and induce heart palpations among other detrimental side effects. Proof in this is just how many times Jillian Michaels has been sued over her diet pills, here is one example. A lot of patients do not understand this and thus are glad when I give them my professional input.

So if a pharmacist knows, wouldn't a weight loss clinic be a great place to try to find my answer?

Although this sounds logical, I would vehemently disagree, and here's why...

Weight loss clinics really play on insecurities of those who are either insecure or desperate enough to ask for professional help to lose weight. However, many of these clinics are nothing more than business fronts that can be fairly lucrative, especially since a lot of these patients usually have good occupations and are willing to pay out of pocket for the services that are rendered.

I had a patient who came into my pharmacy today who really verified what I feel about most weight loss clinics. Possibly even worsening it.

A 30 something year old, well dressed, African American female came into my pharmacy with 2 prescriptions, one for Adipex and one for Lasix. Due to my states stringent laws regarding weight loss medications, I was forced to call the "physician's" office to get the patient's BMI since it was not written on the prescription. While I was dialing the patient walked over to the closest area to me she could and asked me, "Why do you need to call? I have been on this before!" Thus another hurdle my state law gives me is that a patient can only be on Adipex for 12 weeks then MUST take a 6 month break before resuming therapy. Sure enough, she had this medication 3 months prior and was in violation of the previously stated law. Great...

I approached the patient and explained the laws to her and showed her that I had written the date of the last time she had the medication filled, since it could not be legally filled. We went back and forth a little bit, both arguing our points, until she finally asked me, "Why is this so hard to get my weight loss medicine? It's not like this stuff kills people!"

She must have been a carpenter because she hit the nail on the head!

I then explained to the patient about why the combination of Phen-Fen, was taken off of the market and how medications like Adipex may cause health problems. She gave me a baffled look. I also explained to her that by taking the second prescription, Lasix, would cause her to be dehydrated, causing her heart rate to increase and thus cause even more stress on her system. Although, I know some physicians do this, I am not a fan of it. "Well I have had issue of my heart rate going crazy and I have been drinking a lot of water and sucking on cough drops but my mouth is always dry. Do you think this could be why?" I told her it very well could be asked her a few more questions and deduced that it was probably due to the medications she was given.

This is when she dropped a bomb on me.

"Well ya know when I go in there, no doctor even sees me. I only see a few assistants who weigh me, ask me what weight I want to get to, nod their head and give me these scripts. They never really tell me nothing!"

Lovely... Just frickin' lovely! Now I know the "physician" who signed these prescriptions didn't even see her! Even worse, she wasn't really sure if the assistants she saw had any degree above a nursing degree (note, I clarified and she meant RN. She knew they were not CNPs or allowed to prescribe). She said they always left then came back with the prescriptions in hand. That's gotta be legit, right?

I then shared a brief story with her about a patient I had previously who was given diet pills from a weight loss center that were put in a pill bottle with a label that only read, "Diet Pills, Take 1 with breakfast and 1 with lunch". This was done to cover up the fact that the drug was not legal in the USA. By law the label MUST have the drug name, dose, quantity, directions, prescriber and the place they were filled at (if not more in some states). My current patient then said, "Well they did give me Adipex out of their office, that's why I waited so long before bringing in this prescription." Even better! Now they are handing out schedule III medications, like they are blue M&M's!

After explaining to me that she no longer trusted the less than legitimate weight loss center, she asked me "Well what can I take to lose weight

Ah, the trillion dollar question is what is the magic pill to help us lose all this weight? The answer is simple.

NONE!

That's right there is no magic pill that will magically make you lose all of those pounds you put on by being lazy, slacking off and eating like crap. Some pills may help but the only healthy to lose weight is at the very least to watch what you eat and then add exercise as seen fit.

I explained this concept to her, politely, as I could see she was lacking confidence in medical professionals, and she was very grateful. I can't say that I changed the world for her or even solved her problem BUT the one thing that makes me feel good about this situation was the fact that I educated somebody (who hopefully will tell others) about a shady weight loss clinic. I can only hope that this place gets shut down as it is clearly just a money scam that really does not care about the size and health of their patients but rather the size an health of their wallet. This is literally finding a market that there is expendable money, targeting it, and then maximizing it's efficiency to increase profit. What a scam! More proof of marketing at it's finest!

That being said there are many gastroenterologists and other physicians who are more than willing to ETHICALLY and PRACTICALLY help their patients lose weight. I applaud their efforts. However, it truly saddens me how some people have gone so far to turn the practice of medicine and the use of pharmaceuticals into a drive thru business.

One more reason why taking time when necessary can make a difference in your patients health.