The Ten Commandants to getting optimal drug therapy.

I was interviewed by a medical journalist who is working on a book for a major publisher.  A comprehensive guide to the wise and safe use of Rx and non-Rx drugs.  What your PHARMACIST wants you to know.  NOT what your doctor wants you to know.   That is interesting.  There is a sea change taking place.  Let’s help him out.  By tradition and law, we deliver all Rx drugs to the final user.  That is power.  C’mon, help this guy out.  You can do better.

The publisher suggests a list of “Ten Commandments to assure you get the optimal outcomes from Drug Therapy”. I will take #1,  You guys list your in comments.

1.  Make sure that you insist on being counseled by your pharmacist and then trust your pharmacist.

Consider this while you are damning Walgreens to the dungeon where all evil and divisive employers end up.  ENRON FIELD.

The baby boomers are those people born between 1946 & 1964. 

The first of that group just turned 62 in 2008.  There are about 20 years to go and IT IS CUMULATIVE.

In 1997, there was a boomer turning 50 every 7 seconds.  4,000,000 will turn 50 in 2009

In 2009, the boomers are those Americans between 45 & 63 years old.  The BOOMERS are still relatively young.

The pharmacy industry is close to breaking already and look what is coming. 

Here is a 1996 figure. 76,000,000 between the ages of 32 and 50.  If they are still alive,

that was 29% of the population in 2006.

The older you get, the more prescriptions you will need if we continue the medical model of treating sicknesses rather than preventing them.   Remember.  The number of boomers is CUMULATIVE.

The BOOMERS are still relatively young.  Wait a few years and you will see the pay off for POWER. These people (The Boomers) will not “age gracefully” as their parents did.  Why should they?  They eat better, they exercise, they meditate and they have the wonders of pharmaceuticals.

What they want is to stay vibrant, energetic, youthful and sexy for the entire ride.  That ride will be longer and longer.  That means an impossible to forecast number of prescriptions.

This is a “No Brainer”.  Walgreens and CVS and Rite-Aid (if there is one) cannot build enough stores because there is not going to be the professionals to staff them.

Walgreens is prescient.  They see what is coming and they want a piece of it.  They are not sitting on their hands,

The problem for me is the mean way they are handling their employees.  There has to be a better way to transition.  If they hurt too many people, a very angry gorilla may swallow them up by choosing to practice pharmacy elsewhere in the future.

If you find the subject of collective bargaining (A Union) compelling, look above to the page labeled “UNION AGITATOR”  He has offered an introductory message:  Look above and click.

I am not sure about unionizing.  So,  Mister “Agitator” is on his own.  I have proposed the idea that pharmacists are adults, capable of acting in their own best interest.  I am not so sure about that.

However, I was a member of the Retail Clerks Union when I worked for Thrifty Drug Stores in the late 1960s in the San Francisco Bay Area.  I was an Ohio boy agog in what the union gave me.  Time and a half over 8 in a day or 40 in a week.  Plenty of holidays.  Is eleven possible?  Good vacation line-up.   If Thrifty called me in for a sickness or other emergency, they had to pay me for 8 hours.  On and On.

Still, I knew that I was just a novelty to this union.  It was, after all, the Retail Clerks International Association.

My biggest problem is this:   The union was so strong that we had dead wood opportunists who yawned their way through a work day.  They did the minimum and to hell with Thrifty.  I think that this attitude is wrong.  It is the attitude that got American cars the reputation of being “Pieces of shit”.  

Union or not, I have always given my employer consummate value for his money.  Union members who skate their way along a sleazebags.  

That’s what I think.  How about you, SOSP? 

• One Flew Over the Cuckoo’s Nest dvd

I read recently that there is such a thing as a “generosity gene”   The study suggested that certain ethnic groups are apparently genetically endowed to give some of  their time, knowledge, expertise and treasure to other people.  It went on to identify Americans of European lineage as being like this. 

I have been a generous person for my entire life.  I remember giving a Rocky Colavito, Cleveland Indians baseball card to an 8 year old boy whose parents did not think that baseball cards were wholesome.  He had his secret stash of cards, but no Indians and that was the home team for boys in northeast Ohio. 

I guess that family does not count, but V and I are both haunted with this gene.  She has given Vancouver, BC to Houston plane tickets to her sister for the last three Christmases.  I have been especially generous with V’s kids. 

• The Cook

The dad, who was absent for almost all of V’s youngest son’s life,  

refused to co-sign for the first round of student loans.  S, I did it.   He needed a laptop for law school, so I gave him one worth $3000.00 with kick ass programs like Office. 

I am buying an “AS IS” house in the heavily Hurricane Ike flooded Bayou Vista neighborhood for V’s oldest son, wife and baby to live in.  The son is going to do all of the recovery, repair and renewal work.  I provide the down and closing costs and Frosty pays the mortgage, property taxes and insurance (not a small thing on the coast of the Gulf of Mexico).  Someday, we’ll settle up.  When UTMB announced that it will rebuild in Galveston rather than move much of the institution to the Mainland, the house appreciated substantially. 

I am certainly not a rich man, but I can do things for the kids.

What a good boy I am.  Gandhi Plagakis.  Family does not count. 20 Million Miles to Earth

I am thinking of Drug Store generosity. My co-workers have always gotten little things from me.  Food mostly.  I helped a drug store clerk with grocery money way back in the early 1970s.  Her husband stole the money from her purse and bought dope with it.  This was the 70s.  The magic flame of love and peace of the 60s had been snuffed.  I think this was the beginning of the “Me” decade. Changing Lanes dvdrip

I have paid for prescriptions for patients/customers.  I have a thing about earaches.  More than once, I have paid for the Auralgan-type ear drop because the mother had only enough dough for the antibiotic.  I mean, the kid is all runny nose and whining, holding her ear.  I can’t say, “Sorry.  Money on the barrel-head or, like the soup Nazi, ‘You get no ear drops today.’”

Barbie as the Princess and the Pauper full

My sister in donating gene, SOSP, out in Washington State buys big ticket things for her patients, occasionally.  The last I heard was a small, office-size refrigerator for the bedroom of an older woman who shared a place with a “roommate” who stole her food from the fridge that they shared.  SOSP most definitely has this gene.

Awhile back, a young woman wearing the work outfit of Popeye’s Chicken had the money to pay for the prescriptions for one of her children.  She had two with her.   A toddler and a child in her arms.  The problem was that she would not have the $20.00 she had planned on using for milk & bread and the like to fill in until pay day. 

“I guess it will be Ramen noodles,” she said. “Or chicken”. One Flew Over the Cuckoo’s Nest video

I asked her if she had insurance from work. 

She shook her head, “I’m not salary yet.  When I am an assistant, I’ll have benefits.”  Sounded like an opportunist company.  Work them in a hot, greasy kitchen and provide no benefits.

This was a young African American woman in Texas City, Texas, a town where a significant percentage of the population is working the system.  A town that I am happy to just forget.  This girl was working.  She was not on Texas Medicaid and this was before CHIPS money was loosened up.

I told her, “You are trying hard.”  I took twenty dollars from my wallet and told her to go to the grocery store.  She tried to refuse, but I insisted.  She got a little choked up, remarked that a kind man had white skin.  Did she know about the gene?  Hardly.

What I want to know is this:  Are SOSP (blonde and white) and Jay Pee anomalies or is the study accurate?  Is this a white person of European lineage thing or do all pharmacists show generosity on occasion?

Pharmacist licenses are like phantoms.  They follow you everywhere.  I have two active licenses.  Ohio, my first, and Texas, where I now live.  In between came California, Idaho, Washington state and Vermont.   They are not active.

I have a file of recruiting letters, pamphlets, booklets and even one DVD.  It is interesting to see how desperate they can get.  Rite-Aid makes incredible promises.  A grocery chain in Washington touted, “We do not have drive-through windows”.   The most interesting was a prison pharmacy.  The military is an active recruiter.

Recently, I received a nice letter telling me about a job THAT I WOULD RESPOND TO IN A MINUTE if I was only 20 years younger.  I probably would not have the chops, however.  I am an old retail guy.

California hospital/clinical pharmacists. 

This recruiter is looking to help anyone who has either prior experience in clinical/hospital setting or a residency if they’re a fresh graduate.

Specifically San Diego!  

With connections throughout California to help the right candidate.

I talked with the manager of  “Find-A-Pharmacist-Recruiter” and she told me, “Yup, she is in our network.”

I know that you are out there.  There are plenty of you who are like I was in 1965.  Sick and tired of the cold, dismal winters.  Sick and tired of a mother who thought it was her business to run my business.  Sick and tired of being sick and tired.  I got my California license and moved 3,000 miles to the west coast and stayed there for 35 good years.

The Red Violin ipod

I spent part of that time in San Diego.  There is no place nicer in the USA.  The weather is perfect.   Never cold and rarely too hot.  The Zoo and Wild Animal Park.  The beaches.  Baja just minutes away.  Balboa Park.  The people are beautiful and they keep themselves that way.   

Especially if you are younger.  San Diego is a dream.  I guess I am just voicing an old man’s fantasy, but, if you are restless, have sand in your shoes, click the big baby blue banner:  “Find-A-Pharmacist-Recruiter” and take a few minutes to complete the questionnaire.  A current California license is probably a secondary issue.  You can get one.

Harold Cohen is a pharmacist who is the Editor-in-Chief of the magazine U.S. Pharmacist.  Harold and I have had a working relationship in the past.  He was the Editor of Drug Topics magazine.  Harold writes a monthly column called Straight Talk.  He spent two decades in retail, so his voice often rings true. I found Harold’s January, 2009 offering to be interesting.

He called it The Invisible Pharmacist and he was talking about health system pharmacists.  I have often wondered what a health system pharmacist is.  Drug Topics puts out health system supplements on occasion and they always went into the round file.  Nobody has told me that I am a health system pharmacist so I must not be.  After reading Harold’s column, I determined that a health system pharmacist is what I have always called a hospital pharmacist.  There, knowing that, I don’t have an inferiority issue about health system pharmacists anymore. 

Harold talks about hospitals having “state-of-the-art technological marvels that few retail pharmacists can really appreciate.”  He talks about bar coding and scanning to assist in preventing errors like health system pharmacies have a singular domination of modern equipment and methods.

Not so.  Not so, at all.  There are chain drug stores all over the place that scan and barcode and check and recheck and scan again before a prescription gets to the patient.  Same with automatic dispensing cabinets.  Okay, Harold, I agree that “the counting tray found in many retail drug stores looks like an abacus next to a computer”.  The independent that fills one hundred prescriptions a day with basic pharmacy software does not need dispensing cabinets. 

I get the feeling that Harold believes that health system pharmacists are somehow better than you and me and the tens of thousands of us poor bastards who are stuck in retail.  I wonder if he thinks we suffer from health system envy.  I have yet to drive by a hospital and see envious pharmacists with itchy feet on tiptoes peeping wide-eyes into the windows of the hospital pharmacy.

Harold reports that health system pharmacists are no longer “stuck in some out-of-the-way basement of the hospital.. with no patient interaction.”  The following high-sounding sentences indicated that health system pharmacists actually talked to patients. 

At least I think that is what he wanted to say.  You read it and tell me what he said.

What does he think?  That you and I are limp bisket pharmacists?  Harold saves himself at the end.  He lumps all pharmacists together as coming from the same mold.  He labels all of us well-trained professionals. 

I now know what a health system pharmacist is and I am not impressed.  I cannot imagine a hospital pharmacist having to multi-task like you at the retail shop.  Retail pharmacists are the real superstars of our profession.  We get it done regardless of the working conditions.  You are the VIPs.  You make interventions that benefit your patients every day and you do it in between bites of the stale cheese sandwich.  You are not chopped liver.  You are the Retail System Pharmacist. 

I will make a recommendation to independent pharmacy owners.  You have absolutely no time to waste.  You can’t think about this.  You better not hide your head in the sand or you will lose patients by the bagful.

So far, the $4.00 Rx has not killed most of you off because you do not have that many cash-paying patients.  That is about to change.

Medicaid roles are surging, by unprecedented rates.  That means that for every family that has the bread-winner laid off and can qualify for Medicaid, there is a number of people who lost their jobs and do not qualify for Medicaid.  (NYT)

COBRA, you ask.  Has anyone ever told you what the premiums are to COBRA the insurance they had with the employer who laid them off?  Only one in ten signs up with COBRA. (NYT)

10%.  The 90% just roll the dice, neglect conditions and illnesses and end up needing more prescriptions.

You are going to have good customers go elsewhere to get the $1.00 a week generics.  These are people who have been with you for years.  They won’t even ask you about $4.00 generics because they know that you won’t sell your prescriptions that cheap.

You are a good person.  They like it that you know them by first name.  They have brought you cookies at the holidays.  They stop you in the grocery store.  You see them at the high school games.  But, my friends, the family has to eat.  Family budgets will be very tight for months, maybe years.

More foreclosures.  Families in homeless shelters.  Expensive pickup trucks repossessed.  I know that I am painting a dark picture, but it is very dark out there.

They are embarrassed that the dad is out of work.  The job he takes delivering pizzas does not have benefits.  The mom is going to figure out very quickly that she will have $9.00 dollars left in her thin pocket book by getting dad’s atenolol for $4.00 rather than the $12.99 that you charge.  And, with the atenolol go all of the family’s prescriptions, their shampoo, shaving cream, everything.  You will have lost them for good.

The $4.00 Rx is not going away.  You are going to have to copy it or come up with something.  We will have it until there is a single payer system in place.  By then, it may be too late for you.  Just don’t waste time.

The last thing you want is for the general public to start perceiving the $4.00 purveyors as public health angels and you the ‘price-gouger’.  When that happens, it is all over, my friends.  You may as well close the store.

I got a call from a doctor in New Hampshire. He was calling in a prescription for his daughter who is a student at the University of Texas Medical Branch.

The prescription was for SMZ/TMP DS for UTI. He asked me how many tablets and for how long. He is a dermatologist. I told him that it is best to err on the side of too long rather than too short. I added that 3 or 4 days would probably be enough.

“Let’s go ten days,” he grumbled.

I asked him if he wanted anything else and, with attitude, he asked what I meant by the question.

“There is usually stinging and burning,” I said. “We can handle that with a couple days of phenazopyridine.”
Of course, he wanted to know all about it and I wished that I had saved the idea for the OTC strength. I was thinking of his daughter’s budget. The Rx Only version would be covered by her insurance.

He okayed the prescription and then asked, “Is there a lot of this kind of infection down there?” He said it as if he was referring to Yellow Fever. He made it sound as if he thought UTI was a sub-tropical Galveston thing.

“There is no more UTI here than any other place I have practiced,” I said.

“Well this is the fourth time my daughter has had a UTI in four months,” he complained. “She is a healthy girl. There is something wrong down there.”

“Give her a second prescription,” I advised, “With the directions of ‘Take one tablet after each sexual encounter.’”

There was a very long silence of the lambs. He cleared his throat. I knew what was coming. He could not handle the vision of a studly Galveston boy poised above his Princess. Along with the picture, he probably imagined the sounds and the aromas. Poor guy! And he is a medical doctor in the 21st century.

FleshEater movie

“Excuse me,” he said, “My daughter is NOT sexually active.”

Superbad download “I’m sorry,” I said, “Some of the medical students down here are sexually active. My error.”

“Why do you think that my daughter is having sex down there?”

“I don’t think anything about your daughter. I just met her for the first time and why would she tell me, her pharmacist, that she is having sex.”

“That would be none of your business, mister, if my daughter was sexually active. I don’t want her to have anything to do with your ideas. Let me talk with another pharmacist.”

I told him that he was out of luck. “Doctor, I’m the only pharmacist here right now.” I let the silence linger. He was the aggressive side of the conversation. It was his serve.

“All right,” he said, “Her mother and I may have been too protective of her. Just the idea of her having sex with a stranger makes me sick.”

“He wouldn’t be a stranger to her,” I said.

“Have you met him?” His voice was pitched too high.

“No. She was with a female, another student.”

“Are they promiscuous down there?”

I didn’t like the DOWN THERE, like Galveston was a sex farm in Brazil. “Doctor,” I said and my voice was firm. “This is no different from Chicago or Cambridge. Twenty-something students are likely to be sexually active. This is 2009, not 1959. If your daughter isn’t taking oral contraceptives, she should be.”

“Why do you say that?”

“Because she might not be getting recurrent UTIs if she was using condoms.”

To make a painful story shorter, I will skip the drawn out education of a closed-minded father and just say that I suggested he turn this part of his daughter’s medical care over to her gynecologist.

“I don’t think she has a gynecologist.”

“She is 24 years old,” I said, “Ask your wife. Trust me. She has a gynecologist.”

Two hours later, I get a call from New Hampshire. It was the girl’s gynecologist. I did not like her unprofessional sharing of a good laugh at the dermatologist’s expense, but perhaps that is how they do it in New Hampshire. I found out that the girl had been taking an OC since she was a senior in high school. She gave me a new Rx for Yaz and an Rx for Nitrofurantoin. Enough capsules for a 5 day course for this infection and additional capsules for one capsule immediately after each toss in the rack, 30 of them.

Who said, ‘Father knows best’?

They don’t bring us pens and paper anymore.  They haven’t brought in a large, thick crusted vegetarian pan pizza with feta cheese and artichokes extra since around 1998.  They haven’t invited me to a hockey game since 1995.  The last time I was invited to a baseball game, including the tailgate party that started at 10:00 in the morning was in San Diego.  1977.   

What a day!  This “detail man” had San Diego beauties mixing with us.  He said that the three of them were younger sisters of a colleague.  I looked closely and I saw that they could be sisters.  I also saw that they were brilliant big hair examples of young and fit American females.  I asked the “detail man” later if they were really sisters.  He just smiled and refused to talk when I reminded him that the pharmacy manager of the Longs in La Mesa left the box seats on the third base line with the big hair red head in the 5^th inning.  These were swinging times in San Diego.

Let’s cut to the chase so I can go downstairs and watch the Eagles beat the Giants.  You know and I know that Big Pharma will spend enormous mounds of money to get prescribers to write for their products.   It seems that the budget is unlimited.  When you sell a pill that costs 5 cents to make for 5 dollars you have a lot in your coffers even after you pay the enormous development costs.  You will do just about anything, including getting doctors privately laid.  No, I don’t have evidence, but come on.  Don’t be naïve.  If they see morals and ethics in sending the Longs PIC home with the redhead in 1977, they will do it in the 21^st Century.   

Anything to sell their drugs.  Including ignoring research that may slow the sale of their premier drugs. Vioxx!  Bextra!  You can talk about that.  I don’t want to right now.

So, no more trinkets to doctors.  No pens to pharmacists.  No meals.  No tickets to The Nutcracker.  Nothing.  Not from Big Pharma.  They hardly even visit the pharmacists anymore. 

Little Pharma comes in because they can’t compete with Big Pharma.  They bring in all of the little gifts that we like.  They are usually pleasant young women.  If I can, I favor them.

Big Pharma doesn’t show up because they don’t have to.  They are putting their bucks where they can get the most bang.   DIRECT TO CONSUMER ADVERTISING on TV, in magazines and over the Internet.

Big Pharma has “detail people” just to fill in the cracks.  What better “salesperson” than a long time patient demanding your drug after seeing the TV commercial.  Men who barely had a problem take Flomax.  Doctors have gotten in the habit of barely discussing the matter before they get out their pads.

How can they fight this?  They are fee for service doctors.  They are not wage slaves at an HMO who can laugh a patient off.  It is imperative that Johnny Jay Johnson keeps coming back regularly.   Do you think that Doctor Campbell is going to refuse Johnny Jay, a south Texas macho redneck, when the big man demands an Rx for Cialis?  Never!  He refuses and Johnny Jay is gone for good.

This is challenging for us.  Another example of our industry being less and less an industry run by pharmacy.  There must be something we can do.  Direct to Consumer advertising could be a public health issue.  When TV creates a demand for drugs that will kill you if you take enough, often enough, we truly have lost control of our profession.

What?  Start a letter writing campaign to the APhA?   Yeah!   Sure!  Where have you been?

Now that you mention it, folks, does the company I work for qualify for “Jay Pee’s Seal”?  The answer is NOT YET even though this job is my dream job.  I work two eight hour shifts a week.  The scheduler has asked me to work more shifts, but now leaves me alone.  I will qs ad to three shifts a week as a favor to my co-pharmacists, but this is a rare week.

At First Sight dvd

I get an uninterrupted meal/rest break. 

I use the bathroom whenever I want and no one has said, “Will you check this first?”

• Never Surrender on dvd

I have never seen the non-pharmacist store manager butt into pharmacy business.  When I told him that I did not want a certain tech scheduled for the late shift when I was on duty, he told me that the call was up to the PIC.  Gadzooks!  This was a store manager who was not interested in micro-managing in the pharmacy.  I had never experienced this before.

The PIC decides who works in the pharmacy.  Period.

The one time that a totally unreasonable and just plain wrong patient jumped the new guy by running up front and grabbing a manager, I was treated with deference and respect.  I explained why I had refused to honor this patient’s demand and never heard another word about it.

To tell you the truth, I did not expect to get so comfortable so fast.  I have no idea how it is in other districts or even stores, but the company I work for is closer than any to “Jay Pee’s Seal”. 

The drive-through will probably doom almost everyone, but we can compromise, huh?

I have had two jobs that I loved.  My first one and this one.

My first was in a large independent on Main Street.   We had a long lunch counter.  Every Rx customer got a ticket for a cup of coffee.   I would go over and sit with them and talk.  I’d even sneak in counseling in a time when pharmacists were supposed to mind their own business.  I had a few “dates” with the camera department manager.  The store owner (who had a wife) “dated” her too.  That kind of testosterone-driven work benefit is not why that job was one of only two dream jobs.

I have had readers write to me privately and ask where I work now.  They want to check it out and see if they might want to sign on.  I have told them and warn them that it is a very big company.  What happens with this company in Vegas may not be what happens in Galveston, Texas.

I will not reveal where I work here.  That is that and this is this.

IAPharmr at 5:00 PM 1-8-09

He thinks that his company should be the first to be granted “Jay Pee’s Award of Honor for superior working conditions”

No drive throughs..  No Guilt Pee breaks.  Look and see ikf he claims to have a toilet room in the pharmacy…..Pharmacists are always managed by pharmacists……….. Pharmacists are not “knee-jerk” made the culprit when their is a complaint…  PIC is the decider in all matters pharma.

He isn’t getting a free fish.  The company has to talk to me.  I am not easy.

1/10/09

Okay, Cathy & SOSP. 

I’ll add “Pharmacist Friendly computer software.   You tell me how you want it worded.  Simple & declarative pleaese.