Pharmacy. Jim Plagakis. Pharmacist

For the last decade or so, it has been about the money for me. I get no greater pleasure from my job than saving the patient money. This is especially focused in Texas City, Texas where a twenty dollar bill is a lot of money.

I do my best to keep people of modest means out of the “doughnut hole.” I have suggested that doctor’s change from Lipitor to generic Zocor simply because the patient would go without. I love what we used to call “counter prescribing”, the recommending of OTC products after hearing the symptoms. I always pick out the “house brand.”

I could feel a slow burn on my neck when I read a prescription yesterday. In Texas, the only way for a prescriber to get DAW1 is to actually hand write these words on the face of the prescription: “Brand Necessary or Brand Medically Necessary”.

The Naked Gun 2½: The Smell of Fear hd Yesterday, some Bozo wrote “Brand Necessary” on an Rx for Prozac 20mg, #60,
ii qd. I told the patient that there was a 99% chance that her insurance would not
allow the brand name and that the doctor would not allow the generic.

This poor woman began to cry. She sobbed. She obviously needed the drug but you and I know that Prozac would not cheer her up any better than the generic.

“What can I do?” she wailed. “I don’t have a lot of money.”

“I’ll call the doctor,” I said. That is when it got fun.

“We want the brand name,” a young female voice said. “We made that very clear on the prescription. Why are you calling and bothering us?”

“Her insurance will not pay for Prozac. Period. We have a reject if you want me to fax it to you.”

“I told you that we want the brand.”

“So you want her to pay for this out of her pocket.”

“I guess she will have to.” Flippant. Attitude. She did not give one shit about this woman’s pocket book, but I did.

“Are you the doctor?”

A pause. “No, but I am authorized to call in prescriptions.”

“So, you are a Registered Nurse.”

A longer pause. “No, I am not but I ……”

• The Little Princess on dvd

“….. What professional qualifications do you have?”

A much longer pause. “I … ah … I ….”

“Listen. Here is the deal. 60 Prozac 20mg will cost this woman $349.00. The generic
will cost her around $5.00 in copay. You get that message to the doctor within 10 minutes or I will recommend that he fire you for unconscionable disregard to the patient’s health and welfare.”

Five minutes later, the doctor himself called. “Gee whiz, I had no idea about the price of Prozac. Why won’t her insurance pay?”

“The price,” I said, “These insurers are not stupid. Brand name prescribing in many cases is simply over-utilization of a very fragile medical system.”

“Oh, really.” Right over his head. “Give the generic, I guess.”

How long are we going to put up with allowing people with barely a high school
education to represent doctors?

A classic. A couple decades ago, I asked a girl who called in an Rx,
“Was that Seldane or Feldene?” She said, “Yes!”

Rude:
1. Ill-mannered. Disagreeable or discourteous in manner or action. 2. Indecent. Offensive to accepted standards of decency.

You can see where this is going. If you have never been accused of being rude at work, put up your hand. Are you sure? Okay, I see the hands dropping. The ones with the hands still raised. I’m proud of you, but I honestly don’t believe it.

My boss said, “Jim, I’ve had some complaints that you have been rude.”

“Did that say that I was “short” with them? That I spoke fast and, maybe, even walked away from them.”

“Short. Yes. The telephone too. They said that you didn’t even give them a chance to talk.”

Oh dear. I have heard this for 40 years. I have always been a little bit, okay maybe a lot of bit, “Type A” with my jobs. I do not like making people wait if I don’t have to. I am not a fanny patter. I give quick answers like YES, NO, I’LL CALL YOUR DOCTOR, THERE ARE NO REFILLS. I do not tell long stories. I do not stay with a patient any longer than I have to. There is work to be done, for goodness sake. I told this to Karen.

‘This is the south,” she said, “If they have to wait 5 minutes longer for you to give these people what they want, go ahead and slow down.”

Heresy! Decades of training is assaulted. How can I slow down? I don’t know how to go slow.

But, transformation takes only an instant.

“Karen,” I said, “I will do that. It is not going to be easy, but I am gonna charm the socks off these people and I will slow down.”

We smiled and I went back to work. There were probably 10 new Rxs to check and it took me awhile. It felt like slow motion.

Get this for rude. Karen said, “The pharmacist at Walgreens said that you were rude. What is that all about?”

I knew exactly what it was about. I had answered the phone and the pharmacist at Walgreens asked for some transfers. I said this. “Guess who answered the phone?”

“What do you mean by that?”

“The pharmacist answered the phone,” I said, “And I am going to stop what I am doing to get your transfers right now. You are not going to have to wait.”

“What are you getting at?”

“How about we just get your transfers and get you on your way.”

A simple teachable moment between colleagues, not enemies, but … RUDE?

The Technician is NOT the DECIDER.

When I started in pharmacy, they were called drug clerks. A few years later, they became pharmacy clerks. I first heard the term TECHNICIAN and realized it meant something when I worked for Pay ‘n Save in California. They were a Seattle-based
company and I was told that the state of Washington had a licensing process for
TECHNICIANS. When I moved to Whidbey Island in 1984, I discovered that Washington was light years ahead of California and most other states.

As early as the mid-1970s, I used trained pharmacy clerks to type labels. They did not select the drug. They did not price. They were miles removed from any decision-making. They typed labels. Period!

I do not have to tell you what TECHNICIANS do in the 21st Century. I honestly do not think we could manage without them. I absolutely have always loved my technicians dearly. I remember having fantasies about them in the 1970s. Since this is JP Enlarged and not JP at Large, I will be entirely adult and tell you that I slept with two of them during that decade and married one. They do, however, get on my nerves on occasion.

I am the type of pharmacist who feels comfortable with an egalitarian cachet in the pharmacy. I consider myself to be more of a partner with TECNICIANS. Not a boss.
Of course, the TECHNICIAN does not get discretionary powers. They try though.

• First Men in the Moon divx

They try mightily.

One of the TECHNICIANS at Mainland Pharmacy likes to play POLICEMAN. She will say to a patient, “It has only been 24 days of a 30 days supply. You cannot have your Vicodin. It is too soon.”

The other day I looked out front and she was talking to a 60 something man who was absolutely crippled from a lifetime of heavy labor. Pain was etched all over his face. He looked up at her and I could see him deflate. “How long do I have to wait?” He asked.
“I’m all out.”

“You are taking too many,” the TECHNICIAN said. Ohmigawd was she gonna stop this poor man from his evil drug-taking ways. “We cannot refill this for at least 5 more days.”

In her defense, the majority of the hydrocodone users we see are, indeed, drug seekers. They have become disposable in our culture. Let them die. They are too expensive to help. An idea for a JP at Large piece. The TECHNICIAN had lost her objectivity. She apparently could not see the difference between an abuser and a real patient.

I stepped out front and walked right up to the patient. “Why do you need to take more than you are supposed to?” I knew the answer, but I wanted the TECHNICIAN to hear it.

“Because I hurt, man. Because I feel like my knee bones are grinding against each other and because my hip bones feel like they are coming outta dere sockets.”

I advised him to talk with his doctor about changing the directions and told him that his medicine would be ready in 5 minutes. I then went back to the pharmacy where I found the technician giving me a look. “Fill it,” I told her.

“But, Jim, it has only been ….”

I took a deep breath. I don’t like moments like this. It happens every couple weeks, but I will never feel entirely comfortable with it. “I am the pharmacist,” I said. “You are the technician. It is my call and it will always be my call. You are wrong and I am right and it will always be that way.” There was a bite to my tongue. No reason to be gentle. I looked her right in the eye. I did not smile. “You can trust me to do my job. I have been doing it for a long time and I am very good at it. You do your job and I will do mine. The final decision of what we do or do not fill will always be the pharmacist’s.”

No explanations were needed. The pharmacist is a dictator. THE DECIDER. I do not like operating like a martinet, but sometimes you absolutely have to. A good technician
takes a lot of heat off the pharmacist and to expect her to know exactly where the line is
may not be realistic. She just needs to be told once in awhile and it is better to take advantage of a TEACHABLE MOMENT. This was a teachable moment and there will be many more because I WANT the technicians to always stay very close to THE LINE.

Un-Bee-Leev-Ah-Bull

A sincere prerequisite before I start to write about the most amazing, unbelievable “event” I have participated in for a long time. I was, frankly, stunned.

First, you have to recognize that I have absolutely no problems with “foreign” pharmacists. I have actually had enjoyable little conversations with Call Center workers who put their heads on their pillows in India and The Philippines. The Filipinos are much more fun to talk with than the Indians, by the way. Much more laid back, laissez faire in Manila. Much more ready for a little fun and I like fun as you have noticed.

Succinctly, assimilation of pharmacists from other countries is a fact of our profession. They are probably necessary to keep us going. I welcome them. Sometimes, however, you notice that something is awry.

This guy’s name was Rasheed or Brasheed or Some sheed. I couldn’t tell and I asked him to repeat his name twice. So, please be assured that I am good with pharmacists with any accent at all. I do, however, expect some experience on their end. Knowing and complying with pharmacy law, doing a final Rx check, filling prescriptions, counseling (How do some of these accents manage counseling?) and following company policy are not all that it takes. Get this:

Rasheed called from a Super Store pharmacy for a transfer. I work for an independent, by the way, and I was the one who answered the phone. I immediately went to the terminal and looked up the Rx. My conventional manner of handling these requests is to make attending to the needs of a fellow pharmacist a high priority. Come on, you guys. It is tough enough out there. We don’t need to be ragging each other. To actually believe that a CVS pharmacist is in a death battle with the Walgreens pharmacist is laughable.

Anyway, I gave Rasheed all of the information required and then said, “Ah, Rasheed.
Bad news. There are no refills left.” I then gave him the doctor’s phone and vitals.

“The patient said there were no refills,” Rasheed related, “She said that you always call the doctor and get refills. Will you call and get refills so we can fill the prescription.”

GOINK! DISCONNECT! WHAT IS WRONG HERE?

“Ah … Rasheed … How long have you been practicing pharmacy in the United States?”

Silence. …………………………………………. Finally …… “Long enough.”

“I don’t think so, Rasheed. You don’t ask me to call the doctor for you. You call the doctor yourself.”

Another silence …………………………………………. “Are you sure?”

“Trust me, Rasheed. You are very lucky that I am the one that you made that ridiculous request of. I like you, Rasheed. I happen to think that immigrants or guest workers are
very important for pharmacy. Without you, Rasheed, our profession could fall into a
deep hole. You could have gotten a Texas pharmacist with a much redder neck than mine. He would have bored you a brand new asshole.”

“What? What does that mean?” Rasheed sounded genuinely confused about this boring him a new asshole stuff.

“Never mind, Rasheed. Pharmacy is like dancing, my friend. You just can’t walk onto the floor and expect to know the John Travolta moves without practice. You have to at least listen to the music, get your groove on a little.”

“What does get groove on mean?”

“Never mind, Rasheed. You can get dancing lessons from any old American pharmacist.
Ask your pharmacy manager for some coaching.”

“I am the pharmacy manager.”

Is there any hope for Rasheed?

“I’m sorry, but I do not diagnose.”

“But the itch is terrible. Both legs.” This fifty-something woman, stout, but not obese, pulled up a pant leg and showed me her shin and calf. They both were scratched
raw, little red marks like a rash ready to bleed. “Can’t you just give me something to stop the itch?” Her face was distressed like she was about out of her mind. “Please. What is causing this?”

“I may be able to give you a lotion or a cream to help.” I believed that I could actually give her something that would stop the itching like I believed that the moon was made of
tetracycline. “I won’t even guess what is causing it. I am a pharmacist. I am not a doctor. I do not diagnose.”

“It is making me crazy.” She dug her fingernails into the shin and scratched violently.
“It won’t stop no matter how much I scratch it.”

“She doesn’t hardly sleep at all.” Her husband shrugged. “I don’t sleep either.” His face showed it. Gaunt. Worn down with a drawn face and droopy eyes.

“Have you seen a doctor about this itch? You said it is both legs?” A mystery.

“Yes, when I went in for my sugar diabetes check up.”

“You have diabetes?” This was all of a sudden too easy. Careful, Plagakis. Remember.
You are not a doctor and you do not diagnose. You aren’t 150 miles from the closest oasis and the patients do not call you “Doc”. This is the twenty-first century. Not the middle of the twentieth.

“Yes, I do have sugar.”

I drew a deep breath. “Describe the itch to me. Tell me what it feels like and don’t use the word itch.”

She squinted. “I can’t use the word itch?”

“Try,” I urged. I took her all in now. A worn out, but clean plaid shirt. Loose, striped
pants. She wore flip flops on her itchy feet.

“Well, my legs, all the way down. To my feet. Feel like they are burning. Sort of.
But it is very bad. especially at night.”

I asked her if it felt tingly or if like a million pins were poking her skin.

”That’s right! Exactly, I think.” She actually brightened up. Was I the first medical professional to ask her the right questions.? Then I asked her what her doctor had said about the itch.

“To use some oatmeal in my bath water.”

I cringed. “But it did not help did it.” It was a statement, not a question.

She nodded and sighed. “What is causing this itch?”

“How about like if a million fire ants were all over your legs?” This is south east
Texas. She knew about fire ants.

Her eyes grew wide. “This is exactly what my legs feel like.”

Now, I did not diagnose. I am a pharmacist and we don’t do that. What I did was tell her about me. I told her that I had the late effects from polio and that I had been diagnosed
with something called neuropathy. I take a drug five times a day and the tingly, burning, fire ant sensations are much better. The discomfort is tolerable, even on my days of ten hours on my feet at the pharmacy.

“The drug works for me,” I said. “Please go back to your doctor. Who is your doctor?”

“I don’t know his name. He is at the clinic.” She named a health center that specializes in treating low income patients. They certainly had not treated her.

I wanted to tell her physician, “The whole patient, doctor. Slow down. I know that she is poor. I know that she does not communicate very well, but you are treating her for diabetes and she complains about a leg and foot itch so bad that she is almost bleeding from scratching. WAKE UP.” It must have been near his lunch time and she was just another patient, not very sophisticated, not able to navigate the medical care system very well, not very demanding.

Of course, I didn’t even attempt to call out the doctor. What I did was write these two words on a piece of paper. NEUROPATHY & GABAPENTIN. “Tell your doctor that your pharmacist said that he uses this drug to treat the fire ants on his legs. This is what he has and this is the drug that works.”

“Do I have this neuro ……..?”

“……. I can’t say that. All I can do is share with you that I had fire ants on my legs and they almost went away completely after I starting taking this drug five times a day. At least I can sleep very well and the fire ants that I do feel don’t interfere with my life. ”

She promised me that she would see her doctor. Maybe! Fire ants all over your legs is pretty miserable. I sold her a lotion with capsaicin. I hoped that it would help.

What else could I do? If you know, tell me. I need to be educated. After all, I am a pharmacist. I am not a doctor. I do not diagnose.