Pharmacy. Jim Plagakis. Pharmacist

It seems that there is an American sport called, “Let’s bash the French.” At one point a half decade ago, it got so out-of-control that they changed the name of a favorite deep fried potato to “Freedom Fries” in the cafeterias and restaurants in government buildings in Washington, DC. Recently, however, I have found reason to respect the French.

Drug Topics just printed a JP AT LARGE column in which I talked about having to wait for my prescription while the pharmacist and his pink-smocked ancillary staff finished up a whole roast chicken and all the trimmings for lunch. “Interrupt our lunch? How stooopid, Monsieur Americain.” The year was 1976 and I clearly was far from home.

The meal included a bottle of wine. At lunch! I found this to be exceptionally civilized. In that column, I made light-hearted fun of the way we do lunch in pharmacy in America. I suggested that Tom and his techs, Marsha and Olivier, at CVS give a chicken a try. I talked about how it made me laugh so hard that I hurt myself.

Now, today, I read in The New York Times another eye-opening trait of the French. They believe that THE CUSTOMER IS ALWAYS WRONG. A French merchant will not admit that she is wrong and it is impossible for her to apologize. It is just the way it is.

I like it. I have for sale, right here on this site, a little book that I wrote in 2006. “JP’s 20 Simple Rules for the Successful and Satisfying Practice of PHARMACY”. Rule Number 18 is: THE CUSTOMER IS NOT ALWAYS RIGHT. Actually, in the pharmacy, the customer is NEVER right.

The trick in France is to somehow get the offended customer to admit that the mistake was his or her own fault. I like that too, but what do you do when a non-pharmacist manager butts his or her nose in and accuses you of the dreaded crime of BEING RUDE? There are no pharmacy workers out there, with any miles at all on their careers, who have not been accused of being rude. I am beginning to think that customers are very smart rats and have learned that throwing around the “R” word will get a knee-jerk reaction from DNA challenged store management.

All they have to do is say, “The pharmacist was RUDE.” The retail managers go apoplectic over the “R” word. Why is that? Customers don’t like your tone of voice. RUDE! You smile at the wrong time and you are a smart aleck who is RUDE.

I was stopped by a customer with a bottle of Imodium in her hand. I apologized and told her that I was on the way to the wash room. I would counsel her on my way back to the pharmacy. RUDE! What do they want?

“But, she is wrong,” I remember squealing to a little, bald, protruding-belly manager. “She does not have any refills.”

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“No, I will not call anyone. She has no refills.”

He had his index finger in my face, waving it. “She said she has refills. Why would she lie about that?”

I pushed his hand down and moved away. “I will not call the doctor. It is an antibiotic from a year ago.”

He stormed away and came back later with his trump card. “Now she says that she will go to K-Mart because of your rudeness.” He was spraying spit around he was so worked up in his retail customer righteousness mode. “I want you to write a letter of apology to her.”

Of course, I refused to do anything more in the matter. My original inclination was to give her a ring and to TALK HER DOWN with an explanation about the inappropriateness of my calling about a refill on an old antibiotic Rx. Forget it. Why would I want to do ANYTHING for her?

This incident was probably a determining factor in my relationship with this manager. It was dicey and unpredictable right up to the day he was escorted from the store by company security for sexual harassment. I expected the next store manager to be an improvement. I was wrong. I learned that the “R” word is the “R” word and always will be the “R” word.

You know and I know that THE PHARMACIST IS RARELY RUDE. The customer is ALWAYS WRONG. I like it that way.

Do you have a well thought out procedure that you follow when you are serving a person who has been a victim of domestic violence?

A middle aged woman brought in prescriptions for pain medicine. Her eye was puffed up and black and blue. Her arm was in a sling.

What I said was, “What happened?” What I wanted to say was “Who hit you?”

I knew who she lived with. I had him pegged in the weasel category. He was one who thought he could smoke cigarettes anywhere. He was a You-don’t-tell-me-what-I can’t-do guy. When asked to go outside to smoke, he dropped the cigarette unto the floor and smashed it with the sole of his boot.

The woman avoided looking at me. She kept her eyes focused down. “I fell down,” she tried to smile. “I fell.. again.”

“It must have been quite a fall.”

“Down the stairs,” she said and winced when she took a deep breath.

What about when a parent beats the heck out of a kid right in front of you. The toy department was near the pharmacy in a store where I worked. This is what we often heard:

“I told you not to touch.” Smack. “I’m going to teach you to listen if I have to kill you.” Smack, Bam, Yeeow.

“Please don’t hit me again, Daddy. I won’t do it again.”

You watch as the big, burly adult holds the kid off the floor by his arm and hits him so hard that his back bends as he flops in the air. Adults that watch have grim faces. They walk away quickly, but you are stuck because the father is dragging the kid out of the toy department and right by the pharmacy.

There was a woman who was a caseworker for Child Protective Services in Washington State. We had a good relationship. She used our pharmacy for prescriptions for foster children. She also was a patient. I told her one day that I was one of many adults upset when we watched a mother go way too far in her discipline. She downright beat the little girl for putting a bag of M&Ms in the basket.

“You think you can get candy? You have another think coming.”

The stricken look on the child’s face sucked all of my energy. With her eyes, she was begging her mother to stop. She did not, however, utter a sound. She knew that if she did not just put up with the beating in silence, it would just get worse.

My CPS friend gave me a look. “What did you do?”

“What could I do?” I shrugged.

“You are a mandated reporter, Jim. The law says that you have to report abuse. Pharmacists are listed right along with doctors and nurses. (She later brought me the law to read) The law says that a pharmacist must report abuse and neglect.”

I clearly remember her look. She was giving me a very difficult task and she knew it.

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The state even dictated the two questions we are supposed to ask the woman with the black eye. “Are you in a relationship where you have been hit or threatened or forced to have sex?” and “Is there someone you’re afraid of?”

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Apparently, if you fail to ask those questions and the abused woman goes back and gets it again, you can be held liable for the further injuries.

One of three women you see could be a victim of violence. I just do not see that we can do much. Can you see one of the big chains sitting still if you informed them that you were going to be the star witness at a child abuse trial? “The DA said that I might be away from work for a month.”

Check your own state laws. You are probably a mandated reporter. I don’t think we can hide from this. We are health professionals.

Some people are not educated enough to have access to so much information. This happened a few years ago.

This heavy set guy calls me out front and asks, “What are the side effects of See-Met-Eye-Deen (cimetidine)?”

I gave my usual answer which is always a question. I would have to get the package insert to give him a complete list. I asked, “What makes you think that you are having side effects?”

He looked around. There were two people waiting for prescriptions. An elderly woman and a young mother. “Can we go some place private?”

I agreed, but with a condition. I did not have the time to spend doing a detective job. “Tell me exactly what symptoms you are having. What makes you think you are having side effects from cimetidine?” I walked over to a private corner by the sunglasses. He followed me.

“It’s embarrassing,” he whispered so close to my ear that I could feel his warm breath.

The smell of the leftovers from his lunch caused me to step back. “Well, you gotta tell me, man, before I can tell you if it is a side effect.” I crossed my arms. This was taking way too long.

He had a woeful look on his face and his mouth was firmly set. He didn’t seem ready to say anything.

“Man, Listen. I do not have time for this.” I hesitated. I would give him one more chance, but first I had a question. “Have you talked to your doctor about this?”

His face dropped. “I tried. I called 3 times, but he never called me back.”

That is the way it is. These people are given prescriptions and no information. I know that it is our job to counsel, but we get it all. We get the ridiculous questions, the worries, the doubts. We are at the bottom of the funnel. There is no place to go after the pharmacist.

“One more time,” I said, “What’s bothering you?”

His face lost its color. “Geen-ah-co-maystia.” He looked like he would pass out.

“You think you are growing breasts?” He was a heavyset man and had a full chest of fat, but he certainly was not going to be a teen age boy’s pin up.

“I KNOW I am,” he complained. “Just look at this.” He started to unbutton his shirt.

“Sir,” I said with urgency, “Do not take your shirt off. I will not look at your chest.”

He kept right on with the shirt. The young mother was actually laughing and the elderly woman looked stricken. “I know that it is Geen-ah-co-maystia.”

“It’s pronounced gynecomastia,” I said, then almost shouted, “Please stop with the shirt.”

He stood there, his shirt half unbuttoned. “How do they cure it?”

“Surgery,” I shrugged my shoulders. “They have to surgically remove the excess tissue.”

“What”" His eyes go wild.

“Surgery,” I repeated blandly.

He started to argue with me. “There must be something. Will you look it up for me?”

“Sir, they have to cut them off….” Then I got it. When he said the words LOOK IT UP FOR ME, I knew exactly what was going on. I pointed at him. “You have been on the Internet haven’t you? How long have you been taking cimetidine?”

He gave me a sheepish look and looked down at the floor. His answer was a decade or longer.

“Sir, it is not a good idea to go on your computer and look up your drugs when you are bored or there is nothing on TV. You are liable to read something that will scare you.”

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“I want to be informed,” he argued, “I have a right to know about the drugs I am taking.” He gave me a stubborn look and finished off unbuttoning his shirt. He gave me a flash of his chest like a well endowed young woman may do at Galveston’s Mardi Gras for a few strands of cheap beads.

What the hell! I relented and looked at his chest. He just had a fat man’s fat breasts. “That does not look like gynecomastia to me, but I’m certainly no expert.”

“Who can tell me? The doctor is no help.”

I needed some fun in my day, so I directed him to a colleague who probably needed some fun himself. “You need to stop at Rite-Aid,” I said and told him which one. There were 6 or 7 of them in Bellingham. “Ask for James. He will help you out.”

The dirty end of the funnel. With the Internet it gets worse. These people read everything. Some of them think that they will get the side effect just because it is listed. We know better, but answer this question, “THEN WHY IS IT LISTED?”

My pal James called me around two hours later, “Goddamit, Plagakis, why did you send that “tits guy” to me?” We talked. We laughed. The “tits guy” finally went away okay. He had gotten his second opinion from James, a pharmacist.

James told me not to do that again. He did not like being at the bottom of the funnel, but James has a good sense of humor. He laughed a lot. I did too.

A Preventable Death?

How could a pharmacist prevent the death of a world class athlete?

March 4, 1990. One of the best college basketball players in the United States dropped dead on the basketball court during a game. His name was Hank Gathers and he was a big, strong center for the team from a small Catholic school in California. Loyola Marymount. Hank had unlimited potential as a professional in the NBA. He was also young, black and a male. That dangerous blood pressure group.

Hank Gathers was prescribed atenolol to control his blood pressure. According to a medical myth that quickly spread, this kid quit taking the medication because he felt “weak”. He just didn’t seem to have the same spring in his legs. Loyola Marymount was coached by Paul Westhead. The game was run and gun. They averaged 122 points a game. This was not the style of game for a big guy with his exercise tolerance compromised by a beta blocker. He quit atenolol and died on the basketball floor after a monster slam dunk, during a WCC conference tournament game 18 years ago today.

Who dropped the ball and has at least collateral responsibility for this kid’s death. How about the prescribing physician? Didn’t he know? Couldn’t he see the real probability that this amazing basketball player’s energy would tank and that he could be non-compliant?

How about the pharmacist? Was it the pharmacist’s job to take Hank Gathers by the collar, look him in the eye and demand that he get it?

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“Hank, you have to take this medicine. You cannot stop it. You are young and I know that you think you are invincible, but your blood pressure is so high that you could end up like JR Richard of the Astros.”

“Who is JR Richard?”

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“I’ll be okay, man. I will be okay. Just give me my medicine so I can go to practice. We are in a tournament right now.”

Mandatory pharmacist counseling on every new prescription was absolutely not the practice in California in 1990. Congress had just passed the OBRA law in 1989. I’d guess that something like this went on when Hank got his Tenormin.

“That was Hank Gathers,” the star-struck pharmacist gushes to the pharmacy clerk. “Hank Gathers. The Loyola basketball star. I shoulda got his autograph.” In 1990, I’d put money on it that the pharmacist did not have thought one about Hank’s exercise tolerance.

The 21st Century? Eighteen years later. Our focus is entirely different. Modern pharmacists have very good eyes these days. They know that it is their job to give personal counseling. Most conscientious pharmacists would envision Hank on the court, sucking air trying to play Paul Westhead’s game. I am a 40 year feet-on-the-floor pharmacy veteran and even I would look out at this famous basketball player, look down at the prescription, and say “Oh oh”. Would you, a modern pharmacist, call the prescriber and suggest a drug more suited to a world class run and gun basketball player, like losartan? Or would you drop the ball? When he died would you whine, “The doctor should have told him.”

These are not rhetorical questions. I’d like to hear your answers.