The Swine Flu scare seemed to me to be hysterical.  Less than a hundred cases worldwide.  A pandemic only because it was widespread.  Cases in New Zealand and Canada.  That is widespread.

Yesterday, I woke up with a sore throat and a tight chest.  I ran some errands, went to the library to pick up a novel that I had “ordered” and stopped for some bread at the grocery store.  I was tired.  A little voice in my head kept saying, “You have the Swine Flu, man and your ass is grass.” The Night Listener movie download In Her Shoes movie

I have never before thought that I was “coming down” with the “maladie de jour”.   I have worked in drug stores for a long time.  The “Hong Kong Flu” of the mid-sixties was brutal.  Poseidon movie download The coughs were so widespread that every drug store ran out of the Phenergan family of cough syrups.  We bought it by the gallon.  We went through multiple gallons.  Then they switched to Robitussin AC.  We bought that by the gallon also.

I knew that I was in for a siege when I started coughing a bit yesterday.  I took the bottle of Robitussin DM from the cupboard and put it on the counter.  When I went to bed I took a big swig.  I told Victoria, “You may want to sleep upstairs.  I’ll be coughing all night.”

I even took a second swig of plain Robitussin.  I didn’t want the mucus to get so thick that I would suffocate during this illness.  Young healthy people are the group that has the highest mortality in a “bird” flu epidemic.  This is because their immune systems are very strong.  The body produces so much mucus that the patient suffocates.

“The Great Influenza” by: John M. Barry is a terrific read.  In the “Spanish Flu” pandemic (early 1900s) there were doctors who believed that it was the vapors (bad smells) that were the culprits.  Some doctors still insisted on bleeding their patients.  This was in the Twentieth Century.

I was spooked because of an incident at work on Tuesday.  A guy with a pleasant accent asked me to help him with choosing a mask.  He said that he was worried about the Swine Flu.  He coughed politely a couple times.  Then he told me that he had taken an early flight Tuesday morning.  From Mexico City to Houston.

That is all I needed to fabricate an illness that is in vogue.  Last night I knew that I was going to die.  This morning, I knew that all I have is a head cold.  V said that I did not cough at all last night.

 

I have made a lot of mistakes in my 43 year career as a Registered Pharmacist.  I have held licenses in six states.  Ohio was the original, then came the prize, California.  My annual wage went from $8,000.00 to $18,000.00 in a month. 

All I had to do was get in the Volkswagen and drive.  California was not a mistake.  I lived in the San Francisco area from 1965 until 1984.  In Her Shoes movies

Then Washington state.  From 1984 until 2000, most of it living on Whidbey Island.  Washington was definitely not a mistake.  The Seattle area is the best place on the planet for well educated young people, especially single young people.  The Lord of the Rings: The Two Towers buy The education level of the populace is very high. Seattle has a rhythm and drum beat like no place I have ever been.

Vermont was a mistake.  V and I wanted a new place for us.  We moved to Stowe, Vermont just 7 months after or wedding because of the town (a famous summer resort/ski village) and because my brother and Beverly lived there.  I had not lived close to Mark since 1959.  I don’t regret the times with my brother.  We had the best New Years Eves at his house.  Mark and I spent a lot of time at the river down from his house.  Our feet in the cold water, picnicking on snacks.  But, the winters were awful.  

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There were stretches of two weeks straight of below zero.  Sometimes 15 or 20 below.   Well, okay, living close to my kid brother for 5 years.  Vermont was maybe a mistake.

V and I moved to Galveston in November of 2005.  Absolutely not a mistake.  Hurricane Ike sucked a lot of dollars, but we love it here on the gulf coast.

My mistakes were in job-hopping.  I have had a lot of jobs, each one “better” than the last.  More money.  Better location.  I worked for Pay n’ Save in Pittsburg, California and in Oak Harbor, Washington.  From 1981 until 1996.  A very long time for me.  I quit in as hissy fit over the micro-managing of the non-pharmacist store manager.  In Her Shoes psp

I went from a 5 minute commute to an 80-90 minute one way commute.  This is proof that smart people can do stupid things. Adventureland release

My advice to you is this:  If you find a job you like, seal it up and go for the long ride.  Just make sure that the company’s benefits include some kind of retirement or profit-sharing that will help your IRA, 401k and Social Security when you are ready to go part time.  Make demands.  Take no crap.  They need you more than you need them, but no hissy fits.

I worked on union job.  Thrifty Drug Store in Pleasant Hill, California.  It was amazing what the union got for me.  Of course, I didn’t feel challenged and moved on to a “management” job, the first of many.

My partner pharmacist stayed for the whole ride.  At 65, he retired.  He now has Social Security of around $2400.00 a month.  His 401k was still in good shape when I talked with him in October.  The union pays him a pension, the percentage based on his last yearly wage which was over $100,000.00.  He lives in the house he bought for $30,000.00 in 1966.  It is 3,000 square feet, with a pool, on a hill.  Imagine what it is worth now.

The question is: “Who is the smart one?”  I’m still working.  Was my job-hopping a mistake?  Well, Not all of the “hops” were mistakes.  But, some of them were really dumb moves.  I made moves only months before I was vested in “pension-like” plans.  Really dumb.

If the job is pleasant and the commute easy.  That is a lot of “good”.  You’ll get the money no matter where you are.

A young woman who is a medical student at UTMB.  This young woman’s beauty is stunning.  Shining black hair tinged with brown.  Almond eyes.  Immaculate complexion.  Adventureland move A figure that is height-weight proportional.  I enjoy serving her.  I enjoy talking with her.  I enjoy looking at her.

She was in last week with an Rx for metronidazole.  I went over to the register to counsel her on the metallic taste, body aches & pains and the general malaise that can go with the drug.

She asked, “What is this drug for?”  The was genuine concern on her face.

“Usually trichomonas.”  I know that my first wife had given me a good case and it took a week of Flagyl to clean up the discomfort in my prostate.

“I think this would be better.”  She held up a box of Monistat.  Now she was the medical student.  She had a take-charge air about her.  “Why do you think he wrote this prescription?”

“Trichomonas!”

“I do not think it is trichomonas.”  She was getting stubborn.  “I think I want to try this.”  She held up the Monistat.

I went around the counter and sat down in the waiting area.  I indicated that I wanted her to sit beside me.  “Please answer these questions honestly”.  She nodded that she would.

“Is there a ‘cottage cheese-like’ discharge?  Or is there a colored discharge?  Is there an odor?”

She was thoroughly embarrassed at this point, but, to her credit, she answered honestly.

“The discharge is brown-ish and there is a bad odor.”  She looked away from me and frowned.

“It is nothing to be ashamed of,” I said.  “It happens.”

“But I douche regularly,” she complained.

“That is part of the problem,” I advised.  “You have to let the normal, healthy bacillus grow.”

She gave me a look.  “My mother started me douching when I was a teen-ager”

I made a funny face.  “I’m sorry, but that was not a good idea.”   I smiled.  “I’m not a doctor and I do not diagnose, but my guess is that you have a bacterial infection and that you need to be seen by a gynecologist today!   Your friend who is a first year neurology resident did not do you a favor.  You could have ended up barren.”

“Barren?  How do you know that?”

“It’s my job.  I’m a pharmacist.”

“Why do you think its bacterial?”

“It’s my job.”

“I didn’t know that pharmacists knew so much.”

“Baby,” I said, “I know that and I got my four year Bachelor’s degree 43 years ago.  The pharmacists you will deal with will have six years under their belts and will be Doctors, just like you.  You need to trust them and to partner with them.  They will be able to help.  They are very well educated.”

“Baby”, by the way is Gulf Coast like “Honey” is up north. 

She brought in two prescriptions that afternoon.  Clindamycin Vaginal and Clindamycin Oral. 

Now, I’ll get to a serious point.  I can’t fight this fight.  I have too many irons in the fire and, man, I get tired.   Maybe there are a few of you out there with some starch in your pubic arches who might have some time, energy and excellent communication skills.  We, as pharmacists should be ashamed of ourselves.

Pharmacy has screwed the goose by allowing Monistat and the rest of them to be sold OTC.  They should be in the behind-the-counter-sold-only-after-pharmacist-consultation class. Looney Tunes: Back in Action movie full

Give me a wild guess.  How many young women are barren because a convenience store clerk said, “Oh, honey, if you have itching, it is a yeast infection.  Try this”?

And my obligatory American Pharmacists Association question:   How does being silent on this issue fit with the mission of “Improving Medication Use.  Advancing Patient Care.”

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I had been waiting since 10:00 AM to talk to this doctor.  It was now after 3:00 PM.  My first hurdle was the maternal receptionist.

“You will have to fax the request,” she said.  “We do not okay prescriptions over the telephone.”

“I’m not faxing this one,” I said.  “I need to talk to the doctor and I need to talk to the doctor today.”

“Why can’t you fax?”

“What’s your name?”

“Why is that important?”

“Because I am documenting every conversation I have about this transaction.”

“Well, if it is about this woman, good luck.  She has not paid her bill.”

The nurse was next, around noon.  “The doctor will not okay this prescription.  She owes us over $100.00.”

“Taking this patient off this drug abruptly could be dangerous.  The doctor needs to make a more informed choice about this prescription.”

“The doctor knows about the prescriptions he orders.”  Huff, huff!  Imagine her eyes wide. How dare simple pharmacist questioning her doctor.

“He does not know enough about this one.”  This doctor was dangerous.  He was my age, stuck in his ways.  He did medicine by the numbers and memory.  Drugs the same.  He finally called around 3:00 PM.

“What is the problem?  Both Virginia and Doris told you that I will not refill the clonidine for this woman.”

“Because she owes you money?”

“That’s right.”

“Okay.  I will not refill without your permission, but you need to be fully informed about the drug before you make that decision.”

“I know all about Catapres.  I have been prescribing it for years.  Harrumph!  Posture!

“I am talking to you about this because I want full documentation that you refused after my telling you exactly what is in the literature.”

“I know what is in the literature.”

“No one knows exactly what is in the literature, Doctor.”

“What difference does it make?”

“You and I are supposed to know.   Any jury would agree that you and I are responsible for knowing the dangers and that both of us need to protect the patient.  It would not even take a good lawyer.  Any lawyer could make the case.  If something bad happens, it’s going to be on you for refusing to refill.”

“What are you talking about?”

“I’m not getting sued, man, because I am making sure that you know what is in the literature. If you refuse and this woman suffers withdrawal, you are on your own.”

There was a long silence, then a huff.  “What is in the literature that is so damned important.”

I read it to him:

Catapres should not be stopped suddenly. Headache, nervousness, agitation, tremor, confusion, and rapid rise in blood pressure

can occur. Severe reactions such as disruption of brain functions, stroke, fluid in the lungs, and death have also been reported. The doctor should gradually reduce the dosage over several days to avoid withdrawal symptoms.

“That enough for you, Doctor.”

“Fill it,” he said.  A pause.  A sigh.  Then, “Thanks for the warning.”

The truth is that every single prescription is a potential lawsuit.  With thousands and thousands of pages about drugs available on the Internet, a smart rat patient could choreograph a law suit.  A hungry attorney would be all over it.

The worry is that the drug could cause damage, even minimal damage.  We are supposed to know.  We are supposed to warn.  Hell, you don’t even have time to warn your patients about what metronidazole is going to do to their comfort level.  When was the last time you warned about clonidine?

If it is in the literature, a judge and jury will agree that it is your job to know and to warn.

You work in a mine field, my friends.

 

 

 

 

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Argue with me about this if you dare:  80% of all medical care ends with drug therapy and pharmaceutical services being rendered by a pharmacist.  Okay.  I may be wrong.  85%?  90%?

A pleasant woman from the Bolivar Peninsula was paying $11.99 for an antibiotic Rx for her grandson.  Bolivar took a huge hit from Hurricane Ike.  The gulf side is one huge wasteland where neighborhoods once stood.  This woman’s home is in Port Bolivar which is on the bay side.  I asked her how the storm affected her.

“We still have a home,” she said.  “The insurance company gave us a hard time, but my husband hired a lawyer.”

“Did that work?”

“Yes, it did, but why should anyone have to hire an attorney to get an insurance company to honor a policy that we have paid premiums on for decades?”

I shrugged.  “You are able to live in your home?”

“We need it too.  We are parents again.  We had to take my 14 year old grandson out of a terrible situation in Tennessee.  My daughter hates me and she may never talk to me again.”

I told her that I admired her.  I suggested that she and her husband were my champions. 

“Isn’t this $4.00?”  She gave me a look.

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I explained to her all about the $4.00 Rx at Wal-Mart.  The list is 300 generic drugs.  “I don’t think this drug is on the list, but you can drive over there and see.”  Wal-Mart is 72 blocks down Seawall Boulevard.

“I’m not driving down there just to sit and wait,” she said.  “The service here is too good.” 

This brings me to the point I want to make.

The golden goose is cooked.  The genie is out of the bottle.  The days of making a good living from selling cash prescriptions are about over.  The $4.00 Rx and the demotion of you and me back to commodity providers have sealed the deal. 

We must start proving that we offer valuable professional services. 

Forget price.  We have come from a 40% profit Rx business 40 years ago to the $4.00 Rx.  The grocery stores with non-pharmacist middle managers playing copy-cat have ducked the duck for all of us. 

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Have you noticed that the genuine drug store companies have not followed the $4.00 lead?  Some have instituted their own reduced-price programs, but they have not gone along with the grocery store lemmings into the sea.

Those of you independents who are either losing your asses selling cash prescriptions or are losing patients and still think that a single payer means socialized medicine need to do some out-of-the-box lateral thinking.

Single payer would mean that EVERY pharmacy will make the same profit and charge the same co-pay as Wal-Mart. 

Service will be KING again.  From a general observation, no one gives worse service than Wal-Mart.  Single payer puts independents right back in the front row where they were for decades.  Delivery will get and keep patients. 

I hear a whining, “But, JP, the profit would not be 40%.”

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Give it up.  It will never be 40% again.  Take what you can get.  Of course, you will get more volume and you’ll have to work harder.  Is this a Catch-22?  Could this be a closely held secret?  When I worked in the 40% paradigm, we only had to do 100 prescriptions a day to make a terrific profit for the mid-1960s.

My advice to those independents who cannot out-service Wal-Mart is to give up the ghost, sell your store to CVS and negotiate a good agreement that gives you the hours you want and enhanced benefits like a month vacation and first day on the job medical, dental and vision..  

 

 

Senator Jay Rockefeller is investigating out-of-network insurance practices.  He says that how the bill is calculated might be a scam.  The New York Attorney General reported that United Health and Ingenix manipulated data so that the insurance companies paid less on a claim and the patients paid more. 

Cuomo said, “They’re lowballing deliberately.  They cut the numbers so the consumer pays more of the cost.”

Rockefeller said, “It’s scamming.  It’s fraud.”

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I say, “How long are we going to stay stupid?”

In January, United Health agreed to pay $350 million to settle a suit by the AMERICAN MEDICAL ASSOCIATION. 

Cuomo has secured similar agreements from Wellpoint, Aetna and Cigna.

You know and I know that pharmacy claims were part of this.  Where is the AMERICAN PHARMACISTS ASSOCIATION in this picture?  Why was not the APhA right there with the AMA?

The stated mission of APhA is “Advancing patient care.  Improving medication use.”  What happened to advocating for pharmacists?  This is not your grandfather’s APhA and that is a crying shame.

I was a proud member in the 1960s. 

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It was the AMERICAN PHARMACY ASSOCIATION.  William S. Apple was the president who created a legacy that has been lost.  William S. Apple was a brilliant leader. There has been no one close to him.  I trusted that he would act in a manner that would benefit me personally.  Do you feel that way about the APhA in 2009?

The APhA was a pharmacist’s organization.  Apple advocated for a behind-the-counter 3^rd class of drugs four decades ago.  It was the FDA that took up that subject last year.  Not the APhA.  Where was the APhA?  This is a vital issue for pharmacists. 

The APhA has morphed into something else.  Did they say anything at all about the disgraceful $4.00 Rx and the resultant loss of a perception that pharmacists provide a valuable professional service? 

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Have they ever stated, “A tired pharmacist is a dangerous pharmacist!”  Wouldn’t that go with improving medication use and advancing patient care?

The APhA is no longer a pharmacist’s organization.  They have the name.  It is grandfathered.  They need a new name.  Any suggestions?

 

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