Pharmacy. Jim Plagakis. Pharmacist

The technician told me that the person on 101 wanted to talk to the pharmacist. 

“A doctor?”

“A patient, I think.”

I feel that giving patients some time is part of the job of a pharmacist, so I picked up the phone.  The woman had such a deep gulf coast accent that my Yankee ears could not keep up.  So I had to tell her to slow down.    

“Okay.”  She repeated everything slowly and I was able to get most of it.  It was a list of drugs and she wanted to know if they worked together.

“What do you mean work together?”

“Will it hurt me if I take all of these together?”

“That’s quite a list,” I said, “How long have you been taking these drugs?” King Kong rip

“I haven’t taken any yet.  I just got them.”

I had to put her on hold for a few minutes. 

When I came back, she started from the beginning.

“Hold on,” I said, “Just give me your name and I’ll take a look at the drugs.”

“I told you the name of the drugs.”

“I know you did, but it will be easier for me if I look at your profile.”

She told me her name and her birth date.  “Maam, I can’t find you.  Tell me one of the Rx numbers.  I’ll go that way.”

“Well, I don’t think the numbers will help.  I got the prescriptions at Wal‑Mart.”

“Why are you calling me?”  I could feel heat on the back of my neck. 

“Because the Wal-Mart pharmacists make me wait on hold too long and then they rush me.”

“I’m sorry, maam, but I have to take care of my own patients and I’m going to leave you.  You need to call Wal-Mart.”

Four dollar prescriptions, four dollar service.

From: JP’s 20 Simple Rules for the Successful and Satisfying Practice of PHARMACY

The Cardinal Rule

Always Put Yourself First

This is a little of the old, you can drag a pharmacist out of the drug store, but you can’t make her relax.  The last thing on your mind is putting yourself first.  You have doctors to call and another order to complete.  The telephone keeps ringing and the techs keep asking questions.  What are you going to tell Mrs. McKeever.  Her insurance company has said NO to the Enbrel and you have made promises. 

The store manager wants to talk about your vacation request for July and you can smell the weasel getting ready to refuse you.  He’s going to ask you to reschedule for April.  He’ll tell you to take the kids out of school for a week.  You know the drill.

How can you put yourself first?  This job, by its very nature, is not designed to let any pharmacist thrive.  If you let it, your job as a  pharmacist will grind you down and spit you out.  It can affect your blood pressure, your heart rhythm and your regularity.  You may have fitful nights with bizarre dreams.  You may get soaked by cold sweats.  Some of you have spent entire nights filling the same prescription over and over again and never getting it right. 

 Your sex life can be affected.  You may even punish the ones you love the most.  You come home at nine thirty at night and demand of your  spouse, “Where the hell is my dinner?  I work my ass off  for you and the kids and you can’t even have a decent meal ready for me.”

Your partner just walks away.  She turns her back so you can’t see her  stricken face.  She wipes her eyes.  You say you’re sorry, but she brushes your hand from her arm.

She cannot put up with this much longer.  Last night, you were not hungry.  You took a beer in to watch the game and then had a second and a third.  You fell asleep, fully dressed, in your chair.  This is not putting yourself first.  This is hunkering down to survive.

 Notice that I did not put blame on pharmacy.  I said the job.  One is not the other and the other is not the one.  You have made the mistake of thinking that they are one and the same.  Pharmacy is an impressive profession.  It is the job that can ruin you.  Let us explore a paradigm shift.

Don’t even think about your spouse and your children, by the way.   Your real life is not even in play here.  Do you notice that I do not identify your real life as your job and your profession?   Your real life can be profoundly affected by your inability to take care of yourself. 

I know how hard it is to be selfish.  I did not have a clue on how to say NO.  Dignity was just not in play in my life.  I thought about it.  I talked about it.  I wrote about it.  Dignity was something I could get by putting myself first.  I just did not know it.

Think about this!  You are an intelligent, well trained professional.  You have the kind of knowledge and experience that drug store companies fall all over themselves to get.  You can have it your way.  You just don’t know it yet.

Unfortunately, the way it is these days, you have to learn to say NO in order to put yourself first.  I never, truly learned how to do this.  I came out of co-dependency, grew up as a co-dependent and I still have to fight out-of-the-ordinary body sensations and guilt feelings when I say NO, but I have learned to show a thumbs down. 

I can’t list for you the incidences where you must learn to say NO.  You’ll just have to wing it.  I guess that one good imperative is to consider the situation and determine if they are about to take advantage of you .. one more time.

You will learn to spot them coming.  They will no longer be able to sneak up on you.

Talk about it with someone who cares about you.  Take baby steps.  You’ll stumble, but you won’t go back.  Learn to put yourself first.  If not now, when?  Your life depends on it.

JP's 20 Simple Rules for the Satisfying & Successful Practice of PHARMACY

When I think of the best pharmacy job I ever had, I have vivid, pleasant memories.  There was pharmacist overlap and that is the single most important criteria for a job to even get in the running for best job.  One of us came in at 9:00 AM and the other started his shift at 12:00 noon.  We worked together for four hours.  There was a constant back and forth banter in the pharmacy. 

The technicians jumped into the fun with both feet.  We joked and laughed and kidded each other.  There were times when the topic of the day was not so funny.  We stuck together when a tech needed to clear her head about an impending divorce.  Once there was the stress of a child being hit by a car.  For me, it was a second family. 

This was a chain job, but the pharmacy was closed on Sundays.  We had a relief pharmacist who actually wanted to work every Saturday and was willing to pull the holiday shifts.  My partner liked to fish and hunt early in the  mornings, so I usually got the early shift.  What more could I want to make this my best job?  I worked nine to five with a lunch break.  Weekends off, never on holidays.  I didn’t know how good I had it until I didn’t have it good anymore.

What I remember most about what defined my worst job was the required 12 hours shifts.  Of course there was no lunch period. 

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No breaks at all. No pharmacist overlap .. ever.  The technicians would often be pulled from the pharmacy for other duties and the schedule never included a pharmacy cashier after 6:00 PM.

When I had the temerity to make a generic .. directed at no one in particular .. complaint, the store manager would usually sneer at me.  His mouth would curve into a leering grin and he would always say, “That’s why you pharmacists make the big bucks.” He was one of those old-fashioned store managers with a huge case of pharmacist envy.

I would always say, “You know that the chances of making a dispensing error are huge in this store.  We do too much work in too short a time with too little help.”

hat would always erase his grin.  He always said, “It’s your ass if there is a mistake, not mine.”  End of conversation. 

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Clearly, on reflection, this was the lousiest job I ever had.  My meals at work were gobbled down and usually consisted of something peanut buttery or salty and snacky.  Snickers bars were a staple.  I would drink way too much strong re-heated coffee and I would drink it too late in the day.  I would have trouble going to sleep at night and then I would fill prescriptions all night long. 

Now that I think about it, the support of the company or lack of support from the manager was the only difference in these two jobs.   

The interesting thing is that both jobs were with the same company.  They were only separated by a few hundred miles and a couple of years. 

It will never end, the four dollar monkey will be on your back forever.  In ten years, new graduates will think nothing of it just like I thought that the Durham-Humphrey Amendment had been around forever.

Not so.  It was 1952.  Four years before my first boss got me an apprentice license. (Damn I wish I had that now, with eBay.  They quit apprenticeships in Ohio just a couple years later)   Durham Humphrey became law just twelve years before I was given my first RPh license in Ohio.  There were “Legend Drugs” and “Over the Counter Drugs” because of Durham Humphrey.  I thought that was the way it always was.

Durham-Humphrey Amendment,

a 1952 modification of the 1938 U.S. Food, Drug, and Cosmetic Act. It differentiates between prescription and over-the-counter medications and specifies medications that can or cannot be refilled without a new prescription. It also identifies which original prescriptions and refills can be authorized over the telephone.  (Hubert Humphrey was a Registered Pharmacist and a US Senator from Minnesota)

What did they do before 1952?  The pharmacist sold everything and anything, I guess.  That would be pretty cool. 

About a year into my job at Cook Drug, I watched as my boss took 8 ounces of heavy mineral oil.  He put in a few drops of green color, a pinch of Sucaryl and a few drops of peppermint oil. 

• FeardotCom divx

Sucaryl, Abbott Labs, Chicago (cyclamate sodium).  Sucaryl is a terrific artificial sweetener that is still sold in Canada.  In the USA, a couple Rhesus monkeys got skin cancer after being immersed in concentrated cyclamate for 48 days straight or some nonsense like that.  The Searle family owned the Chicago pharmaceutical company named Searle Laboratories.  There was a Hatfield/McCoy type of rivalry between Searle and Abbott.  The word on the street was that Searle had connections with the lab that did the monkey studies and reported to the FDA. 

Anyway, my boss took the mineral oil concoction out front to an older woman who had complained about constipation.  He charged her $2.00.  I was the stock boy.  I was the one who marked a quart of Rexall mineral oil 29 cents.  I asked about the outrageous profit.  Even then, a teen ager, I was a bleeding heart, but Dolph taught me an important lesson.

The Ringer rip

“Jimmy,” he said, “It will work at two dollars.  At 29 cents, it wouldn’t work.”  That was the first time I ever heard the words perceived value.

Ah, I rambled.   Friday, I asked a doctor why she had told her patient that an Rx of 28 Macrodantin (generic of course) would be $4.00.

“Well, it is $4.00, isn’t it?”

“Doctor, No no no and it doesn’t matter what the price is, I don’t tell your patients what your fee is for a first office visit (I happened to know it was $175.00).  How would you like it if I told a patient to expect to pay forty four dollars for you to see them for the first urology visit?”

“That analogy doesn’t fly.”  Uh, goddam, but bite Jay Pee on the ass with fangs the steel in her voice was so hard.  “I provide a professional medical service.  Pharmacists just provide a drug.”

I took on the voice that has gotten people to accuse me of being rude for four decades.  Sharp.  Not friendly.  Quick with a rise in volume and inflection at the end of sentences.  I call it my business-like voice.

“Doctor, you couldn’t be more wrong.  This patient has been seeing a gastro-enterologist for about five years.   Did you know that?”

“Uh, well, uh….”

“The patient should have told you, but I noticed that she has been taking Prevacid for the last five years.  She had a bottle of Maalox on the counter and a bottle of Rolaids.”

  The Secret of Moonacre rip

“Okay, she should have told me.”  A more soft, warm doctor voice, but still a doctor voice.

“The reason I’m calling is not about the $4.00.  I called to ask you if you really want her to take nitrofurantoin with her stomach?”

A long pause.  “The only reason for the Macrodantin was that it is………….”

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“Four dollars?”

“Okay, you proved your point.  I won’t mention any price from now on.  Let’s go with Levaquin for 14 days.”

“That’s a hell of a lot of money, Doctor.  If the price is a consideration, how about ciprofloxacin 500 mg twice a day for 14 days?”

“Is that cheaper?”

“How about a couple hundred dollars cheaper.”

“Okay, okay.  I’ll call the pharmacy if I want to know about price.  Okay?  Just give her the Cipro.”

The Four dollar Rx.  New RPhs will think it started in 1952.

California is often the first domino to fall.  This could be very big.  Contact the Assemblyman and support him.

This is an excerpt of the 7/6/09 post by “The Drug Monkey” Go to the links on the right and click on “Your Pharmacist May Hate You” for the whole thing.

Bill Monning is chair of the California State Assembly Committee on Labor and Employment, which held an informational hearing back in April entitled “Working Conditions of Retail Pharmacists: Are Workers and Consumers Being Harmed?”

One retail pharmacist testified anonymously to protect his identity. He stated that he had been employed as a PIC for 20 by CVS.

He expressed his concerns, including.  Staffing levels. Some company policies discourage breaks, rest periods or bathroom .

Second, he testified that there is simply not enough time to provide proper counseling and there is a lack of proper space for patient confidentiality.

Finally, he expressed concern about certain prescription quotas that were linked to employee bonuses and created pressure on pharmacists to work faster.

California Assemblyman, Bill Monning.  He cares more about you and the safety of your patients than your employer.  

Funny thing is, Bill Monning probably isn’t your Master and Commander: The Far Side of the World movie State Assemblyman. But again, he’s doing more for you than your employer ever will.

Your state board doesn’t seem to care. Probably because there is a good chance they are run by your employer.  We have been telling them that a tired pharmacist is a dangerous pharmacist for decades.

So the only player in all this who’s on your side if you dispense or receive a prescription is a member of the California State Legislature. I want you to think about that as the health care reform debate unfolds over these next few months.

It might not be a bad idea for all of us to thank Bill Monning.   Click on his name. Get the word out.  Pass this around or are pharmacists truly disinterested and apathetic.

There are very few occupations that do not have intrinsic hazards.  In an article in The New York Times , I read about a group of poor bastards in Buffalo who worked in the plants supplying pumped up radioactive materials to the nuclear weapons industry.  This was in the 1950s and they are now getting sick with cancer.  Because of poor record keeping, some of them are not able to take advantage of a medical program specifically designed for them.  Some are just dying.

You probably do not suffer such dramatic conditions related to work, but there is one very real condition that is pervasive to people doing our job.  Of the 200,000 pharmacists out there, I’d bet that 90% of them have suffered from this condition at one time or the other during their careers.  It can be debilitating and dangerous.  It can harm marriages and relationships.  Health can suffer.  So why is it not addressed?

Every single person in our industry is susceptible to this malady.  It is all-encompassing, dangerous and difficult to treat.  Probably because it is just accepted as part of the job. 

We suffer stomach problems, shoulder and neck pain, hypertension and other insidious difficulties because of this illness.  It is a thoroughly modern ailment that, frankly, is not recognized as a source of difficulty.  It is probably the condition most prevalent among all medical professionals.   There is a name for it.  You can find it in the best reference sources.   It is labeled as:

Hurry Sickness.  Let’s define it”

“A modern malady caused by constant rushing.”

 “A compulsion to do everything quickly, or a chronic feeling of being short of time, attributed to the fast pace of modern life and causing symptoms such as anxiety and insomnia.”

Let’s add symptoms like divorce, drug abuse, adultery, alcohol abuse, patient neglect and “eff you” syndrome.  And we spent all of those years studying and preparing for a nice, comfortable life.

Hurry Sickness!   How long are we going to stay stupid?

“You can’t do that,” I said, “You will kill this guy.”  I had waited for a good five minutes for this nurse in Omaha, Nebraska.  She sounded like your mother’s Aunt Eda.  Slow talking.  Slow responding. 

She giggled nicely though.  I was expecting a “Whatever!”

“Mister Frasier knows better than to use Nitroglycerin on the same day that he has used Cialis.”  This nurse was very sure of herself.

“Norma, Mister Frasier will be taking the vitamin form of Cialis.  Daily 2.5 mg. That means that he can NEVER use Nitroglycerin.  Never, ever.”

“He’ll be okay.  He has had a nitro prescription for years.”

My question to my readers…Is this kind of prescribing normal…anywhere?

“Norma, I will fill the vitamin prescription, but I am refusing to fill the nitro for him.”

“Well……..”

“Just have the doctor phone me about this.  But warn her that I am refusing.  If another pharmacy does fill these two together and Mister Frazier uses the nitro at a very climactic moment with his wife and has a stroke or worse I will testify for the family.”

“What are you talking about?”  There was no giggling now.

“I am setting a precedent.  If this guy dies because of Cialis and nitro together, the wife will remember that the pharmacist in Galveston refused to fill.  She might tell this to her attorney.   The attorney might just pay for an investigator to find me.  I get all expenses first class plus a per diem that is more than a pharmacist’s daily wage,  plus a four figure consulting fee.  Can you hear the judge.  ‘Why did you refuse, Mister Plagakis?’” 

IT’S A NO-BRAINER.  It’s in the literature.

“You are over-reacting.”  This nurse wanted to argue with me.

“How can anyone over-react with death?  Just have the doctor call me.”  I didn’t even say a polite good bye.  I just hung up the phone.

I am a package insert directed pharmacist….if I know what the literature says. We have a duty to warn whether we have the time or not.  We are supposed to know what is in EVERY package insert.  What, are you kidding me, Plagakis?  No, every means every.  Think about it.  There are drugs that warn about sudden death. 

How do you warn about that?  “Mrs. Jones, you need to understand that sudden death is a side effect of this drug.”

What do we do instead of warning?  We oversee the Prescription Mill.

The literature is a mine field.  There are bombs all over the landscape.  I am only halfway joking when I say that I am surprised that the attorneys that used to be called ambulance chasers are not standing out in front of CVS handing out cards. 

The doctor was cheery when she called me back.  I asked her about the weather in Omaha and told her about another 90+ day on the gulf coast.  Then I was silent.

“Norma said that there is a problem with Mister Frazier’s prescriptions.”

“You can’t use the daily vitamin dose of Cialis and also prescribe nitro.”

Here is what we can call ass-covering.  “Oh, no! I wanted the 20 mg PRN for Mister Frazier.  Please warn him to never use nitro in that 36 hour window.”

I hate it when I have to correct the doctor and not get dollar one.  I hate it when the doctor screws up and escapes Scot-free.  I have been covering for doctors for four decades.  Not this time.  I had already had that good talk with Mister Frazier. 

Update from Jay Pee 6-9-09

Wyeth Vs. Levine: Joe Six Pack Trumps The FDA

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This is a game changer.  If they ban the hydrocodone/APAP combinations, that will be the end of Schedule III hydrocodone.  JP thinks this would be a good thing.  If MDs want to run “Prescription Mills” I want their DEA recorded with each Rx.   Here is the whole magilla if you want to read it.

FDA urged to ban popular painkillers

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A federal advisory panel voted narrowly Tuesday to recommend sweeping safety restrictions on widely used painkillers, including reducing the maximum dose of Tylenol and eliminating prescription drugs such as Vicodin and Percocet, because of their effects on the liver.

ADELPHI, Md. — A federal advisory panel voted narrowly Tuesday to recommend sweeping safety restrictions on widely used painkillers, including reducing the maximum dose of Tylenol and eliminating prescription drugs such as Vicodin and Percocet, because of their effects on the liver.

The two drugs combine a narcotic with acetaminophen, the ingredient found in popular over-the-counter products like Tylenol and Excedrin. High doses of acetaminophen are a leading cause of liver damage.

Acetaminophen is combined with different narcotics in at least seven other prescription drugs, and all of these combination pills will be banned if the Food and Drug Administration (FDA) heeds the advice of its experts.

Vicodin and its generic equivalents alone are prescribed more than 100 million times a year in the United States.

Acetaminophen is included in a vast array of over-the-counter cough and cold products, including Nyquil, Excedrin and many others. A small share of accidental poisonings result when people take two or more of these combination products without understanding the peril.

Laureen Cassidy, a spokeswoman for Abbott Laboratories, which makes Vicodin, said, “The FDA will make a final determination, and Abbott will follow the agency’s guidance.”

The agency is not required to follow the recommendations of its advisory panels, but it usually does.

The panel’s 20-17 vote to recommend a ban on the combination prescription drugs was one of 11 it took at a meeting called to advise the FDA on problems arising from the extraordinary popularity of acetaminophen. In 2005, U.S. consumers bought 28 billion doses of products containing the ingredient.

While the medicine is effective in treating headaches and reducing fevers, even recommended doses can cause liver damage in some people. And more than 400 people die and 42,000 are hospitalized every year in the United States from overdoses.

In hopes of reducing some of these accidents, the committee voted 24-13 to recommend that the FDA reduce the highest allowed dose of acetaminophen in over-the-counter pills like Tylenol to 325 milligrams, from 500. And members voted 21-16 to reduce the maximum daily dosage to less than 4,000 milligrams.

But they voted 20-17 against limiting the number of pills allowed in each bottle, with members saying such a limit probably would have little effect and could hurt rural and poor patients. Bottles of 1,000 pills are often sold at discount chains.

“We have no data to show that people who overdose shop at Costco,” said Dr. Edward Covington, a panel member from the Cleveland Clinic Foundation.

Some doctors already avoid prescribing pills that combine acetaminophen with narcotics like oxycodone (found in Percocet) and hydrocodone (in Vicodin).

“It ties the doctor’s hands when you put the two drugs together,” said Dr. Scott Fishman, a professor of anesthesiology at the University of California, Davis, and a former president of the American Academy of Pain Medicine. “There’s no reason you can’t get the same effect by using them separately.”

He said the combinations were prescribed so often for the sake of convenience but added, “When you’re using controlled substances, you want to err on the side of safety rather than convenience.”

Still, some doctors predicted the recommendation would put extra burdens on physicians and patients.

“More people will be suffering from pain,” said Dr. Sean Mackey, chief of pain management at Stanford University Medical School. “More people will be seeing their doctors more frequently and running up health-care costs.”

In a statement, Johnson & Johnson, Tylenol’s maker, said it “strongly disagrees” with the proposed restrictions on acetaminophen, adding that they would be likely to “lead to more serious adverse events as consumers shift to other over-the-counter products,” such as ibuprofen and aspirin.

Linda Suydam, president of the Consumer Healthcare Products Association, said the committee ignored studies showing that doses sold by her members — two pills of 500 milligrams, up to four times a day — were safe.

“I think this is a very effective dose and one needed for individuals who experience chronic pain,” she said.

The committee also turned its attention to over-the-counter children’s medicines containing acetaminophen, voting 36-1 to limit them to a single formulation. Right now the liquids are sold in two different concentrations, leading to confusion among doctors and parents.

The FDA asked the committee whether it should ban combination products that include acetaminophen. The vote was 24-13 against such a ban, with many members saying consumers saw the products as valuable.

“Based on the data provided, the combination OTC [over-the-counter] medications really contributed very little to overall poisonings,” said Dr. Osemwota Omoigui, a panel member from the Los Angeles Pain Clinic.

The panel voted 36-1 to recommend that the prescribing information for such products include a boxed warning, the agency’s most urgent caution, about liver dangers.

I was up to my ass in alligators when a heavy set twenty-something woman asked for my help.  She was pleasant and waited her turn.  I was happy to help her, if I could.

I had a hard time not laughing because she sort of hopped as she walked.  Her problem was a broken toe, the long one right beside the great toe.  It was bruised purple.

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“Are you sure it is broken?”  I asked.  She was in beach clothes and was wearing flip flops.

“I just came from the doctor’s.  They took X-rays.”

“What advice did the doctor give you?” 

“He said to stay off it, but I’m not ruining my vacation.”

“You’d be better off in shoes.” 

“But this is her vacation,” a woman who identified herself as the mother complained.

I spoke to the young woman.  “I think you should stabilize it by taping it to the big toe and the third toe.” 

I actually had experience with this.  One Friday night in 1970, I was having an argument with my first wife.  I came home after work to find her drunk….. Again.  We were in the back yard.  I was sitting on the picnic table.  She took a drunk’s aim with her foot and missed.  She was going for my privates, but kicked the bottom of the table.  The doctor at Kaiser Permanente suggested taping the three toes together for stabilization.

“I never heard of that,” the mother piped up.  She was a forty-something beach beauty.  Well tanned.  Buxom, with a few pounds too many on her ass and waist-line.  It doesn’t take much to take bikini out of the picture.

“If you are going in the gulf you probably better use the best tape.”

“Tape toes together?”  The mother.  “That doesn’t sound right.  Don’t you have a toe splint.”

I turned to her.  “Do you want to help her, Maam?”

“Just leave us alone, Mom.”

“But a splint would………….”

I started for the pharmacy.  I pointed at the mother and said, “I have work to do so you are on stage now, Maam.”

“Mom, he’s the pharmacist.”

“I just want to help, Precious.”

“You aren’t helping.  Go.  Get away”

I didn’t miss a beat.  I kept walking to the pharmacy until I heard a hopping sound from behind me.

Please, Mister Pharmacist.  She’s gone.   My Mom’s gone now.”

It is bad enough that we do not get paid for this.  I walk from this type of situation, but the one where I walk the most frequently is when a “customer” argues.

“Well, why is this the best?  Why isn’t that the best?”

I am outta there.  “Sir, I gave you my best advice.  Take it or leave it.”  I am gone and they will have to wait until I am really not busy before I will give them a second chance.