Pharmacy. Jim Plagakis. Pharmacist

“A Little Dignity” Jay Pee Radio

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My first shot at Jay Pee Radio.  I will get it.  I have to slow down.  Pause at the right places.  Enunciate clearly.  If might help it I worked with notes.

Jimi Hendrix ‘All along the Watch Tower’.  A Vietnam War protest song very popular with our soldiers.  It may be a war protest song for retail pharmacy ‘Galley Slaves’.  That epithet was coined by ‘The Ole Apothecary’.  Check his blog.

This very short talk is about ‘Dignity’.  I just did it, without any rehearsal.  Many of you can relate.

Christmas Eve morning, 2007.  Victoria and I took a fifteen minute, early morning drive to a beach on the west end of Galveston Island.  This was right after the sun came up.  It is pretty messed up after the hurricane.  Some of these houses were lost.

I have received some comments at jpgakis@hotmail.com about Jay Pee Radio.  One woman said, “This is stupid.  You are a pharmacist, not a disc jockey.  You are the undignifed one.”   Well, Bxxxxa, this is the 21st Century.  It’s okay to have fun and perhaps I will say something worth listening to.”

Two guys told me that my “old timer music”, “vintage rock and roll” was really good.  The want me to record all of “All along the Watch Tower, by Jimi Hendrix.”  This piece is my choice for the protest anthem for retail “Galley Slave” pharmacists.  I will put the whole song up for you this weekend.

Two pharmacists who called themselves “a fan since Drug Topics” and “a Jay Pee addict” want me to show my face.  Well. that is a confrontation.  Maybe, one of these days, I’ll shave, put on an “island time” shirt and see what happens. 

The rest of you, take just a minute and comment on ”Jay Pee Radio”.

The American dream is no longer just a North America thing.  You can find the dream coming true in the magnificent homes in upscale gated communities in Bangalore or Beijing.  They are driving nice cars.  Harley Davidson franchises are opening all over the place. 

The economies are good over there and well educated, highly skilled immigrants are leaving the USA to take jobs in their home countries.  They see more promise in the economic futures of China and India.  India’s gross domestic product is expected to grow by 5.4% this year.  China’s GDP by 7.5%.  The USA by 2.6%.

A company called WuXi AppTec is an example.  They do research for pharmaceutical companies.  85% of senior managers at WuXi returned to China from other countries, mostly from the USA. 

The opportunities are vast.  The Indians go back for mid to senior management.  10% of all managers in India are returnees.  They are Indian.  They understand India and they have the added experience of living outside of India.

China seeks out highly skilled Chinese living elsewhere.  The government is offering incentives to return.  Financial assistance and housing among them.

Highly skilled immigrants are not leaving because the USA economy is in idle speed.  They are leaving because it is better for them at home.   Can’t you imagine the thrill?  They thought that they were going to have to endure red-blooded Americans slurring, “Chink” or “Raghead” or “Terrorist” every time they had to stop for gas.  Think about it.  We have not proven that we are, as a rule, generous people.  There is a xenophobia in the United States that we should be ashamed of.  I’d leave too. 

They are moving home for quality of life and family ties.  There is a support system and family and friends.  Life could be lonely in the USA when you tie together a darker skin and a thick or sing-song accent.  Things have changed.  They can live in a gated community, drive a Mercedes, send the kids to a private English-speaking school.  They can still watch CNN, BBC and NFL football via satellite while they are having a drink at the club with Americans and Brits who have immigrated to India.

I read about one American who has a senior level job in an Indian biotechnical firm.  He makes half the money he made in a lower level job with an American company, but has four times the house and four times the investments.   

Amanda Lim is a pharmacy student in Indonesia. The language of her pharmacy school is English.  The language spoken at home is English.

There are companies who search out and hire H1b visa holders.  It seems to me that CVS depends on them more heavily than other companies.  Have you noticed that?  What happens when a few thousand immigrant

 

pharmacists decide to go home?

I have acquaintances who vociferously argue that the “shortage” is going to end.  They say that it will be the 70s all over again.  No more sign on bonuses.  No more easy entry for new pharmacists.  Apocalypse.  Wages going down.  Working conditions degrading even more. That is what some of my friends say.

I have never agreed with them.  I see Walgreens, for example, as prescient and proactive with POWER.   The number of prescriptions that our industry provides for America is going to double before you know it.  Many reasons that we can discuss later.

Right now, I’m very interested to see what happens when companies that have been recruiting and hiring immigrants start seeing pharmacists going home, leaving holes that they believed they had filled for years.  It will not take many to create a crisis.

There is one ethnic group of pharmacists that will not be going home any time soon.  Persian women. (They never identify themselves as Iranian) They are always Persian.  I worked with a number of them in the Pacific Northwest.  Everett, Washington.  They were attractive, hard-working and competent pharmacists.  Their English was usually British accented.  They dressed very well and never covered their heads. 

What do you think about this?  I’m especially interested in hearing from a few immigrants.  Immigration delays have discouraged immigrants who have been sitting on their hands for a decade waiting for permanent status.  They are frustrated with the uncertainty.  It is good back home, so what the hell, they just give up on the INS and get out of Dodge.. 

Some of you remember when our profession was all white and testosterone charged.  Not anymore.  The voice is feminine.  The tint of pharmacy is every shade.  I think that more immigrants will stay than will leave.   But, the ones who go home will leave a hole.  The question is:  How deep?

 

JP at Large Up to Date. A compilation of Jay Pee columns from January, 1989. For ordering information, see “A Section For Pharmacy Matters” in right hand column.

More than 50% of the people I serve at my two shifts a week job are medical or nursing students, residents, faculty members, regular doctors or scientists at one or the other laboratories at the University of Texas Medical Branch. The Galveston National Laboratory is one of two in the USA that have air locks and shower rooms and high security. They study bad “germs” like Ebola.

My favorite GNL scientist gets her Allegra and Yaz from me, every fourth Friday night. Her name is Evgeniya Volkova. A six foot two Russian thirty-something beauty who, if she became unemployed, could make a living on the midnight to six in the morning shift at the San Luis Resort. Sexist? Yes. Could she? Oh, man. Absolutely! You gotta see Evgeniya to appreciate Evgeniya.

I have hesitated to say this, but I have been convinced for awhile that a good, seasoned pharmacist is a better primary care provider, in many cases, than a resident.

Friday night, around 8:30 PM, a very pleasant Bengali woman with an American accent told me that she was born and raised in New Jersey. She is a resident at UTMB. With her, were a toddler and her sister-in-law who had an Indian accent. I had been trying to get a pharmacist at a grocery store in Austin for a transfer of the child’s prescription.

The two women showed consternation when I said that I had been put on hold three times and that I refused to wait longer than two minutes.

The mother, maintaining a patient face when she really was impatient, said, “But two minutes is not that long.”

“Only 120 seconds,” I answered. “121 seconds is too long.”

“Can’t you try again?” the resident asked.

“My technician just left,” I said, “I’m all alone and two minutes is my limit.”

It was almost hilarious how they studied their watches as I held the phone to my ear. At two minutes, the mother squealed and the doctor sighed.

I walked back to the counter. “Doctor, what is the problem? You are a Texas licensed physician. You can write the prescription yourself.” I put an Rx pad on the counter.

“What do I write?”

The mother said, “Write this” and she handed her sister-in-law a bottle. The doctor handed it to me.

“Well, you can’t write this,” I said, “It’s a compounded Protonix prescription.” There was no hope at 8:45 PM. “But you can write for Prevacid 15mg Solu-Tabs.”

“Is it the same?” the mother moaned, “My child can’t eat. Please help us.”

I waved my hand at the mother and showed her an extended palm. I was done with her. It was now time to instruct this young doctor. I gave her the quick version of Protonix vs. Prevacid and the value of a dissolve on the tongue tablet.

The doctor started with the questions and I showed her the palm. “Trust me,” I said.

Then she showed me something. “I’m sorry. You know more about this than I do. Please dictate what I should write.” That done, she asked, “Where is the Blistex? Her little mouth is terribly chapped.”

“You don’t want Blistex,” I advised. “It is a runny mess with too much of the volatile oils. If you use Blistex, her terribly chapped little mouth will stay terribly chapped until she is sixteen.”

“Really?”

There was a homeless looking guy standing behind them. He had a bottle of store brand Maalox and tipped it over to show me that it was empty. He shrugged his shoulders.

“Really!” I said to the doctor. “Trust me.” Then the homeless guy (who was very clean by the way), I told him where to find the Maalox. He smiled.

“Is that why I have had chapped lips forever? Blistex is what I use.” Her eyes were wide. Her smile was brilliant. She had found a valuable resource. The pharmacist at the neighborhood drug store.

“That’s probably why,” I said. I told her that the best for chapped lips was the original, black tube Chapstick. “It has more wax than any of the others. The wax will protect.”

While In was doing the computer work, the mother asked what would be good for the cold sores in the child’s mouth. “I can’t get her to eat.”

I looked at the doctor. “They are canker sores if they are in the mouth. Kanka is over the counter and pretty good, but, since you can prescribe, write for lidocaine viscous. Your sister-in-law can put a little on her clean finger and apply it that way. You don’t want the kid (I used the child’s name) to have a numb mouth.”

Ten minutes later, they had two tubes of Chapstick, Prevacid Solu-Tabs and lidocaine viscous and were on their way.

That was only one incident, but it was so over-the-top and the doctor was very willing to listen to me that I had to report. I am also convinced that I deal with plenty of residents who let me take the lead, but fake it.
This girl was terrific. She was ignorant and did not care that I knew it.

OTC. I don’t even show respect anymore. It doesn’t matter if they are students, residents or faculty,
I treat them as if they know nothing. That is more often than not the case. A faculty member recently was going to buy Pepto-Bismol for stat use for gastric hyperacidity. I handed him a pack of Rolaids. He showed a skeptical eyebrow raise and expressed doubt.

“You want magnesium hydroxide,” I told him. When he asked “Why?”, I told him to either trust me or not, but that I knew what I was talking about. I smiled and turned my back on him and walked back to the pharmacy. He bought both.

A resident Friday night asked me why I recommended guaifenesin 400mg, diphenhydramine 25 mg and pseudoephedrine 30 mg separately when she could buy a combo product.

“The combo is what I call a ‘dirty formula’. In order for you to get enough guaifenesin to help, you’d be getting way too much antihistamine and pseudoephedrine.” I had to repeat three times that Benadryl is more likely to stop the post-nasal drainage that was gagging her (her description) than Clarinex or Zyrtec.

That’s enough. I’m out for today. Doubt me if you dare. What you know, what you are conversant in, what you are an authority on is not what doctors are experts on. Period. Watch out. Especially if you are the patient. 90% of the time, you are much better off if you allow the doctor to diagnose, but you choose the drugs she writes for.

For years, I have privately instructed pharmacists to DOCUMENT, DOCUMENT & DOCUMENT some more. It took me about 20 minutes and I always recommend the same points. I am going to give you the advice I gave him in detail.

Any incident that makes you uncomfortable, document. It is not easy every day because you are tired when you get home. You want a bite to eat and TV. You do not have to write long story like this:

“Mister Jones came into the pharmacy when we were very busy after the Labor Day holiday. It is always very busy the day after a holiday. We actually had a few kids with Swine Flu and we are out of Tamiflu liquid and we may not be able to get any more. I’ve been warning every patient about hand-washing, coughing into their elbow or a tissue. Mister Jones called me back into the corner of the pharmacy. He always scares me. He is the store manager. But what he bawled me out for was awful. He made me feel like I am not a pharmacist. He told me that I counsel too much and that I needed to stop it or cut it short. He said that I have real pharmacist business to do at the counter and I can’t make customers wait. He actually said, “Stop counseling so much. I may have to write you up.’”

You do not have to write a story. Just the facts. Simple declarative sentences.

The non-pharmacist store manager threatened to “write me up” if I continued to counsel at a level that I consider to be my professional duty. He said, “Stop counseling so much.”

You, my friend, have Jones’ balls firmly in your grasp. But pile these up. You might need them.

Document these incidences.

…..Not being able to take an appropriate lunch or rest break.

…..Not being paid overtime for hours over 8 in a day or 40 in a week.

…..Being told not to use the bathroom when you need to.

…..Non-trained ancillary help sent to the pharmacy to help.

….Any incident when a non-pharmacist tries to counsel. Technicians usually will not do this. It is the fill-in clerk. “You need Monistat. It worked for me.” You must correct this behavior, by the way.

…..Any violation of HIPAA by anyone.

…..Any time any of your supervisors suggest that you engage in any kind of fraud, anything illegal or anything that compromises your professional ethics.

…..Any incident of a manager or co-worker touching you in an inappropriate manner. You will know. You must espress that this is unwanted.

…..Blatant, outright sexual, ethnic, age, gender harassment. They may laugh it off, but that does not matter. You must express that this is unwanted.

…..Any incident where store or pharmacy management do anything illegal or suggest anything that is illegal.

…..Document insurance fraud to cover your own ass. A simple DAW-1 when it is not indicated.
Document when your PIC allows DW-1 instead of DAW-2. Just one example. Days supply, another one. Cover your ass. Are your initials on the Rx?

Non-pharmacist store managers probably resent you. She has worked for Billy Bills for 25 years. You are a brand new pharmacist and make more money than she does and you work less hours. For sure, she hates what you represent. Document any snide remarks. The most common is this, when you report that you have a problem with no cashier after 7:00 PM (example), “That’s why you make the big bucks.”

…..Document how you feel when you get home. If you document, “My right knee hurts bad again tonight.” 300 times in 5 years, that could get you full disability when you get the knee replacement.

……Document ergonomic issues. “My right hand just stopped working today. I had to stop using it for 30 minutes. My doctor said it is carpal tunnel and that I could not continue doing the repetitive typing.”

……Body dynamic issues may not bother you when you are 35, but it will be good to have 20 years of documentation when something breaks down. Legs can go by the time you are 40. A little overweight? Your hips will take a beating. If your abs are weak, your lower back will hurt at 30 years old. All of these and whatever you have can be reason for disability leave.

……Document any and all health issues… ANY AND ALL.

……Again, document anything that makes you uncomfortable. Women, watch out for the guy who smiles, chuckles and runs his hand through your hair. That is sexual harassment. You must tell him that it is unwanted.

…..Men, document favoritism shown to the female pharmacists. This is blatant. Sorry, ladies. Document that the female RPh hasn’t worked a weekend in 2 years. Document that she never works the late shift.

…..Ladies, ditto. Often, because you are part time, you get the short shrift on vacations. This is yours. I frankly do not know how you are discriminated against.

Be smart, take 10 minutes at your computer evry work day. Have a beer or a glass of wine.
Get it all down. It does not have to be fine writing. Sloppy will work iof you include all the details. With an attorney at the EEOC, it is all about the details.

Trust me. Documentation can make you the driver of your train. Without documentation, all you can remember is that it happened. Legally, you need names, times and dates and a description of the event.

“Please pick up the telephone so I can hear you.”

“Why? I always talk on the speaker phone. I like it.” This was a pharmacist in East Cow Pie, Texas. “All I want is a transfer. That shouldn’t be a problem for you.”

“You sound like you are talking in a tin tunnel.” My voice had transmuted into the infamous Jay Pee business-no-shit-listen-to-me. “Will you please pick up the phone.” I said.

“I need my hands free to…….”

“I’m not doing shit for you if you insist on making it hard for me.”

“Well, I don’t like…..” Still on the speaker phone.

“Did you notice that I picked up the phone within 30 seconds after you were put on hold?”

“Well…..yes.” Still the speaker.

“I will never make you wait unnecessarily. I will always cooperate. You are my colleague. I respect you. I cannot understand you with your accent and the distortion of the speakerphone.”

This is an expensive speaker phone.”

“Do I really need to hear the loudspeaker in the background? ‘Clean up on aisle three’. Is that really one of the singing cowboys you have for music? This is the 21st. Century. Roy Rogers and the Sons of the Pioneers were big for me 55 years ago.”

“…. I never.”

“Your mulish attitude about your goddam speaker phone is pissing me off.”

“My what?” Still the speaker.

“Mulish.. Like in Mule. Jackass. Pick up your goddam phone. Now!”

“Don’t be snippy with me…..”

“I apologize. Give me a minute.” I punched the “Hold” button.

Then I did about five minutes of work.

“Geez, Jim. What happened? I’ve never heard you like that.” The technician’s arms were folded. I think she was mad at me. Does a frown mean I was in trouble?

“Yeah, I could have shown more patience, but she’s not getting the transfer unless she picks up the phone.”

It was actually worse than I have portrayed. I mocked her East Cow Pie culture. I was a bully. I was a big damned bully and I did not care. I still don’t care, one day later. I was way off my game after coming in for the late shift and having to work in a mess. My neck hurt and my legs had fire ants all over them. I was not the generous, bleeding heart Jay Pee. I was mean Jay Pee.

After about five minutes, I returned to the transfer. She had picked up the phone. It took less than 60 seconds. I was syrupy polite. She was too. She said “Thank You”. I said, “You are welcome, Joyce.”

Did I feel guilty? Hell no! My shoulders still hurt and the gabapentin was not holding its own with the neuropathy. Probably because I had missed two doses. I had forgotten to bring them from home.

I know. Plenty of gabapentin right there. “Water, water everywhere, but not a drop to drink.”

Am I all alone? Please tell me that you can be an asshole too. Please confess that you too have been a bully.

“Es” this and “Es” that! Lilly has a “Flu” and a “Dul”. Both “Oxetine”. I thought that this was just another example of “Patent-extension” until I was doing research on neuropathy for myself. Cymbalta is supposed to be good for the neuropathy in my legs and feet. My neurologist gave me three prescriptions. Lyrica, Cymbalta and gabapentin. 1800 mg of gabapentin on work days and 1200 mg on days when I am not on my feet all day does the trick. I’m not changing unless there is a compelling reason. Can any of you “Smart Rats” tell me why I should switch?

Back to the subject of “Es”. What is up with this? Esomeprazole and escitalopram and the
price is 10 times what omeprazole and citalopram go for. These are clearly examples of “Patent-extension”. Am I off base suggesting that the “originals”, available generically, are therapeutically efficacious?

Big Pharma often uses its muscle to peddle expensive drugs that are no more effective than the older model that is sold for a fraction of the cost. Hello, Plagakis! What planet have you been on?

Lexapro is our lesson for the day. The Senate’s Special Committee on Aging showed how Forest Laboratories turned a “Medicinal Afterthought” they named Lexapro into a best seller.

88 pages of a document entitled: “Lexapro Fiscal 2004 Marketing Plan” is stamped “Confidential” on every page. Forest tried all of the tricks to get psychiatrists all the way to primary care doctors to favor Lexapro.

What Forest did to get prescriptions for Lexapro written was to find and use many ways to put money into doctors’ pockets and food into their mouths. And we are supposed to trust doctors to get onboard to lower health care costs?

Whatever happened to buying pharmacists? Everyone has a price and, hell, a good pizza with a salad and soft drinks around 1:00 PM could be the price of many of us. Gawd, I hope not. If Big Pharma ever comes after us again (And it could happen when health care reform ends Direct-To-Consumer advertising) I hope we aren’t that cheap.

Federal prosecutors in Boston are proceeding with a civil lawsuit against Forest. They claim that the company illegally marketed both Lexapro and Celexa for use in children and pad kickbacks to doctors.

What is our responsibility in this? All I do is jump on the chance when a patient complains about the price of Lexapro. I write down the two generic names. I explain about “Patent-Extension”. I circle “citalopram”. I tell them that it is cheap. I tell them to talk with their doctor.

I overheard a conversation between two UTMB nurses. The blonde was telling the brunette that a certain doctor was pissing her off and that she was about to go over his head and complain.

“He tried to tell me how to abrade a burn. I’ve been doing it for 30 years and when Shriners opens up again, I’ll be back there where everyone knows how to treat burns…”

The Galveston Shriners Children’s Burn Hospital is the number one rated burn hospital in the western hemisphere. Patients are from Mexico, Central & South America, Canada & the USA. Hurricane Ike closed Shriners, but, it will be back soon.

Shriners works closely with UTMB. There are only 30 beds (I think), but the building is six stories. The teenagers who live in halfway houses walk down to the drug store. They stay in Galveston for extended times for multiple plastic surgery. They are badly scarred. Some are missing fingers, hands, an arm up to the elbow. These kids come in to the store and spend a lot of time. When they ask for help at the pharmacy for out front items, I always very willingly help. I have said that I will give them eye contact. I will not look away. I will not look at their feet. I always get a smile. Behind the scars, these are some beautiful kids. I had to tell you that.

The brunette answered, “Tell him yourself. You are the patient care expert. Tell him to mind his own business. This is 2009, not 1969.”

It occurred to me that pharmacists and patients need to step up and take our spots. Patients pay the doctor for medical services and they should expect to get their money’s worth.

Yesterday was the Friday before Labor Day. A three day holiday for the medicos. Around 6:00 PM, I listened to the Voice Mail and a woman named Anita gave two prescriptions. She was very ill-prepared for this task. She was hesitant and sounded like she was over her head. She dictated two prescriptions.

The first for Amoxicillin with a Sig One TID, the second for Amoxicillin with a Sig of one or two q 4-6 hours for pain. You can see what she did.

The significant issue is that she used the Voice Mail. Had she waited about two minutes, I could have helped her along.

The patient moaned when I told her what happened. She went and sat down and her husband wrote a check.

“I would not pay the dentist’s bill,” I said.

He gave me a look.

“That woman was not trained properly. It is a holiday weekend. Your wife is in pain and will be in pain for three days. That is the dentist’s fault. He is causing your wife extreme discomfort because of his negligence. I would scream my head off. I’d withhold every penny and if you have dental insurance, I would recommend that you report to them.”

“Can I do that?”

“Of course you can. You drive the train, man. Your check book is the only tool you have. If you took your car to a mechanic, would you pay him if he neglected to do the job properly?”

Why not, you guys? Give me a reason why we should be a dispenser period? Tell me why we should not serve our customers and guide them in getting their money’s worth?

A disclaimer. I pick and choose these opportunities very carefully. A doctor’s office that causes a patient unnecessary pain is one windmill I will almost always go after, because I will be right.

Plus, it is fun! Plus, you are giving instruction. How else is that dentist to know that Anita has been given too much responsibility? Anita could be dangerous.