I had been listening to the technician talking on the telephone.  She kept saying, “I don’t know.” Then she said, “That’s not our business.  That is between the boy’s mother and her insurance company.”

There was a long pause.  The technician pronounced each word carefully and with some force, “Doctor…I told you.. I DO NOT KNOW. That is not our job.  We do not set prices.”

Another pause, then… “I AM DONE TALKING WITH YOU.  HERE IS THE PHARMACIST.”  She handed me the phone.

I got to the doctor first, before she could get to me.  “Doctor, what is the problem?  I was listening to the technician and she is right.  We do not set copay prices.”

“Three hundred and sixty-five dollars?  Isn’t that ridiculous?”

“If that is the copay it IS ridiculous.  The patient’s mom needs to get different insurance, complain to her employer or…..”

“I want the generic, but that WOMAN told me that she can’t give the generic.  Why is that?”

I took a second to ask, then back to the fray.  “There is no generic available for Pulmicort Respules.”

“That’s ridicuolous.  It is budesonide.  You are a pharmacist.  You should know that.”

“Everything has a generic name.  That does not mean that there is a generic equivalent to the brand name product available.”

“But, $365.00 is ridiculous.”

“I agree, but I can’t influence the copay.”

“You pharmacists make too much money.”

Oh oh!  You will be proud of Jay Pee.  I took a swig of my Diet Coke and drew a long breath.

“Oh, that’s rich,” she laughed.  I did some checking of pricing.  She is a pediatrician.  “I prescribe Questran in Eucerin all the time and my patient’s moms complain about the price.  I checked and the prices around here (South Houston) go from $50.00 to $150.00.  That’s ridiculous.”

“That’s a compound,” I said.

“A what?”

“It has to be mixed.”

“So?  One packet of Questran and a few ounces of Eucerin.  Those can’t be expensive.”

“It isn’t the ingredients.  It is the compounding that costs.”

“That much?”

“Of course.  The only people who are trained to compound are pharmacists.  We learned it in school and we perfected our techniques as we gained experience.”

I paused, but she was silent.  So, I continued.  “Doctor, I have been a pharmacist for a long time.  I learned compounding when one of every ten prescriptions had to be mixed.  I have compounded papers, capsules, suppositories as well as creams and ointments.  I am good at it, even though my talents are rarely called upon in the 21^st Century.”

“But, $150.00?”  Oh, she was smug.

“Doctor, you charge for YOUR education, knowledge and experience.  Why shouldn’t pharmacists?  I have compounded the Cholestyramine/Eucerin prescription.  If you were the mom, you would like my product.  It is creamy and non-gritty.  It is as elegant as the best cosmetic products.  It turns out that way because I WAS trained in the 1960s.  I have a learned talent, doctor and I AM NOT GIVING IT AWAY.” 

I was getting loud.  The technician to my left was smiling and nodding.  She gave me a thumbs up sign.   I lowered my voice.  “You are a physician.  There is never a second thought that you should charge for your knowledge and experience.  Why shouldn’t a pharmacist charge for her knowledge and experience?”

Later, I called the prescriber back and told the receptionist that I needed to speak with the doctor.  The message I conveyed about the $365.00 “copay” was that this mom had a $500.00 deductible on her prescription insurance. 

Last week, I worked over a pharmacist at Kroger.  He is a mature man and a career Kroger employee.   When I shop there, I usually stop in and say hello.   When I called him for transfers, he really irritated me.  I did not hold back anything.

I called for 12 prescriptions.  I told him that all I needed was one that day.  I suggested that I call later, when he had some space, for the other eleven.

“It’s not gonna happen’” he said.

“What does that mean?”  The hairs on the back of my neck stiffened.

“That means that I won’t have time. 

Just call when it is time to fill them.”

“You want me to keep pieces of paper here when we can file the prescriptions on the patient’s record.”

“Yeah, that’s what I want you to do.”

That was it.  “Listen, man,” I said, “You and I are not enemies.  We are colleagues. 

Giving transfers is a courtesy that has been in pharmacy for as long as I can remember.”

“I know, but I have work to do.”

“I don’t care how much work you have to do.  When you call here for a transfer, you will always be my number one priority. 

“That is admirable, but every pharmacist I talk to hates giving transfers.”

“Man, I do not care what every pharmacist loves or hates.  It is part of the job.  The prescription belongs to the patient, by the way.”

“You expect me to take the time to give you 12 prescriptions?”

“Just one right now.  I’ll call you back later, when you are not busy for the other eleven.  I’ll tell you again, that you are my colleague.  You are not my competitor.  We are in this boat together, man.  The more we cooperate and treat each other in a friendly, professional, collegial manner the better our jobs will be.”

“I’m not used to this.”  He went on to whine about dollars off coupons and shopping cards and whatever else he hated.

“You know what?  I don’t give a shit what these companies do to each other.   I just care about the treatment that pharmacists give each other.  It is pathetic that you tell me IT’S NOT GOING TO HAPPEN when all I am doing is doing my job.  I would rather you fill this lady’s prescriptions, but she wants them here.”

“She’s been a customer for a long time.”

“Someone over there pissed her off.  End of story.  I’ll call you whenever you want, but, my friend, it IS gonna happen today.”  I then asked for the technician.  I gave her the eleven Rx numbers.

It happened at 7:45 PM.

I know, I know.  I am an idealist.  It is more fun and more satisfying than struggling and resisting transfers. 

Give Thanks.   You are not a soldier patrolling the perimeter at Bagram Air Base in Afghanistan.  You are not a single mother in south Chicago feeding her three kids Macaroni & Cheese and Stove Top Stuffing for their holiday dinner.  We who work in pharmacies do have a lot to be thankful for.

A Holiday for those of you in the United States of America

And.. who said the shortage is dead?  Cincinnati is a major metropolitan area and it has a pharmacy school

NEW RATES JUST ANNOUNCED

CALL US NOW – THIS OPPORTUNITY

I have been floating the idea that pharmacists are at “point” for triage in many cases.  Especially for poor people.  Even families making a living wage can end up on our doorsteps because we are the most accessible health professional and we are FREE.

We are also at THE BOTTOM OF THE FUNNEL.  After they realize that they need medical care, they go to see a physician, MD or DO or another primary care provider.  They have tests performed, the see a nurse to get their prescriptions.  Often they see no one.  The Rxs are called in, faxed in or sent by Email.  They have questions and the next medical professional they see IS YOU, at the bottom of the funnel.    

More and more, the primary care provider will be a PA or an ARNP.  That is just the way it will be.  The best primary care could be at a CVS “Minute Clinic”, a “RedyClinic” at Wal-Mart or a Nurse Practitioner at a Walgreens location  “Take Care Clinic”.

“RedyClinic” is an endeavor that leases space from Wal-Mart.  “RedyClinic” pulled their operation from 14 Wal-Mart stores in the Houston area.  I wonder if patients pulled out a four dollar bill before they pulled down their pants.  Wal-Mart likes to make the appearance that they are on the high road, but they really are not.

Last Tuesday an elderly woman handed me a bottle that was SMX/TMP DS.  She did not look good.  Her skin was pasty.  Her eyes wild.

“I don’t want this,” she said.  “I want the real thing.  Bactrim DS.”

I asked her why and she said that she was having side effects.  She did not have swelling around her neck.  No rash.  She was breathing fine.

“Maam, if you are having a reaction for this, the same thing would happen with Bactrim DS.  What exactly are you experiencing?”

Look out, Mamey, and listen to this.  She said that she could not feel her feet at times, that she had trouble picking up things with her left hand.  Her short term memory was impaired.

“Maam,” you need to contact your doctor immediately,” I said with attitude.  “What you described could be serious.”

“What could it be?”  Her eyes were on fire. “I want the brand name.  I do not want the generic.  It is inferior to Bactrim.”

I answered her question.   “It could be a TIA or even a stroke.”  I asked her to do all of the tests.  Raise her arms, stick out her tongue, Recite Peter Piper picked a pack of pickled peppers. 

She got pissed off.  “I did NOT have a stroke.”

I got pissed off.  I said strongly, “Contact your doctor right now.”

She left in a huff only to come back later to accuse me of being rude.  While she was telling me that was a bad-mannered and boorish druggist, she dropped the bottle of water that she was holding in her left hand.  She failed to pick it up with the left hand and had to use the right hand.

That is when I offered to call 911 and that was when she spun on her heel and marched out of the store.

Five minutes later, she came back and said, “I can’t unlock my car door.  I can’t remember how to unlock my car door.  Can you help me?”

“All I can do, maam, is call 911 for you.”  My hand was poised over the phone.

“I just need a little help.”

I gave it my best.  Strong, loud.  I jabbed my finger at her with every word.  “Please go sit in the waiting area.  I am going to call 911.”

“No you are not.”

“Maam, you absolutely need to get medical care RIGHT NOW.”

TRIAGE?

You will find more stories like this on the page “Blasts from the Past”.

The Bulletin of Pharmacy

Detroit, Michigan, January 1919

A NARROW ESCAPE.

By E. M. R.

It had been an unusually busy day, and it was after twelve when I slowly climbed the stairs to my room above the store. I hurriedly undressed and almost immediately dropped off to sleep. I had not been in bed very long when I was awakened by the buzzing of the night-bell. Slipping on some clothes I went down to the door, and there stood a small girl with a prescription. I told her to come in out of the cold night air until I filled it.

In a few minutes it was finished; and after being wrapped up, away she went with it. I locked the door after her, and then went back to the prescription department to arrange the things I had used. The first object my eye fastened on was the bottle of strychnine sulphate instead of an almost harmless alkaloid which the prescription called for. I realized instantly what I had done and what the outcome would be. As soon as I could catch my breath I grabbed my hat and out I rushed in search of the girl with the prescription.

Up and down the street I ran, but neither I nor the few people I met saw anything of the girl. Disheartened, I went back to the store to wait—for what? How long I sat there virtually waiting for the authorities to come and get me, I do not know.

A knock at the door and up I jumped to let in— whom? There stood the small girl with the contents of the prescription dripping from the paper wrapper. She had let it drop and was crying for fear her mother would whip her for being careless. Thoroughly awakened I put up the prescription a second time and sent her on her way smiling and her pockets bulging with gum drops.

“All’s well that ends well,” of course, but when I think how different it might have turned out—

 

There are plenty of cities in the USA where the pharmacist shortage seems to be easing.  They tell me that RPh jobs are not plentiful in Pittsburgh.

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Rural areas are still suffering badly.  Take rural northwest Alabama.  My good friend RB works for a chain that is not Rite-Aid.  They want their stores open on Christmas Day.  This has been going on for years.

They have to offer premium pay to lure pharmacists and techs away from their families.  Pharmacists: Triple Time which comes out to $193.56 per hour or $1,540.00 for the day.  Technicians will get Triple Time up to $60.00 an hour.  $480 for the day.  In the past, RB has refused. 

He and his wife do not have children.  They are big players in the charity that gives protection to and helps to heal battered women and their abused children.  There is something to be said about a pharmacist’s place in small town America.

But, What the?  How busy can TBX be on Christmas? 

You guys and gals who aren’t tied down might want to look into a decade in the boondocks.  Houses will be cheap… I mean cheap compared to Seattle, for example.  You will be RICH.  How many other young people earn $135,000.00 a year? You will be a respected medical professional.  Rural people are less likely to abuse you.

 Mind your money, max out the 401k and you’ll be headed to a retirement at 55, when you still can work part time.  I’d love this chance.

 

 

Two weeks ago, a late Friday afternoon, I get a call.  I asked the tech who wanted me.

“She didn’t say, but she wants you and she pronounced your name perfectly.”

I did not make her wait.  If she could say PLA (as in plug) GA (as is gas) KIS (as in kiss), I wanted to know who this was.  I get all kinds of pronunciations, including Pla-ga-SKI.  I complimented her for saying it right.

“Well, when you want a favor, I think one should at least try.”  She laughed and introduced herself as an assistant prosecuting attorney for the DA’s office.  “I was told that you are a part time pharmacist and probably off next  Monday.   Is that correct?”

“I am off on Mondays.  That is correct, but who told you what about me.?”

She named a pharmacist at a big box store.  “He told me that you would probably be willing to help me.”

For fun, I asked, “Why not CVS or Wal-Mart?  They must have a pharmacist free on Monday.”

“Well,” she sighed.  “I really need a witness that the court can understand, if you know what I mean.”  The pharmacists she was referring to are nice enough, but their accents are difficult and the girl from The People’s Republic of China might have a stroke testifying in open court. 

“What do you need me to do?”

“Just identify a white tablet for the record.”

“White tablets are like zebras, dear.  There are thousands of them.  Even the park superintendant in Kenya can’t distinguish one from the other.”

“Well this one is round, it has a Vee on one side and a number (can’t remember) on the other.”

“The Vee probably signifies that Vanguard is the manufacturer, but it was probably marketed by one of the generic suppliers.  The number, I don’t know.  You can call the 1-800-1POISON number.  They would tell you.”

“That’s not good enough.  I know that it is Soma, carisoprodol.  I need an expert to take the stand, be sworn in and to testify.”

“And you want that to be me.”

“At 10:30 AM on Monday morning.”  She paused.  I think that she thought that my silence meant acquiescence.  “I’ll meet you in the hall on the bench directly opposite the door to Court Room C.”

“I will be an expert witness.”

“That is correct.  I will show the court that you are an expert, because you are a pharmacist and because you are well known for your pharmacy writing.”

I wondered which pharmacist had suggested me for this task.  “10:30AM could mean 3:00PM, right?”

“Unfortunately, that happens.”

“How much do you pay your expert witnesses these days?”  I had done this for a defense attorney in California in the late 1970s. 

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He paid my regular wage for 8 hours, plus bought my lunch and paid me an additional per diem of $100.00 for incidentals.   This request was not stroking my ego.  I wanted the expert witness fee settled before I agreed to anything.

“Unfortunately, there is nothing in the budget for witnesses.”

I told her what pharmacists make per hour.  Minimum 8 hours for wrecking my day and, if I had to take a lunch break, I expected the DA’s office to buy my lunch.

“I am sorry.  I can’t do that.”

“I’m sorry too.”

Here you go, just another example of the prevailing beliefs.  Pharmacists give free advice and counseling.  Pharmacists do not expect to be paid.

Where did we go wrong?  Before the Durham-Humphrey Amendment (1954), pharmacists did get paid for their knowledge and expertise.  There was no such thing as a prescription-only drug.  Routinely, pharmacists answered health care questions by mixing up a potion for the complaint.  Coca-Cola originally was a druggist’s drink that contained cocaine.

My first boss, at Cook Drug on Main Street, rarely sold a product off the shelf.  He compounded products extemporaneously.  An example.  I watched him do this.  A farmer  wearing bib overalls whispered, “I got the constipayshee.”

Dolph told him to wait.  He poured mineral oil in a 6 ounce graduated bottle.  He added peppermint oil, a few drops of Sucaryl and a few drops of green color.  He typed the instructions on the label.   He collected $4.00.

After, he said to me, “Jimmy, I know that you put up mineral oil and mark a quart bottle 59 cents.  The reason I charged $4.00 for that compound is because only pharmacists know how to mix medicines.  No other professional can do what I just did.”

I am a smart rat.  When I said goodbye to the prosecutor, I remembered Dolph’s words.  No other medical professional would be considered an EXPERT witness in the matter.  I suppose some pharmacist afflicted with I-Am-Important-Syndrome said Yes and helped to perpetuate the belief that Pharmacists are always Free. 

Note: This guy was charged with a CRIMINAL offense.  Watch your ass.
 
The Center for Safety and Clinical Excellence and the Institute for Safe Medication Practices will present a very important webcast that should be of great interest to all clinicians involved in the medication use process. On November 20th at 12 noon Eastern, 9 AM Pacific, the case of Eric Cropp will be discussed.

Eric is an Ohio pharmacist who was involved in a tragic medication error that cost the life of a 2-year-old

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patient. Eric did not catch a technician’s IV compounding error that involved use of concentrated sodium chloride in place of normal saline, resulting in a final sodium chloride concentration of greater than 20%.

Eric’s human error could happen to anyone, given the inherent weaknesses in our manual system. Eric’s error has resulted in criminal prosecution and he is now serving a 6 month jail sentence, to be followed by 6 months of home confinement.

He has lost his pharmacy license permanently and been ordered to pay all court costs, pay a $5000 fine,
and serve 3 years probation. 
 
The webcast will provide a summary of the medication error, including the circumstances that lead to this system error. ISMP staff has visited Eric in jail and Michael Cohen will discuss his conversation with Eric. Eric’s attorneys will discuss the criminal proceedings and what led to the harsh treatment. ISMP staff will provide an overview of practices observed in IV compounding, including both good practices and
practices that could lead to errors similar to this case. Bona Benjamin from ASHP will provide an overview of recommendations from the recent IV Safety Summit. Dr. Bob Wachter from UCSF will discuss the potential future impact of this case with regard to accountability, possible impact on voluntary error reporting, just culture, and support of the “second victim” of a medication error.
 
Eric is a hospital pharmacist, but other clinicians have recently been charged with criminal counts

This is supposed to be healthy? The book Fat!SO? is simply revisionist propaganda!

I will not identify the person in the picture.  I picked it off the Internet as a picture of a woman who is obese and, at the same time, doing a lot to maintain an agreeable presentation.

There is a “Fat Pride” Community.  The author of the book “FAT!SO?” is a  champion for the growing population of obese and overweight Americans.  With the cost of health care being the focus of the attention of our nation, there is the view that extra weight leads to chronic conditions and, therefore, increases the cost of health care for all of us.

I recently wrote an essay here that presented the cost of treating obesity related illness is more than the cost of treating cancer.  Think about it!

Everything runs on agreement and there are so many obese Americans now that, banded together, make up a huge MAJORITY of Americans.  66% of all Americans are overweight or obese.  In Alabama, Mississippi, Tennessee and West Virginia 30 out of 100 are obese.  That is a hell of a lot of agreement for the specious argument that “fat people can eat healthy food and add movement to their lives and be healthy.  Healthy should be the goal, not thin.”

That is what Peggy Howell, the director of the National Association to Advance Fat Acceptance, said.  I’ll give you that, Peggy Girl, but I want to see the drug list of the average 50 year old in your group.  

Linda Bacon, author of “Health at any size” said, “Public health care policy is harmful. We give a direct and clear message that there’s something wrong with being fat.”

There are many web pages about the author of FAT!SO?  I could not find what she weighs.  She does say that she is, “Fat and uninsurable.”

I think that pharmacists have something to do here.  I have said before that we are at the bottom of the funnel in health care.  What doctors ignore or give perfunctory counsel on ends up in your lap.  You see it with prescriptions every day.  The patient will give you a look and say, “What are these prescriptions for?”

Now, there are organizations promoting that obesity is okay, good and healthy.

Geezuz, gimme a break.  For every John Belushi, who could do back flips as well as a Russian gymnast, there are 100 obese folk getting geared up for an early funeral in an over-sized coffin.

I am all for the obese and fat eating healthy food and adding movement.  But then they would be run out of the club “FAT IS FINE-LOOKING”.  They would lose weight. 

We, all health professionals, have a huge job to do.  If we do not watch it, the new national health care program to come will really bankrupt us.  Not because of you and me and our tennis-playing parents.  Not because of our vegetarian 18 year old who is a soccer player at her college.  It will be because 66% of Americans are either overweight or obese.  They will be covered and they will suck off enormous resources just because they now have agreement that “Fat is somehow charming in the 21^st Century”. 

I am telling you as clearly as I can that they “get no soup from me.” 

I will not AGREE that FAT can be healthy.  Period! 

I defy any obese person to bend over and tie their shoes and tell me that they did NOT have to hold their breath.  Six weeks ago, JAY PEE was 10 pounds heavier and I got short of breath bending over and tying my shoes.

For balance.  Jim Fixx, a Mensa member, was dumb.  He did not see any doctor regularly.  No physicals.  He ran ten miles a day.  He wrote “The Complete Book of Running.”  His father died in 1984 of a heart attack in his 40s.  Jim Fixx died of a heart attack after a run one day.  He was 52 years old.  He was not fat.

You must have something to say.  Can pharmacy play a significant role in helping to alleviate this epidemic?  What about the “drive-through”. 

I love our young friend’s suggestion that a significant percentage of food stamps can only be used for fruits and vegetables.

Talk to me!

PS: The woman in the picture is a prominent advocate of the idea that “Fat can be healthy”.  I know her name and what she wrote and where she has presented her arguments.  But, I am a smart rat.  Only the shadow shall be told.