Pharmacy. Jim Plagakis. Pharmacist

I received a note from a PharmD who has been working for only three years.  He is already feeling that he made a bad career choice.  This is an edited version of some of what he wrote.

I work at a closed-door LTC pharmacy in Utah.  There seems to be a high turnover rate at the “Big Boys” when sign on contracts run out. 

He spoke of the potential of becoming an owner, the prospects of adding on to the business and having fun.

I can see how a new grad would sign his/her life away for 3 years for a sign-on bonus just to pay down student debt.  I have plenty of student debt.

He declared that the owner/s are apathetic about taking business away from places that give terrible, rude and poor service such as Pharmerica.

How can I get motivated again?  I love this profession, but find my morale being drained and definitely am not having any fun.  Do you have any words of advice for me?

I’ll tell you what I think.  You will probably hear from other pharmacists in the Comments. 

Owners have run this scam for decades.  It is the old:

COME AND WORK YOUR ASS OFF AT MY INDEPENDENT PHARMACY AND YOU CAN BECOME PART OWNER SOME DAY. 

I have never met a pharmacist for whom this DREAM ever paid off.  Ever.  They are using you, man.  You have been snookered.  It has happened to thousands of us.  They probably don’t even want to talk about it.  They keep putting you off.

My advice is talk to the “Big Boys”, make them wait and then make a deal.  First, however, go to www.thepharmacyalliance.com.   Download and print the TPA Sign-on Bonus Agreement and drive a hard bargain.  Take the money, pay off some student debt, get all of the benefits that they will give you.  Max out the 401k.  Make immediate eligibility to the company’s 401k and immediate medical part of the deal.  If they say, “We can’t do that.” they are lying to you.

Three years out.  That makes you 27 or 28 years old.  Patience, man.  Patience. 

This is YOUR profession, man.  You bring your “fun” to the job.  They can’t allow you to have fun or not to have fun.  That is up to you.  I’ll tell you this.  I would never work in an environment where I did not have patient contact. 

Buy my little book, “JPs 20 Simple Rules…….”

Francis Collins, the new Director of the National Institutes of Health said on C-Span that he is shocked by the apparent conflicts of interest between Big Pharma and scientists. He was talking about scientific studies regarding pharmaceuticals.

We do not see the representatives of Big Pharma much anymore, but when one of them does show up, I will do what I have done since the early 1980s. I refuse to take any paper they want to give me and tell them, “I will not read anything. What I want from you is to answer three questions. WHAT DOES THIS DO? WHAT ARE THE DANGERS and WHY IS IT BETTER THAN THE OTHER GUY’S?

Some younger argue and hold up the paper, “It’s all here?” The older guys don’t bother. They know that it is at least 50% a popularity game. If I like them, I will listen longer.

In 1983, when I was the manager of a pharmacy in Pittsburg, California, it was 100% a popularity game for Merck. She was 30-something, gorgeous and small. For me, she was the equivalent of fried Twinkies at a bikers’ rally. Her energy seeped from her pores. Men are attracted by energy. You single women, more cheerleader WORKS.

This Merck girl was the only Big Pharma Detail Person allowed in the pharmacy. She knew right where to go. The stool, beside the sink, at the far end of the pharmacy, counter was her web. She could not be seen from the front. My ashtray was there. Food was usually abundant. The coffeepot was pushed back under the shelves.

I always smoked a cigarette, sipped stale coffee and listened intently to her “detail”. Never more than five minutes. I refused to take any study she was waving around. I was in love with an idea that included her naked. The testosterone surged and my head was definitely in the game.

This darling girl (why are they always 10 years younger?) would always smoke her cigarette and make my pharmacy her hideout for a half hour, forty-five minutes.

Finally, she put me on the expense account and took me to lunch. It was on a day off. We met at a restaurant on Yganico Valley Road in Walnut Creek. The lunch was long. We drank wine. The crescent booth was rich red and black leather. The lights were dim. The music soft, low. She suggested Hennessy after we ate. She extended her hand and held mine for a few seconds. Her eyes were wet and I was lost. I really fell in love………AGAIN.

“You are a married man,” she said, “I can’t.” She let go of my hand.

“I shouldn’t,” I said, and it was over. Her visits after that were five minutes. She never again sat on the stool. She continued to try to peddle Merck’s studies. I refused to take them. Ah life, it has offered so many tastes that I was allowed to chew but not swallow.

All of that was meant to entertain you before I report about ghost-written papers that are signed by NIH scientists as the authors when they have been written by writers employed by Big Pharma.

You and I have suspected this for a long time. How can one study on Cozaar tell us that Avapro is inferior and a study the next week tells us how bad Cozaar is. You notice how the detail person will always lead with a prominent paragraph criticizing the others guy’s drug?

Direct to Consumer Advertising is marginalizing you, my friend. We are getting farther and farther out of the loop. That must change, but it is up to you. I have other windmills. Put down the beer, turn off the game, go to the Internet. There are politicians championing the end of DTC ads. Ask yourself, “Is it worth three phone calls to my Representative and Senators to get this stopped?” Direct to Consumer advertising is the engine that is running our profession straight to the dump. The voices of pharmacists have to carry weight with the legislators.

Anyway, you can see the NIH Chief on C-Span’s NEWSMAKERS show this Sunday (12-27) at 10:00 AM or 6:00 PM ET. With the anything-to-help Big Pharma Bush years behind us, there is a “Proposed Rule” that would require disclosure of financial connections between medical firms and NIH funded scientists. The rule would forbid “ghostwritten” studies WRITTEN BY DRUG FIRMS but attributed to researchers. Pathetic that this went on for decades. Why hasn’t the NIH busted this up a long time ago? You can answer that one.

The NIH Director, Francis Gibson, said he was SHOCKED by some reported conflicts. The years 2000 thru 2008 almost put us under. “The Have Mores” prospered while you guys were held hostage by the PBMs.

Now, who was the smart one? I didn’t know that the studies contained bullshit. I refused to accept them because I SUSPECTED that they contained bullshit.

Since 1989, when my first “JP at Large” column appeared in Drug Topics, I have had a pretty good eye at what is coming up. I wrote about the baby boomers 18 years ago and predicted a monumental surge in the volume of prescriptions. Back when third parties were involved in 15% of Rx payments, I suggested that it would be 90% before too long.

I told you that PBMs were not our friends ten years ago. I put forward the idea that Pharmacy Benefits Managers were profit-making enterprises and that they were going to screw you and the patient every chance they had. My idea was that you had to say, “No Frikkin’ More” as a group. The more you let them, the more they will take. Walgreens actually said NO to one PBM a few years ago. Patients complained to their benefits coordinators when they could not get their Rxs filled at WAG. Walgreens got the deal they wanted.

I have something new for you to consider, especially you uber-educated young people. You are sitting in the driver’s seat. You just have to pay attention and be ready to act.

Not very long from now, when you need to have medical attention for a regular, every day malady, you will NEVER see a doctor (MD or DO). It is that way already in urban clinics. Your family’s Primary Care Provider will be an ARNP, PEDIATRIC NP, PSYCHIATRIC PA…Keep naming them. It looks like there is an opening for you.

Let’s call you a CERTIFIED PHARMACIST. It may take a process to get certified, but right at this very minute, 90% of RPhs (and that includes old guys like me) can competently diagnose nasal rhinitis and prescribe fluticasone nasal spray. 90% of us can listen to a young woman’s complaint and tell if she has a bladder infection. We can prescribe the appropriate drugs.

The poster girl for a condition that should never have OTC drugs available is vaginal monoliasis. It is damn near criminal that Ortho put out Monistat OTC. After that, you have 4 feet of shelving loaded with creams and suppositories.

A Certified Pharmacist (actually any of us) will ask the right questions. Is there a discharge? Is it colored or is it white and like cottage cheese? Is there an odor? After these questions are answered, we can prescribe that Monistat that is now behind the counter or we triage and tell her to get her bottom to a doctor because a bacterial infection could ruin all her chances to ever be a mother.

I’m probably never going to do this because I don’t think that I will be willing to give up 8 or 12 or 16 consecutive weekends to get CERTIFICATION.
But, what about you? You are 34 years old and here is an opportunity that will be lost if Pharm Ds do not step up and take it.

Play with me. I named three conditions that I believe we could be PCProvider for. We are at the bottom of the funnel, remember? We are the go-to medical providers for poor people. Give me more conditions that could reasonable be added to our lexicon.

This is a conversation I had this week with a Registered Nurse.  She works in the Primary Care Clinic at UTMB.  She noticed our sign that we had H1N1 shots available.  I told her that we were not discriminating and that it was “First Come, First Served.”

“Have you had your shot?” I asked.  Patient-contact medical professionals had been on the priority list, but the county made it difficult.  One location, a half hour away with long lines.

“No, I haven’t.

“We can give it to you right now.”

“Ah.. I don’t think I’m going to get one.” 

“How so?  You are a highly trained medical professional.  You have to know the value of vaccination.”

“I’ll let old people get in line before me.. and babies.”

This was amazing.  Her ignorance.  “The preponderance of deaths have been healthy young people.  You are a healthy woman in your early thirties.  You need this shot.  You are around sick people all day.”

She gave me a blank look.  “Well, I’ll ask one of the doctors.”

Well, that did it.  I delivered a soliloquy.  I smiled.  I talked slowly.  I used friendly inflections.  “I have been a pharmacist for four decades.  My practice of pharmacy has always been patient-centric.  It has always been evidence-based.”

She grimaced.  “What does that mean?”

I knew that she wanted to escape, so I trudged on quickly.  “It means that patients’ needs come first and that any advice I give is based on literature or lectures and my education, from long ago and my current inquiries.  Very rarely do I use anecdotal evidence like, well, Mister Jones said it worked 4 years ago, so I’ll recommend it again.”

She was listening now.  I had graduated from the guy who provides the drugs to a more interesting character.

“I am very well educated about bird flus.”

“But this is Swine Flu.”

“It is a bird flu,” I assured her.  “It originated in birds, just like the scare in 2006, I think 1957 and sometime in the 1970s.  The 1918 pandemic was the one that killed millions.  The people who died were young and healthy.  Plenty of them were nurses.”  I took a breath.  “These victims had immune systems that were so effective that they produced so much mucus that the patients suffocated to death.  Doctors were impotent.  Some of them actually bled their patients and this was the 20^th Century.  Some doctors still believed it was the humors (bad smells) that caused the flu.  Modern public hygiene was yet to come.   In the late summer in Philadelphia, it was business as usual.  They let the gathering places like saloons and cafes, churches and theaters stay open.  People died all over the place.  It was the nurses who were the heroes.  They gave patient care and nurses saved lives.  They were in contact with dying people all day long and nurses died.”  I looked at her.  “You need to get the shot and you don’t need to talk with a doctor.  Trust me.”

“Really?  You think I should?”

“Yeah, I think so.  Why take a chance?  They don’t know what’s going happen with H1N1.   It could mutate to a harmless virus like the 1918 flu, but it could become more virulent.”

She was still hesitant.  I was about to walk away, but I still was bothered that she thought she had to consult with a doctor.  “Listen,” I said, “I have probably spent more than 30 hours of my life reading and watching presentations on bird flu.  It interests me.  I have seen doctors who are clueless talk about it on CNN and MSNBC.  One guy from WebMD said that old people are vulnerable when old people fare very well with H1N1.  Our immune systems don’t work as well as yours.  I am up to date on this and your welfare is a concern.  After 40 years, I am really good at my job and my job is to watch out for you.  My advice is that you take a few minutes and get the shot right now.”

She gave me another look.  “Don’t insult the pharmacist,” I said, “We are main stream medical professionals.  We are on the cutting edge.  We see way more people every day than a doctor does.”  I smiled.  “Get the shot.”

She smiled.  “Okay, I will.  I didn’t know that pharmacists knew so much.  Did they really bleed patients?”

This takes a lot of energy.  I get emotionally involved.  Why do I do it?  Because it makes my day worth more and it gives me something to write about.  I am also tired of the disrespect we get.  All of you who help to perpetuate the unexamined notion that pharmacists are prescription mill managers period need to take a good look at the satisfaction you do not get by allowing patients in need to walk.  More on that later.

More on the fee for compounding.  Doctors and dentists do not sell a product.  They sell their talents.  Why not pharmacists?  Are we so tied to cost of ingredients that we are doomed?

Victoria and I are at home after a week out of town.

While we were away, I found too many mainstream media articles criticizing us for the price of compounded Tamiflu.  They were written by writers who are ignorant, who have not been educated.  

These writers aimed right at the cost of the ingredients and there was no one representing pharmacy to explain about compounding.   APhA had nothing to say.  In fairness, APhA was probably not even consulted.   The APhA does not represent you and me, so who cares?

In the meantime, the public thinks that we are cheating them.  They believe that we are taking the cost of ingredients and are profiteering.  No one has educated Mr. and Mrs. America about compounding.  This needs to come from some official organization that represents us.  We just don’t have one.

My first year as an RPh was 1965.  Every single customer/patient knew about compounding because we compounded a lot.   These patients understood that compounding was a methodologically precise function of the pharmacist and the pharmacist only.  They knew that pharmacists were trained over hundreds of hours in the classroom and the laboratories of colleges of pharmacy.  We also learned on the job.  My mentor was Harry Arvidson, RPh.  Harry was just about done with his practice when the Durham-Humphrey Amendment was passed in 1951.  He hung around for another 15 years just  to compound.  He made big batches of Miracle Rub.  Lawsie Welch, a local septuagenarian strong man sold it carnival style.

I learned the nuances on the job.  

Like levigating a difficult, insoluble powder (think Sulfur) before attempting to make an ointment with thick base like Aquaphor. 

Now, newspaper writers are telling me that I am ripping off Mrs. America the younger because I DARE to have the audacity to charge for something that only a pharmacist can do. 

First, my friends, the newspapers can kiss my ass.

Second, the organizations that have the names DO NOT walk the walk.  They should have been way ahead on this.  They should have been educating the public on this years ago, before it was an issue.

My talent is worth something.   I will not give it away.

APhA does not even talk the talk.  Pathetic!  And there are those of you among us who still pay dues to them, expecting things to be different.  That is perseveration, a bona fide mental illness.