This is easier than e-mailing the pdf. The first 11 pages of “The Rebels of Comfort” without the illustrations.
“You don’t need a weatherman
to know which way the wind blows”
The Rebels of Comfort.
Jim Plagakis, R.Ph.
Copyright by Jim Plagakis 2011
All rights reserved. No part of this book may be used
or reproduced in any manner without
written permission of the author
Jim Plagakis, R.Ph.
For more than twenty years Jim Plagakis has been the author of the popular Drug Topics magazine column “JP at Large”. He has been a prescient observer of the drug store industry and his predictions have been consistently accurate. Jim loves pharmacy and he knows that it is the job that can present problems. The profession is just fine.
He has recently published “The Prisoners of Comfort” (Lulu.com). It is a study of the unfortunate state of institutionalization that is prevalent in the job of working at a retail pharmacy.
Pharmacists are well-educated and highly-trained medical professionals, but, in the retail setting, the job of pharmacy is regularly relegated to monitoring The Prescription Mill. This is not practicing pharmacy. It will be independent professional acts that will define what our profession is in the 21st Century. Every independent activity (counseling, primarily) is a profound revolutionary event.
In The Rebels of Comfort, Mister Plagakis presents the difficult situation we find ourselves in, the reasons why pharmacists feel so helpless and what we need to do to get professional pharmacy back in the hands of pharmacists.
Where cost is king
Prescriptions in 15 minutes, guaranteed
When I refer to the company in this book, I will be talking about the mythical PriceWorld Pharmacy. PriceWorld embodies every evil in our industry that I can think of. The $4.00 Prescription. Free antibiotics and free diabetes medication. The infamous timers that some companies use to motivate pharmacists to work faster. The Drive-Through that relegates the pharmacist to a worker in a certain kind of fast food category. Hair-brain schemes to promote the prescription business such as a guarantee that prescriptions will be delivered in less than 15 minutes.
The executives of the company are exclusively non-pharmacists. The CEO is a transplant from a big box store where he had considerable success selling general merchandise, electronics and food and beverages. This CEO had no drug store experience. The executives of the company are non-pharmacists and the middle-managers are all non-pharmacists with MBA degrees. The pharmacists at PriceWorld can be found in the stores or, one level up, as District Managers. The District Managers are supervised by the MBAs.
It was the MBA middle-managers who came up with the ideas of the $4.00 prescription and the guarantee that prescriptions will be ready in 15 minutes or a $5.00 gift card will be handed out. When pharmacists complained, the Pharmacist District Managers acted like the Capos in the concentration camps. They came down with heavy hands to squelch any rebellion because they were afraid of the MBAs. In the end, these unprofessional schemes strip away the patient’s perception that a valuable professional service has been rendered. We become cheap.
The model for PriceWorld is hierarchical. There is one person at the top of the pyramid and that person is the CEO, the ruler or the dictator. At PriceWorld, the CEO is a martinet. He expects the MBAs, the District Managers and the store-level pharmacists to do exactly as they are told. This is not a model that is sustainable for professional behavior. Pharmacists have the right and responsibility to make decisions based on professional discretion. This is not being done at any of the 6,000 PriceWorld stores. Pharmacists fear that they will be punished for behaving in a manner that pharmacists should behave.
The company is well known for cutting corners in the pharmacy. It paid a multi-million dollar fine for snubbing its nose at the federal government and neglecting to do the proper record-keeping for pseudoephedrine sales. The PBM business it runs has engaged in restriction of trade and has violated antitrust laws. If you Google the company, you will find page after page of legal difficulties.
I trust that most of the readers of this book will be pharmacists so I will leave it at that. You know exactly what I am talking about. You could easily add a few paragraphs to the characterization of the company.
The Pharmacist’s Role
The role of the pharmacist has transformed during the past six decades and we have not come out ahead. Look at the result, the reality of our situation in the second decade of the 21st Century. The pictures of pharmacists that are presented of us by the APhA predominantly are laughable. The clinician who spends the day doing MTM for a livable wage is one of the fairy tales that comes out of the American Institute of Pharmacy Building in Washington, DC. Those of you who have followed me know that I am one of the legion of veteran pharmacists who have little respect for the APhA. They do not deserve to be able to call the organization the American Pharmacists Association because they do nothing to advocate for pharmacists. It is almost as if there is a conspiracy to ruin the profession.
The reality is that most of us do not practice pharmacy at all. We bean-count for the company. We tend to the “Prescription Mill”. We don’t even fill prescriptions anymore. We make sure that they have been filled correctly. Filling prescriptions is no longer a professional task. Well-trained technicians can easily fill prescriptions from the intake to the final product with no pharmacist involved..
Sixty years ago, soon after the Durham-Humphrey Amendment of 1951 changed pharmacy forever, pharmacists had two distinct professional tasks. We filled prescriptions for Pharma-made standardized strengths and dosage forms and we compounded prescriptions.
It took decades before we realized that filling a prescription for thirty tablets or capsules is not a professional task that requires a pharmacist for every single step. Recently we have realized that a pharmacist is not needed at all until the final step and perhaps not even then. Advanced technicians will be the prescription-fillers sooner than later. Advanced Technicians will check the work of other Advanced Technicians. Filling prescriptions is no longer a professional task that only a pharmacist can do. There are those who argue that filling prescriptions is no longer a professional task at all.
Durham-Humphrey created Big Pharma. Standardized strengths and dosage forms made the pharmaceutical industry. Until recently, compounding has neglected by pharmacists. It is making a comeback because there is perceived value in non-standardized strengths and dosage forms. Compounding is the quintessential art of the pharmacist. No one else is trained to do it.
I am reminded of a story told by a compounding pharmacist in California. The patient presented the prescription and asked how much it would cost. The pharmacist reported that this prescription could be ready the following day and that it would cost $75.00. The patient complained and said that the doctor said that it would cost $20.00. The pharmacist handed back the prescription and told the patient, “Have your doctor mix it then.”
Pharmacists who compound must be well paid for their efforts. They have specialized talents that are worth a lot of money. Only pharmacists have been trained in the art of compounding. Don’t give it away.
The chain drug store pharmacist wears two hats. One is a distinctly professional hat and the other is arguably a non-professional hat. For those of you who hang your hat on running the “Prescription Mill”, you are basically just bean-counting. I have watched pharmacists pay practically no attention to what they are doing. They tap the keys with barely a look at the screen. When the computer displays potential problems, they give only perfunctory attention. Running the “Prescription Mill” is not a professional task.
Counseling is a professional task. It is what will define us as a profession for the 21st Century. There are important points about counseling.
Counseling is a legal requirement and if you do not counsel, you are almost hopelessly institutionalized. You say that you do not have enough time, that the demands of the “Prescription Mill” are so heavy that you cannot take the time to be a pharmacist. You are short-sighted. What more security could you want? The MBAs at the company would be idiots if they told you not to counsel. Counseling is your responsibility and your right as a pharmacist.
I will repeat the advice that I have given loudly and often. Document, document, document. Write down dates, times and who said what. I can’t imagine that the pharmacist District Managers for the company have a kamikaze death wish. They know that their ass is grass if they dare tell you to break the law.
Professionals do not bean-count. It does not take a Doctor’s degree to run the Prescription Mill. Don’t blame me. I didn’t make it that way. I am just the messenger. A professional is a practitioner who uses discretion and makes independent decisions for the benefit of the patient. Your counseling and my counseling will differ on most drugs. However, neither of us is right or wrong. Both of us behave independently by acting for the benefit of the patient.
The key word is independent. The company can’t tell you how to counsel. That would be idiocy. The company can’t publish a big book outlining how to counsel on every single drug and every single combination of drugs and conditions. The company can’t tell you how to counsel a middle-age man who you suspect of being an alcoholic on the use of temazepam. Or how to counsel a pregnant woman on the use of metronidazole for vaginal trich after she tells you that her husband sleeps around.
We spend most of our time at the company’s stores working for the company at the Prescription Mill. When we counsel, however, we perform an independent action and that is a profoundly revolutionary act. When you counsel, you no longer work for the company. They pay you for practicing pharmacy at their location. They pay you for doing only what you can do, at their location. They can’t tell you how to do it. The company should be very pleased that you are as accomplished as you are because they look very good when you are very good.
Bean-Counting and running the Prescription Mill are not very satisfying, but they take up so much of your time. It is no wonder that you are so miserable at your job. You are wired and using million-dollar technology, so why doesn’t it make you feel any better than five, ten, fifteen, twenty? Counting pills and licking and sticking labels? You spend 90% of your time caught on this hamster wheel. Pharmacists have been whining about the job for thirty years. Is it any wonder?
Counseling is 100% an independent professional activity. As Forrest Gump would say, “Professional is as Professional does.”
I want to be fair. Very few of us can have a 90% Counseling practice and 10% Prescription Mill job because we have not evolved to that yet. Pharmacy is in transition. The company has to survive or we would not have a place with thousands of dollars of space and equipment where we can work and practice pharmacy for a very nice wage. We have to do what is needed and wanted to keep ourselves in a good situation.
That being said, you must practice your profession by counseling or they might try to take the opportunity right away from you. You have no choice if you think you will still be able to pull down $10,000 a month and more in the future. Would you pay that much for an employee who only did the work that a well trained Advanced Technician can do for $20.00 an hour? Hell no! The company has been studying what you do. They would love to pay you less.
There is a law in every single state that every one of us must be willing to go to the barricades to see to it that this law remains in the books forever. We must be willing to temporarily sacrifice our time, our money, even our well-being to protect us from forces that are hell bent on eliminating our profession eventually. We must be willing to get dirty and bruised and bloody if any force tries to change this law. We must aggressively enlist the public for their support. Look out in Arizona.
The law that I am speaking of is this: There must be a pharmacist present when a prescription is dispensed to the patient.
The law makes sense. Counseling needs to take place. The patient may have questions. The Boards of Pharmacy are mandated to regulate our profession for the benefit of the public. It is a no-brainer that the health and welfare of the public could be endangered if they eliminated this law. Look out. The boards have not shown consistently that they are good thinkers.
The company doesn’t care about the patient no matter what they say. The MBAs could not care less if Maggie Jones dies because she was not properly counseled. The company would love to fill the prescriptions in a remote location and deliver them to a dispensary store and have the prescriptions sold by a clerk. You can help prevent this nonsense by showing your value as a professional. Trust me! You get no professional points for running “The Prescription Mill”.