It’s a Mine Field Out There
A Pharmacist Who does what he is told.
I had been waiting since 10:00 AM to talk to this doctor. It was now after 3:00 PM. My first hurdle was the maternal receptionist.
“You will have to fax the request,” she said. “We do not okay prescriptions over the telephone.”
“I’m not faxing this one,” I said. “I need to talk to the doctor and I need to talk to the doctor today.”
“Why can’t you fax?”
“What’s your name?”
“Why is that important?”
“Because I am documenting every conversation I have about this transaction.”
“Well, if it is about this woman, good luck. She has not paid her bill.”
The nurse was next, around noon. “The doctor will not okay this prescription. She owes us over $100.00.”
“Taking this patient off this drug abruptly could be dangerous. The doctor needs to make a more informed choice about this prescription.”
“The doctor knows about the prescriptions he orders.” Huff, huff! Imagine her eyes wide. How dare simple pharmacist questioning her doctor.
“He does not know enough about this one.” This doctor was dangerous. He was my age, stuck in his ways. He did medicine by the numbers and memory. Drugs the same. He finally called around 3:00 PM.
“What is the problem? Both Virginia and Doris told you that I will not refill the clonidine for this woman.”
“Because she owes you money?”
“That’s right.”
“Okay. I will not refill without your permission, but you need to be fully informed about the drug before you make that decision.”
“I know all about Catapres. I have been prescribing it for years”. Harrumph! Posture!
“I am talking to you about this because I want full documentation that you refused after my telling you exactly what is in the literature.”
“I know what is in the literature.”
“No one knows exactly what is in the literature, Doctor.”
“What difference does it make?”
“You and I are supposed to know. Any jury would agree that you and I are responsible for knowing the dangers and that both of us need to protect the patient. It would not even take a good lawyer. Any lawyer could make the case. If something bad happens, it’s going to be on you for refusing to refill.”
“What are you talking about?”
“I’m not getting sued, man, because I am making sure that you know what is in the literature. If you refuse and this woman suffers withdrawal, you are on your own.”
There was a long silence, then a huff. “What is in the literature that is so damned important.”
I read it to him:
Catapres should not be stopped suddenly. Headache, nervousness, agitation, tremor, confusion, and rapid rise in blood pressure can occur. Severe reactions such as disruption of brain functions, stroke, fluid in the lungs, and death have also been reported. The doctor should gradually reduce the dosage over several days to avoid withdrawal symptoms.
“That enough for you, Doctor?”
“Fill it,” he said. A pause. A sigh. Then, “Thanks for the warning.”
The truth is that every single prescription is a potential lawsuit. With thousands and thousands of pages about drugs available on the Internet, a smart rat patient could choreograph a law suit. A hungry attorney would be all over it.
The worry is that the drug could cause damage, even minimal damage. We are supposed to know. We are supposed to warn. Hell, you don’t even have time to warn your patients about what metronidazole is going to do to their comfort level. When was the last time you warned about clonidine?
If it is in the literature, a judge and jury will agree that it is your job to know and to warn.
You work in a mine field, my friends.
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Jim,
Let me start off by saying I have enjoyed reading over your blog during the last few years. I am a new pharmacist but have been in the business for a decade now. I greatly appreciate your attempts to inspire those in our profession to stand up for ourselves, especially for us wet-behind-the-ears types.
That said, sometimes I think we need to take a hard look at the reality we have right now. The truth is, our future as medication dispensers is exceedingly short. Would it be great acquire the long-sought vision of the happy pharmacist working in the small shoppe and chatting with Mrs. Jones about the weather? yes, but for most of us that vision will never become a reality. At the end of the day, pharmacy is a business and if people are not willing to pay, the business model will have to change or it will fail. The public does not truly value our knowledge, only our access. Case in point, imagine if tomorrow the government repealed every law related to pharmacy, dissolving the FDA, DEA and FTC regulation. Do you think any significant portion of the population would go to a “pharmacy” pay 5x the price for their drug just to have the benefits of pharmacist’s knowledge? Would they go to a pharmacy that sells nothing but drug advice? Sometimes I really think we are falling into the same trap the APhA snared decades ago looking at pharmacy as “what it ought to be” instead of “what it is”.
Pharmacy appears to be a hose who’s shut off valve has broken. Instead of replacing the valve, we are stopping the flow of water with duct tape. There is only so much duct tape in the world, and the volume of water running through the hose is only increasing.
So I ask you JP, is it time we let hose fail? Do we let patients “have it their way” and give them unlimited access to cheap drugs with no educated intervention? Would we then realize that we need to give up the duct tape and buy a new valve? Don’t get me wrong, I don’t want this happening any time soon as I’m only a year out of school which had a net cost for me of about $300,000 and I only made about 150,000 last year. Do we, however, keep taping up the wound until the entire planet is flooded from our leaky hose?
Is is time to let pharmacy fail?
Jim has hit on something important. We need to provide information to physicians and patients regarding drug side effects. What I would like to see is some kind of standardized side effect sheet which lists the primary side effects and the percentage of people, during the drug trial, that had those side effects. A list that contains 50 side effects without any information regarding the frequency of those side effects is not worth much. What about a small card for each drug with the side effects and the percentages? I think we need to move more toward the model used in hospitals. They will have you sign a form which states that they have explained everything to you about what you should do upon leaving the hospital. We need to be able to sit down with the patient, counsel the patient, and have them sign a form that we explained all these things to them. This is not just for our protection, but to cause us to counsel each patient and give them the best available information. So, what we need is a new method of doing pharmacy. This new method is really what we are suppose to be doing. But, in the real world, it is not happening this way. Just try counseling a patient at Wal-Mart. I can bash them because I work for them. They don’t have counseling rooms and trying to counsel is about the most inconvienent thing you can do. The design of the pharmacy should be where counseling is made easy. Maybe there should be somekind of standardized format for a pharmacy. I am usually opposed to laws and being forced to do things. However, I think the time has come for some standards and procedures be put in place in pharmacies to improve patient care. I think Jim will agree with me that the retiring of the baby boom generation is going to bring a more educated populace to the pharmacy and generation of people that are seeking better service from pharmacies. If pharmacy does not improve its methods of providing drugs to patients, then legislators will dictate it, because the baby boomers will not sit still for poor service.
The solution of course lies with the pharmacist. In WI counseling is state law on EVERY Rx. While there are many pharmacies that ignore this, the pharmacy I spent 3 years at didn’t. A pharmacist made it over on every Rx, even at 3AM. There will still be people that don’t want to wait and say “I’ve been on this for years” to which I say “Then I’m sure you know it’s state law you talk to a pharmacist.” I think this can be done without a law. Have the tech request the patient wait to be counseled. If the patient doesn’t want to be counseled just have them sign a log stating they refused counsel on all future rx’s. By giving out little cards it only makes it easier for the pharmacist to cop out and furthers us more from our patients. This might sounds idealistic but I think it would be pretty simple to put in place. Just need an rx manager willing to rock the boat and do the right thing
I believe there is a misunderstanding about my mentioning cards with drug side effects. The cards would be for use by the pharmacist while counseling the patient, not something to be given to the patient. Of course, a computer designed especially for counseling with this information would do the same thing as the cards. Of course, we know a lot of the side effects of drugs. But, we don’t know all the major side effects. Lets say the top 5. That is where a card or computer could help us. Or, the patient printout could have the major side effects along with the percentage of people having those side effects. Just a list of side effects without a percentage does not tell us much. We need the percentages. We need to be able to evaluate whether a patient is likely to have a given side effect. Jim mentioned the severity of side effects that can result from the quick withdrawal of clonidine. I was totally unaware of this!
Good one Jim. I have always worried about the kids that are on clonidine for ADD. Many times the rx is labled as “one at bedtime AS NEEDED”. It’s the “as needed” part that bothers me. It trivializes the abrupt discontinuation of the drug. Even though we stress the consequences during counseling, the ultimate decision is with the parent who gives it or not depending on…God knows what. I see late refills so I know they aren’t giving the med every day. ARRRGGGG!!!
Stumbled across this blog.
Stories like this frighten me.
I live in the UK, and so the only charges for medication is a flat fee for each prescription.
Rev
I’ve just entered the field of health care and I’m at the base of it all, freshman? In American terms…, grade 13 around the world…, when I see or read even come to the knowledge of stories like this, it makes me wonder where, pharmacy as a practice was and where it is now, It is despicable suffering suckatash to know that healthcare is a business like anything else in the world. I feel that if a more holistic approach was taught by the man, we’d be able to sustain ourselves, yes alot of pharmacists would go out of business but what was pharmacy initially, being able to compound a food/drug/medicine name it what you will, that would help you feel better, cure your ailment, its that kind of knowledge that will help our species push further into a positive direction, like Jim said this is a minefield we work in, which is brought upon us by need of an immaterieal object that isn’t even real and is made up in on a daily basis, fluctuating our economy, for what so 1% of the world can be living like Emperors?, educate yourself, sustain yourself, but come together to help one another, provide the necessary information for a patient without having money be the motivation, – Baus