There IS a Way Out of the Mess

Jp Enlarged

The dispute about how the prescription-providing industry will move forward is long over.  It ended in a virtual deadlock.  However, the issue of money has tilted the game in favor of those who defend the bits and pieces like Wait Times, Metrics and the Low-Profit (18% GP) High-Volume business model.

These are the PROCEDURE people.  They say that the PROCEDURE model has proven itself, over and over.  The most important thing is putting out lots of product by using the correct PROCEDURE.  The PROCEDURE will guarantee that pharmacists do not deviate from a winning plan.  If they resist, bully them with the dreaded write-up, below the line performance reviews, with new pharmacists (Robo-dispensers) begging for jobs put them on the list for termination.  The PROCEDURE will eventually calm the ESSENCE people.  They throw in MTM, BP screenings, Hemoccult programs, immunizations and they say, “See what good boys we are.  We are all about professionalism, the ESSENCE.  This is what you want, isn’t it?

The PROCEDURE people are not usually pharmacists.  They hold powerful positions that did not even exist when pharmacists (ESSENCE) were directing the profession. The PROCEDURE people (Call them Masters of the Universe) crunched numbers and came up with some radical new business strategies, but they have neglected patient care, the ESSENCE of any medical profession. I suppose had they paid attention to the fact that pharmacy is a profession and not just another variety/grocery/big box store department they may have had something that could be worked with.  Alas, they don’t get it and they never will.  Not a pharmacist, never a pharmacist and unable to think in the retail box that was perfected by a dying breed..the DRUGGIST.  I mean totally incapable of getting what DRUGGISTS did to satisfy the patients and make a damn good living with the moderate to high profit (40% GP) Low Volume business model.

Those who still emphasize ESSENCE, argue that the Masters of the Universe are defined by their business school beliefs. The ESSENCE people, like me, reject the idea that a pharmacist is a fucking drone, run by a productivity program at the company’s headquarters.  When you turn a profession over to business school Fanatics of the Universe, you have done nothing to advance the PROFESSION.  The Masters of the Universe are all about profit.  The patient be damned.  The major pharmacy retailers (Chains, Groceries, Big Box) have been allowed to subvert the profession and worse, the Boards of Pharmacies have sat back and watched.  If your mandate is to protect the public from dangerous pharmacy practices and you do not even wink at violations of counseling laws because the PROEDURE leaves no time, are you a hypocrite or a fucking hypocrite.

The important thing is to get people like that out of power, even if it takes a program designed to OUT the BOPs to the public.  The goal is to weaken the PROCEDURE, by nearly any means.  Did I hear Pharmacist Bob spell U-N-I-O-N?  I am still waiting for one of you to contact the Guild for Professional Pharmacists for advice on how to go about organizing.

It was all ESSENCE when I was a new pharmacist.  My goal was to get a job with Horton and Converse, a real pharmacy chain in Los Angeles.  Horton and Converse ran operations that would cause any ESSENCE pharmacist to over-excited, but the stores were small, with a small OTC out front and a huge pharmacy in the back.  Of course, a decent size pharmacy counter with like three typewriters.  One counter back was a large compounding area.  They were 24 hour operations.  This is a 50 year memory.  I did not get a job with Horton and Converse because every new pharmacist applied.  I was told, “You are new from Ohio.  Frankly, we will hire California graduates first.”  I went to work for Thrifty Drug Stores up in the San Francisco Bay Area.  My first job in a PROCEDURE based store and the PROCEDURE in 1965 would be to die for in 2013.

The events of the last 50 years have vindicated the PROCEDURE people.  Population growth.  Many more drugs.  In 1964, the choices for blood pressure with a diuretic and either hydralazine, reserpine or a combination.  Today.. count them and count the patients who are on two or three.  Third parties. With only a copay, drugs are cheap.  The boomers.  Every single thing says to the PROCEDURE folks that their way is the only way.   The ESSENCE pharmacist, forever, will say, “Patient care is the most important thing.  This is pharmacy we are talking about.  Not dispensary.  No pharmacy no need for the pharmacist.  A dispenser in the PROCEDURE model could be a well-trained high school graduate.  I have harped in the past…. The law that you be ready to go to the barricades to make sure it is sacrosanct is the one that says, A PHARMACIST MUST BE PRESENT WHEN A PRESCRIPTION IS SOLD.  What do you think will happen if you let that one get away?  You believe that the PROEDURE Masters of the Universe will NOT find a way to get rid of you and you are the guy who believes that the stripper will change her ways after you marry her.

PROCEDURISTS have shown that they can run effective and profitable departments as long as they keep the sword over the head of the pharmacists. “You want the job, you make the metrics sing.”  You know what, they lack the mental equipment to govern a profession.  They aren’t pharmacists to start.  But, once they have the power, they are always going to centralize that power and undermine creative thinking in the stores.  Once the PROCEDURISTS got the power, they subverted any review from the pharmacists in then stores.  You think that $25.00 gift cards for a transfer would be the gold standard promotional tool if pharmacists got to sign off?

The Masters PROCEDURISTS have built a tight-knit cadre of mid-level managers that is resilient.  (The also did not exist 30 years ago).  The ESSENCE crowd has not a chance in hell unless someone wakes up and points “Look, the emperor has no clothes.”  When I read that in the Wall Street Journal of the USA Today with statistics of probably harm due to non-counseling, I know that the PROCEDURISTS can feel their rear ends pucker up.  I honestly believe that, in marketing pharmacy, that incompetence is built into the intellectual DNA of the PROCEDURISTS.  Oh, there are pharmacists among the PROCEDURISTS.

The ACPE, The NABP, the APhA, the Boards of Pharmacy and the Colleges of Pharmacy have not handled this situation particularly well.  They have shown disgusting deference to the money bags, the big prescription-sellers.  They want good relationships with the PROCEDURE people who can write a whopping nice check for that new laboratory.  Put on a nice shiny brass plaque.  THE WAL-MART DISPENSING LABORATORY.  The ESSENCE people cannot compete.  They are much better preceptors however.  They must teach these kids about what it takes to be a DRUGGIST.  It is the only hope for pharmacy.

The status quo is bad.  Most of you have absolutely no practical idea how to make things better.  You all believe that you will end up on the float team, have your hours cut or out of a job.  Small thinking.  With so many ESSENCE fans still out there, what is the problem?  You can overwhelm the PROCEDURISTS be numbers alone.  You are not going to do it alone though.  You need direction.  I can hear Pharmacist Bob in the background spelling G-U-I-L-D.

PS.  If the new pharmacists lose the traditions of pharmacy, and I like to call it THE WAY OF THE DRUGGIST, it is all over.

This is not rocket-science.  If you keep your feet on the floor in a pharmacy department all week long, you cannot deny that all that I have outlined is the distillation of what we are facing as we enter a period of incredible growth in the number of prescriptions filled.,




  1. Pharmaciststeve  •  Jul 9, 2013 @9:27 pm

    JP… you might as well save your breath.. they don’t have the balls/back bone to organize… and if by some very weird reason.. they were able to get enough to organize.. they would not go on strike.. in mass.. they couldn’t “abandon” their pts.. the same pts.. that most could not give a rats ass who is behind the counter.. just as long as they get their meds fast & cheap.. without any hassles.. like asking questions about their meds or their conditions..or counseling them about their meds.. if you can get them off their cell phone…

    We accuse all of those entities of being “out for the money” and during the 90′s and up to mid 2000′s .. how many were happy to pick up that extra shift… or take that above average pay increase.. or just jump from job to job to get the sign on bonus..

    I think that this is where a phrase that I heard from my Father many times – when I was a teenager.

    If you shit in your nest.. you will just have to learn to sit in it…

    Btw… there are 51 BOP’s .. each state and the District of Columbia…
    From my perspective.. our individual and collective narcissism … is coming home to bite us in the ass..

    Actually, more than 51. I forgot Puerto Rico, Guam, US Virgin Islands.. where else? Also, what is this bullshit about not wanting to abandon their patients. They abandon them every 15 minutes. Dispense a first Rx of Plavix and don’t say a word to them. The cashier is supposed to notice the OTC Prilosec and have bells go off. Abandoning patients is the hourly rule for modern retail pharmacists. By the way, if they are nervous about going out, they can take a loan from their 401k to pay the bills. Nobody can stop them. There is a way, Steve.

  2. Mark  •  Jul 9, 2013 @10:27 pm

    I’m interested in more info about the pharmacist guild. I think a professional organization might be a good way to pass on the beauty of what a “druggist” does to our new grads. You and I have talked about those who precepted us and what an impact they had on our ability to practice in a positive manner. It seems like the AphA should embrace this concept, but they are just too out of touch. I’ve tried throught the years to give them another chance, but my encounters with them just leave me sad and hopeless. Not what our next generation needs! I’m not looking for a way to “go on strike” but rather a way to promote professionalism among our peers. I believe a few meaningful relationships are much more valuable than 200,000 names on a roster. Those close relationships with older pharmacist meant so much to me. Where can they get that now? I don’t think it has to be a massive group of folks, maybe just a few dedicated folks who want their profession to be better. I agree with pharmaciststeve, that most will not organize. But a few might. I know I greatly benefited from older wiser pharmacist who took an interest in me, and offered encouragement from time to time. I’m not aware of any such system for our new grads. If we just leave them alone and hope for the best then we all lose. So tell me how to find out more about the guild! I’m interested!

    I will contact the Guild for you guys. Okay, Mark. You got the ball. Find out how we do this. Give Claudia a call. My experience with the Guild is that you will got excellent service. The scone and very good cup of Joe you treated me with were distinct morning pleasures. The Einstein Brothers Bagel Cafe was a spot I will return to. More important, we talked it over. I could tell that what we are missing is communication among our group. I am up to meeting regularly at Einstein. Let’s go for 4 pharmacists next time. You can probably make the quorum all by yourself.

  3. Farmercyst  •  Jul 10, 2013 @12:41 am

    The problem is that,we as pharmacists have no real skill…Now a lot of people will go crazy and hem and haw…but unfortunately all the “secundum artum” stuff went by the wayside and is kinda obsolete…I’d like to make powders and solutions and emulsions but the only time I got to do that was in school in a lab 18 years ago and ever since it has been looking at paper or digital images, checking it once, then twice, and then pretending to care what the person who gets it does with it…I say pretending because of the way things are and have been…In school they give you a doctorate…What doctor works with someone who makes $11.00 an hour and is basically untrainable except to count and stick and type…What doctor has bosses who come in and make sure you have no stool or a chair to sit on in the pharmacy?…What doctor has to hand a product to a patient as part of their job?…A physician, lawyer, dentist, fireman, basically any other human living on earth has some specific skill and is relied on for that skill…I won’t include hot dog vendors and people who sell stuff…That is what pharmacists are…people who sell stuff…Apart from our product, what are we?…Can I sit on a street corner with a table and chair and charge people to repeat their drug label to them?…a few years ago there was no Information highway…Now, do they need ME to tell them to take it with food?…Is this information not avaiable on a thousand web sites?…
    Don’t get me wrong…I’m dejected by this…this willful nullification of an essential process and product…but what can I do?…or anyone do?…independently?…Apart from all of us walking off the job on a certain day at a certain predetermined time, what else is there?…I’m willing to do that if anyone is behind me…or in front of me…
    I cannot say I blame everyone either…The corporations are trying to make some money…Most patients don’t have more than the $4.00 or $6.00 for their drugs…They can’t afford 40 bucks just for the lisinopril…Even with loss pricing I see people paying at least $50.00 to $100.00 for monthly meds…Can I ask them to pay me for talking to them?…
    Since I was in school, they’ve been doing studies to analyze the pharmacists impact on patient care…They’re still at it…Mars will be colonized before that happens and by then patients will be breathing a different air mixture and most ailments will probably be cured and we’ll live to be 500 years old…
    …There is no fix for all the students who’ve been sold a lie and continue to believe it because they have no other choice…I’ve worked with interns who at their best parrot clinical mantras but somehow are employed by chains…
    Maybe there’s a way out, but it won’t be easy…Why wouldn’t someone choose another profession rather than stay in one or pursue one that has no clear role except for “clinical co-ordinators” or “preceptors” or “experiential educators”…I should have seen the writing when the only pharmacists who were clinical were the teachers…I just talked to a physician who said clinical pharmacists were a great help with information…So am I just a “google” for a less than stellar physician…It seems that way…Patients or customers don’t care who gives you the meds…Like someone said, they want it cheap and free…Do you remember the person you last bought coffee from?…Do you go back for him or her…?
    …It sounds like I’m filled with negativity about the profession…I am, but not 100%…
    I’d be happy making half the salary if I could do the job with some idea that I was doing it right….Right now, I’m constantly distracted doing too many things at once like almost all of you…and I have no real skill…stapling a bag, holding a bottle, recognizing a common dose…Its not a doctorate level job…Its an average, and now below average skill…Patients look at me, us, sometimes with sympathy as they see how we’re forced to follow many rules and regulations…I’ve never once felt that way about any health care profession I’ve encountered as a patient…I’ve seen it every where else….
    …Unfortunately, it underlines the fact that we’re not a health care profession…We sell stuff used by patients and the health care profession, not unlike those who sell wheelchairs, bandages, scalpels…etc…We’d like to think we are professionals, perhaps even in health care, but if patients can look up the stuff you’re telling them, then clearly you’re not needed in the equation, much to my chagrin…

  4. broncofan7  •  Jul 10, 2013 @7:38 pm

    You know Farmercyst, I read your post and initially thought that I may agree with you..then I started thinking deeper…have you heard of

    How about this…why do patients need to see a Doctor when they can self diagnose? It’s not the doctors who perform the CT scan, it’s normally a technician and the MD/DO then evaluates it.Now if one needs surgery then yes, a physician visit is warranted but can’t a seasoned lab CT tech probably look at my CT results and tell me what’s wrong? Perhaps I can get a copy of it and Google my result? My point being, Physicians outside of surgery have no real skill that can’t be Googled either. They use algorithms after asking the patient some questions. The law however forbids the CT tech from diagnosing and also prevents anyone other than a MD, DO, CRNP or PA-C from prescribing a medication to remedy that diagnosed ailment. It’s our professional duty that bis granted by law to note Drug-Drug interactions, Drug allergy information and to supervise the dispense function making sure that the physician’s medication order is therapeutic and then following suit to verify the drug name, drug dose, drug directions etc.That is OUR professional duty and it does require training and skill. Our computers pull up many insignificant drug-food, drug-drug allergies that we must weave through and evaluate for significance. That is professional discretion. I fill around 200 rxs per day and we make ~ 7-10 calls a day to MD’s offices for everything from prescription dosing errors, to drug allergies to getting a quantity adjusted so that the patient can get the benefit of a 90 day supply. These are all done with the professional oversight that we are afforded by virtue of our 5-6 year educations and 1500 or so intern hours. Is is true that the chain drug stores treat us like any other department worker? YES. Is it true that PBM mail order Pharmacies monitor our keystroke metrics and bathroom breaks like we are slave labor? YES.(

    So how can one feel like a professional again and be respected by your patients as an asset in their lives and as a healthcare provider? BY PURCHASING OR STARTING YOUR OWN PHARMACY.The chain environment has beaten down Farmercyst to the point of him losing the self respect for his very profession………..and I don’t fault him for feeling that way. I truly don’t. I just wish that those who browse this website truly understand that the possibility for a well rounded Pharmacist to gain the professional satisfaction of being a Pharmacy owner is truly attainable. The breakeven point is 90-110 rxs per day (or figure $900-1400 a day GROSS profit (in 2012 the average gross profit was $12.50 per RX))…how many more RX’s are you filling at the Chain stores (250-400?) with 1.5 techs and NO clerk. You’re sitting on goldmines with direct access to patients (many frustrated)and these chain stores believe that you’re too chicken sh*t to leverage yourself into an ownership position.Think about it.

  5. Peon  •  Jul 11, 2013 @8:19 am

    JP…this is a very good post! It tells it like it is! We are being POLICIED and PROCEDURED into nothing more than minions. The POLICIES and PROCEDURES are getting more and more stupid.

  6. pharmacyslave2000  •  Jul 12, 2013 @9:39 am

    Wow Farmercyst, you’ve managed to put all of MY frustration and anger into words as I feel EXACTLY the same way. I can not add anything else.
    The biggest issue we face is not that we are incapable of being an important part of the healthcare team, but that we are viewed as the ugly stepchild of healthcare. We suffer from a public image problem. People, i.e. customers/patients, do not hold us to the same standard as doctors. Doctors are getting paid for cognitive services. “Professionals” get paid for what they know, not a product they dispense. Until we break through that barrier, we will continue to spin our collective wheels as dispenser monkeys.

  7. broncofan7  •  Jul 12, 2013 @10:01 am

    Today I had patient who just transferred in her lisinopril therapy. I aksed her how she was doing and counseled her about the ~1 in 12 chance of her developing a dry hacking cough. Her husband who was standing beside her literally said “OH, that must be it!” and we proceeded to call the MD for an RX for Losartan. That got her to ask me a question about possibly METORMIN causing her nightmares because she took it at night. I looked at her profile and saw that she was also on Metoprolol and told her that it’s more than likely metoprolol that is causing her nightmares. These are services that many of us offfer EVERYDAY and for FREE. Should we be reimbursed for them? absolutely! But currently these services are tied into the miniscule DISPENSE fees ($1.25) that we get in addition to the product reimbursement. All of us can provide this value to our patients; we simply need to leverage ourselves into a position to justify charging payors for it.

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