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Saturday, September 26, 2009

When did a pharmacy become a part of the fast-food nation? You walk into a pharmacy with your prescription in hand, present it to the technician or pharmacist, and start to walk away, confident that in a few minutes you will have your medicine and begin your life anew.

When did that happen? I started in this business in 1983. At that time I remember this same expectation of quick, efficient dispensing, though I also remember that a busy pharmacy back then did about 100 prescriptions a day. We were still typing labels, though a few envelope-stretching chains and independents did have computers. So if we did ten Rx's an hour that was a busy. That works out to be one Rx every 6 minutes. Nowadays we do one Rx every minute or two. (That doesn't mean you get your prescription in two minutes; it's more likely to be an hour as the volume has sky-rocketed.)

But back in the Jurassic period of pharmacy, independents used to fill prescriptions in a back room, beyond the view of customers (we used to call them patients). This actually has a lot to say for it, as privacy worries are supposedly at the forefront of everyone's concerns. These were the days when a lot of compounding happened, capsules and tablets as well as creams, ointments, suspensions, elixirs, suppositories, would be made in a lab. Labels would be typed. It took a long time to make a prescription. I doubt if anyone left off a script and just stood there tapping their fingers.

Yet now I have to listen to the constant complaint: "How long's this gonna take?" "Forty-five minutes? All you have to do is put pills in a bottle!"

It's just like going into McDonalds or Burger King, isn't it? Place your order and take two steps to your right, wait a few minutes while some technician pours pills into a bottle, and hand over your credit card. Would you like to super-size that? How about a nice stool-softener with your morphine—we have a special today!

Sunday, September 20, 2009


Since everyone else and their pet dog gets to sound off on what is the best plan to overhaul the United States healthcare system, I thought I'd put forth a few of my own.

(Note: anyone who has been following this blog knows my reasons for advocating a single-payer system, so the following remarks are meant to be as an alternate to that most desired of solutions.)

  • Lacking any real reform, which indeed seems now to be the resultant predicament we find ourselves in, we could save millions just by having one uniform billing form, and one uniform insurance card. I have seen insurance cards without any ID number, group number, processor number, or even a logo to let us know whom to bill. Honest.
  • Give pharmacists the power of therapeutic substitution. If your insurance wants you on Prilosec OTC instead of Aciphex I could switch you to that drug without having to fax or call the office and wait the three days to hear back from them. They're only going to say switch it anyway.
  • Advocate the use of free discount cards. We switched a patient taking generic Topamax to the generic saving quite a lot, but then we tried on a lark to send the claim to a free discount program. The price went from about $240 to $28! We use it a lot on the phentermine drugs which are never covered on insurance, causing the price to go from $30 to $12.
  • Reimburse pharmacists to review patient medication profiles with the physician. I could save people—and insurance companies!—thousands, maybe millions, if I could afford to go over profiles. But I now do not have the time and no one can afford to not fill prescriptions in place of examining profiles. This would also probably prevent many unnecessary hospital visits due to adverse effects and interactions.
  • Set up a regional or state-wide pharmacy ad-hoc committee every couple of years to go over ideas to send to government boards and insurance oversight committees. Pharmacists have a lot of great ideas for saving money.

Take away Sen. Chuck Grassley's insurance. See, if he didn't have insurance like the 50 million other Americans you'd have real reform, saving the country, oh, about a trillion dollars a year. Probably the best idea I've ever come up with.

Wednesday, September 16, 2009

or not to err, that is the question.

Lately I've noticed interesting reactions from patients when something unusual is noticed with their prescription. Let's say someone receives a prescription for a quantity that they did not expect. Joe Schmoe gets some Zantac 150mg, and takes it twice a day. He looks at the bottle before he leaves and sees that it is for sixty tablets. He points out, none too courteously, I might add, that we've made a mistake. He had asked for a ninety day supply. We should have given him a quantity of #180.

Note: We've made a mistake. Us. The pharmacy team. The druggist. The stoopnagle with the white jacket who can't count. You know the guy, the one who can't read the prescriptions with the silly handwriting on them.

Except that guy didn't make that mistake. Didn't make too many others either. This is the guy whose job it is to catch mistakes. That's right. The job of a pharmacist is to catch the mistakes of others. It is not—principally—to dispense medication. That really is secondary. His first job, and this is really what he gets paid for (because the drugs are sold at a loss or close to it, believe it or not), is to act as a gatekeeper of sorts. He—or she—watches for errors in the prescription process. It used to be that many errors were the result of bad handwriting. This was especially tricky to catch if the pharmacist was new to the area and unfamiliar with a particular doctor's script. Now it is even worse, I'm afraid, due to the increasing percentage of prescriptions sent to pharmacies via electronic software, e-scripts as they are called.

E-scripts are tricky because you never know if a doctor (or nurse or secretary or physician's assistant or the pet dog) merely clicked on the wrong line. For instance—and this is only one of a myriad examples, some much more subtle—did a doctor mean to write for Lisinopril+Hydrochlorothiazide 20/25? Or did he click the wrong drug? Let's say that the patient has been on plain Lisinopril 20mg for years. But the patient's blood pressure might have recently changed causing the doctor to add another drug to the regimen. Well? Do you call the office? Sure, you say. Just call. But know this: you are filling a prescription every minute for twelve straight hours. You also know you won't be able to talk to anyone. You'll get a voicemail message (after navigating through some stupid voice prompt: push "1" if this is an emergency; push "2" for the office manager; push "3" for the dog warden…") and likely won't hear back until hours later or even tomorrow. Or ever. In the end I usually just jot a note to ask the patient if there was a change meant. Sometimes they know. Sometimes they don't have a clue. Ah, well, another day at the pharmacy.

Oh, and when I show Joe Schmoe the original prescription for #60 Zantac, proving that it was his precious perfect physician's assistant who wrote the wrong quantity he treats it as nothing wrong. He even still insinuates that the error happened in the pharmacy. Nice. It seems doctors don't make errors, only pharmacists. Even when they catch them.

Sunday, September 13, 2009


As reported in The New York Times today, Sunday Sept. 13th, 2009, Nikki White died not from her lupus but from a horrific health care system that refused to care for her.

Every half hour another person dies from lack of care in this country (National Academy of Sciences).

And there is no outrage.

As Nicholas Kristof writes, every two months as many people die in this country as died in the World Trade Center attack, which resulted in this country spending hundreds of billions of dollars to prevent such an attack from happening again. But we balk at universal health care.

No outrage. Christians sit on their hands. Republicans call the President a liar. Fox News spreads misinformation. And no one cares.

If you care that Nikki White died needlessly, then you need to do something. Fax a congressman, the president. Something. Anything. Why be part of the problem when you could be part of the solution?