Hurricane Jill

It’s a MOCkery

Last night was my one and only training day for night shift. It wasn’t busy at all, but since it was the first of the string, my sleep schedule is now totally whacked. I came home and crashed, but now I’m up again.

Tonight I fly solo. I’m sure there will be at least one or two things that stump me, and that I’ll have to figure out on my own. But that’s how it is when the buck stops with you, and it’s a constant, regardless of how long you spend training.

Luckily, this pharmacist stint has given me an unexpected opportunity to study for and take my Pharmacotherapy Board recertification exam. My certification period was up last year, and there was no way I could have recertified at that time. So I thought it was a lost cause. But apparently, if you have a good reason, you can petition for an extension. And med school/internship is pretty bulletproof in that respect.

The thing is, it’s a hard exam with a 50% failure rate, and that’s within a group representing some of the most knowledgeable practitioners in the field. Not the kind of test you can take cold and expect to pass if you’re not working as a clinical pharmacist. And there aren’t many jobs even in clinical pharmacy that obviate the need to study for it. So most people choose to recertify via continuing education rather than risk failing the examination. But that requires 150 hours of specially designated CE. I had about 30 before I started medical school, and hadn’t done any since. So that method wasn’t feasible, and the exam was my only option. Consequently, it’s nice to have the time to study. And the resources to purchase some study aids.

So the test is about a month away, which means I have my work cut out for me.

Mostly dead all day

You remember a few posts back, where I described my personal version of hell? Yeah, that was the pharmacy today. I doubt we broke 100 prescriptions. The five of us sat there twiddling our thumbs for all but a few brief stretches of time. I kept asking to be sent home, but the regular pharmacist kept saying, “no, no, the techs are all leaving early, so someone has to stay.” And I’m thinking, I am totally the wrong person to keep around. Not only do I cost an arm and a leg (of which I get to keep the arm, and the leg goes to the staffing agency), but I’m no substitute for a good pharmacy tech.

But you can’t stop the clock, no matter how slowly the minutes pass, and eventually the day was over and I got to go home.

"Would you like us to leave?"

Today I worked at the county’s free and indigent care pharmacy. I don’t know what I was expecting, but it definitely wasn’t what I found. (I seem to be saying that a lot, lately.)

The pharmacy today had a very skewed workload, in favor of new prescriptions. So although it wasn’t very busy, it felt busier than it was. And despite what you’d expect from a pharmacy where everyone was indigent or on welfare, the customers were exceedingly well-behaved.

The only drama today was from a little 5 (or so) year old girl who’d just gotten some immunizations. I swear, she was a miniature version of a grown up pain patient, her descriptions of her pain were so vivid.

Kid: “Ow! It hurts so bad! It feels like…like a little needle went into my skin.”
Mom: “Well, honey, that’s exactly what happened. You can’t go to school unless you get the shots. All the other kids have gotten theirs already.”
Kid: “It hurts! It hurts! Like electric shocks! This Charlie Brown bandage isn’t helping! I have to scratch it!”
Mom: “OK, you can scratch it.”
Kid: “No! I don’t want to scratch it!”

And so on, inconsolably. At this point, we’re all chuckling at her utter lack of any pretense at logic. Which was even more funny because she had the verbal skills of an adult, and we all know adults who behave that way. Then came the coup de grace. After about five minutes of screaming how much pain she was in, the little girl said:

“I think I need a drink!”

I had to duck behind the counter so the customers wouldn’t see me laughing hysterically.

I really liked her mom, though. That little girl would test anyone’s patience, and yet her mom somehow managed to maintain a dry sense of humor despite it all.

Outside Hospital

So I started the training for my upcoming return to hospital pharmacy. It’s a 7-on/7-off arrangement, in which I work seven 10-hour shifts in a row, and then have the next seven days off. It’s considered a tough schedule, and people who work it are generally considered to have lots of stamina, or to be crazy (or both) by the regular workweek people.

This strikes me as incredibly funny. That’s like, four whole hours a day less than I’m used to working at the hospital. Not even counting the seven whole days off every other week. That is cush, my friends.

Now, give me two of those jobs, alternating weeks, and it might approach a resident’s work hours. But even so, that would likely be the work hours of an upper-level, non-surgical resident. I knew a pharmacist once who held down two 7-on/7-off jobs like that, and his colleagues all considered him a freak of nature. He subsequently went to medical school, where I’m sure he seemed just like everyone else.

So I pointed out to the lead pharmacist that this schedule still left 10 hours I could work before they had to pay me overtime. I said they were welcome to schedule me for another shift during the day or evening. The lead pharmacist was concerned that this would have me working eight days in a row, and surely I would want a day off before the extra shift? It took me a minute to comprehend what she was saying, because again, I’ve routinely worked fourteen days in a row of fourteen hour days–and that, only because I had to go home for ten hours to keep my program out of trouble.

It’s just a totally different world outside of medicine. But that was one of the things that drew me to medicine in the first place: the job is about getting the work done, not putting in X number of hours regardless of the workload. I am just not a shift worker, and I never have been. I would rather be overwhelmed by the workload than be bored. Hell, to me, is being trapped someplace with nothing to do, and prohibited from either leaving or taking a nap.

It’s also interesting to observe the contrast in how medicine is practiced at hospitals with and without residents. The hospital I’m training at has no residents, so the allied health staff are given a significant amount of protocol-driven decision-making authority. Seriously, it seems like everything is designed so that you really only need to bother the physician if there’s a significant deterioration in patient status. Otherwise, from the physician’s perspective, it all runs on autopilot.

I’ve always worked in a University Hospital-type setting, so this is very new to me. I’m holding off forming an opinion on it just yet. It seems like, in either setting, the potential exists for certain things to slip through the cracks. But they may be different things, with and without residents.

Go get ’em, CMS

The Angry Pharmacist has an interesting post about pharmacy benefit management firms, and their opaque and easily corruptible business practices. The dainty flowers among you will likely find the imagery and language offensive. But it makes the point.

Perhaps the best thing that could come from the Medicare prescription drug benefit is CMS scrutiny of these firms. Because they certainly seem to be a law unto themselves at this point, and I don’t see a whole lot of difference between what TAP describes, and an attending billing for a surgery that a resident performed in his absence. Except that the resident gained valuable experience from it, while there is no such greater good served by PBM’s billing practices.

The only problem is, it’s hard to make an example out of a nameless, faceless company that few people even know about, much less understand.

Rite Aid, Robbins and recklessness

DB talks today about getting through M2 (or T2, as we called it at Tulane). He does not have fond memories of that year. He also dislikes teaching that year.

I’m trying to think back on my own second year. It’s kind of a blurry juxtaposition of sunny days and torrential rain, Rite Aid on weekends and Robbins Pathology during the week. I lived on iced tea at CC’s Coffee House during the day, and Diet Coke in the Dean’s conference room at night.

The Dean’s conference room was the unofficial study headquarters for all the neurosurgery gunners in my class. The library had sucky hours, and at that point there wasn’t a 24 hour coffee house, so one of the Vice Deans had given a classmate of mine the key, in order for us to have a quiet, safe place to study when everything was closed.

My classmate practically camped out there for most of the year. But I liked to people-watch during study breaks, so CC’s worked well for me. Plus, it was where a lot of my classmates studied, and this guy I liked would occasionally come there to get coffee. And you almost always had to share a table with someone you didn’t know, so it at least gave me the illusion of a social life, and the potential to meet someone interesting outside of medicine. The only bad thing about it was that it closed at 11pm. So sometime around 8 or 9pm, I would pack up and head to the conference room at school.

I had the good fortune of studying with a group of people whose strengths complemented my weaknesses. My classmate with the key was very detail-oriented, and was excellent at drilling down to the thing that didn’t make sense. He would often ask questions that our professors couldn’t answer, and the responses he got from them were often helpful in figuring out what would NOT be on the test. But he would often get bogged down trying to understand some piece of minutiae that didn’t really matter. I had another classmate who had a knack for making complicated things simple, yet accurate enough to be practical as conceptual tool. Another classmate was good at keeping us going when we were all sick of the topic at hand. He also always knew the political backstory of everything that went on in the school administration.

As for me, I was good at identifying the information that was clinically relevant, or fundamental to understanding clinically relevant material, and therefore likely to be on the test. I think that’s really the only reason people let me be a notetaker for the class: in my notes I used boldface fairly sparingly, but we never were tested over something I hadn’t boldfaced. It was kind of freakish, actually. I never thought much of it, until one time I was sick as a dog and didn’t have time to go back through and bold anything before turning in my noteset, and most of the class bombed that part of the test.

Of course, the gunner in me felt cheated. How much better would my grades have been in relation to the class if I hadn’t been doing that the whole time? But it also felt good to know that my study guidance actually made a difference. So in the end it was a wash.

That was also the year I got serenaded in public by a guy I liked. It was incredibly sweet, and horribly embarrassing, and utterly reckless of him, all at the same time. No matter what comes of it, you have to admire a guy who would put himself out there like that. (Unless of course, it’s part of some pattern of stalkerish, manipulative behavior, which this wasn’t.) Unfortunately, I am not that reckless.

But on the whole it was a fairly good year. It was actually the best year of my entire med school experience. It shouldn’t have been, and wouldn’t have been were it not for Katrina. But it was. There were some low points, but in retrospect they were not so low in relation to the disaster ahead.

Score one for common sense

Today, and for the next several days, I’m working at another giant chain. Well, not so much that the chain is giant, as that everything about the chain is humongous. Except the prescription volume, which is about average, 300-400 prescriptions/day. But it felt like half that much.

The computer system is a weird hybrid of UNIX, windows and barcoding, and is a little clunky, especially the part the techs deal with most. The pharmacist side of the system is much more streamlined, and the workflow is extremely well-thought-out. Also the shelves are arranged entirely by the alphabet, regardless of dosage form or brand vs generic, which is actually the most efficient way to organize them.

Old school pharmacy dogma mandates that products be separated by dosage form. In other words, lotions and creams in one section, eyedrops and eardrops in another, elixirs and syrups someplace else, and pills and capsules in the middle. Some places even have a special section for birth control pills. The other thing you frequently find in an old school setup is for brand and generic drugs to be placed next to each other, with the location determined alphabetically by one or the other. So you have to know the generic name and all the various brand names of each drug in order to find it.

The point of this seems mostly to make things as unfriendly and disorienting as possible for part-time staff and floaters. The regular staff will always be more efficient, because they know where everything is. –Although the argument used is that it’s “safer” for patients, in that it prevents dosage form mixups. But consider: the most harmful error you can make in this regard is to substitute eardrops for eyedrops (due to pH and tonicity differences), yet the “old school” setup still places the otic and ophthalmic versions of each drug right next to each other. So that argument doesn’t even support the thing it’s used to justify. There’s actually no evidence at all to support it. On the contrary, most studies of workflow efficiency support the strictly alphabetical setup, with at most a small section of fast-movers.

At various times, people have tried to tell me that, a) state pharmacy laws require it, b) Joint Commission mandates it, and c) pharmacy professional societies have it as a standard of practice. None of these things are true. Believe me, I checked.

There is no law, regulation or professional standard that requires the separation of dosage forms. And it’s far more efficient to sort strictly by alphabet. Especially when turnover is high among technical staff, and the frequent presence of floating professional staff is a reality. And yet, most pharmacists react to this idea as though you threatened to kidnap their children.

So I was very happy to note that this pharmacy had sorted their shelves exactly as I’d have done. If nothing else, it enabled me to help the techs more effectively when the workload started to bog them down. Because this pharmacy could run on a quarter of my time as a pharmacist, and what they really needed was an extra tech.

русская фармация

Today’s assignment was at a niche pharmacy that serves the Russian immigrant population here in Puget Sound. It was kind of cool. All the techs and cashiers spoke primarily Russian, although they were all also fluent in English.

The labels were printed in English, and the techs would write the Russian translation on it for the customers. I got to listen to them answer the phone and talk to each other in Russian, and was surprised by how much of the conversation I could piece together. I recognized a lot more words than I thought I knew, and was also surprised to find that, with a number of verbs, I would visualize what was meant before my brain actually translated it.

The other thing that surprised me was how many medications each patient was getting. For one person to have upwards of ten active prescriptions was not at all uncommon. I can’t even imagine taking that many medications.

If I ever get to go back there (which may be unlikely, since I felt like the pharmacist in charge didn’t particularly like me), I’m definitely going to study up on my Russian beforehand.

In the eye of the beholder

Ah, retail pharmacy. Home of the freeloader, land of the brazen. My assignment today was with the Evil Empire of pharmacy chains. Or at least, it’s so regarded among the pharmacy community.

I’m on the fence.

As a physician who has and will treat many poor and uninsured patients, I’m glad that there’s a place they can get some of their prescriptions for $4. And I’m doubly happy that the medications this company has chosen to price at that level are generally the heavy hitters of disease prevention and treatment. The good drugs that keep mom and dad, and grandma and grandpa out of the hospital.

But as a pharmacist, I feel compelled to point out that these $4 prescriptions are essentially a venus fly trap. This company has turned its pharmacy outfit, normally a profit center for any chain providing the service, into a loss leader. A loss leader. The very idea of that is anathema to anyone who’s ever run a pharmacy, and had to deal with the ever-present question: can I fill this patient’s prescription without losing money? And if I can’t, does this customer’s other prescriptions cover the loss?

Pharmacy is a business, as well as a health profession. Physicians get to choose what health plans they accept, and hence, who they will see. Pharmacists get to choose what insurance they accept, and hence what prescriptions they fill. So, as a business practice, having the pharmacy as a loss leader is OK if your goal is to draw customers in so that they spend money on other things. However, if your goal is to bring in all the pharmacy business in the area, thus driving your competition into bankruptcy because they can’t absorb the losses like you can, that’s a predatory business practice. Because once everyone else is bankrupt, you can price with impunity and recoup every penny you lost.

And you know you will. Because even the Evil Empire doesn’t have enough bargaining power with Big Pharma to make $4 prescriptions profitable.

The disapproval of the pharmacy profession is evident all across the internet. So this company has difficulty recruiting pharmacists, and has turned to multiple staffing agencies for temporary help so they can keep their doors open. This is where I come in. I like to make up my own mind about these kinds of things. Plus, they’re not doing anything illegal, and scruples on any higher ethical level than that are a luxury I can’t afford at the moment. And I do think there’s societal value in what they’re doing.

The bottom line is, poor people are getting medications they need and could not otherwise have afforded. And it’s not like this is the lone unsound pillar of an otherwise stable health care system. No. The system was already unsustainable, and it’s all going to come crashing down around us if big changes aren’t made, and soon. It just may happen a little faster, now.

So it certainly can make sense, in a twisted Atlas Shrugged kind of way.

Having said all of that, I will also say that from an operational standpoint, their pharmacy workflow is very slick. It’s among the best I’ve seen. Then again, I started out in retail back when almost every chain’s system was still UNIX-based. Which wasn’t very long ago, in fact. So anything Windows-based looks fabulous and intuitive to me.

Oh! And I almost forgot: we caught a forgery today. While I’d like to credit my superior sleuthing skills for the catch, the truth is it was a pathetic and obvious fake. Seriously, the forgers in Texas are so much more sophisticated than the ones here. This one might as well have had an asterisk at the bottom saying “I also have a bridge to sell you, if you’re interested.” In fact, I’m embarrassed for the pharmacist who didn’t catch the forgery this same person successfully presented yesterday.

Anyway, I figured if it were under my name, that’s the kind of thing I’d like to be called about on a weekend, even if I’m off. So I paged the doctor, and he confirmed that it was in fact a fake. I’m not sure what happened to the person, but no doubt I’ll find out tomorrow.

And that’s retail pharmacy for you.