You just don't know!

By now, most of us who work in pharmacies have come to accept that there are misconceptions about what happens within a pharmacy.

The misconceptions aren't any easier to manage when your pharmacy is located INSIDE of a medical facility. If anything, they become far worse as both fellow employees and clients expect things from you that aren't reasonable, or even possible sometimes.

There have always been issues with prescribers when it comes to prescriptions, how long it takes for us to fill things, and overstepping our boundaries when it comes to what's been prescribed. With the increase in nurse practitioners, it's become more of a hassle as they expected to be treated the same as doctors (reasonable to ask), yet seem to in many cases be more offended when you question what they're doing.

Here in particular, we've gone through several of them in primary medicine. They often seem to be overwhelmed by what they got themselves into, not understanding the mental health aspect of this facility. One CNP infamously had a client ejaculate on her on her first day here.

It can be a bit rough if you aren't prepared. The regular prescribers are as most have worked in mental health for years. The CNP's coming in are usually new and/or are using this facility as a springboard into other places.

The first one was always requesting a single vial of albuterol solution for inhalation, something that we can't do. She also used to order a bunch of lab tests that weren't necessary and/or expensive. She didn't last long and was replaced by a new CNP who was more worried about how she appeared to clients than what she was prescribing.

More recently, some of the mental health prescribers have agreed to take on some primary medicine roles, and two new CNP's were brought on board to help expand the scope of primary medicine.

This would be fine and dandy, except one of the new ones likes to change her mind moments after she sends the e-script, only to change her mind several more times after that.

One's client chart had six different medications started, then discontinued the same day they were prescribed. That's not normal, nor good.

Worse, the prescriber thought that when they discontinued something in the main system, we received notification of that so we could do the same.

Except we don't. So we didn't.

And the client ended up with multiple blood pressure medications (not uncommon as many are used in conjunction with each other), not knowing which one they were supposed to take.

This led to a string of e-mails asking how the pharmacy wasn't aware of these discontinued medications and demands that the software send something our way. Our IT guy politely explained there's no way for that to happen, as the e-prescribing systems aren't designed to automatically send that out to pharmacies.

The first solution suggested was that the pharmacy check the main record and if there's a discrepancy, call the prescriber. This notion was shot down immediately as outside pharmacies wouldn't be able to check the main record.

Finally, my boss suggested that the prescribers put a note in the correct prescription telling us what medication to discontinue. This was reluctantly accepted as a solution, especially once our IT guy said this was the best way to handle the situation.

When asked who told the new CNP that we received discontinue orders, their response was "No one, I just assumed you did."

Assumed.

They had no credible information telling them that's what happened, they just assumed without asking.

The moral of this story is if you aren't sure, ask. You'll likely get an answer and if you don't, at least get some direction as to what to do next. Yet prescribers don't seem to like to do this. They don't know how insurances work with prescriptions, yet they'll act like they do when something is rejected.

They also don't like when you refuse to fill a script because the person it's for is shady as hell.

Finally, the notion with prescribers that we in the pharmacy are familiar with their e-prescribing software is one of my favorites. At least once a week we get a question asking why something on their end isn't working (like not being able to find a drug or manually enter directions) and we always say we have no idea, that we're not familiar with that side of the main software.

Yet they still ask because they don't know and instead of asking IT, they ask the pharmacy.

Makes sense, no?

So the misconceptions continue, and the lack of knowledge makes things more fun for everyone.

Until next time. take your meds correctly!

Once in a blue moon

How are you all doing out there in pharmacy land?

Once again, it's been a while since I decided to sit and write some things in here in this space that was supposed to help me deal with the things that were going on.

Obviously, much has changed in the 3 years since I last posted.

My pharmacy manager is the same, but the other pharmacist is different, the previous tech I was working with is gone, and I have two new partners to help me out here.

We also have a third pharmacist here as well as two other locations staffed by new people additionally.

When I said business was booming at the end of my last post, I had no idea how much it was going to explode.

We've gone from an operation that was lucky to hit 100 scripts in a day to routinely doing 300-350 on our busiest days. We've pushed past 4,000 scripts in recent months, a testament to how busy we've become.

But don't worry; the clientele have not changed much since I joined this pharmacy 5 years ago.

Oh, and I no longer work for my other job.

We've changed what pharmacy software we use, lost our courier, had several spats with USPS over the process of mailing scripts out, and have had a few spats with some fellow coworkers when they fail to understand how a pharmacy operates.

Our drug treatment program continues to be a tremendous pain in the ass, even with a new coordinator and constant complaints about the way the pharmacy is treated in the process. We've essentially been reduced to messengers and only when we absolutely put our feet down about dispensing someone their meds to some individuals listen to what we have to say.

But, life is good in the pharmacy. The entirety of the pharmacy staff across all three locations is great. The teamwork is tremendous, and we make difficult days seem pretty easy sometimes.

So while there have been rough stretches, I absolutely cannot complain about this place and the effect it's had on my life.

I can't promise I'll be rolling out posts regularly. The idea is to utilize Microsoft Office's cloud save feature to "jot" down ideas as they come to me while I'm at work or thinking about work, then follow Dr. Grumpy's model of waiting an extended period of time before actually posting the content.

Of course, the best ideas often fail to materialize and right now I'm going through a very tough stretch of time in my own personal life.

But I want to keep this going as it can give you some insight into the day to day operations of a small, independent pharmacy in America.

Or how insane it can be.

Anyway, here's to me actually updating this occasionally and engaging readers in conversations about pharmacy and healthcare in general.

Monday mania

Hi.

I haven't written in a while.

Today was so bizarre that I had to include some of the more memorable moments.

It started with my pharmacist having someone try to follow her in the employee entrance because they thought it was the lobby.  Then, the person's significant other came storming out of their appointment, mad as hell at the doctor.

They apparently were mad because the doctor wouldn't give them a full prescription for their benzo.  In her words:

"I want it filled as fast as possible so I can get out of here.  I'm fucking pissed off at the doctor."

She then proceeded to smoke outside for 25 minutes.

So much for that.

We had another one walk up right after the gate came up asking if we filled her script yet.  She's always doing this even though we haven't had a chance to fill it.

That was followed by one of the busier mornings we've had in a long time, filled with waiters, people wanting transfers, and just nonsense.

One prescriber tried to buzz in 6 times while my pharmacis was on the phone with an insurance company.  He always does stuff like that because he refuses to actually write a script.  He always e-scripts it or calls it in.

So when he can't get through to us the first time, he just keeps trying.

Overal, it's been a bizarre day.

Sorry for the lack of posts, but it's actually been pretty busy around here.  Business is booming.

I'm updating soon...I promise

I haven't posted in here in a while.  To make a long story short, the new part-time pharmacist hasn't picked up on a damn thing in the four-plus months since they've been working there, a nurse practicioner who thinks giving everyone Gabapentin is the only way to treat anxiety, and the other tech STILL can't get to work on time even though they've been warned multiple times.

In short, it's been an adventure.

I know I should be posting regularly, but it just hasn't been easy to find time to get the posts up, plus I usually am just trying to forget about the shit that goes on from time to time with the aggravating people.

In the coming month though there should be a post about the Suboxone program that has been going on since last fall to mixed results, posts about the adventures we've had with the part-time pharmacist, and just random pharmacy posts about general pharmacy topics.

So stay tuned.

And lay off the Xanax already you crackheads.

Oh, and we can't forget the joyous inventory we just had, which was uniquely frustrating, which is saying something considering the inventory experiences I've had since the pharmacy opened.

It must be the shirt

Mrs. Subtle: You are so fucking sexy in that red shirt you're wearing.

MPT: *crickets*

*click*

Yes, it was subtle.  A few moments later, the same person called again, this time the other tech answered.  The woman asked about me again, but then proceeded to tell the tech what she would do if I were single.

She was told not to call again.

This on the heels of a client who owed money, insulted everyone in the pharmacy, and showed up demanding an apology today.

Yes, it's been an odd day.

Needless to say, even if I wasn't in a happy relationship, I wouldn't give the solicitation a second thought seeing as the clients here are mentally unstable.

So thanks, but no thanks.

Hiding Mental Illness

Mental illness is a funny thing.

I've seen any number of people come in here who look like normal people.  They talk friendly enough, and seem like they don't have much of an issue.  In fact, in looking at them, they don't appear to have a reason to be coming here.

When you look in their note review however, the story is drastically different.

Some have dependency issues but keep them fairly well-hidden.  Others have rage issues.  Some are paranoid and think everyone is out to get them.  And some do really hear voices telling them to hurt themselves.

The trick for some is to appear normal out in public.  These are the people you see walking around in the mall, looking like they are the happiest people in the world.  The people you see sitting in a restaurant with their significant other, having a lovely little conversation.

Seem blissful don't they?

Chances are, looks are truly deceiving.  Over the last few months, I've taken the time to look at various people's notes to get an idea of what kind of client they are and to see if it's possible to tell what their issue is just from how they appear when they sit in the waiting area.

Granted, some are obvious.  They walk around in circles aimlessly, have full-blown conversations with themselves, go from happy to angry in the time it takes to blink, and have panic attacks out of the blue.  In some cases, it is easy to tell who has an issue and who doesn't.

One client who was sitting in here looked calm and well-kept.  When I looked in their history, I saw a history of paranoia along with a poor relationship with both their mother, brother, and 18 year-old child.  The client was afraid that their family was going to turn their child against them if things continued the way they were going.

Another note talked about someone who was convinced that their significant other was cheating on them while working at a bar.  In the course of the relationship, there had been several fights, most of them ending with fisticuffs and the possibility of charges being brought.

What it shows is that some can be completely out of whack, out of touch with reality, or have some kind of serious mental issue, but when out in a public setting, can appear to have no problmes whatsoever.

There really isn't much depth to this entry though.  It was just something I noticed and felt like posting since I hadn't written in a while.

To follow up my last post where I talk about growth, the pharmacy has continued to grow month to month, although we seem to have consistent issues with whoever the part-time pharmacist is here.

The first one is now the full-time pharmacist, the last one was fresh out of school and apparently this wasn't what he was looking for, and the current one seems to have issues remembering things and understanding what we're telling her.

Oh, and there's the issue of her not completing her CE in time.

I guess 3 years isn't enough time for some.

holy moly

It's been a minute since I wrote in here.

It isn't for lack of material.  Anyone who works in a pharmacy knows there isn't a lack of material, ever.

In the last few months we've had our share of WTF moments.

Some of it is relationship-based.  I am the type who'd rather spend time with their significant other rather than sit in front of a keyboard.  Some of it is related to my computer going down the toilet a couple months ago.  Some of it is being busier at work the last couple of months.

Yes, the little independent pharmacy where I reside has grown significantly in the last few months.

I'm convinced some of it is just because of the simple change that took place in late August.  My previous head pharmacist, well she meant well, but she wasn't able to provide the type of leadership and stability that this little operation needed.  In steps our current head pharmacist, and things are much more organized, much more structured.

They're just much, much better.

Of course, now the challenge becomes trying to break our newbie of some of the things he learned in pharmacy school.  He has yet to completely understand that what they teach and what actually goes on are often two very different things.

In short, he's intelligent, but he lacks what we know as pharmacy common sense.

In the short time he's been here, he's questioned whether an allergy issue has been raised or not on a medication that the patient had been taking for months, questioned a dose that someone else had been on for over a year, and pretty much anything else he sees that goes beyond what is typically recommended.

This would be fine and all except we warned him he'd see things that aren't common or go beyond what is normally prescribed.  We told him that he would have to adapt on the fly.  He assured us he had retail experience and that he would be able to adjust.

I could spend the next several paragraphs detailing how opposite everything has been from what we thought we were getting, but frankly, I've vented enough about him as is.  What I do know is the crap needs to stop soon before something bad happens.  I understand wanting to follow proper procedures and all, but real life rarely follows procedure.  You can be the smartest person in the world, but still be a bad pharmacist.

**Sidebar**

I worked with a girl for a few years as a tech who decided she wanted to be a pharmacist.  Intelligence was never her issue, but she gave true meaning to all the blonde stereotypes you've heard over the years.  She's pretty much about the glitz and has pretty much been the type of person who annoys me greatly.  Anything her company wants its pharmacies to do, she follows blindly, no matter what.  Every program, every phone call, everything.  As a result, she's moving up the ladder fairly quickly, but she'd drive me crazy.  I'm glad that I don't work in her store, well, the store she used to have as she's moving on.

In short, she's the type who knows a lot, but doesn't apply common sense to the equation.  I'm happy she's made it where she has, but maybe it's just me, but she was awfully annoying to work with the few times she filled in at my store.

**End**

The main point is pharmacy isn't just about what interacts with what and is the dose too high.  It's about what works for the patient within the legal limits.

The thing I've seen sometimes is a pharmacist thinking they're smarter than the doctor.  Look, I'll take a pharmacist's side in a lot of things, and there are some doctors where I do wonder, but generally, the doctor knows what they're doing.  It's one thing to ask why something is being prescribed, a different thing if you're trying to tell the doctor what they should do.

All I'm saying is it makes me wonder what they're teaching in pharmacy school more than ever.  Are they being realistic?  Or are they presenting students with what an ideal pharmacy operates like, rather than what reality dictates?

It seems to me that it isn't an accurate representation of what a normal pharmacy looks like.

In any case, one of the more interesting things to watch is Walgreens being involved with another spat with an insurance company, this time Express Scripts.  Some will remember a few years ago they stopped taking (or were denied depending on the version of the story you received) Medical Mutual (processed by Medco).  Some said Walgreens didn't like the dispensing fee that was offered, while a different story I heard was that Walgreens got caught with its hand in the cookie jar (in other words, improperly billing items) and Medco smacked it.  Hard.

Regardless, the story going around is that Walgreens refused to take the cut that Express Scripts tried to push on them and thus let the contract expire without renewing.  Some are lauding Walgreens for taking a stand against an insurance company, but to me it's a slippery slope.  While insurances do drive me nuts generally (and have notoriously tried to squeeze pharmacies at every turn), it's easy to forget they're trying to make a profit as well as pharmacies (and there's no disputing that the larger retail chains took in a massive profit last year).  So while they make me crazy, they are still a business trying to make money.

In short, there's a lot of concern within the pharmacy industry about reimbursement.  One blog pointed out most major pharmacies make their money off brand name drugs and that the number of big name brand drugs is dwindling quickly.  Very few are left any more and there isn't anything coming down the line to offset all the new generics coming out for the aforementioned big name brand drugs.

Independents tend to get hurt most in situations like this.  They are the ones who get squeezed hardest by insurances just because they don't have the clout that a CVS or Walgreens has.  They can't just sit up and say "we won't take your insurance then" and then cover their ass with the other plans they do take.  If an independent loses a carrier, it's possible to lose a significant chunk of what little business they do have.

It's a slippery slope.

For now, a place like where I work is going to be okay.  A majority of our business comes from people on welfare and right now, aside from Medicaid branching back off again into managed care providers, things are relatively stable.  The spat between Walgreens and Express Scripts is nothing more than something to amuse us when we get bored.

Here, life is relatively good.

Let's hope it stays that way.