Priorities

Patients with Medicare Part D sure don't have good memories. No, they certainly don't remember a long, long time ago, all the way back in 2005, when there was NO DRUG COVERAGE for Medicare patients, and they had to pay out of pocket for everything. I remember little old ladies meticulously writing out their checks for their monthly meds in the $700 to $800 range. Now, these patients have just gotten spoiled. Spoiled, I tell ya!

I had a patient call and ask for the total on her medications. Everything was covered by Part D, except for her Vitamin D 50,000IU. Eight capsules, for a two-month supply, was $15.49. I explained that it wasn't covered under Part D law because it is a vitamin, but that if she is deficient, it was important to her health. Her response? "I ain't paying for THAT! My insurance pays for my meds! If they ain't payin' then I ain't either."

This is awesome. This is where I get to do my job! "Ma'am, did your doctor explain why she prescribed this for you?"

"Yeah, she said my Vitamin D was low."

"Did she explain why it was important for you to get your Vitamin D up?"

"Well, no..."

So I go into the explanation of what Vitamin D does, how it's important for bone health, keeping the immune system healthy, and decreasing risk for some cancers. I tell the patient, "If your lab tests show that your levels are low, I think $15.49 for two months worth of medication would be a good investment for your health."

"Let me think about it..."

When she picked up her prescriptions, she told me, "I thought about what you said...and I'm going to just pay for the Vitamin D."

"I think you have made a good decision. Have a nice day!"

Now I'm not going to pretend that I know what it's like to worry about 16 bucks. I don't. I have been very blessed in that regard. My patients often have to struggle with how to pay for their meds and the light bill. I don't know what my patient had to forgo in order to buy that Vitamin D, but I'm glad I could encourage her to make her health a priority.

I thought I had seen it all...

So I got a phony phone-in prescription the other night. Not so unusual, right? What was it? Vicodin? Xanax? No...this chick was trying to call in her own prescription for...Diflucan! It went like this.

Ms. Itchycooch: "This is ER PA, agent of Private OBGYN, and I need to call in a prescription."

Me: "Ok..." I call shenanigans on this one at the first sentence, but I play along.

IC: "..."

M: "Yes?"

IC: "It's for Ms. Rotten Itchycooch."

M: "Ok, what are we giving her?"

IC: authoritative tone "Diflucan, one dose."

M: "What strength?"

IC: "The one dose pill."

M: "Ok, what strength?"

IC: "The one dose pill. I dunno, it's like 250mg or something like that?"

M: "It's 150mg."

IC: "Yes, yes, of course, it's the 150mg."

I collect the prescriber's phone number and thank the caller. A quick call to the ER, where ER PA works, and I confirm that this is a bullshit Rx.

Ms. Itchycooch walks up to the counter and I do something I have never done in all my 13 years in the pharmacy...I laugh in her face. Rude? Yes. Unprofessional? Absolutely. Wrong? Probably. I said, "I talked to the real ER PA, and she didn't phone in this Rx. You have got to be kidding me with this." She smirked and walked away.

What should I have done? Probably should have been a little nicer, and more helpful, and directed her to an OTC treatment for her issue. I actually feel like I let down a patient in need, but I just get so sick of the bullshit that patients try to pull every day in the pharmacy, and this was the first one that was so clear cut that I could say whatever I wanted to this girl and there was no way anyone could argue that I was wrong. So I guess I took it out on her. Yeah, I feel a little bad about that now.

Anyway, it must not have bothered her that much, because the very next day she showed up at my pharmacy with that same smirk on her face, and a prescription for Diflucan in her hand from the ER. Diflucan 100mg once daily for 10 days. I guess it must have been really bad...

Professional Judgement a.k.a. You Are Not A Robot!

I understand that a lot of drugs have dosages that vary according to various factors, such as weight. But can we please use some professional judgement and round some doses? I saw a Lovenox prescription today for... are you ready? 99.7mg. Yes, that was 99.7mg. For those of you not in the know, Lovenox is an injectable drug that comes in a variety of strengths in prefilled syringes, among those being 80mg, 100mg, and 120mg. Now if we calculate the dose based on weight and we come up with 99.7mg, can we please use our FREAKING BRAINS and round that dose up to 100mg? How the hell is someone going to measure 99.7mg?

Or how about those Amoxicillin doses...I have seen such craziness as 6.13mL. Are you freaking kidding me? I don't think a kid is going to die of an Amoxicillin overdosage if we round it up to 6.2mL, which is a volume that can actually be somewhat accurately measured. That "extra" 0.07mL isn't going to kill anyone.

Prescribers, you are not robots! Use your judgement and try to do things that make some damn sense!

Thank You, Techs!

October 26th, 2010 is National Pharmacy Technician Day! I would like to thank all of the hardworking technicians out there for all that you do to make my job easier. Being a pharmacy technician is often a thankless job. They man the front lines, solving problems before they even come to me. A good technician will take care of as much as they can, letting me focus on being a pharmacist. Techs do not get paid anything near what they are worth, especially with the increased demand placed on them by the cut in hours and flu shot program.

I am very thankful that I have a wonderful partner pharmacist at my new store, but I am even more grateful to have excellent techs. My two daytime "keystone" techs have made a choice to treat their jobs as careers, and they are excellent, with lots of experience, and fabulous customer service skills. My evening techs are mostly pharmacy school interns, and they do a good job of juggling the demands of a rigorous program with the need to work one or two nights a week.

What are you doing to let your techs know how much you appreciate their hard work? I'm bringing Krispy Kreme in the morning :)

Aaaaawwwkward!

So there is this guy who was a very regular customer of mine when I worked overnights. He would come in, I would remember his name, we would chit-chat. He thought he was pretty sexy with his shirt unbuttoned and his leather cowboy hat and ponytail, but our chats were friendly and quite harmless.

Fast-forward a few months later, when I had come off of days and was covering a leave at my old store. He came in, I helped him, and he told me about an injury that his daughter had sustained, hence the reason he was there. There was a question of whether it was more serious than a simple injury, and tests and assessment were to follow. I gave him my good wishes, and he left. A couple of days later, he comes in with his wife, whom I had never met. I see them finish up at the counter, and as they walk away past the consultation window, I say, "Hey, how is your daughter?" Wife looks at me, her eyes wide, then looks at her husband and her eyes narrow. Ooookay. He mumbles, "She's fine," and they walk off.

Um, I don't know what kind of extracurricular activities of his that she was used to dealing with, but I most certainly was NOT one of them...just your friendly neighborhood pharmacist. He came in on my shift a couple times after that, and out of extreme awkwardness, I always made sure I was way too busy to even make eye contact with him. Thank goodness I have switched stores and don't have to deal with that again.

"I Hope You Feel Better"

It was about 3 a.m. A young woman in her twenties and her concerned boyfriend presented prescriptions for Keflex and Percocet to be filled. Her right hand was heavily bandaged. She was crying, and the boyfriend was very quiet and looked extremely serious and upset. I filled the prescriptions quickly, and after I rung them out, I made a horrible mistake. She was still crying, and the boyfriend just grunted, "Thank you," when I looked at her with concern and said, "I hope you feel better."

At this point, her face fills with rage, she waves her bandaged hand in my face and screams, "Well, I DON'T HAVE A FUCKING FINGER!!!"

She stormed out and the boyfriend quickly followed, and I just stood there, shocked. I then realized how callous and glib my words must have seemed to someone whose life will never be the same after losing a finger. I felt absolutely terrible for making her difficult day even worse. And I realized that expressing my wish for her to feel better was only to make myself feel better.

I did learn from that encounter, and I try to read people a bit better before offering my wishes, and I have learned that in a serious situation, a simple, "Take care," voiced with concern works much better. And the folks that want to talk about why they went to the ER, or what kind of phlegm they are hacking up are more than happy to share.

Fear of needles...

I walk out to the immunization area to greet my next flu shot patient. She sits nervously as I introduce myself to her. She is wearing a sleeveless shirt (thank you!) and I can see several well-done tattoos on each arm. As I'm cleaning the area on her left arm with an alcohol swab, she turns her face and clenches her eyes shut.

"Are you ok?"

"I'm terrified of needles!"

Uhhhhhh....ok. I guess her tattoos were done with ink pens.

"But you have all these gorgeous tattoos! That one of the praying hands on your right arm is beautiful...tell me about that one!"

She looks at it, her head turned away from me, and starts to tell me about how she and her daughter went together to get tats...yadda yadda yadda, and I quickly stick her, discard the syringe in the sharps container and start applying a bandage. She looks at me and says, "Did you give me my flu shot already? I didn't even feel it!"

Damn you, Purdue Pharmaceuticals!

Dear Purdue Pharmaceuticals,

I appreciate the fact that you reformulated your blockbuster pain medication, Oxycontin, to make it more difficult to abuse. The new tablets are hard, will not dissolve, and cannot be crushed. Therefore, they can only be swallowed whole, not injected or snorted, the way the product was intended.

However, you made one mistake. You changed the markings on the tablet. Instead of "OC" they now say "OP." You cannot imagine the problems this has caused me. I had a woman yesterday come in to get her routine prescription of sixty tablets of Oxycontin 80mg. I explained when she picked it up that we only had the reformulated tablets. I explained the purpose of the reformulation, and told her the markings were different. I assured her that if they were used properly they would still be effective for her pain. She appeared to have no problem with this, and we proceeded with the $700 sale. Thirty minutes later, she wants a refund because the markings are different. You see, they have now lost their street value, and she won't be able to make the $6000 she could have sold them for.

On second thought, you have achieved your goal, while annoying me in the process. I guess I will take the annoyance in exchange for making it harder for people to abuse drugs while keeping pain meds avalable to those with legitimate need.

Sincerely,
Pharmgirl

Black does not equal "ghetto"

Last week, I started at my new full time "home" pharmacy...no more floating! When I shared the news of my new location with various coworkers, they responded with comments about the "'hood" and the "ghetto." Let me explain something...just because a neighborhood is predominantly black does not mean it is 'hood, ghetto, crime-ridden, or full of blight. I would say 90% of patients I serve there are black. Many walk to the store, and most are on Medicaid. The majority are older, and have been living in the area for years and years. They know my pharmacy manager by name, and he asks about their kids or their parents. The first day I was there, several patients introduced themselves to me, shook my hand, and welcomed me to the store. The younger folks come in with questions about medical issues with their kids, and they are very respectful, and appreciative of my advice.

Let me say that I am a white girl, born and raised in the Midwest. I am now living in a Southern city that isn't aware that the Civil War has ended. There is a huge black population here, and still a lot of racism, which is something I'm not used to. There are cultural differences between myself and my new patients, and I am getting used to understanding that a "pump" is an inhaler for asthma, and that crazy high dose of narcotics is probably treating a sickle cell patient.

I would rather work in the "'hood" 20 minutes away than the store a mile from my house, where the clientele is rich white people. They can be demanding, entitled, rude, and disrespectful. The pharmacists I know who hate working in black neighborhoods probably have difficulties because they don't treat the patients with respect. The Golden Rule is the key. I think I'm going to like my new home.

I eHate eRx's...

ERx's. Brilliant idea. Horrible execution. I got one with these directions.

"Take one tablet daily. 1/2 tab qd."

Time to make a phone call. After giving the "nurse" the patient's information and explaining that I have a question about the directions on the eRx that was just sent over to us, she locates the order in her system and proceeds to tell me, in quite the authoritative tone, "It says, 'take one tablet daily, one-half tab qd.'"

Oh ok, that clarifies things. Thank God this unparalleled genius answered the phone because I FORGOT HOW TO FUCKING READ!

Me: "Yes, that is what it says. So which is it?"

"Nurse": "Take one tablet daily, one-half tablet daily."

**crickets chirping**

"N": "Well, I think the doctor means one-half tablet daily."

M: "Ok, do we think? Or do we know?"

"N": "I'm pretty sure that's what he means."

M: "I don't want to guess, but if you are ok with guessing, what's your first and last name?"

**pause**

"N": "What'syournumberI'llcallyouback."

(For the record, I would have insisted she check with the prescriber before I filled the Rx.)

Tip of the Day

If you are being treated by one doctor with Subutex or Suboxone for "pain" and you go to Doc-in-the-Box for muscle relaxers and narcotics, take those prescriptions to a different chain. Because even though you assure me that you discussed your current medications with Doc, I am going to call and make sure he is aware that you are being treated by Dr. Drew with Subutex. Then don't get mad and yell at me for getting up in your "business," because if you had been smart enough to go to a different chain, you could have gotten your narcs and saved me from an adrenaline-induced splitting headache that I have suffered for the rest of the fucking day.

Worker's Comp!!!

I used to work overnights, and we would get some...uh...interesting people in there at the wee hours of the morning. At 4am, this beautiful girl, probably in her twenties, came in and wanted a recommendation for back pain. She was wearing a Pink jogging suit, had tons of makeup on, false eyelashes, and I think I saw a little glitter on her. Her shiny brunette hair was down to her butt, and she had huge boobs. She was gorgeous. (Aside: I'm not attracted to women, but I can objectively say that she was a pretty little thing.)

So I walked with her over to the pain relievers, and began my questions. Taking any meds currently? No, just birth control. Any chronic health conditions or history of ulcers? No. So how did it happen?

Wait for it...

Wait for it...

"I was doing the splits at work and I think I pulled something in my back."

Of course, I remained professional, and helped her choose an anti-inflammatory. I don't remember if she paid me all in singles, but if she did, I know I hit the hand sanitizer pretty heavy after she left.

Please Dress Professionally

Today we had CPR class at the district office. I am now able to give immunizations again, a fact for which I'm sure I will be sorry in a month when we start up with the flu extravaganza. The "rule" is that we are to dress professionally at the district office, even though we don't come into contact with any customers. Some of us came dressed up, and some came in jeans or shorts. I don't have a problem with dressing up, but we are doing skills assessment on each other, as well as mannequins, which means getting down on the floor. In my dress pants and shoes. And the shirt I chose to wear was the wrong choice, because everyone got a free show while I was bent over doing chest compressions on the mannequin. Oops. My partner was wearing a dress, so I spent more effort keeping her modest than making sure I could turn her over if she were unconscious. And since they haven't vacuumed the carpet since the office was opened, I left there covered in lint, dirt, and God knows what else all over my black pants. Lesson learned. I'm wearing jeans next time.

Judging Patients

Anyone else have trouble not scrutinizing a patient's hairline when he picks up Propecia? How about checking the size of the ass on that girl picking up Phentermine? She is usually smaller than me...maybe because she is taking weight loss drugs.

Light It Up and Take a Puff

I knicked this one from www.notalwaysright.com, a funny site about customer service encounters...occasionally they have pharmacy-related stories...


Don’t Hold Your Breath For This One
Pharmacy Boulder, CO, USA

(I am counseling a patient on using an inhaler.)

Me: “Do you know how to use an inhaler, sir?”

Patient: “Nope, never used one.”

Me: “Okay, you’ll want to begin inhaling, and then depress the inhaler as you are breathing in. Then, hold your breath for as long as possible to allow the medication to be absorbed into your lungs.”

Patient: “Oh, sort of like smoking pot…”


Actually, the patient is spot-on. I may have to incorporate this into my inhaler counseling...

Lord Help Me

Got a call from a lady today whose doctor had to change her from Diovan 160mg to Benicar for insurance reasons. Prescriber started her on Benicar 20mg, which I thought was pretty reasonable. She was concerned that it wasn't equivalent. We discussed the situation for a while, and I thought she got it, until she said, "So I need to take eight of these for it to work the same as my Diovan?"

OK, let's go over this again...

On the upside, at least the lady can multiply...

The Readerless Blog

I am readerless. I am the only person who reads this blog. I haven't promoted it to coworkers or on my Facebook because I don't necessarily want people to know that it is me writing it. I want to feel free to write about my coworkers as well, and I don't want to hurt anyone's feelings. My two best friends know about it, God bless them, but I don't think they read it either. Someone please leave me a snarky comment and make my day :)

Why I Love our Patient Voicemail

At my company, we have a voicemail function that is most often used by prescribers or their agents to leave new prescriptions or refill authorizations. We also have a voicemail function for for patients to leave messages. This idea apparently brings out the stupid in people. Whenever the little icon pops up on my screen that there is a new patient voicemail, I just cringe in anticipation of what I am about to hear.

Usually, it is from some poor clueless old lady who got caught in the phone loop. Goes like this...

*sound of phone buttons being pushed* "What is this...this thing never works..." *touchtone buttons again* "Oh hell...Ed...I can't get this thing to work..." *click*

My favorite is the person who calls and wants to know if their prescription is ready, or has a complicated question they need answered. Really, why are you leaving a message for that? It invariably happens when it's been dead and the phone hasn't rung for 45 minutes, so it's not like they couldn't get through to speak to someone. So they leave me a message to call them back, and when I do, I get their voicemail. WTF, people?!

If I'm lucky, it's someone who is requesting a refill and I can take care of it without playing endless phone tag with the patient. That only happens once a month or so...

Hyphenated Names

Ok, I’m just going to come right out and say it…I hate these uppity bitches with their hyphenated names. And it’s not so much the annoying Feminazi aspect of it…it’s because of scenarios like this…

Me: “Hi, how can I help you today?”

Mrs. Uppity-Bitch: “Yes, I’m picking up a prescription for Bitch”

Me: “Ok, let me see here…I am not seeing anything under that name…Was it a refill? Or did you drop off a new piece of paper prescription?”

Mrs. U-B: *with attitude* “I gave it to her right over there two hours ago and she said it would be ready in 15 minutes”
*huff*puff*

Me: “How do you spell the last name again?”

Mrs. U-B: *yelling* “B-I-T-C-H, just like it sounds”

Me: “Ok, let me dig a bit here”

Mrs. U-B: “Every time I come here, there is some kind of problem…you people can’t ever get my stuff taken care of on time. You are always losing my prescriptions”

Me: “Is there any other name it could be under?”

Mrs. U-B: “It’s under first name 'Raging,' last name 'Bitch.' That is my name. I don’t see what the problem is here.”

Me: “Ok, what’s the date of birth?”

Mrs. U-B: “6/6/60”

Me: “Could it possibly be under Raging Uppity-Bitch?”

Mrs. U-B: “Yes that’s me.”

Me: *sigh, finishes transaction* “Ok, so should we change your name from Raging Uppity-Bitch to Raging Bitch?”

Mrs. U-B: *irritated* “No, my name is Uppity-Bitch. It’s hyphenated.”

Me: *goes into the stockroom and hangs herself from the top shelves*

So, the moral of the story is…Bitches with hyphenated names should decide if they are going to be hyphenated or not. Or at least be halfway intelligent enough to realize that when we have trouble finding something using your name, tell us about the hyphenation. If you want a hyphenated name, use your hyphenated name ALL THE FUCKING TIME! Or I will hang myself in the stockroom. The end.

Why I Hate $4 Prescriptions

Yeah, they steal my business. Yeah, they cheapen my profession. Blah, blah, blah. The real reason I hate them is that they undermine patient safety by promoting the use of multiple pharmacies. I got a call from a woman whose husband was "out of it" and "running into the walls." She wanted to know if the new antibiotic he had started could cause that. I start asking questions. He gets all his prescriptions with us, but he decided to get this new prescription for an antibiotic filled at a grocery store chain that charged him only $4. I check his profile. He happens to be on Tegretol, an anti-seizure medication. He has been stable on it for several years. The antibiotic that was prescribed? Erythromycin. Which dramatically reduces his body's ability to process the Tegretol, essentially causing a Tegretol overdose. Which causes things like...you guessed it...acting "out of it" and having difficulty with coordination...AKA "running into walls." Even if this patient had filled this at another pharmacy and used his insurance, the interaction would likely have been caught through a message from his insurance company. But the $4 prescriptions are promoted as the "usual and customary" price, and are given to everyone without billing insurance. Erythromycin is cheap as hell, and he probably wouldn't have paid more than $10 for it anyway...was it worth it?



I wonder sometimes how the pharmacists who work for these $4 companies feel? Does it change their practice? Are they more careful about asking what other meds the patient may be taking? Or is it "not my problem"? I would love to hear your point of view. I can only hope that the prescriber inquired about other medications the patient was taking, but that doesn't guarantee that the interaction would have been caught. I advised that the patient should stop the antibiotic and contact his doctor. And to call and ask us if there would be an interaction if they chose to go the $4 route again. People, I don't care if you fill it at my pharmacy or not...I just want you to be safe.

Does This Look Like Athlete's Foot to You?

As a pharmacist, at least once a year, usually on the most sweltering day of the summer, I have the unique pleasure of having someone standing before my consultation window, bracing their weight on the counter as they wiggle out of their shoe, bending down to remove their sock, then placing their nasty, sweaty, naked-ass foot RIGHT ON THE COUNTER and saying, in a Deliverance-esque accent..."Does this look like athelete's foot to you?" And believe me, it does, and I don't need to see it. I can help you just fine by asking you about your symptoms and recommending an OTC treatment. I don't need the fungus-among-us cultivating on my counter. I am armed with Isopropyl Alcohol and Lysol, and I am just waiting for your ass to hurry up and pay for that Lamisil so I can sanitize that counter all the way into next week. I actually prefer the ample bosomed ladies lifting up eight pounds of braless tit to show me the fungal rash they've got going on under there. Why? BECAUSE IT DOESN'T TOUCH MY COUNTER!

I Just Put Pills in a Bottle

Welcome to my blog. I hope to share some funny retail pharmacy stories, as well as educate the public a little bit about what pharmacists really do. I know a lot of people think that all we do is put pills in a bottle, and I will often get interrupted with questions like, "Hey, where are the shoelaces?" My first story will be the educational sort...

Your pharmacist is a safety net against erroneous or inappropriate prescribing from your doctor. I will not doctor-bash on this blog, as I have much respect for physicians, but they are human. They make mistakes. Heck, we all do. My "catch" last week was a new prescription for Levothyroxine, written as "Synthroid 0.25mg." This is a drug used to replace thyroid hormone when your body isn't making enough of it. I checked the patient's profile, as I always do with a new one, because Levothyroxine is one of those drugs that some patients prefer to be dispensed as the brand. Patients can be very sensitive to changes in manufacturers because the drug is dosed in micrograms, which are thousandths of milligrams. So any minute change in the amount absorbed into the patient's system can result in clinical changes in efficacy. Therefore, I like to check. This patient had never had this drug before. Now, when starting Levothyroxine, it is usually dosed low and adjusted up to the patient's response. We are talking 25 to 50 micrograms here. My gut instinct told me that the doctor meant 0.025mg (25 micrograms), NOT 0.25mg (250 micrograms)! Doctor verified that he intended to write for 0.025mg, and the prescription was dispensed with the correct and appropriate dose. Now let me point out here that 250 micrograms CAN BE an appropriate dose...for someone who has been on the drug and needed a higher dose for the proper response. But it would have a new patient climbing the walls. It's knowing those little nuances that make us an integral and vital part of the health care team. And I can tell you where the shoelaces are...