THE PROOF IS IN THE PUDDING

As part of the process of renewing one’s annual pharmacist registration (in Ontario at least), it is now necessary to pledge that one has read the Code of Ethics and that one fully understands the Standards of Practice.  This would seem a minimum expectation.  In the language of these documents and videos, as well as in other publications, and continuing education materials which emanate from these regulatory bodies, pharmacy associations and academia, much is made of how pharmacists are now the “medication experts”, and that it is now not only necessary to correctly/accurately dispense medications, it is the legal obligation of the pharmacist to ensure the “therapeutic appropriateness” of the medication taking into account the patient’s allergies, drug interactions, health status, lab results etc.  The pharmacist represents the moment of truth, and saves the day by rescuing the patient from an otherwise preventable error…a lifesaving act in some cases.  Why are there no TV shows about brave life- saving pharmacists?   Grey’s Anatomy move over for Have Spatula, Will Travel.

This is all great stuff in vitro, but I wonder how practical it is in vivo.

Taking it from the top.  The patient visits the physician who, using his/her own expert knowledge, plus a plethora of available testing modalities (lab tests, imaging, etc.), makes a diagnosis.  In the majority of cases the physician prescribes medications of some kind specifying the molecule, strength, directions, repeatability etc.  But, I guess the assumption must be that the physician does not have the required level of expertise in medications; he/she is not the “medication expert” that the pharmacist is, and that the physician is relying on the pharmacist to serve the purpose of ensuring the therapeutic appropriateness of his prescribing.   I wonder how many physicians would agree with this assumption?

Imagine if the aerospace industry was structured this way.  One person designs the plane, another one builds it, and when it is all ready to fly the last person looks and finds all of the problems, fixes them, and prevents catastrophe.  In this analogy the last person is the pharmacist.

In a closed system, like in a hospital, this system might work.  All the medical records, all the tests and images are all there in one place.  As importantly, the patient is fixed in one place and follows directions to the letter from the healthcare team.  Adherence is not a problem.  Head Nurse ensures this, and the hospital pharmacist is in constant touch with all elements of the patient’s medication needs in context, and with all of the other elements of the patient therapy.

Flash forward to the retail pharmacy marketplace.   The patient/customer is constantly barraged with messages to switch pharmacies.  Loyalty points are a big draw.  Then there are discounted dispensing fees.  Shoppers Drug Mart is now advertising on TV that in the interest of patient care and concern, it does not charge the $2.00 co-pay…many prescriptions are free at SDM for eligible patients.  “It’s easy to switch” say Sobeys.  And you know what?  Many patients do switch, and switch many times depending on the incentive, who is giving it, and where it is.

Costco has a dispensing fee of around $4.00.  Many patients have 8 prescriptions or more.  Do the math.  Instead of a $12.00 fee (a saving of $8.00 per Rx), this represents a saving of $64.00.  You bet this patient will switch.  I love going to Costco and invariably I visit the pharmacy.  I am always astonished to see a line- up of patients 8 or 10 people deep, waiting patiently to hand in their Rxs to a pharmacy assistant.  No wonder…look at the savings!

When a patient presents a prescription at a pharmacy counter, the Rx must indicate the patient’s name and address.  Usually also indicated is the DOB and possibly an OHIP number.  If the patient is paying cash, the patient is not obliged to produce any other information if the Rx is not a narcotic or controlled drug, and often the patient chooses not to do so.  The pharmacy assistant asks if there are any drug allergies and that’s about it, as far as compulsory information goes.  Pretty limited.

Let’s say we are talking about one of these really busy Big Box stores doing 600 Rxs per day with one pharmacist (doing a 12 hour shift) and several assistants and maybe one technician.  In the meantime there’s a sign stating “injections, no waiting” and whole families are now waiting for the pharmacist to give them their shots (soon to include a whole bunch more injections, thanks in Ontario to OPA’s successful increase in qualified injections).  The prescription is for an antibiotic and an analgesic.  The pharmacist now needs to determine the “therapeutic appropriateness” of these medications for this patient whom he has never met before, knows nothing about, and frankly the patient is in a real hurry after waiting in line for the last 15 minutes.   Maybe if the pharmacist was Wonder Woman or Superman with super powers this might be possible.

Maybe it’s OK to reach for certain goals in life, even if they are not attainable; the striving is important and performance is kept at its peak.  Maybe it’s OK to use words like “therapeutic appropriateness” if it makes people feel good, and at least people put in the required effort whenever possible.  But let’s not kid ourselves, nor our pharmacy students, that this is how their pharmacy career is going to go.  Leave it to the academics and the other association and regulatory boffos to invent fancy phrases in their ivory towers, but in the real world you have to know what it really takes to stay alive.

I am resigned to receiving a lot of poison pen letters from many starched white coated pharmacists who will profess that I am a nasty, cynical, out of touch fossil.  But the other 95% will breathe a sigh and will be in agreement.

The problem is not the pharmacy profession or the commercial environment that has it by the throat; the problem is in the resignation and delusion that the majority of pharmacists sentence themselves to.

Anyhow, maybe once in a while something really terrific happens, in which case you can send a Valentine.

WHAT DO YOU DO WHEN THE DECK IS STACKED AGAINST YOU?

In a recent blog by Brandon Tenebaum, on the Canadian Healthcare Network, re the qualifications of the next CEO of the Ontario Pharmacists Association, there was a high degree of heated reaction.  The issue began with whether the CEO necessarily needs to be a pharmacist or not, but inevitably became a debate as to the validity of the OPA as an association and whether it is dedicated to the interests of pharmacists, or those of Big Pharmacy Retail (BPR).

Over and over again the OPA is held to task for what it does, or does not do.  I am sure the departure of Dennis Darby, who was a well-intentioned individual, was somewhat precipitated by a good degree of frustration on his part as well as those around him.

Nevertheless it can probably be stated with some validity that the OPA is having problems.  Membership is either static or dropping, and actual pharmacists (not technicians) may represent somewhere close to 50% of potential.  If BPR did not pay for its employee pharmacists’ OPA fees, membership would likely plummet.

It can also be generally stated, that there is a great deal of dissatisfaction on the part of pharmacists with the direction that their profession has taken, especially over the past decade or so. Things seem to be going from bad to worse.

At a time when physicians are burning down the castle because they are not getting huger increases in remuneration (pity the poor physicians struggling on $300,000 per year), pharmacists have had average wage decreases somewhere close to 50%, now at par with hospital technicians.  And pharmacists like to consider themselves professional colleagues with physicians?  More like very distant poor cousins, maybe.

At the same time that pharmacists continue to complain about poor remuneration, abysmal working conditions, and lack of respect from the public and/or their non-pharmacists owned employers, their frustration continues to grow because there does not seem to be any way out.  Weak leadership together with powerful vested interests in place to protect the commercial business model are the prevailing realities.

Institutions like the OPA, the universities/academia, and even worse, the regulatory bodies like the OCP who continue to abandon their obligations, just bury their heads in the sand and hope to survive intact for another day.  They are always busy creating new committees, new programs like PharmDs, regulating technicians, and expanding endless regulations…all mostly designed to ensure self-preservation.

This is a bleak picture and manifests itself through an endless “weeping and gnashing of teeth”.  Cries for unionization never stop, though the reality of this ever happening is close to zero.  “Join the OPA and help rebuild the association”…might make you feel better, but not likely going to change anything.  The dark forces are just too powerful.

Whether it is BPR, the government, or any of the other vested interests, a confused and dissipated profession works in their favour.  Does the government really want to deal with a powerful united OPA?  Does the government really want another headache like the one it currently has going on with the OMA?  I don’t think so.

At times like this it may be helpful to take a little inspiration from a historic figure, who in the face of overwhelming odds, revolutionized a nation…Gandhi.  And Gandhi did it by peaceful means, not one bullet fired by him or his followers.  There are others like Gandhi:  Nelson Mandela, and Martin Luther King Jr., who utilized similar strategies and changed the faces of their nations.

Perhaps the path to change will not come from a new pharmacy association, or a new leader (a messiah) who never comes, or from a sudden change of heart by the powerful vested interests.  Perhaps this change will come through the individual small decisions pharmacists make every day in their practice settings, even if that setting is a 12 by 24 foot cubicle in a discount grocery store.

When given a quota for professional services, don’t meet it.  Do just a couple less.  When asked about the efficacy of Cold-FX, tell the truth is spite of the fact there are 1,000 boxes on the end of the aisle you are standing in.  When the district manager wants to talk to you about some new policy or complaint, keep him/her waiting.  When there’s a line up for injections, keep attending to pharmacy duties until you are free.  Avoid rushing in an attempt to meet so called “performance standards”.  You may not be covered by employment standards legislation, but you are protected by statutory law.

It will be through the thousand small acts of disobedience by thousands of pharmacists simultaneously that control of the profession may slowly begin to slip back from the firm grip of BPR and the other vested interests.  If nothing else, such actions will give you back some self-respect, and may just brighten your day a little.

Remember, prison bars do not a prison make.