Cannabis, Cannabis, Cannabis: enough already. October 15, 2018

 

This stuff has been around for 5000 years at least.  It’s called grass, or weed, or pot, or hash or dope for a reason; it makes people dopey.  Some people like feeling dopey and that’s OK as long as they don’t harm anyone but themselves.  The latest move to decriminalize cannabis is an overdue idea as it is widely used for so called ‘recreational’ reasons.  To some people, feeling stoned or dopey is their form of recreation.  Apparently as many as 4 million Canadians use pot regularly, in spite of its illegal status.

While anecdote is not evidence, there are some documented experiences of patients using so called ‘medical cannabis’, especially in treating chronic pain, nausea during cancer treatment, and some forms of epilepsy gaining some benefit, largely from the cannabinoid component in weed.  This is a teeny fraction of cannabis users (about 120,000) and for them the term medical marijuana may not be an oxymoron.

For everyone else, the term medical marijuana is an inside joke.  It is ‘medical’ if the person says it is, kind of like ‘medical bourbon’.  It’s all in the eyes of the beholder.  The CMA remains doubtful about the usefulness and/or efficacy of medical cannabis.  Only 10% of physicians will even touch the stuff.  So why does pharmacy keep talking about it?  The main reason is as always money, big money.

In reality, what most ‘users’ are after is the THC; the “good stuff” that makes you stoned.  The use/harm of cannabis is probably no worse or no better than the use of alcohol, another toxin widely used by people for ‘recreational purposes’.  Way too much money, police resources, courts and prisons and way too many ruined lives have been wasted since the prohibition of cannabis in the 1930s.  Criminalizing cannabis for political and misinformed reasons, has been one of the largest examples of wasted taxpayers’ money in history.

Cannabis legalization is coming to Canada on Oct. 17, finally legalizing the stuff.    Plenty of enterprises across the country, from growers to retailers to the tech and tourism sectors, to stock brokers and of course drug stores are all chomping at the bit to reap a windfall from legal marijuana. But there remain difficult questions about cannabis use in the workplace, in homes, & while driving or operating dangerous machinery.  How many lives may be lost on the roads before someone realizes that maybe this whole thing was rushed for political reasons?  It’s fine if people like being stoned while listening to Pink Floyd in their own home or at a party.  It’s another thing if a stoned truck driver hauling 100 tons of steel plows into a stream of stopped vehicles on a highway because of his reduced reaction time.

Globe & Mail October 15, 2018                                                                                              Cannabis makes it harder to identify and react to driving distractions that can result in crashes, a clinical trial at McGill University found. About 80 per cent of the participants, aged 18 to 24, also reported feeling less safe to drive after using the drug, including five hours later.

One thing for sure, lots of people are going to make many tens of millions of dollars on cannabis.  The stock market thrives on hype like this.  It reminds one of the heady days of high tech.  As always, the usual suckers are going to get burned badly.

So what is Pharmacy’s official position on cannabis?  To say it is total confusion would be an understatement.  Note that at this point in time, pharmacies are not even part of the distribution channel for either ‘medical marijuana’ or the recreational stuff.  Pharmacies are presently not in the loop.

But as pharmacy struggles to find a place in this Wild West cannabis landscape, it is torn between its professional obligations , and the dominating reality that pharmacy is largely now controlled by corporate interests (BPR) in search of profits from the sale of any products, even the many useless or even harmful products found in many drug stores today.

To illustrate this embarrassment to pharmacy, this week an email was sent out by the OPA (Ontario Pharmacists Association) re a deputation made on October 11th before the Standing Committee on Social Policy at Queens Park.  The delegation consisted of the Chief Pharmacy Officer and the Vice Chair of the OPA.  In this document the OPA clearly states that the 10,000 pharmacist members represented by OPA OPPOSE the sale of recreational cannabis products in pharmacies.  The deputation largely advocates that pharmacists be allowed to dispense medical marijuana; the document also alleges that cannabis is just another drug that pharmacists can and should be available to consult on.

OPA deputation October 11, 2018                                                                                                   “In the absence of an amendment we would ask the Ontario government to seek formal approval of the Federal government for provincial authority to task pharmacists with the dispensing of medicinal cannabis pursuant to a medical order

At the same time, we want to make it absolutely clear that the members of the OPA   DO NOT want to distribute recreational cannabis”

Of course everyone knows that this is NOT where the real money is.

In contrast to this position, the NPAC (Neighbourhood Pharmacy Association of Canada (hitherto known as the Canadian Association of Chain Drug Stores) made a submission recently to the government of British Columbia (as well as to other provincial governments) re cannabis regulation.  In this document, argument is presented that pharmacists should be part of the distribution channel for medical marijuana for the same reasons as the OPA submission did.  The big difference in this NPAC document is that the NPAC clearly states that its members (Big Pharmacy Retail/BPR and all the assorted pharmacy brands/banners) DO want to sell recreational marijuana, and a spurious argument is outlined to support the position that pharmacists know how to handle tricky goods.  So does the LCBO.

Recent submission by NPAC to BC government                                                                         “Our members strongly believe that the Access to Cannabis for Medical Purposes Regulations should be amended so that pharmacists can be authorized to distribute and dispense medical cannabis.  Pharmacies play a significant role in managing the distribution of controlled products and they would be committed to work with all levels of government to ensure that recreational cannabis products are also sold legally in pharmacies”

And of course everyone knows that this IS where the real money is.

The large majority of the 10,000 pharmacist members of the OPA work for NPAC companies.  What is their individual position?  Who really represents them?  What about individual choice?  Do pharmacists support their provincial advocacy body’s position or their NPAC employer?  Some may not want to get involved with cannabis at all?  Will they be granted this choice by their NPAC backed employers?

Recognizing this contradiction, does anyone know what most pharmacists really think about being involved in the sale of cannabis products?  The non-pharmacist pharmacy owners (BPR) know what they want; they see a great opportunity to create traffic and boost profits at the retail level and there is no way BPR wants to be left behind.

Additionally, what is the position of the Pharmacy Regulatory Bodies?  The OCP (Ontario College of Pharmacists) has declared its position.  As part of its ‘Opioid Strategy’, it will now require all Ontario pharmacists to complete formal cannabis education as a condition for licensure by the year 2020.  Why isn’t there compulsory education for other drugs?  What makes cannabis so special?  Is this just more politics and an attempt at appearing proactive?   Isn’t this a case of overreaching of authority?  Would this OCP licensing requirement withstand a legal challenge?

In BC only 8% of registered pharmacists voted in recent council elections.  The BC College of Pharmacists is puzzled as to why.  Wonder what the percentage is in Ontario.

All this for a substance which may never actually come under the control of pharmacists, ‘medicinal’ or recreational.  There is a good possibility that pharmacy may be shut out altogether…not even the medical stuff, let alone the recreational stuff.

All this hype acts to give a 5,000 year old herbal substance, known as cannabis a heightened position within society that it simply does not deserve.  In the final analysis cannabis is just dope by another name.  Enjoy it if it’s your thing, but remember it still stinks, turns your hair yellow, probably does nothing for your libido, and makes you slur your words…so please don’t glorify it

Those pharmacists who consider themselves to be ‘conscientious objectors’ when it comes to cannabis in any form, must retain the right to just say no.

 

 

 

 

 

THE PHARMACY PROFESSION & THE EVENT HORIZON September 20, 2018

You know the pharmacy profession’s future is looking somewhat dim when people continue to proselytize that you should look at the cup as half full, or to put on your rose coloured glasses, or to examine your feelings and start thinking positively.  The big put is to “just get involved” in your association, or latest committee, or attend a conference, or seek representation on your regulatory body.  All this to suggest that if you just keep moving, turn on and tune out, it will all go away somehow.

Maybe.  And then maybe not.

The past reactions to a few blogs on the Canadian Healthcare Network (especially the comments from readers both young and old) have been especially angry and despondent re the profession of pharmacy and what it has degraded into.  But this did not just happen recently.  This was a gradual process which started exactly 64 years ago when the 1954 Pharmacy Charter was enacted.

Think of this date 1954 as an ‘Event Horizon”.  An event horizon is that special place in space where objects, as they are sucked towards a black hole, cross a point, and once they cross it can never turn back.

The 1954 Pharmacy Charter recognized the looming danger approaching by the entry of big business interests into pharmacy.   From that date forward all pharmacies were to be owned and/or controlled by pharmacists, and corporations had to have a majority of directors as pharmacists.  Great idea, except for the ‘grandfather clause’ stating that all existing pharmacies (pre-1954) were exempt from this provision, and could be sold to anyone, pharmacist or not.  From this single grandfather clause provision, motivated by the greed of those pharmacists involved and in power at that time, today we are rewarded with Big Pharmacy Retail (BPR) which has taken over the profession.  Even the provincial regulatory bodies quake in their boots in the presence of BPR.

Fortunes were made selling a single pre 1954 existing pharmacy to a grocery chain or big box merchandiser etc.   From that single charter purchase, a non-pharmacist retailer could open hundreds of locations across the country to the point where today BPR controls 85% of pharmacy across the country.  With this kind of clout, BPR can exercise the Golden Rule: ‘He who holds the gold makes the rules’

It was pharmacists who allowed this to happen.  It is pharmacists today, ensconced in the multitude of pharmacy associations national & provincial, regulatory bodies, and academic institutions, which continue to sustain the status quo and to gain succour feeding off the existing system.  Pharmacists did this to themselves and continue to put personal gain above the interests of the profession.  Hence professional fee discounting, fierce retail competition and plummeting compensation.  A race to the bottom, and no end in sight.

What to do?  The event horizon analogy, dictates that there is little one can do except to get sucked into the vortex.

In fact, there is much that can still be done in spite of the consequences of the mistakes that were made in the past.  The first and most important thing is to refuse to accept the status quo.  Radical thinking and disruptive actions are required.

Over and over, ‘pharmacy advocates’ come up with weird ideas and initiatives which deny the reality that the profession of pharmacy is not controlled by individual pharmacists; pharmacy is controlled by BPR.  BPR are not bad guys, they just have a different agenda from pharmacy professionals and the two often have diametrically different mandates.

First thing.  Severely limit the number of graduates coming out of pharmacy schools across Canada.  Some schools should be shuttered.  How much worse must the present pharmacy reality be for recently graduated PharmDs with six years of education, $150,000 in debt which they can never pay off and working in a 10’ by 20’ cubicle in a grocery store?  The professors and deans will squeal like crazy of course.

Second, shut the door tightly to any further foreign trained pharmacists.  Zero.  No more International Pharmacy Graduates get licenses.

These two actions will begin to tilt the supply and demand curve back towards pharmacists and away from BPR as retail employers.  It will take 10 years to have an effect.  BPR won’t like this as it was BPR who encouraged opening the floodgates to international graduates for good reason, to depress wages, and it worked big time.   Tell the IPGs working today in Toronto for $30 an hour with no tech support that immigrating to Canada was a great idea.

Third, encourage all existing pharmacy students to parlay their degrees into new directions, not necessarily retail pharmacy which is a dead end professionally which will destroy their souls within six months of graduation.  Law, business degrees, politics, education, anything but not the black hole vortex of retail pharmacy controlled by non-pharmacists totally consumed with commercial interests.

Fourth, put pressure on the regulatory bodies to tackle the real issues confronting pharmacists today, those which are having a negative effect on the public interest; tackling things like fee discounting, unlawful rebates, performance quotas, dangerous working conditions, etc.  There is much that these regulatory bodies could do if they had the guts to do it.  Requiring mandatory cannabis education to qualify for licensure (while both medical and recreational cannabis may never be sold in a pharmacy) is a good example of wrong-headed focus.

Fifth, inundate the so called pharmacy associations, with letters, phone calls & emails to turn their attention towards the interests of individual pharmacist practitioners, and less to the interests of pharmacy businesses large & small which employ these pharmacists as essentially retail employees.   Are they ‘pharmacist associations’ or are they ‘pharmacy associations’?

Agreed, some of these suggestions may never come to fruition, but at least they speak to developing the right attitude, an attitude of not complacently accepting the status quo and developing a willingness to do anything to avoid the despair and complacency prevalent today.   Take action against the realities facing pharmacy today, and avoid delusional Pollyanna thinking wherever it comes from.

Naval gazing, denial, and especially false rosy outlooks are never going to cut it.

‘PHARMACY’….WHERE’S THE MONEY?

If you asked anyone (in any way connected to pharmacy) about the financial health of pharmacy today, the response would be largely by way of lamentation, & weeping and gnashing of teeth.

Government cut backs, never ending reductions in drug costs, elimination of ‘professional allowances’, depressed wages, unemployment, and it goes on and on.  Not a pretty picture.

But is this an accurate picture really?  Well it all depends on what you define as ‘pharmacy’.

I have written before about the difference between a pharmacy and a pharmacist.  The two are so different with different goals and objectives that they hardly share a common genesis.

A pharmacist is an individual who practices the profession of pharmacy, drawing upon the education he/she received, and in adherence with the regulations as set out by his/her provincial regulatory body.

A pharmacy is a place, a store, a department, a kiosk where stuff is sold.  Some of this stuff is health related and OK, but a lot of this stuff is useless, the opposite of health related, and often even harmful.

Just look at the next grocery store or big box merchandiser you approach.  The name of the store is front and centre: Sobey’s, Metro, No Frills, Food Basics, Super Store, Walmart etc.  Then in large letters, usually to the right side of the front door logo, is just the word ‘PHARMACY”

What does this one word signify to the average consumer?  What is the word intended to inform the shopper as to the type of merchandise which will be found inside the premises?

Apart from the obvious ‘prescriptions’, which are increasingly not the priority of the non-pharmacist owner of the pharmacy, the word is supposed to convey to the shopper that drug store type merchandise (DSTM in industry parlance), & so called Schedule 3 drugs are available for sale.

DSTM can be virtually anything from tooth paste, to hot water bottles, to health & beauty aids, candy, soft drinks etc. etc.  …all stuff which can be sold anywhere, but which usually people go to the ‘drug store’ to purchase.  Here the words ‘drug store’ stands in for ‘pharmacy’.

Then there’s Schedule 3.  This is all the stuff which “although does not need the direct intervention of the pharmacist, must be within a specified distance from the pharmacist, in case the consumer wants to ‘consult’ with the pharmacist.   This includes cough syrups, analgesics, hemorrhoids preparations, vitamins, antihistamines etc. etc.   …so called over the counter drugs or OTC’s.  This stuff can only legally be sold in a ‘pharmacy’.

So now we now understand why all the members of Big Pharmacy Retail (BPR) have inserted a ‘pharmacy’ into every grocery store or big box merchandiser.  It’s an opportunity to create increased store traffic and to boost revenues through increased sales.  This is exactly what BPR is supposed to do…sell as much stuff as possible.  Any stuff.  BPR now controls over 80% of Canadian pharmacy sales.

Interestingly as well, the sales volume of all the other stuff that the grocery store sells, like carrots, meat, beans, bread etc. all goes up by more than 10 % just because the DSTM & Schedule 3 stuff is under the same roof.  Increased store traffic.

The truth is that much of this OTC stuff is ineffective and/or useless.  Most vitamins are way over hyped.  Cough syrups are both useless and can be harmful.  Then there are the ridiculous diet aids, fat flushes and COLD-FX  And a thousand other products which are hyped on television to a gullible audience which will purchase anything it sees on TV…one big waste of money, and which any respectable pharmacist would try to persuade a patient to walk away from.  Such action would of course not be consistent with the non-pharmacist retailer’s objective, which is to sell stuff.  Hence the contradiction between a pharmacist and a pharmacy.

There is big money to be made in selling OTC’s, DSTM, and all Schedule 3 stuff.  Not so much money selling Schedule 2 drugs (a drop in the bucket) nor selling prescriptions which are becoming less & less profitable by the day.

The truth is that most consumers of so called Schedule 3 drugs, just pick up what they want (and have been presold on) from the shelf and leave the store.  No ‘pharmacist intervention’. Maybe 10 % will ask “which is the best cough syrup?” as they look confused at 40 feet of cough syrups with various claims slapped on the labels.  Hard to answer this question and remain honest to the profession which is always to act in the interest of the patient.

Schedule 3 products are dream products for BPR.  These are products have limited distribution channels for reasons mostly dealing with dubious regulatory issues, and are driven by big money advertising, not pharmacist recommendation.

In this story, the pharmacist is a prop. The pharmacist presence allows for the word ‘pharmacy’ to be slapped to the side of the building, and hence allow for the sale of all this high margin restricted distribution stuff.

Also, the designation ‘pharmacy’ conveniently allows the regulatory bodies to collect big bucks annually by way of so called accreditation fees.   Not sure what is being accredited.

So now at least we know what the word ‘pharmacy’ means.  The word ‘pharmacist’ remains a bit of a question however, as the profession attempts to evolve in a fast changing, cost reduction environment which is totally dominated by non-pharmacist pharmacy business owners.

The conclusion to this story is still up in the air, but the plot at present is not looking too good for the profession of pharmacy.  Pharmacy however is looking great.  Making lots of money.

 

HOW MEDICINE EATS PHARMACY’S LUNCH June 20, 2018

The pharmacy profession is faced with many challenges today.  The profession’s financial viability is under siege from many fronts as a result of government pressure to address spiraling healthcare costs, with a particular focus on the cost of drugs.

Pharmacy Business is in less financial trouble, as the retailing and mass merchandising of drug store type merchandise (DSTM) and endless aisles of OTCs, many of which are useless, continues to grow unabated.

Against this backdrop, the independent pharmacist today who attempts to set up a practice in a medical building together with several doctors and the usual ancillary medical services like radiology, lab, physio, etc. is confronted by yet another challenge.

Medical practitioners directly represent roughly 30% of healthcare costs, but through their ability to generate prescriptions, lab tests, and radiology they control a far larger percentage of healthcare costs (excluding hospital costs).  The problem is that many physicians believe they are entitled to benefit somehow from all these activities which they directly generate.

So today we are increasingly seeing two unfortunate scenarios developing.  These are not new developments, but lately they are becoming more and more the norm, and represent yet another challenge to individual practicing pharmacists attempting to set up their own practices outside of Big Pharmacy Retail (BPR).

Scenario 1 involves the situation where the physician is the developer of the medical building or medical centre.  The physician may build the real estate or may lease it, but in either case he/she is in control of the leasing of the complex.   Through various complicated arm’s length structures, the lease rate for the pharmacy in the building is set at a multiple many times greater than the going rate for the geographical area in which the complex is situated.   Through this disproportionately high rent, pharmacy profits (thin as they may be) transfer from the pharmacist to the physician.   Clearly, both the pharmacist and the physician are complicit in this scheme, and both are willing parties to this arrangement with the obvious conflict of interest implications.  The reason this scenario happens at all is the subtext that the pharmacist owes the physician something beyond rent for the prescriptions generated by the medical complex.

Scenario 2 involves the situation where the pharmacist is the developer of the medical complex, once again as either builder or lease holder.  In this scenario the pharmacist controls the leasing.  So in order to attract physicians as tenants, especially those who write high prescription volumes like pediatricians and general practitioners, the lease rate for medical office space is set at a fraction of the going rate for office space in the geographical area the medical complex is situated in.   Once again this transfers potential pharmacy profits from the pharmacist to the physician through subsidized lease rates.  This again represents a direct conflict of interest.

The two scenarios described are common practices, and every pharmacist knows the rules when it comes to any effort to situate themselves in a potential medical complex.

The College of Physicians & Surgeons of Ontario (CPSO) are well aware of this situation, but choose to turn a blind eye to it as it pursues what it believes to be more important transgressions like sexual abuse or opioid overprescribing.  The overall number of complaints the CPSO receives apparently runs into the thousands per year, most of which are frivolous, but every one of which still requires a file opening & investigation in every case.

The Ontario College of Pharmacists (OCP) is also aware of this situation, but once again turns a blind eye in the face of what it considers  to be more important issues like sexual abuse & fraudulent billing,

This whole situation is most unfortunate because these scenarios represent major obstacles to independent pharmacists working collaboratively with physicians and other healthcare providers in a collaborative setting with the goal of the development of improved patient care, to say nothing of the conflict of interest these scenarios create.

Both physicians & pharmacists need to be held accountable here, as these scenarios only serve to perpetuate the notion that pharmacy serves as a hand maiden to medicine.  Beyond this, this situation is not in the interest of patients or the healthcare system.

In this regard, both the CPSO and the OCP are derelict in their responsibility as regulators of the respective professions of medicine and pharmacy.

Recent CPhA Conference: What I learned. billbrownblog.com June 11, 2018

When I was recently approached by officials from the CPhA to participate in this year’s conference in Fredericton NB, I was frankly surprised; I have often been critical of the CPhA, and I have questioned its relevance in the face of today’s seemingly overwhelming pharmacy challenges.  I have also been generally sceptical of the value of the many endless conferences that pharmacy seems to hold (the Ontario Pharmacists’ Association Conference followed immediately on the heels of this CPhA national conference).  Admittedly, I had not been to a conference in many decades.

Nevertheless, I agreed and I took part in ‘The Great Debate’ re the viability of pharmacist prescribing, or expanded scope of practice (ESP).  My position was to act as ‘antagonist’ meaning I was to be against this initiative to expand pharmacists’ role in the healthcare system.

This premise was difficult to defend, and I indicated at the outset that I was indeed NOT against pharmacist describing or ESP.  As I have indicated in my previous two blogs, I believe ESP is critical and timely in the face of three realities:

  1. Automation which is rapidly overtaking many functions which are data based, repetitive in nature and subject to algorithmic applications
  2. The ‘corporatization’ of pharmacy as a profession by non-pharmacist owned & controlled Big Pharmacy Retail (BPR)
  3. Plunging drug prices, which are inherently good for patients, but bad for pharmacy under present pharmacist compensation structures.

It’s not the rationale, or the justification, or the clear & urgent need that are the problem; it’s whether the pharmacy landscape, as it exists today, is conducive to the professional development of pharmacists’ patient skills.  And I still maintain that the landscape is not fertile for this kind of development; I wish it was.

While the profession of pharmacy is under the control of non-pharmacist retailers, and pharmacists are essentially unrepresented retail employees of BPR, these kinds of initiatives will remain successful largely ‘in vitro’, and will fail the test of time ‘in vivo’.

Of course the young, enthusiastic, passionate delegates at the CPhA conference would have none of this, and more power to them!

I would not have wanted to throw cold water on their vitality or their optimism for the world.  I admire them all greatly, and I truly hope they achieve their life goals and enjoy outstanding successful careers and total professional fulfilment.

And this is the big lesson I learned from the conference.  No matter how dark the present situation may appear, the vitality & passion of youth can overcome many obstacles.  These traits can lead to the achievement of the dreams this new cohort of pharmacists seeks to turn into reality.  I will be first in line to boost them on.

My only parting words of caution and advice are these.  In order for a tree to flourish and grow, it must be planted in fertile ground.  Do not make the mistake of believing you can achieve your goals if you plant yourself in the wrong environment.  I know this will be tough, especially in markets where BPR totally dominates the landscape/marketplace.  Find or create your own environment and then do what you were educated to do, and do it with passion.

Choose the wrong environment, and it will take less than six months before your spirit is broken.  Search out your predecessors and find out how they feel after a year in the BPR trenches.  Don’t rely on my warning alone.

You have so much to offer.  Put it all to good use where it can flourish and make a difference.   This is your obligation and your destiny if you take control of it now.

 

 

EXPANDED SCOPE OF PRACTICE (ESP)? (PART 2) MAY 14/2018.

The reaction to the topic of ESP, by way of comments, appears to have hit a nerve.  Clearly there is a high degree of mixed feelings as to the direction in which ESP is headed. Most comments suggest caution.

Everyone appears to agree that expanding the scope of pharmacy practice is urgent, especially at this historic juncture when automation, decreasing drug costs and corporate (BPR) domination are all approaching the high water mark.  Any divergence of opinion appears to be questioning the particular direction this expansion is taking.

It is a statistical fact that the majority of pharmacists are employed by Big Pharmacy Retail (BPR) as unrepresented retail employees.  U of T pharmacy Professor Austin Zubin refers to this as the “corporatization of pharmacy as a profession” in his seminal paper Barriers to Pharmacy Practice Change. It is also a fact that success in retailing is all about scale.  This means selling as much stuff, any stuff, as possible out of a given foot print of retail space.  Think Costco or Walmart here, masters of this skill.  This is what retailers are hard wired to do, and in a highly competitive market, threatened by internet shopping, only the strong will survive.

So the initial question becomes: how will these pharmacists (the 85% employed by BPR) who are to diagnose & to prescribe for minor ailments, and to perform more time consuming non scalable patient focussed care, square this with their employers’ number one, seemingly contradictory, priority which is to increase productivity at all costs in a razor-thin margin industry?  .

Severe cut backs in pharmacy assistants and technician assistance are the prevailing trend.  Larger quotas to perform even more medication reviews and any existing billable services are the rule.   Pharmacists are now expected to perform as many flu injections as come through the door while still maintaining their responsibilities as dispensers of medications.  As well, any existing monies which are derived from providing any of these professional services goes to the non-pharmacist owner, none goes to the professional who delivers the actual service.

The whole notion of non-scalable professional services is diametrically at odds with large scale retailing.  This becomes even more untenable when so far there is little or no funding for these professional services except when a product is actually sold.  In other words, only when a product is actually sold to the patient directly & money transfers hands.

Even in Alberta (the provincial leader in government recognition of pharmacy professional services) has recently slashed funding by 150 million dollars.  It boils down to one thing.  Government considers these payments as a cost, one to be controlled and minimized.  Government does not consider pharmacy professional services as an investment.  Pharmacy has done a very poor job of establishing a clear value proposition.

In jurisdictions where Med Reviews have enjoyed a significant thrust like in Ontario, evidence has shown little measurable financial benefit over the long run, and initially, at least, a significant degree of abuse and poor quality.  This has not been aided by aggressive quotas to churn out these “revenue generators” by big business imperatives.  It bears repeating that when and if professional services are recognized and funded, the business of pharmacy will predictably institute yet new quotas and treat such services as additional SKUs (stock keeping units).  Five UTI diagnoses per eight hour shift.  Retail business is hard wired to think this way.

Further, the inherent conflict of interest created by both prescribing and fulfilling medication cannot be denied.  This situation is greatly exacerbated when the compensation is all on the fulfillment end, and none is on the front end, which at present is largely free.  This reliance on the actual selling part is almost guaranteed to deliver compromised healthcare and to validate what physicians are already warning, fragmented healthcare.

When it comes to the provision of flu injections, some pharmacists profess it brings them ‘closer to their patients’.  But how far does this thinking go?  Are wound management & direct diabetes care next? As one physician recently wryly wrote in, “will it be “pap smears in aisle four?”.

Many students enter pharmacy because they do not have to physically engage with patients; it is not their inclination.  It is clear that physicians, nurses and pharmacists are quite different from one another in personality and approach.  This has been borne out in many studies.  If pharmacists are going to do physician and nursing type stuff, then the entrance criteria into pharmacy schools will need to take this into account.  Professor’s Austin’s paper clearly sets this out.  But what about the existing cohort of pharmacists who will be around for the next 30 or 40 years who are being pushed in a direction they are not comfortable with and never asked for in the first place?

The reality is that pharmacists are missing the really big opportunity.  Pharmacists have a great deal to offer by way of medication management, therapeutic determination, dosing, monitoring therapy, therapeutic substitution etc.…all of which evolve out of their core skills which are by discipline pharmacological/pharmaceutical.  This happens today in many major hospitals.  This is what pharmacists are educated to do, and any practice expansion should consider this direction, not some whimsical notion of playing doctor or nurse.  As one physician recently aptly put it, “there is a big difference between medicines and medicine”.

To notion of imposing patient focussed, time consuming, professional services into a retail environment owned & controlled by non-pharmacists with little compensation, appears to be a significant leap of faith.  And then to suggest that it is sustainable under the present scenario where any compensation would flow not to the pharmacist, but to the non-pharmacist owner, is even a wilder stretch. Why would pharmacists want to do this?

ESP is timely, but presently it appears to be taking a poorly thought out direction out of a desperate attempt at survival, and is mostly based on the notion of ‘accessibility’.  Certainly pharmacists are very accessible.  In many urban environments there are at least two or three times as many pharmacies as the market actually demands.  If this is the value proposition, it’s an awfully thin one.

This accessibility notion, and the further self-described notion of ‘most trusted healthcare professional’ are very shaky platforms on which to build pharmacy’s future and they will not withstand the test of time.

Pharmacy ‘leaders’ must be compelled to take a second breath before going much further in this present rather ill-fated direction.

EXPANDED SCOPE OF PRACTICE? LET’S TAKE A BREATHER. billbrownblog.com April 19, 2018

“Expanded Scope of Practice” (ESP) is the current mantra for pharmacy’s salvation, constantly embraced by pharmacy regulatory bodies and pharmacy associations.  As drug costs continue to fall through the floor, and while pharmacists’ compensation continues to be tied to drug costs, ESP is seen as the answer to the survival of the profession of pharmacy.  But is it really?

First of all the term itself is misleading.  Flu shots are not an expansion of pharmacy knowledge/expertise.  Injections are a technical or nursing skill.  Secondly, diagnoses be they urinary tract infections or contraception or other so called ‘minor ailments’, all of these are not an extension of pharmacy as it is currently being taught in any of the universities in Canada today.

So the word should probably be changed from ‘expansion’ to ‘accretion’ or maybe to ‘replacement’, but this new ESP direction is not an expansion of core learned skills, it’s the assumption of skills currently held by other professions be they nursing, lab technicians, or medicine.

This then begs the questions: Do pharmacists possess the required education and/or training to perform these new duties?  Having studied for one profession based on pharmaceuticals/therapeutics primarily, do pharmacists really want to perform acts associated with other professions?  How happy are pharmacists across Canada today doing flu injections?

Another critical question is: How welcoming are other professions with this ESP development?  The following is an edited version of a letter recently published by the president of the Saskatchewan Medical Association entitled “Patients Should Be Wary of Simple Solutions”; I have a hunch it represents a large chunk of medical opinion in Canada today.

 

“We at the Saskatchewan Medical Association are all for improved patient access to high-quality care. Doctors don’t lack for things to do and we are happy to share duties with other professional colleagues. Unfortunately, sometimes problems that appear to be simple (read minor ailments) and easy to fix turn out to be signals of something more complex.

We have raised concerns about this new development. (read Pharmacists’ ESP) The SMA believes it is critical for patients to have what is called a medical home: a continuous source of comprehensive care, where patients have a relationship with their family physician and other providers. In such a setting, signs and symptoms of a health issue can be diagnosed and interpreted in the context of a patient’s overall life and health experience. This isn’t pop psychology or overkill — it is verified by a great deal of research. Put simply, fragmented care increases the risks of something going wrong.

Many community pharmacists practice in independent facilities (read your local food/drug combo) and may have little or no relationship with their patients’ doctors.  Will the pharmacist accept responsibility for an adverse event? Will the diagnosis and treatment automatically become part of the patient’s health record? Will the patient get conflicting advice from her doctor and her pharmacist?”

 

The SMA President goes on to state further observations.  When pharmacy professes that ESP will save the healthcare system big money (presumably by decreasing the number of visits to doctors’ offices) the inference must be that pharmacists will do these activities for free (not surprising if we look at historical experience).  Or will pharmacists be paid by governments but at lower fee rates?  Or will pharmacists charge patients directly for their services?  …as there is current encouragement from pharmacy associations to do.  And if pharmacists do charge patients directly for their services (because governments refuse to pay them) then doesn’t this fly in the face of free universal healthcare, the touchstone of Canadian identity and the direction of government political wind?

What about conflict of interest?  If the only way that pharmacists continue to be compensated is when they actually sell something, isn’t there a conflict of interest when the pharmacist is both the prescriber and the dispenser of medication?  Isn’t this why pharmacy and medicine were separated a thousand years ago?   Isn’t this why physicians are forbidden to own an interest in a pharmacy?  (Though many physicians do through astronomically inflated rents to pharmacists in physician owned medical buildings).

How long before some number cruncher in ‘head office’ figures out that 60% of customers coming through the door are women, and at any point in time 8% of them have a UTI?  Look forward to quotas from head office for pharmacists for the prescribing and dispensing of MacroBID.  You heard it here first.

So on the surface, although ‘expanded scope’ has a nice ring to it, there exist many pitfalls and a potential mine with further implementation.

When I discuss this issue with my physician colleagues, I invariably get the same response, which many of us have heard before:  “If you want to practice medicine, why don’t you just get a medical degree?”.

Just because pharmacy may be headed towards increasing irrelevance through automation and corporate/commercial (BPR) domination, encroaching upon the professions of nursing, lab technicians, or medicine may not be the soundest strategy for survival.

 

INNOVATE OR EVAPORATE April 15/18

 

Automation, artificial intelligence, robotics, are all coming at once.  The speed is overwhelming and threatens to alter society in ways not yet fully predicted.  How will this affect pharmacy? … But more importantly, how will it affect individual pharmacists?  And a corollary question might be…What is Academia telling pharmacists re this very different fast changing world and the impact it will have on them?

In a recent piece in the Globe and Mail (from which I am borrowing heavily) on the subject of robotics in the work place, a striking example is given of London’s taxis, of which there are 20,000 weaving through the city daily. Getting a licence means passing the ‘Knowledge Test’ which involves memorizing thousands of street names, landmarks and routes. Passing the Knowledge Test is difficult & key to becoming a licensed cab driver.

And then along comes Uber.

No Uber driver ever takes the Knowledge Test because Uber’s mobile app is displayed on a driver’s smartphone which provides turn-by-turn instructions on where to pick riders up and where to drop them off. Street names, landmarks and routes are all laid out in detail, and the driver simply follows the instructions.

So when it comes to driving riders around, the app – not the driver, does the heavy work.

Therein lies the challenge. The app circumvents the need for knowledge of London’s streets: knowledge that riders historically paid a premium for. The result is a lower qualification standard for would-be taxi drivers; one that ultimately drives down wages, because as the job becomes more simple, it means that anyone can do it, so why should anyone incur the cost of a higher paid individual when this is unnecessary.

Anyone who performs tasks which are considered repetitive, routine and predictable is vulnerable to being replaced by a machine. The Industrial Revolution déjà vu all over again.  This is the type of work machines do well without tiring or faltering and more importantly, they do not demand any compensation or lunch breaks.  No washroom breaks either.  Sound familiar?

Many venerable professions, once thought to be untouchable, are at risk for the same reasons.  Dermatology and radiology are prime targets.  A computer can memorize millions of images of moles or MRIs and recall them in a nano-second and compare these to the image at the moment.  Plus the computer can be anywhere in the world including a low cost country like India.  Ever wonder why there are so many cosmetic skin therapy shops popping up all over?  The new market is more cosmetology and less skin disease.

Any activity which is based on accumulated data, or an activity which is repetitive and subject to an algorithmic formula is vulnerable to digital technology applications and artificial intelligence… which means the machines can actually learn from the experience they gain.

Now go back to the London taxi drivers and substitute ‘pharmacists’ into the example in place of ‘drivers’, and ‘pharmacy’ instead of ‘London’ and ‘drugs’ instead of ‘streets”.  Are we not seeing the effects of technology?  Script filling machines, computers which identify interactions and contraindications instantaneously, face recognition technology, e-prescribing etc.

Pharmacy education continues to produce graduates who in 85% of cases enter what is referred to as ‘community pharmacy’, meaning they end up working for Big Pharmacy Retail (BPR) and stand all day in a 10’ by 20’ cubicle staring into space or checking prescriptions till they get cross eyed.  A good deal of time is also spent bagging pizzas and toilet tissue, as the customer does not want to check out at the front cash where the lines are long.  The customer is always right.

How many times can you say, ‘Take with food’, or repeat instructions already printed on the label, or recommend a useless cough syrup, before delusion and apathy set in?  About 6 months after graduation, on average.

We are already witnessing Big Pharmacy Business (BPR) instituting two policies which are having a direct effect on employee pharmacists.  BPR is replacing more mature experienced pharmacists with freshly minted graduates (or IPGs) at significantly lower pay scales (so much for appreciation for loyalty and years of dedication).  Secondly the use of more pharmacy assistants (maybe also some so called pharmacy technicians) is becoming more prevalent.  Anything to save a buck in a razor thin margin business activity, namely dispensing drugs.  Still lots of money still to be made selling all the other stuff of course: cough syrups, fat flushes, homeopathy, useless vitamins etc. and we must not forget the pizzas, candy and pop.

So what has pharmacy Academia done in the face of this reality?  First Academia ignores reality, and then, if all that data isn’t enough, it pours on more data and forces all pharmacists to become PharmDs.  So now we are seeing PharmDs sitting in those 10’ by 20’ cubicles making $38.00 an hour, agonizing about how they are ever going to pay that 120K (or more) student loan, and wondering where it all went so wrong.

A Pharmacy Degree does not have to be a life sentence.  Change is happening quickly.  Pharmacists are already getting caught in the cross fire.  Plunging compensation, under employment, and even unemployment are now becoming the norm.  Meanwhile hungry governments keep picking away at pharmacy’s flesh.

The answers are: not clear.  But we can start with: adapt, innovate and be prepared to take risks & to change one’s personal environment.   If pharmacists continue to hope for the best and to rely on so called ‘pharmacy leaders’ to lead them out of the desert, doom is the inevitable conclusion.  If pharmacists leave their fate in the hands of others, the future is predictable.  Not good.

Every pharmacist must take a hold of his/her own destiny and shape his/her future with hope, job satisfaction and future security, and this just might be outside fast disappearing  traditional retail pharmacy.

It’s never too late to reach out for what you want in life, and a pharmacy degree does not have to anchor you to the sea floor.

PHYSICIANS & PHARMACISTS…PROFESSIONAL EQUALS?

We often hear about the need for more professional collaboration between pharmacists and physicians.   How realistic is this really, when pharmacists often position their raison d’etre as to be second guessing a physician’s direction?   What does it mean to be a “medication expert” and to have the duty of determining if a particular medication is “therapeutically appropriate” when pharmacists most often have no medical data on the patient?   How many physicians welcome pharmacists performing this self-created second guessing role?

All this may be standard procedure in a hospital setting, where pharmacy as a profession not only still exists, it’s thriving.  Too bad all those PharmDs that Academia is churning out can’t get jobs in hospitals and really put to work that 6 years of education, instead of getting stuck in a 10’ by 20’ cubicle in a food/drug combo bagging pizzas and toilet paper, or surfing the internet for something to do.

How does society value a particular profession, and what is society prepared to pay for a service given?  How does society perceive the value of a given function?

Let’s have a brief look at current negotiations which are about to begin between the Ontario Medical Association (OMA) and the Ontario government to hammer out an agreement…the biggest labour contract in North America.

Physicians have seen their fees cut by 7 % during the time they have been without a contract.  The docs want all this money back.  Millions & millions & millions.

Ontario docs bill on average $375,000 annually before overheads.  That’s an average, which needs to take into account part time docs, and female docs who insist on restricted hours, which means many docs are billing well over half a million a year to the Ontario government.

The docs want a 4.26% fee increase effective back to April 1, 2017.  Back pay.  In addition to this, the docs are looking for annual increases which amount to a further 15% increase by 2021, three years from now.  Docs work hard and it takes a lot of time and money to get a medical degree, so why not?  The docs want no cap on the physician services budget.  Limitless physician services is what physicians want, and they believe their value is there. Great if they can get it.

Of course the docs want to preserve the present fee for service system…the more services they perform, the more money they make, even though it is commonly known that this is a highly inefficient costly system which emphasizes the provision of more services while less effort is given to the prevention side.  No money in it.

The government is offering 3% over four years and no back pay.  It also wants to cut back money to those docs billing over one and two million dollars.  Yes…that’s 2 million in billings for just one doc.  Well let’s see how all this is going to pan out.  My hunch is that the docs won’t get all they want, but they will make good headway in recovering their position.

The reasons for this are simple.  Docs have a strong bargaining position, and though they do not always agree that their own association, the  OMA, does the best job possible in getting them the best deal, docs know the government will eventually cave in because the public will not tolerate any interruption in physician services.   The docs’ hands are firmly grasped on the handle of the vice.

Compare this to pharmacists for a moment.  Not that long ago, a pharmacist in a community setting in Ontario was “valued” at about $60.00 per hour in the Greater Toronto Area (GTA)…about $120,000 per annum  Today that number is maybe $38.00 representing a decrease of at least 35% over the past 5 years.  Coincidentally, the business of pharmacy has been hit at least three times from different angles.

Big Pharmacy Retail (BPR) can absorb these hits (though not happily) by selling more stuff, any stuff, and cutting costs (especially pharmacist compensation) to make up for the losses.  So pharmacists, who are essentially unprotected/unrepresented retail employees, just get nailed.  Hence the 35% decrease.  This compensation decrease is not government mandated, it’s commercially driven and to be expected in a highly competitive retail environment.  One wonders if the government even knows (or cares) about the financial impact its policies have had on individual pharmacist practitioners.  When government thinks of pharmacy, it thinks Costco, Walmart, Loblaw, Shoppers Drug Mart, Pharma Plus, Sobeys, and Metro etc.   Big Business, not pharmacy practitioners.   Which advocacy group zeros in exclusively on the financial plight of individual pharmacist practitioners?  It doesn’t exist.

Back to our physician colleagues, the ones taking home a minimum of a quarter million a year after expenses (and often much more).  How do we square pharmacists as professional equals to physicians when docs are valued at a multiple of 6 or 7 times over pharmacists?  This is a tough one.

Whenever pharmacists are portrayed on television in one of the many investigative journalism exposes lately (usually about abuse of the system by pharmacy) the camera zooms in on the little blue tray and the pharmacist is seen counting pills.  Well what’s that worth? … a machine can do that easily.

During the recent devastating Fifth Estate piece about Costco and kickbacks (sorry, rebates) not a single pharmacist was interviewed.  Plenty of great shots of the Ottawa professor who described the whole pharmacy landscape as corrupt and the Ontario College of Pharmacists (OCP) as weak & ineffective.   The OCP building was seen in the background as the CBC journalist and whistleblower hacked pharmacy to bits on the sidewalk; no one came out of the OCP building to defend or represent pharmacists.

The real hero of the CBC piece was a physician at St Michael’s Hospital in Toronto, who through personal efforts managed somehow to get medication to 400 patients who had no coverage.  Get the Super Hero analogy with pharmacy described as the dark side?

Docs are always portrayed as kindly counselors with a stethoscope wrapped around their neck patiently listening to their patients with only the patient’s welfare in mind.  That, or they are doing brain surgery.

It begs the question.  Why spend 6 years earning a pharmacy degree to earn one seventh of what a GP earns after spending years of study at an equal level of academic challenge?  Why, when the value is clearly not recognized?

And how do our various pharmacy associations respond to this terrible image problem?  The latest is the suggestion that Pharmacist Awareness Month (PAM) be changed to Pharmacy Awareness Month to “recognize the whole pharmacy team”.  Is this an effort to be inclusive and politically correct?  Dilute the pharmacist?  Is this a move in the right direction for an already besieged ‘profession’?

There’s a whole lot of difference between the OMA and the OPA, and it goes a lot much further than a change in the middle letter from an ‘M’ to a ‘P’.  The image of pharmacy today cannot get much lower, hence its value continues to go down with it.

Pharmacists deserve a great deal more from their leadership whether academic, association, or regulatory.

 

A CLEAR SIGNAL March 2, 2018

Last week, the Chief Executive Officer (CEO) of Loblaw Cos Ltd. (Loblaw/Shoppers Drug Mart, Zehrs, Super Store, Fortinos, No Frills, etc.) while addressing financial analysts, made the following statement:

“We face exceptional external headwinds in 2018 ranging from higher minimum wages in some provinces, to the effects of generic drug reforms.”

The Chief Financial Officer (CFO) later went on to state that … “to put the $250 M generic drug pinch into perspective, it compares with $70 M to $80 M in annual drug reform costs over the past three years”.

He also stated that higher minimum wages will cost Loblaw $190 M this year alone.

These statements from the CEO and CFO resemble the sound of those big bells ringing through the village foreboding something really important is about to happen

These are big numbers.  Half a billion dollars to the bottom line in this year alone.

The problem for CEOs is that their job is not to make excuses; it’s to find solutions.  Shareholders are not going to respond with…’well that’s OK, nothing we can do about it.  We’ll just take the hit.’  Shareholders will vote with their feet and take their money elsewhere if these funds are not recovered and recovered fast.

A rough estimate of the market share of Big Pharmacy Retail (BPR), which Loblaw companies have in Canada today, might be close to 40%, give or take.  My best guess.

This makes the CEO of Loblaw Cos. one of the most important pharmacy leaders in Canada today, and he probably doesn’t even know he is.  He needs to recover half a billion dollars, which was yanked out of under his feet by government, through two possible ways.  He must increase top line revenues in any way he can, which means selling more stuff, any stuff.  Secondly he must cut costs.

And all this before we calculate in Jeff Bezos and Amazon, who is out to eat the grocery and drug industries’ lunch.

Automation comes to mind.  Look for even more self-serve checkouts.  More ScriptPro Robotic Prescription Dispensing or other types of human replacement technologies.  More central filling stations.  In other words, more ways of taking relatively high priced human resources out of the equation.

In many ways, BPR and governments share a common perspective.  When they look at ‘drug costs’, in other words what insiders describe as AAC (actual acquisition cost…meaning the real cost of the drug to pharmacy), plus a mark-up (a retail concept), plus the dispensing fee (meaning counting the pills on the little blue tray and putting the pills in the little vials, from their perspective)…when both BPR and governments add up these three components, they see one thing: drug costs.

There is a very important, not so subtle message here.  The pharmacist bit is considered a cost, not a service.  Pharmacist compensation is totally integrated into the cost of drugs.  As drug costs go down (which is good for the public) so does pharmacist compensation, and this process is just beginning.  National Pharmacare is coming up with the objective of universal coverage (a most worthy goal) and more so, lowering the cost of drugs.

When pharmacists have to create a ’Pharmacist Awareness Month’ (a whole month?), …when pharmacists have to constantly preach out how they are ‘medication experts’ and ‘therapeutic appropriateness experts’ …and how they are the ‘most trusted’ practitioners in the healthcare system, …and still the value of a pharmacist is relegated to a cost component within drug costs, we know there’s a problem.

But the problem is eventually manageable for BPR and for governments.  These corporations (Amazon, Loblaw, Walmart, Costco, Sobeys etc.) are massive, with hundreds of thousands of employees and experts who will find ways to survive and thrive in a viciously competitive environment.   Pharmacy remains an opportunity for growth and profit for BPR, and a big opportunity area for massive cost savings for governments at all levels.

The problem, with an uncertain outcome, is for the profession of pharmacy which continues to flounder, and to attempt to create a value proposition outside the cost of drugs.

Some things for sure:  flu shots, and meds reviews, and counselling with constantly reduced technical help, while professional fee discounting, are not going to cut it.  Yet this is where all the effort by associations and other bureaucrats appears to be concentrated.  Increased ‘scope of practice’?

Once again, what is academia’s role in informing pharmacy students of the future which lays before them?