Pharmacy is an evolving profession and while I believe there are many pharmacists across the country who are working hard to dramatically change and improve the direction of pharmacy, I don’t like the public perception of where pharmacy is going, which seems to be robotics. In school, one of my pharmacy rotations was a small, locally owned pharmacy in Madison that is of course, now out of business. I found it so cool that at this pharmacy the pharmacist knew everyone who walked in the door. All a person had to do was walk in the front door of this small pharmacy, take five steps to the counter and the pharmacist or technician had already pulled their prescription from the ready bin and was standing, ready to check this person out, answer their questions, and get them on their way. This is part of the reason I went into pharmacy. I either wanted to 1) do research for a drug company or 2) own my own little coffee shop/pharmacy. To be fully transparent, there were two big problems with this small pharmacy I did my rotation at: 1) they weren’t getting enough people through the door to be profitable, especially as insurance companies kept scaling back on reimbursements and 2) they did mis-fill several prescriptions while I was there, mainly because they didn’t have scanning technology which is of course a big expense. So, contrast this small pharmacy to where I worked at the time, a large retail store. We had several repeat customers, for sure, that I (even being a casual, part-time employee) would recognize when they walked in. But, for the most part no one really recognized anyone unless they were coming every other day (which, who wants to do that?) or a problem customer. So, at my large store, you would have to walk past all of the food, toys, make-up (all things that are problematic to walk by with young children I might add), finally get to the back of the store, then wait in line, then wait 10 minutes while someone tried to figure out who you were (of course we always needed address confirmation, which offended plenty of people right off the back) and what was going on with your prescription (oh, it’s probably in the stack of 20 faxes that we’ve been getting all day, but haven’t gotten a chance to look at). The pharmacist at these big stores, the person you are counting on to correctly check your medication, check your allergies, check for drug interactions (although, frankly so many people use multiple pharmacies that it’s only really a 50% check), check for appropriate refill history and any other items to do their job as a pharmacist is running around like a chicken with their head cut off trying to manage the technicians at different workstations within the pharmacy, data entry, filling, check-out, and the dreaded drive-thru. As a parent, I love the drive-thru. Pharmacists HATE the drive-thru. I always found it interesting that as a pharmacist, I would make the same amount of money whether I worked in a store with a drive-thru or without a drive-thru. Really, when I practiced in retail pharmacy years ago, half the problem was insurance. “Umm, I need your insurance card” ….” Why would you need my insurance card!?!…. Here, take this” “Umm, that’s your library card”. Not sure if it’s still such a problem, it probably is, but I find it ironic that in pharmacy school we prepped for all of these big, important research projects and conversations we would have with other professionals regarding the best therapies and in practice, we were really just insurance detectives and pill dispensers.
Back to my experiences as a patient, most of my prescriptions come from a mail-order pharmacy. While I enjoy getting my prescriptions delivered to my front door, overall, I do not enjoy the mail-order experience. Just for a quick example, today I received an automated call from the pharmacy stating that I needed to call them. I’m sure anyone who’s dealt with any company over the phone can guess how the next 20 minutes went…. I called the number in the message…. automated system…” please listen carefully as our menu options may have changed” …. then about 10 minutes of menu options are listed before my option “oncology” comes up. Finally, I get someone on the line.
“What can I help you with?”
“Well, I just got a message to call you”
“Okay, I’d be happy to help you with that” (WARNING…RED ALERT, these words actually mean this phone receptionist that you are talking to is not going to help you at all. What will happen is that you’ll end up on the phone for a really long time, at some point resort to yelling, and then either get cut off or the conversation will end without any resolution).
“Okay, please give me your name, birth date, address, first-born child’s middle name, social security number, favorite teacher’s name” (okay, that might be a little bit of an exaggeration).
I give her my information.
“You need to give me your first name and zip code”
“ Oh, right I’m sure you have me mixed up with the other WARD on my street with my birth date…of course you need to my first name and zip code to clarify”
“Okay, I see you in the system, I’m not sure why you were told to call us, are you sure you are calling the right place?”
This is it, folks. This happens all the time, it is so frustrating. As a working mother who’s dealing with cancer, I feel like I have negative 2 hours to spare in a day, here I am monkeying around with a less-than-pleasant receptionist who just asked me why I was calling. Every conversation I have with this mail order company goes like this.
There is another niche of pharmacy that I’m getting exposed to as a patient. I now visit with a pharmacist who works with my oncology team periodically about my medications. This is a relatively new thing at my clinic. They obviously have always had a specialized pharmacist who checks and dispenses the chemotherapy that is administered at the clinic, but this is a more clinical type pharmacist who visited with me in person after an appointment a few months ago and periodically calls me to check in on my medications. I like this guy (or it might be multiple people, honestly I’m not great at catching names when I talk to people on the phone) and he seems knowledgeable, but I get the feeling he’s still trying to find his place within the clinic. Being a pharmacist, my perception of how helpful or necessary a pharmacist consult is to me is a little bit hard to judge. My opinion based on my consults both in person and over the phone is that none of them were really necessary or helpful. It felt like he just regurgitated information I had been told by a nurse or could read in one of the many informational hand-outs I’ve received. I think that there is a good possibility that this is because either I am a pharmacist or because I haven’t (thankfully) experienced much in terms of adverse reactions to my medications. Before I become the most hated pharmacist ever among my colleagues, I would like to add a few more comments. I know for a fact that this pharmacist who is now a part of my health care team is incredibly intelligent and knows quite a bit about cancer medications. While receiving one of my infusions one day, I overheard him discussing some nuances of some of the chemotherapy medications with the nurses. He was giving high level advice to an audience that, quite frankly, already knows a lot about their drugs. In summary, my experience with this oncology pharmacist was like many typical experiences I have had as a patient with pharmacists, I didn’t see his true knowledge in his interactions with me. His vast knowledge of medications, interactions, dosages, etc. was not apparent when he simply read a 6th grade level handout to me.
I’ve thought a lot of about the combination of my frustrations with inefficiencies in the healthcare system and frustrations with the limitations of pharmacy practice. My solution to these frustrations is that pharmacists need to be able to prescribe. This isn’t a revolutionary idea. I remember it being mentioned at the Minnesota School of Pharmacy in 2002 and it is already a practice in the VA system for chronic conditions such as diabetes, heart disease, and cancer. I’m sure this is what pharmacy associations and schools have been and continue to strive for, I just think it needs to and can progress faster. With all of the technology we have and advanced knowledge of pharmacy technicians, we almost have a scenario where a skilled pharmacy technician can run a pharmacy. In Wisconsin, many, if not most pharmacies employ a tech-check-tech program where a technician actually does the final check of a drug product. This is a very important job, a technician has to have a lot of experience and expertise to do this, so why not elevate this position and pay to give all technicians a realistic job ladder to climb and achieve. We need to move pharmacists out of jobs that do not really require the full education and knowledge that a pharmacist has.
I understand at least some of the issues with introducing a pharmacist prescribing scenario to the healthcare team. I am sure most prescribers have a particular regimen in mind when diagnosing a patient. I can only imagine it would be difficult to give up that control. Who would ultimately be responsible for the patient who is either misdiagnosed or mistreated? I understand this would be an issue, but it seems like we are already moving to more and more collaborative relationships between providers with doctors, nurse practitioners, and physician assistants working together to increase access to care. I imagine a pharmacist would enter the picture in the same way the nurse practitioner and physician assistant are under the umbrella of the physician. I really envision that used efficiently, a pharmacist could take a significant amount of work off of the plate of my oncologist and free him up to take care of more patients. In addition to medication selection and follow-up, pharmacists can easily order and evaluate lab values and interact with insurance companies when prior authorizations are needed. Finally, I really believe that every healthcare team should employ a pharmacist that has the job of placing medications orders and following up with the patients and pharmacies to ensure medications were received and are being taken in a timely manner, keeping a clean and correct medication history, and serving as the patient’s number one resource for drug information. This system we have today of haphazard communication between a patient, receptionist, nurse, doctor, insurance company, and pharmacy is not working and I believe pharmacists can play a crucial role in fixing it.