Shooting yourself in the foot, 10% at a time.

Something bad happened in California this year.  Something very very bad.  Something so improperly thought out that it could ONLY happen in California.  Something so horrible that it forces you to wonder if the person who came up with this was drunk, stoned, or just an absolute fucking idiot.

I’m of course, talking about the MediCal 10% reimbursement cut.  For those not in the Stupidty State, MediCal is our implementation of Medicaid.

Let me back up to explain some stuff before I go on this rant so those not in pharmacy will understand.

You know when I bitch about getting paid $1.50 over my cost of the medication fee?  Thats called our dispensing fee.  Thats the amount that I make over the cost of the medication that covers my labor, the vials, the power, the tech who fills it, the clerk who has to take your annoying phone call, etc.  I’m hesitant to call it a ‘profit’, because in most cases its not.  It allows us to stay in business.

Now, back to the rant.

Usual reimbursement from MediCal is our drug cost (give or take a few percent to account for wholesaler markups, etc) plus a dispensing fee of a single digit number (less than 10 bucks for those drunk at home).  If I dispense, say, Fukitol, with a ballpark (yet entirely reasonable) price of $200, I can expect to make about $210 bucks.  Those slow out there may be saying “HOLY SHIT, YOU GOT $210 BUCKS FOR THAT PRESCRIPTION! PHARMACY IS A GOLD MINE!”  For those who think this, go work for the State of California, because you are a fucking retard.  Yes, we did get reimbursed by the state a whopping $210 dollars, but unless I can wave a magic wand and make drugs out of thin air, my wholesaler wants $200 out of that $210 so he can pay HIS bills.  So I get $10, which really is fucking good.

So California; despite having Silicon Valley, Google, dot.millionaire companies, San Francisco and LA (that combined pay more taxes in one second than we will all make in a lifetime) is broke.  Go fucking figure.  They decide to whack the MediCal reimbursement for drugs by 10% to stem the bleeding of throwing the baby out with the bath water.  This first was voted into effect on June 1st.  Us pharmacy and medicine peeps said “HOLY SHIT, YOU CANT DO THIS” and did what Americans typically do, tie it up in the courts (read on and you’ll see why).  Well, recently they lost the injunction, so the cuts happened.

Now you may be thinking “gee TAP, 10% cut in your fee isn’t so bad, thats only like a buck”.  Therein lies the problem.  MediCal didn’t cut our dispensing fee, they cut THE WHOLE FUCKING REIMBURSEMENT.

Quick and Dirty:

Drug costs 200 bucks.  We get paid 210 bucks.  Take 10% off of that 210 bucks and you’re left with 190 bucks.  The drug still fucking costs the pharmacy 200 bucks.  We make a whopping -10 dollars.  Thats right, the pharmacy LOSES 10 dollars (in this case) with EACH FUCKING HIGH DOLLAR TRADE NAME FILL.  Throw in some chemo drugs like Xeloda that costs the pharmacy THOUSANDS or HIV drugs at 600 bucks each, and you have yourself a closed pharmacy.

But no, it gets better.  You see, MediCal is in bed with the drug manufacturers.  The drug manufacturers give “kickbacks…er..REBATES” to the state to use THEIR  product.  Why else do you think Nasonex is the ONLY nasal steroid instead of generic Flonase.  Why do you think generic Morphine ER isn’t covered, but BRAND ONLY Kadian is?  The state is getting a rebate for having these on their formulary.

So not only do we lose money on each brand-name prescription, but we are forced to use brand name for certain drug classes.

See how absolutely fucked this is?  So whats a pharmacy to do?

Easy, send the patient somewhere else for brand name drugs.  California Business and Profession code prevents the selling of products for less than what it costs you.  Its part of the anti-predatory pricing laws.

Does this suck for the MediCal patients who need HIV/Actos/Nexium/Kadian/etc? Yup, it sure does.  Our hearts are out to those patients who can’t get their drugs filled, but what other choice do we have?  The chains can absorb the cost for a time until they pull the plug, and the independents cant absorb any of that.

Oh no, it doesn’t stop there.  You know how I said that the cuts were put into law June 1st but got held up in court?  Well they made the cuts retroactive.  Pharmacies are going to get a BILL from MediCal for the 10% difference for EVERY FUCKING PRESCRIPTION they filled since June 1st.

If you are an independent store owner, give money to the Pharmacy Defense Fund (if you haven’t already).  If you’re a district manager for the chains, get your head out of your ass and tell your people to STOP FILLING BRAND NAME DRUGS or you might be out of a job.

I’ll leave you with that.  Don’t send me the bill to cleanup the mess of your head exploding.

December 9th, 2011 by theangrypharmacist | 77 Comments »

All in the same boat

Before I continue on my usual tirade of broad stereotypes, foul language, and shit that makes Drug Topics avoid me like a crackhead the night before a holiday weekend; this post is dedicated to the brave men and women who risk their sanity day in and day out so the ungrateful masses can focus on your petty first-world problems.

I’m talking about people who work with the public.  Hair dressers, Pharmacists, Doctors, cashiers. The kid who bags your groceries to the checkout line clerk to the nice lady who takes your order at the fast food joint.  You know who they are, they greet you with a smile and a silent anxious look in their eyes that you won’t rip their head off over something that is completely out of their control.

What sparked this?  A visit to the supermarket.  They were having problems with their ATM/Credit Card thingy.  The cashier said outright “Im sorry, but we’re having system problems processing ATM/Credit/EBT cards, it make take a try or two for it to go through”.  The ungrateful waste of skin proceeded to give her both barrels about how this was unacceptable, that they should have their system fixed, they should have a system in place to fix this, should have, should have, should have (notice I didn’t say ‘should of”? Be proud Mr Woo).

I was the next in line, and by the time this douchecanoe actually got his 6 pack of natural-ice with a carton of cigs ran through the one out of 3 credit cards that were not maxed out (after getting pissed that their food-stamp card can’t be used for that/it was tapped out), the poor checkout clerk nerves had been totally fried.  It only takes one asshole to ruin your day.  I gave her a smile as she rambled through the warning that the checkout computers were going in and out, blah blah blah, to which I said that there was no problem.  I realized the look in her eyes was the same look that I probably have when I miss filling a prescription that was buried in a profile and expect both barrels from the patient when they have to drive back to the store because I overlooked something.  I was kind and patient, and she gave me a sincere thank you.  I told her that I work with the public too and its like she knew that I understood her pain.

I’ll be upfront.  I have never sent back food anywhere because it wasn’t up to my standards.  Even if its the absolutely wrong thing I just eat it.  I tip the person who cuts my hair the same even if its a horrible job or the best job they ever did.  Someone fucks up putting the price in wrong at the grocery store and I don’t get that $0.50 discount I don’t say a word.  People say that I just reinforce the mediocre half-ass-is-okay work-skill that plagues our working class.  I say that I don’t want to be ‘that guy’ that makes people drink as heavily as retail pharmacists do.

You ever stop and realize that the assholes of the public will gladly wait in line for 15 mins for a seat at a restaurant, but can’t be bothered to wait 15 mins for their 5 (free) prescriptions?  Interesting isn’t it.

During the supermarket incident, I realized that all of us who work with the public are in the same boat.  We deal with the same assholes, the same impatient fucks, the same douches who bitch that their prescription isn’t ready yet when the power is obviously out and I’m trying to keep the pharmacy systems up while a generator is obviously screaming behind the store.  I can always tell when a patient of mine works with the public.  They are pretty nice, easy going, and realize that sometimes shit happens.  They patiently wait for their prescription, and use the foreign words we never hear like “please” and “thank you”.  They are mindful of our time and actually show appreciation to the service that we give them.  How foreign is that in a pharmacy?

Its ironic that the most important aspect of retail pharmacy isn’t all the drug-drug interactions, the kinetics (learned for the test, then quickly forgotten; never to be used again), knowing the pharmacology of benzodiazepines, or even the rationale behind giving someone an ACE-I in CHF; its dealing with the unwashed masses.  The most important aspect (and the #1 cause of burnout) that is just blatantly ignored in pharmacy school.  “You’ll just learn it on the job” they say as your day is shattered by someone yelling at you who have never worked a day in their life.  Thats like teaching you how to swim by throwing you into the deep end and yelling “You learn by doing” as you slowly sink to the bottom.

Pharmacy school should have a class that is like a boot camp, you get yelled at each class so you’re used to dealing with idiots who give you both barrels over the most stupid things. You learn how to defuse situations.  Ah shit, who am I kidding.  Pharmacy schools would probably teach you to use fruity ‘touchy phrases’ like:  “You know by saying that, you hurt my feelings and make me feel less about myself” to which the patient would reply “Good, you’re fucking stupid, my vicodin is due now, not next week”.  Color me surprised that pharmacy schools are so out of touch with the ‘real world’ that they wouldn’t know their poop-chute from a hole in the ground.

I realize that this post isn’t your usual swear word ridden bitchfest, but fear not, I take care of my readers (sorta).  If you want to re-post this article, this would be a good time to stop copy/pasting.

So to all of you ungrateful fucking assholes out there who decide to ruin the day of us who get our asses up every fucking morning so we can serve you, heres a fucking tip from the guy who double-counts your fucking dope so you don’t come back and say that I shorted you.  Get a fucking job, work with the fucking public, see what its like to deal with your own fucking kind.  Get your day shot to shit because you had to serve a fucking asshole like yourself with the social skills of a fucking steaming turd baking in the afternoon sun.  Get a dose of your own fucking medicine.  The world owes you shit.  Be thankful you live in a fucking world that we accept you for the shit you do to us day in and day out and don’t take you out back and shove our boots in your fucking yappy twatty mouths.  If you think you can take your bad day out on us, feel fucking free; but beware, theres nothing I can really do to you in pharmacy, but I’m sure the server would be more than happy to let your fucking food you sent back 3 times because your steak “wasn’t cooked enough” fall on the floor a few fucking times when you’re not looking.

I hope I filled your use of the fucking word ‘fucking’ per post requirement.

November 16th, 2011 by theangrypharmacist | 92 Comments »

Careastatin, 0 refills remaining.

Anyone who has been in a relationship (professional – personal, it doesn’t matter) knows that it takes two to tango.  Your patients come in, put their life in your good judgement, and in return you may have to do things that are ethically sound, yet legally grey at best.

I’m talking about the dreaded ’0 refills remaining’ with the patient being out for 2 days.  This phenomenon is so prevalent in pharmacy that we should have received a class on how to handle it.  Since pharmacy schools give two-shits about retail, here is your class on the subject.  Pay attention!

This is how 99% of the cases take place:

  • The patient will call you over every little change on the label (expiration date, change in manufacturer, quantity, doctor) yet will gloss over how many refills remaining until they are out for exactly 2 days.
  • The patient will let you know they are out of refills in person…. On a Friday… Before a 4 day holiday…. At 2 min’s to closing…
  • The mediation won’t be Vicodin, Valium or any narcs.  It’ll be something awesome like insulin.  You know, the kind of shit that you ethically can’t tell them to go fuck themselves over.
  • They won’t be out of something simple that you can drop a few tablets in their bottle, it’ll be something that comes in a unit-of-use bottle, like Januvia, Actos or Nexium.
  • In the event that they are out of something simple and stupid, they will forget their old bottle despite you telling them 10 times “MAKE SURE YOU BRING YOUR OLD FUCKING BOTTLE”.  This leaves you out the cost of ANOTHER bottle and ANOTHER label.  Regardless of how shady this all is already, dispensing drugs into their open unwashed hands is just crossing the line.
  • The patient will use the phrase “BUT I NEED THIS MEDICATION” or “CANT YOU JUST FILL IT”.

Here is where the legal waters get the product of Go-Lytely dumped into it.  What do you do?

  • Legally (sorta), you can only give a 3 day supply without authorization.  Its insulin.  Are you going to suck out a 3 day supply?  If you are, I hope your employer fires you for being a dumbshit.  Are you going to break open that box of Humalog Flexpens to dispense just 1?  To make this worse, if the MD finds out (usually patient taddling) he/she could file a complaint against your license with the state board of pharmacy for filling without authorization.  If you billed the insurance company, they can ding you for filling a fraudulent Rx and pull your contract.  This is all worse case mind you.
  • Realistically, you know you won’t get the OK from the MD for at least 5 or 6 days.  A week to 10 days if the patient goes to a county-ran clinic at the local hospital.
  • Ethically, you know that if you don’t dispense this insulin, the patient will have to go to the ER (or worse) thereby costing the taxpaying citizens a few thousand.

Pretty fucked situation all around?  Yes, yes it is.  For those of you at home, we deal with shit like this about 20 times a day.  Now this is how I would handle it:

If it’s a regular patient (regular in the term that we have a professional relationship, not that they can poop fine), then I take the potential legal hit to my license (and to the store) and give them the insulin without the authorization.  I figure the patient will stand with me against the state board (and their doctor) to justify my actions as being in their best interest.  I politely tell them to bring me a new Rx before this amount runs out, and all is happy.  Wait, can you hear the collective jaws of every MD out there dropping as I spill the beans that yes, we do dispense medication without your authorization in certain cases.  Here’s a fucking reality check, your patients are dipshits.  They can program their phones to play the most obnoxious ghetto rap-song ring-tone at 1000db while waiting for their drugs, yet they can’t program a simple alarm to remind them to call in their refills a week early so we can get the authorization.  If you are unable to grasp this concept, then actually listen to the ‘blah blah blah’ that comes out of their mouth when they visit you and you’ll realize that you’re dealing with someone that’s half-step above my dog on the evolutionary chain.

If its Joe-Crackhead who treats me like utter shit, bitches at me about EVERY-FUCKING-THING and looks for things to argue about; fuck him.  Let him sit in the ER for 10 hours.  If he paid as much attention to his medication refills as he does his fucking cigarettes, we wouldn’t be in this mess.

Harsh? Yes.

Surprised? No.

Agree with me? Probably.  Here is my rationale.

Personal responsibility is something isn’t to be taught by your Pharmacist.  Sure, everyone has a brain-fart and forgets to call their medications in.  However why should I legally put MY license on the line for someone who has no respect for me, doesn’t treat me like an equal, or always tries to pick a fight for me?  This kind of bullshit patient would be the first one to throw me under the bus to not only the MD but the state board if the shit goes south.  I’m not going to put my livelihood on the line for someone who doesn’t give me an ounce of respect, and doesn’t realize that I’m doing him/her a huge favor.  Unprofessional? Sure, if you want to look at it that way, but you also need to look at the irresponsibility of the patient who put him/herself in that situation and expect me to put my ass on the line to remedy a situation that he/she put themselves in.

The easy solution is for everyone to have a little bit of self-awareness and personal responsibility regarding their own health.  Yeah, I’ll get right on that after I finish filtering all the piss out of the ocean.

September 16th, 2011 by theangrypharmacist | 125 Comments »

How to succeed at retail pharmacy according to the chains

So during my 0.004 second lunch during the clusterfuck of a day after a holiday, I checked out this article on DrugTopics.  Nothing special at face value, however this paragraph really bugged me:

Several factors led Morton’s executives to make the decision to sell most of its retail pharmacy business. “It’s the declining reimbursement environment, mandatory mail-order plans, the closed networks that are starting to become popular across the country, $4 generics programs, and predatory audits,” Morton said.

Both health insurance companies and government programs are slashing reimbursements, according to Morton, a practice that is “not providing enough margins for us to serve patients.” In addition, the purpose of audits conducted by pharmacy benefit managers (PBMs) has changed from detection of fraudulent claims to making extra money for the PBMs, according to Morton. “They are looking for administrative mistakes so they can look to recoup claims. It is a revenue-generating technique,” Morton said.

For those not in the industry, Walgreens has a Pharmacy Benefit Manager called Walgreens Health Initiative.  This is similar to how CVS/Caremark work, and the infamous Merck/Medco.  Now for those of you who work retail, this whole article makes perfect sense.

  1. Have your PBM give ridiculous low reimbursement rates to kill the independents.
  2. Be first in line to “take your failing pharmacy off of your hands for you”
  3. If they refuse, audit the shit out of them for every little fucking thing until you bankrupt them
  4. See step 2
  5. Profit!

Funny, how it’s technically illegal for a bunch of independents to meet to discuss if they are going to take a PBM contract due to antitrust laws, but the major chains and their PBM backers can pull this kind of bullshit.  Of course the major chains can bribe (yes, I said bribe…er.. LOBBY) the corrupt government to look the other way.

Having gone through a dozen+ audits, the article is 100% right.  The auditors aren’t looking for blatant fraud and abuse, they are looking to generate profits.  When you fill an Rx, if you mark a faxed back OK as ‘written’ in your software (instead of a ‘faxed’), that’s grounds for them to take the entire cost of the Rx out of your next check.  I bet, with a bit of digging, you’ll find that these auditors actually get an incentive-pay based upon how many ‘errors’ they find on the pharmacy end.  I will also bet that Caremark doesn’t audit CVS stores, WHI doesn’t audit Walgreens, and Merck doesn’t audit the Medco mail-order chains.  Even if they did audit them, do you really think they would take the money out of their next check? Isn’t that taking money away from themselves?

Sometimes the audits pick up things that are just mistakes, like when you have a Robatussin-DM in your computer as 1 bottle of 273mL and your floater bills 273 bottles by mistake thinking that it’s in the computer as per-cc instead of per-bottle.  Those I can see, but taking back the ENTIRE reimbursement over a 28 day supply vs 30 day supply for eye drops is petty and bullshit.  We have the Rx, its legit, yet you are back-charging us for the entire amount due to a clerical error (and a stupid one at that).  The Rx wasn’t filled fraudulently, and it was filled in good faith with no intent to fraud.  However try to argue this point with the auditors and you’ll just get a blank stare and 100 more ‘errors’ that will make your next reimbursement turn into a bill.

So the million dollar question is: Where is APhA in this mess?

September 6th, 2011 by theangrypharmacist | 53 Comments »

The dreaded RTS

What is the public enemy number 1 of any pharmacy?  No, its not the patients.

Its the dreaded RTS bin.

Thats right! The Return To Stock bin.  The glorious bin of drugs that patients called in to have refilled “RIGHT NOW” yet never got off their lazy asses to come and pick up.  You know, all the simvastatin and lisinopril that the patient pitched an absolute fit right in the store because they “were out” and didn’t have any refills remaining yet never bothered to pick up 2 weeks later.

RTS’s absolutely kill pharmacies.  Here’s why (to those at home who don’t work in a pharmacy).

It takes money to fill a prescription (gasp!) other than the raw cost of the drug.  Everything from the vial, to the label, to the computer system/printer/toner that spits out the label (that you fucking don’t read) to the tech that fills it, to the pharmacist that checks it, to the clerk that puts it in a little bag and takes your whiny phone calls.  All of those steps cost money.  Thats not even counting the electricity, insurance, employee taxes, etc.

We get a dispensing fee paid for by YOUR insurance to cover these fixed costs.  Why are they fixed? Because the dispensing cost is the same if the drug costs $1 to $5000 kerzillion dollars.  When you pick up and sign for the medication, we have proof to your insurance company that you in fact received the medication and their piddly $2 dispensing fee was in fact put to its intended use.

Now say that drug filled vial with your name on it just sits out front for a few weeks.  It starts to get lonely sitting by itself in the pharmacy because contrary to what you read on the internet, just ordering your medication doesn’t make it magically work, you need to TAKE the fucking medication.  Eventually, we need that space to store medications for people who give a fuck about their health.  Your vial then gets RTS’d.  Since we didn’t dispense that medication, we legally cannot accept the money that your insurance company paid us for the drug + dispensing fee.  So now, we “back out” the prescription (meaning we give the money your insurance company paid us BACK to them, all of it), and now must PAY someone to put the drug back into the big stock bottles.  We have to throw away the vial and the label as well.

Your laziness now has cost the pharmacy double the labor + the cost of the vial/label  for which we are getting paid a whopping $0.00 for.  All because you called in a refill and didn’t get off your ass to pick it up.  My store has a policy that we call people once their medications have sat for a week, then we give them a second call 5 days later.  Yes, we PAY someone to call you to remind you that the prescriptions that YOU CALLED IN have sat here for a week.  This is after we told you when you called in your refills that they will be ready later on that day.   Ask me how this can be any more straightforward!  Oh, I guess its as straightforward as paying your fucking phone bill because every time you come in you give us ANOTHER phone number (thats disconnected 2 days later).

After about the second time I RTS a prescription for a patient, I put a big note in their profile to make sure they are told that we will fill their prescriptions when they are IN the store due to us always putting back into stock what they order.  What do I get? A bunch of swearing at me from over the counter by some idiot unwashed mouth-breather to the tune of “I called these in a week ago, why aren’t they ready yet!”  This is after they were EXPLAINED why they must be here for me to fill their “diabeetus and list-o-pril” pills.  I swear I can’t fucking win.

This shit really pisses me off.  Its a waste of my fucking time and a waste of the stores money.  Since my store doesn’t do auto-fills, if you’re not going to take your fucking medication, then save us all the headache and don’t call it in.

Oh, and a cool pharmacy fun-fact, is that controlled prescriptions are a good chunk of what I fill everyday, yet less than 1% of the drugs I RTS.  Big fucking surprise.

August 2nd, 2011 by theangrypharmacist | 115 Comments »

Pissing into the wind of medicine

This is all made up.  Uh huh.  Its a bit of a hard read to protect the identity of the stupid er.. the made up stupid… Uh huh.

It was your usual day at the Angry Pharmacy.

I got a call from a resident that I’m on fairly good terms with.  She wanted to increase the dose on a patient diabetes meds.  She wondered why the patients A1C was climbing lab after lab and thought the medication wasn’t working.

I pulled the patients profile up.

Month supply filled Jan and March.  Something wasn’t right here.  Maybe he/she was going to another store? Only one way to be sure.

I told the resident to ask the patient to bring in all of his/her meds in so I could “take a look at them”, which in pharmacy speak means “See if you are fucking taking them”.

Patient comes in with a plastic bag full of pill bottles (oh dont we just fucking LOVE it when they do that) and a new Rx.

Every single bottle of maintenance med was full.  EVERY FUCKING ONE OF THEM.  It had more fucking diabetes medication than I did on my shelf in that one plastic bag.  Most were from us, some were from a different pharmacy dating back almost a year, all were filled exactly on time.  This looked like two big scoops of not-fucking-good.  In fact, the refilling gaps in MY system were accounted for by another store’s filling.  This required a “come to Jesus meeting” by yours truly.

I asked the patient, who had almost every risk factor for diabetes in the book, why it wasn’t taking the medications.  Then the bomb was dropped.

“I know my body, and I know what its doing, I dont need this shit.  I just need my pain pills”.  Hear that needle being pulled off of the record of medicine?

Now its A1C would score a solid gold in the A1C Olympics.  I could use his/her urine to compound in place of simple syrup.  If it wasn’t the copious amounts of bullshit flowing through its veins I’m sure they would of died by now.  I asked the pushy patient if the doctor knows its not taking its medication.

“No, if I told her that, she wouldn’t give me my pain pills”.

I wanted to punch him/her in the face.  I asked if he/she had side effects, or any reason why he/she didn’t want to take the medications.  Sometimes the twice a day is too much for people, there are options that I could suggest.  This resident was an awesome one who loved pharmacists thanks to yours truly (you’re welcome) and would do whatever I suggested.  Look at me! Being all pharmacist like!

“I told you, I know my body, I dont need these, I’m fine.”  I fucking love it when they use that line.

Nothing I could say could make his/her take them.  Threats of blown out kidneys, to losing his/her sight, to not having legs, nada.  So.. Fucking.. Frustrating…  I tried to play the pain card, saying that her pain could be because of damage to nerves.  “Gabapentin doesn’t fucking work on me, neither does Vico-dan.  I need Percocet”.  This was said with a straight face as I could line the entire pharmacy an inch deep in unused gabapentin caps.  I offered to work with the patient and the doctor to help her.  I even offered to fucking blister pack the medication to improve comp-LIE-ance.  Nothing would work.  The patient had either given up, had a fucking stroke and got incredibly dumb or just really wanted to get high.  Maybe if I printed “HAVE YOU TAKEN YOUR MEDICATION TODAY” on a package of cigs or a lotto ticket it would make a difference.

The conversation turned into the “I dont want to talk with you anymore.  How long until my Percs are done” song and dance when I called it on bullshitting the doctor to get more narcotics.  Sometimes it takes being an asshole to get the point made.  My preceptor used to tell me, “TAP, never argue with an idiot, they will drag you down to their level and beat you with experience”.  If I followed that advice, I wouldn’t have any patients.  I knew that short of a diabetic complication 2×4 across its face, there was nothing I could do.

Then the blood started to boil.

This person gets FREE care and FREE medications.  It isn’t out anything but his/her own time to take care of her condition that could leave her legless, blind, and on dialysis.  Of course all care related to stupidity would be happily covered by the state.  None of that mattered to him/her.  90% of the working population would KILL to have what he/she is getting for no cost.

You know when I ranted before about how a person places no value on something that they aren’t paying for? Case in point, right in fucking front of me.

Now this person is spending, nay wasting, hundreds of taxpayer dollars a month that could be used towards someone who actually gives a shit about their health, about their care, about their body.  A person who could actually get a better quality of life while they get their life back on track.  If this douchebag wanted to just get fucking high and watch his/her health spiral down the shitter, thats great – just don’t take the resources that could be used to help someone who gives a shit.

So the question remains: at what point do we, the healthcare people, decide to cut-bait on a patient that obviously doesn’t give a shit about his/her health and is only seeing you because they are being forced to (or to get narcotics)?

Oh, and I paged the resident (I REALLY hate paging doctors, but I figured this was important) and let her know what was going on.  After a bunch of “are you fucking kidding me” she requested the patient go back to her for “clarification” on the percocet prescription.  I think someone is going to get a type-1 ass-chewing, but something makes me think its not going to make much of a difference.

I love making shit up *ahem* to prove a point.

June 8th, 2011 by theangrypharmacist | 84 Comments »

The true story about Retail Pharmacists and Twitter Doctors

Ive been asked on more than one occasion (by MDs), why the ‘Angry Doctors’ on Twitter have such a strong Pharmacist following.  Since I have undertaken the task of being the official spokesperson of Pharmacy on twitter, I decided to turn this answer into a well though out response vs a 120 character tweet.

If you’re looking for profanity, slurs against the downtrodden, just skip over this whole post.  This is a post to generate discussion about a real issue that us retail Pharmacists have with our MD counterparts.  Yes yes, I know that the past few posts I have been quite uppity and boring about some issues going around, but fear not, the poop-talk is coming.

What I shall grace before you is from my own experiences only.  Although I represent a voice of pharmacy, I cannot speak for every pharmacist (although I do damn near get all of them to agree with me).  I want the MD’s in the audience to think about this article, because its not meant to inflict harm, just bring to light exactly how us in retail feel we are perceived by you.

  • Whenever we call for a clarification, you are “in the room with a patient”.  We are unable to speak with you directly.  Even if its about issues that can get you in serious trouble, like forgeries/stolen pads or narcotic shoppers.  We speak with your “nurse” who gives the message to you.  While we are waiting for your “Nurse” we have a line out the door and the hospital on the other line calling in discharge medications, yet we patiently wait.  Your “Nurse” then gives us a response which is totally different than the original question, obviously there was a miscommunication between us and your translator which wastes both of our time.  We feel that your time is worth FAR FAR greater than ours since you can’t spare 30 seconds to have a conversation with us even though we are treating the same patient.  We feel like our concerns about OUR patients (which if we are calling you, its a concern, we dont have time to just piss away) take a backseat to everything else in your office.
  • On your answering machine or answering service, you give a option for doctors or hospitals to get an express route to you.  Yet you do not give pharmacists an option.  Since we respect you (and aren’t a hospital or doctor), we are thrown into the call pool with your patients to be answered by a staff, who transfers to another staff, to transfers us to your nurses voicemail box, all while your patient is feeling ill and just wants to get the antibiotics (thats not covered) and go home.  All of our IVR systems give you an express hotline to us, yet the courtesy is not returned.
  • When we see you at the CE dinners, we introduce ourselves only to be shunned by you chatting with your MD friends.  When you do actually talk to us, you don’t ask us how we’re doing; you ask us to pass the wine, or to fetch you something.  We introduce you to our fellow pharmacists, yet you dont even extent the common courtesy to introduce us to the other doctors.  We treat the same patients, we are on the same team.
  • When is the last time you spoke with a pharmacist that you do a lot of business with.  Not just call in prescriptions or yell, but actually ask how they are doing.  Have you ever offered to have a cocktail after work with them? We would gladly treat you to cocktails after work, yet we never get the chance to speak with you to extend the offer.  Do you even know what their name is? I guarantee that your local pharmacist knows what your first name is, shouldn’t you respect him/her and do the same?  You do treat the same patients.
  • Pharmacists, on the other hand, talk to each other.  We ask how we are doing when giving transfers.  We go out for cocktails after work.  We warn each other about forgeries.  Even ones who are in direct competition have a fraternal-like bond regarding reimbursement rates and looking out for each other.
  • Pharmacists have a closer relationship with your front end staff than we do the MD that employs them.  We know your nurses, they know us.  We laugh and crack snide jokes about our patients who want yet another refill for that prometh w/ codeine.

Notice a trend here?  Retail pharmacists get scooted to the side by MD’s in all aspects of our job.  Now compare this with the angry doctors on twitter, who openly joke, converse, and treat pharmacists there as equals.  Do you see why they have such a huge following? Do you see WHY pharmacist jumped to the defense of a faceless, nameless anesthesiologist who was bullied by an MD who seems like he fits the above description?  The doctors on twitter are the doctors that pharmacist love.  They don’t put us on hold or communicate to us via a 3rd party, they speak directly to us.  They are approachable and friendly.  I can send one a message and not wonder if they will ever get back to me because they will.  I don’t need to watch what I say around them for fear of getting the “oh he’s just a pharmacist” eye-roll and subsequent ignoring.  They are people, real people, like us.  If you, the stereotypical MD, treat a fellow professional like us this way, how are you treating your patients?

I regularly go drinking with a NP and an MD friend of mine from a hospital nearby, and we discussed this whole issue about retail pharmacy and the local docs.  They, working in solely a hospital setting, had no idea that this huge gap between us existed.  They thought that all the docs in the area called up their local pharmacist and ask questions as basic as whats covered, to a suggestion for suitable beta-blocker for a patient with a low CrCl.  They wondered how you can practice medicine safely without asking advice from someone who is knowledgeable about medication.

I find it interesting, that pharmacists; most if not all have doctorates, who went to school, studied, and work with drugs for a living, are ignored in general by your average MD (except when the patient bitches the “pharmacy wouldn’t fill what you wrote”, only to be yelled at by the MD because the drug wasn’t covered and costs $400).  We are on the opposite side of the same coin, and ultimately the person who suffers the most is the person who is generating the revenue so we both can eat.

Part of this is the fault of pharmacists in general.  Most of us really don’t have the time/balls to stand up for ourselves when push comes to shove regarding MD’s and medication therapies.  We have allowed ourselves to be walked upon for decades.  Ask a pharmacist who graduated in the 70′s what doctors were like back then (shout the orders, slam down the phone, “just fill the fucking prescription”).  However the tides are turning.  Residents are being taught to ask us for advice.  There are too many drugs and conditions now for one profession to master every small aspect of both fields.

I’m really not bitching per-se, just letting you all know what your image is like on the other side of the fence.  Do I expect this to magically change with one blog post? No.  Behavior that has been refined over the past 100 years can’t change overnight.  I hope this brings some insight on why the docs on twitter have such a strong pharmacy following.

May 28th, 2011 by theangrypharmacist | 47 Comments »

EXTREME UNPROFESSIONAL MAKEOVER -or- PIMP MY UNPROFESSIONALISM

I’m taking a break from my usual silence (I think i’ve flogged the welfare crackwhore/dumbshit patient enough) to comment on a few important points.  Social sites and you.

Thats right, Facebook, Twitter, etc and the drama/flak they cause (as well as the laughs).

I want to start with a story.  When I was a lowly intern, I was at a very large hospital being the beating-boy for the medical team comprised of a few residents, an attending, myself (go pharmacy!) and a dietitian (wtf?).  We were examining a scrotal hydrocele case that was admitted.  The attending flings back the curtain, and the guy is laying there with his legs spread, and what looked like 2 large grapefruit between his legs.  The attending said “HOLY SHIT THOSE ARE THE BIGGEST BALLS I HAVE EVER SEEN”.  I laughed, the other residents were stone-faced.  The patient looked at me and the attending laughing, got a sense of pride in his crotch-fruit, and laughed.  He completed the exam (including one of the residents who really wanted to stick a needle in them) and left.  The most senior resident said as we were walking the halls “THAT WAS THE MOST UNPROFESSIONAL EXAM I HAVE EVER SEEN”.  The attending, in true Dr Cox style, said “Listen, you need to laugh or you’ll go crazy, sure it was off-color, but thats what makes us relate to the patient in a way that makes them feel not like they are some rat on an exam table”.  The patient, after his nuts drained and looked like prunes again, personally gave his thanks to the attending to making him feel like ‘one of the gang’.  Word got around the hospital about the nut-of-the-year award, and although no names were dropped and not personal information was given out, it was something that pharmacy and medicine could open dialog about.

Thats one of those lessons that you can’t be taught in a classroom.

The second part of this rant is some Twitter drama involving @mommy_doctor and (although a valid point) a bullshit article written by DrV.  Realize that I follow a lot of MD’s, mostly from the ER who say some pretty damn funny things regarding their profession. Much like myself, they give an insiders look at really goes on in the world of medicine.  In fact, I view these angry doctors with a ton of respect, mostly because they make us in pharmacy realize that we’re not alone in dealing with idiots; and their sense of humor/rants about their job makes them (in my eyes) someone who you can hang out and have a beer with.

Before I go further, let me explain about @mommy_doctor (herein known as m_d).  I’ve been following her for a few years now. Shes an anesthesiologist (obviously she is a female, hence mommy).  Her job is rough.  She puts her ass on the line day in and day out to save people.  She deals with surgeons, scared patients, and is a really really stand-up woman.  Her tweets are funny, usually clean, and show how much she cares.  She gives us an inside look at the crazy mixed up hybrid of pharmacy and medicine.  I view her with a huge heaping of respect and admiration for doing what she does on a daily basis.

Anyways, I got a major case of blue-balls when I saw that link, because I immediately thought that ole @BurbDoc was under fire for one of his many hilarious (and totally true) tirades about the unwashed masses.  However reading the holier-than-thou rant just got me pissed off.  I really wasn’t pissed off at the whole concept, but at the bullshit cliquish high-school drama that took place in the realm of Doctors.

First off, DrV, in an article about the lack of ethics, decided to copy/paste screen-captures of the tweets of @mommy_doctor treating a priapism case, one that she obviously felt empathy and sorrow for.  The tweets weren’t crass, funny, or even note-worthy.  However the MD fanboy population decided to textually masturbate themselves about how unprofessional this was.  Mind you these seem like the MD types who will DAW-1 everything, not give you the benefit of a clarification, and refuse to speak with pharmacists.  You know, the MD’s that us as pharmacists HATE dealing with.

Rather than using the text as an example (and blurring out the name), he unethically decided to just drive the bus over her and publish the tweets unedited.  Ironic that in an article about unprofessional behavior, he commits an unprofessional act by doing something that she obviously had the moral-high ground to not do.  Pin something to an individual vs a concept/idea.  In the comments he stated “Regarding outreach, I don’t engage anonymous people.”  So wait, you dont engage anonymous behavior except when it benefits your argument?  How does that work?

Second: This whole clusterfuck over something absolutely stupid makes me realize how much MD’s are gunning at each other.  How quick and petty they are to nail someone on the cross over something that (in the grand scope of whats out there) a non-issue.  Yes, she made a joke about pripiasm, but I’m sorry, dicks are funny, and a 36 hour boner (although a medical emergency) is going to get SOME reaction.  If I had a boner for 36 hours, after the 10 tubes of KY jelly and the absolute destruction of my wifes vagina, I’d painfully tweet about it on my way to the ER.  If she were a male would this be an issue? Of course not.  @BurbDoc doesn’t get thrown under the bus for the outrageous things he says, but her being a female the rules were obviously changed.  How unprofessional.

This is the same sort of shit that Scrubs is made of.  Do the masses think doctors are “unprofessional” after watching Scrubs?  Do they think that House is unprofessional?  No!  If the doctor is anonymous, and writes a few crude humor lines on a medical condition that could happen to say, ANYONE, whats the harm?  The poor gal was probably on call, stressed out, and wanted to get some sort of outside reaction from a case that us, anonymous internet medical people, would get a chuckle about.  Do I feverishly check all of twitter about the patient with a horrible case of hemorrhoids the moment I leave the doctors office? Of course not!  The humor on twitter could happen ANYWHERE, yet the MD population thinks that it can be narrowed down to ONE office out of 10000000 in the United States (if she is from there) instantly.

I’ll be blunt here.  Voicing your frustration means you care. Your patients aren’t perfect, their conditions aren’t perfect, and sooner or later you are going to have to blow off some steam and vent to those who are in the trenches with you.  If you just saw patients, collected your paycheck, and went home without a care in the world, you dont care about your patients because they didn’t have a personal impact on your life.  The world is far from perfect, and yes, I bitch about crackwhores/welfare/shitty state of pharmacy because I do care.  I do care about those abusing the system or the crackwhore mother who obviously cares more about her early norco refill than her child who is ignored.  I can’t solve the worlds problems and that gives me frustrations.  I bleed the relief valve on twitter and on here to keep myself from going insane.  Burnout is huge in the medical world, and if we; the faceless medical community from all races, specialties, locations, etc, are unable to joke, laugh, and support each other then thats just going to separate US from our patients.  All of us have been the butt of jokes, all of us are patients in one form or another but as long as nobody is singled out and no harm is done (intentional or unintentional), whats the harm?

But what do I know, to these MD’s im just a fucking pill counter who gets yelled at because Solodyn is 500 bucks and the patient cant afford it.

Oh, and to close this off, heres an awesome twitter quote: If I had a 36hr priapism and Dr. V was attending, one thing’s for sure: There’d be two prominent dicks in the room.

May 25th, 2011 by theangrypharmacist | 16 Comments »

My made up graduation speech

I’ve always wanted to speak at a pharmacy school graduation.  Give my thoughtful insight of my many years in the trenches of a profession that is going down the shitter faster than that burrito I had on cinco-de-mayo.  If I ever received the privilege of talking to a classroom full of new graduates and their parents, it would go something like this (before the school snipers took me out).

—–

Fellow graduates, family members, and friends.  We are gathered here today to celebrate a special person in your life and their accomplishments in recieving their Doctorate of Pharmacy degree from this wonderful instution.  Before you, in their regal cap and gowns, are your professors, who have worked day and night to mold the clay that you came in as into something that will help people.  Well ladies and gentlemen, let me tell you how this shit is going to go down once you enter the real world.

Look around you.  Go ahead, look around you.  Those smiling faces will be bitching at you as to why you are taking so long to fill their fucking prescription.  They will pester you on the phone about stupid shit like the price of condoms as your tech is texting his fucking girlfriend about the parking-lot blowjob he just received (nod to BKBJ, sorry I made your vagina sandy at work, pussy) while the backlog is out the fucking door.  See grandma over there? Shes proud of you now, but will demand you cater to every one of her fucking drug needs at this very moment, want free delivery after you have been on your feet for 10 hours, and make you special order the blue ones instead of the pink ones.  Oh, and she’ll say “I never paid last month” when she has; EVERY FUCKING MONTH.  Your uncle will be too stupid to have the Rx numbers, but will gladly call in “the pink ones, and the capsules that help him pee”.  Oh, and your parents? They will want “all my regular meds” and make you RTS all but the pain pills.

Your professors smugly sitting over there haven’t work a retail job since Lozol was trade name only.  Sure they can recite the pages from Lexi, but throw an angry patient in front of them and they cry to administration.  Maybe one day you can fill the heads of students with knowledge and not any practical retail skills.  Get working on that.

The “hard work” that you have accomplished with your royal sash of dark green is worth $1.50/Rx to the insurance companies.  Its worth even less to your employer that demand you fill 500 a day by yourself without the luxury of a lunch.  Oh, sure, they say you can take a lunch, if you want to get dinged on your metrics and be out of a job.  From here on out you go from student to the bitch of your employer, and the bitch of your patients.

You, in the back, stop your sniveling.  Yes, I know you just wasted $100k on an education, but its not MY fucking fault you haven’t stepped foot in a pharmacy until you graduated.  Moving on.

To those uppity students smugly smiling that you got a ‘residency’, prepare to be a doctors bitch.  Yeah, they will treat you like an ‘equal’ to your face, but you’ll just be their walking drug reference book and get made fun of in the lounge.  You’ll run the clinics that they don’t want to deal with and think you’re getting a good deal.  You’ll be walked all over by attendings and residents because you’re just a PharmD and they are an MD.  You’ll go to sleep at night with the feeling of “at least I’m not in retail, but I should of went to med school.”  You will live life as a “should have”.

Lets all cut the bullshit.  You didn’t go into pharmacy because you want to “help people” like those smiling idiots in APhA magazines, you did it for the fucking $100k/year salary.  Well I’m sorry to say, but a lot of professions make $100k a year, and that ship sailed without you about 3 years ago when you stepped foot on this campus.  Looking down on all of you, it reminds me of that time I visited the slaughterhouse.  All those cows walking in a single line unknowing that their life was about to get really shitty really quickly.

In closing, I would like to take a second to reflect on all the hard work you have done to further your career, and cheerfully remind you that I am at least 10 years ahead of you to retiring, if you make it to retirement age, with the MI you’ll have in 15 years.  Pray its a stroke, one that kills you quickly, at work, in front of a crowd, so your employer can get sued.  You’ll laugh and think I’m wrong now, but in about 10 years you’ll be singing my praises.  Don’t say I didn’t warn you.  Thanks.

—–

All joking aside, I really do with our new grads the best of luck as you enter into our profession (you’ll need it).  Its good to have you in the family, because misery LOVES company.

May 13th, 2011 by theangrypharmacist | 63 Comments »

Be a dick, get a gift card!

A wise man (OK, its my employer, fine) told me that the smartest investment a business can make is in its employees.  That’s right, happy employees mean productive employees which are good for the customer, business, everyone.

I sure as shit wouldn’t be happy if my employer rewarded complete dickhead patient behavior with gift-cards.  In fact, I’d feel like my employer feels that a shitty patient attitude is more of an asset than the feelings of its employees.  A feeling that my professional opinion/ethics is worth less than a $10 STFU gift-card.  Chain pharmacists, I don’t know why you put up with it.  Oh, its because they blew a bunch of smoke up your ass when you were in school (when you thought you knew everything), offered you a fat sign-on bonus in return for years of slavery, and now you’re stuck with a tech who paid $20k in schooling but asks you daily what the trade name of hydroxyzine is.  Lame.

So I hope Walgreens, Rite-Aid (15 mins!), CVS and the like need to listen the fuck up, because I’ll tell you why the profession is going down the shitter (and why we are treated so).  The mighty bribe..er..gift cards.  CorpoChains are shitting in their own beds for the sake of ‘loyalty’.

At my store, we have no gift-cards.  You treat me (or my staff) like shit and we politely ask what pharmacy you would like your Rx’s transferred to.  If you continue, you get the front door opened with your face.  We don’t reward asshat behavior (unless we REALLY REALLY FUCKED UP, then we deserve it), most (if not all) independents operate the same.  Its just common business sense!  If the pharmacy fucked up – sure, throw them a gift card to say that we’re sorry.  However word from the trenches is that they are throwing gift cards away to people who have complaints that are in no way the fault/responsibility of the pharmacist nor the pharmacy itself!  Chains, grow a pair of nuts and realize that the customer is usually dead-fucking-wrong!

Hey, if you are pissy because your doctor hasn’t responded to your vicodin request then you are FREE to go get a new Rx directly.  Upset because you have 0 refills? Your bottle clearly stated that fact when you picked it up, try reading it for once.  Don’t like this whole novel concept called “responsibility” and “planning ahead”? Go get your own MD license and you can write your own prescriptions.

Unhappy that we didn’t have all 120 of your Xeloda?  Are you unhappy that the pharmacy TOLD you that this was a special order and to call a week ahead (which you promptly forgot/ignored)?  I’d be happy to order you a year supply if you want to foot the $20,000+ tab and I’ll keep it safe for you.  Maybe a little inconvenience will pound into your thick skull to do what we tell you next month.

Pissed that we didn’t have the full amount of a trade-name item that only YOU take (and you didn’t call ahead like we asked)?  Well, I’m unhappy that my grocery store doesn’t have a certain brand of salad dressing in stock, yet you don’t see me raising a stink and demanding compensation via gift-cards.  Call ahead.

Pitching a shit-fit that you drove “all the way across town (2 miles)” to find that we’re still waiting for the refill authorization on your pain pills (even though the 10 maintenance meds are ready to go)?  Its called a phone, you have one in your pocket, its nicer than mine.  Amazing how you can know everything that your baby-daddy is doing behind your back yet you are unable to make a phone call to the pharmacy to see if your crack got approved.

Whats the solution to all of these scenarios?  Gift-cards to the loud-mouth crackhead by some ignorant store manager who couldn’t be a pharmacy tech if his/her life depended on it.

The chains are doing nothing but demoting the profession (if you still want to call it that) of pharmacy by rewarding patient complaints.  If your dog pissed on the carpet do you give him a treat?  The chain stores do! Rewarding such piss-poor behavior just breeds more bad behavior.  Shit-hole patient chainitude (that’s chain attitude, I’m so clever!) behavior spills over to independents, and god dammit we don’t give out fucking gift cards nor do we want your douche-canoe “Eye wanna gyft carrrd” patients!

So my in at the Low-Stock-Price-Leader says that Rite-Aid has this 15 min guarantee for when your vicodinprescription will be done.  If you don’t get your Rx in 15 mins you get a $5 gift card (insurance problems don’t count, some restrictions apply, see your friendly Rite-Aid associate for details, blah blah blah).  Now considering how short staffed most chain stores are, I’d rather them keep the $5 (the going rate for almost 5 shares of stock, no bullshit), have them take as long as needed, and have my Rx be correct (ie: not killing me).  In fact, this whole 15 min bullshit really pisses me off.  Who cares if your Rx wasn’t done in 15 mins or less (sounds like pizza delivery).  Guess what Rite-Aid; people die due to medication errors, people don’t die from a cold pizza. If you want to hold your pharmacists to the same standards as a pizza-worker, then expect the same quality of service of a pizza-worker.  Hope the impending lawsuits don’t push your stock to the point where you need to PAY people to claim ownership of it.  Oh wait, its $1.11 a share, strike that last statement.

In all honesty, I really do feel bad for the pharmacists, tech, and clerks who have to deal with their employer who puts the opinion of the public over their own employees.  Its one thing to offer something to a patient as compensation for a mistake, an oversight, or just plain forgetting (nobody shit smells better in this regard), but for a 15 min guarantee?  Way to value patient safety at a whopping $5.

March 14th, 2011 by theangrypharmacist | 253 Comments »

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