ATAP: What exactly do you do?

Welcome to another installment of Ask The Angry Pharmacist, where the most famous pharmacist on the planet (heh) answers YOUR questions and concerns in a not-so-nice (usually) way!
This is a genuine question, so I won’t be burning her at the stake (much) 🙂 For those of you new here, mail druglord@theangrypharmacist.com with your questions and I’ll answer them on here. Be warned that the answer may end up making fun of you, but I wont publish who you are.. 🙂

Dear Angry Pharmacist,
My husband and I, (physician and nurse practitioner, respectfully) recently found and subscribe to your blog. Wow. You really are one angry guy.
Before you go hating on us, if you knew us or worked with us peripherally, you would most likely put us in the category of “good guys”. We genuinely appreciate pharmacists who check dosages and allergies, and sincerely thank you if you catch a mistake on our part.
But humor me for just a minute and allow me to ask you something that Hubby and I have always wondered about. Please recognize this question comes from a combined total of over 18 years of higher education, and is meant with absolute respect and sincerity:
Just what is it that pharmacists DO?
We know you guys are smart…colleges don’t go around passing out Pharm D’s based on your looks. And from our own painful experience, we know there is more paperwork and red tape involved in your work than should be allowed by law. But I gotta tell you, from John Q. Public’s perspective, it appears that you guys have these huge bottles of pills in the back, count a few out, put them in a bottle, and put a label on it. Why does that require a doctorate and 7 years of college?
I’m being dead serious, not disrespectful. Oversimplifying it, yes, being jocular, yes, but I really am serious. Hubby and I are above average in intelligence. If we don’t know…and we actually WANT to know…then I am sure the docs with whom you regularly engage in sparring matches don’t have a clue. Even the ones with God complexes.
So, would you take the time to explain to us, and to your readers, what all you guys do? What you studied for 7 years? Maybe it would help them have a better appreciation for your intelligence and get that huge chip off of their shoulder.
(Who am I kidding? That chip is soldiered firmly onto said shoulder. But maybe some people would appreciate it…and you…more. We would.)
Thanks, TAP. Keep ranting.
Just The Nurse Practitioner

Well Nurse Practitioner, you partially answered your own question. How do you think we catch said mistakes and dosing errors and allergies without the 7 years of college? Most pharmacy computers marginally handle this (or go overboard with the interactions part) but almost all the time we do it off the cuff. Amazing isn’t it with all the drugs that are out there.
Let me run down for you what a typical Rx filling process goes like in retail:
1. Patient comes in with an Rx. We get the insurance information, personal information, allergies, etc.
2. Patient has 400 questions about OTC products, we answer those so they don’t bug you about if Tylenol will help their arthritis vs Ibuprofen.
3. We start to input the Rx into the computer. The computer, being a computer, spits back at us 900 drug interactions (99% which are theoretical and drug-food and drug-alcohol interactions) to which we blaze through sorting out the true interactions (warfarin and Codorone, Flagyl and Alcohol, etc) from the ones that are in the system because one idiot in Nebraska had it 30 years ago once. Knowing what is crap and what is a legit concern comes from the 7 years of college (however mostly experience).
4. We learn to find that the Rx is not covered. So we select the next best alternative that the insurance will cover and ask you to change.
5. We bill the insurance (to watch them reimburse us $3 over cost for all this work).
6. We tell the patient how to take it, as well as handle another 400 questions about if it will cause headache, diarrhea, anal seepage, hemorrhoids, when the next shipment of cards will be in, etc.
7. We send the patient on his/her way after a long discussion about how high the $1.05 copay is, and why he/she has to pay it.
8. We spend the next week getting phone-call after phone call from this patient about every little side effect that he/she is having claiming them to be ‘allergies’.
Now, this is if 1 person is bringing in an Rx. Most pharmacies have at least 3-5 (or more) of these processes going on at the same time with only 2 or 3 pharmacists to handle this. Add this with Dr’s and NP/PA’s calling at random times (which causes us to drop what we are doing and get the phone) and you have yourself quite a mess. We don’t get to shove people in rooms to wait and come around to them and work one on one. Imagine if you were seeing a patient in a big room, and someone just came in and tapped you on the shoulder derailing your train of thought. We shovel medical advice out the front door as the money is being spooned in through the window.
This doesn’t even touch on the clinical folks at the hospital who need to know what a patients renal or hepatic status is when selecting drugs. Try to give atenolol to someone with a GFR < 20 and you'll have quite a mess on your hands (hint: use metoprolol instead). Unless you're a specialty doc, we know as much (if not more) about drugs as you guys know about diagnosing stuff. Sure, any pharmacist can diagnose heart-failure, or diabetes, or hypertension just like any MD/NP/PA/etc knows the basic drugs to give, however when someone has no kidneys, or is in hepatic failure, or their insurance doesnt cover it, or how much Tylenol to give to a 4 month old baby, we don't have to look these up. Retail guys don't carry around PDA's or Tarascon (which is full of mistakes, be warned). Sure, we have Lexicomp or a Facts around for the weird stuff, but all the things that you have to look up we know off the cuff. Plus retail folk don't get their heads polluted with drug-company shit from the reps (which reminds me, I need to rag on the reps some more). Finally, (this is a big one), most (if not all) pharmacists have a uncanny ability to translate medical -> commoner. Doctors are notorious for using medical-speak to patients (which sound scary and just confuses them). We are the ones who get the “what does this word mean” when patients get the warning from their doctors about rabdo with statins. We are good at bridging the gap between a very precise big-latin-word based language to the language that is used by people with annoying song ring-tones on their cell phones.
I hope this answers your question, I’m sure that the commenters out there will add on what I leave out.

The word of the day is WORK

If anyone would come up to me while I’m filling Rx’s and say “Boy, you look like you’re hard at work” I would just give a casual smile and continue along.

However, that line coming from someone who is on welfare is like nails on chalkboard.  On Monday, the busiest day for pharmacies everywhere, having someone on welfare come in and say “Boy you all look like you’re just hard at work! Are my “Soma’s” ready?” makes me just want to leap over the counter and ninja-kick them in the forehead. 

Yes, I am hard at work,  you know, that strange word that is the holy-water against your evil lazy soul.  ‘Work’ is in the same category as ‘abstinence’ in your ghettoictionary.  Actually, I’m surprised you know what this foreign ‘work’ is, moreover,  maybe you should try this foreign concept called ‘work’, you might actually like it.

I’ve been tempted to say to them “you know, by me WORKING it allows you to get your Nexium and your “Vico-DANS 750’s” for free, so I would just leave me be so I can WORK rather than disturb me with stupid questions like when the next shipment of greeting cards or earrings are arriving.”  Yes, people do interrupt me with such important questions such as these.  Fuck going to school for 7 years, just tell them when 90 pills at 3/day dosing is due and when the next shipment of earrings come in.

People who brag about how nice it is outside also have the same nerve-grating effect on me.  Yes, you have told me 4 times already how wonderful it is outside.  However, I, being the responsible one out of us two, need to WORK so you can continue to sit outside enjoying the wonderful weather and NOT WORK.  So, until that time which you actually get off of your lazy ass and WORK to support ME, I shall have to view the wonderful day through the glass that is the front of the store.  Thanks for playing, go fuck yourself.

Don’t get me started about welfare folk who sit and BRAG to me about the wonderful vacation they have lined up.  I’m tempted to say “you realize that vacation implies that you WORK, thereby a vacation is time off of WORK.  Your life, in fact, is one giant vacation because you DO NOT WORK”.  Do you know what happens when I do not WORK, I starve.

You’re right, its jealosy that I’m stuck in a box for 9 hours a day dealing with the sick, entitlement-stricken, rude, ungrateful, pushy, “WAH POOR ME”, asshole public while they can do whatever they want all day every day and have their basic needs taken care of by the nanny-state.  Sure I have nice things that they don’t have, but I also WORKED for these things rather than skate by and take the lazy way out.  I’ve made the choice to WORK when they have made the choice to get-a-doctor-to-sign-SSI-paperwork-to-avoid-WORK.

I want to get all the doctors to just blindly sign off SSI paperwork, round them up, and firmly implant my boot where their scroatums should be.

Paging Dr Dave… Your douche is ready..

Out of your options for refusing to help with the current (non)
cutbacks (see, that is what a court order does genius, STOPS something
from being implemented, hence NO 10% cut….oh, skip trying to explain
THIS to a pharmacist) I must take option 3 below.

Genius? Me? Did you even read the first paragraph of that last entry? You know, the one that I said “However, last Saturday the courts overturned the ruling until 8/11/08. Their computer systems still have the 10% cut, but they will let us know how they wish to deal with that ball of wax once the shit stops falling from the sky in the legal department.”
Update: Got the fax yesterday saying that the 10% cuts are here to stay. The injunction was injuncted upon by yet another injunction reversing the injunction-junction (whats your function). Yeah, I cant believe it either. This is really going to suck.

1. Lazy
2. A dick
3. Think so little of us that you don’t give two shakes of a mouses
dick what happens to us.
4. Have some ill-gotten god-complex that fell out of fad about 20 years
ago when managed care/insurance companies snipped off your scroatum and
dangled it in front of your face while saying ‘HAW HAW’
4. All of the above
Since most pharmacists I have to deal with here are 1, 2, 4 and (the
other) 4 (with THAT counting ability can you wonder why I doubt the
competence of most people in your business? 5 comes after 4 genius!). I
really think 3 is my own position. Sorry you won’t get a 150% markup on
your generics for a while, but in case you didn’t notice, the Feds
tried to do the exact same thing to us, and it fell through too. The
10% cut will also die on the vine thanks to the court order.

Yeah, I did put 4 twice. Sorry, my mistake. Thanks for pointing that out to me in the most asshole way possible. I originally had 4 be “all of the above”, but then I decided to add something in about the god-complexes that you oh-so-quaintly have shown everyone still exists.

Unless the PHARMACISTS start lobbying. When they are through WE will
have to pay the State….

Uh, we’re lobbing the hell out of the state. However lobbying does only so much when the state is 1000 trillion dollars is debt.

Here is my own quiz, based on the previous model:
Most, but not all pharmacists are:
1. Lazy
2. A dick
3. Think so little of everyone BUT themselves that they don’t give two
shakes of a mouses dick what happens to us.
4. Have some ill-gotten god-complex that fell out of fad about 20 years
ago when managed care/insurance companies snipped off your scrotum and
dangled it in front of your face while saying ‘HAW HAW’
4 (which SHOULD be 5 – leave it to a pharmacist). All of the above

Thats cute, just copy and paste what I wrote. I can see now how you got through medical school.
— Round 2 —

I am NOT a chronic pain patient, I am a practicing physician and I am
absolutely sick and tired of idiot pharmacists having a bad day calling
me to tell me what I fucked up on my scripts.

Then don’t fuck up on your scripts 🙂 Seriously, do you think we want to sit there and waste our time calling your obviously unhappy soul to tell you what you messed up on? Do you think it gets us off to be yelled at by some doctor who obviously takes his frustrations out on his office staff and the pharmacist who calls to save his ass? No.

If I wrote a particular
treatment prescription I did it for a reason. Please don’t argue with
me as you attempt to be so many amateur physicians. I realize that you
went to 5 years of school to learn pharmacology, and I respect that.
What I can NOT stand is that fact that none of you seem to respect that
I and my colleagues went to school for 10-12 years and, whether you
want to hear it or admit it, know a fuck of a lot more about medicine
and pharmacology, and more importantly how they interact and will
effect OUR patients than most of the arrogant, self absorbed, insecure
pharmacists that call to tell me I can’t prescribe A with B.

See, the fact of the matter is that if we just “fill the prescription” and the patient dies due to your arrogance and stupidity, then we are at fault just as you are. However if we call and you make our requests known (and obviously document it), then when your arrogance and “10-12 years of school” kills someone (or lands them into the hospital), we don’t get hauled into court. Well, I take that back, we do get hauled into court, and there is no doubt that you would lie and say that you didn’t talk with us about our concerns.
Now due to the condescending asshole tone of this email, I have no doubt in my mind that if we are sitting both in court, the very first thing you would do is point at me and said “THE PHARMACIST SHOULD OF CAUGHT THE MISTAKE” (even though you bitch here that we bug you too much).

Shut up
and fill the fucking scripts unless you are damn sure there is a
mistake. As I get at least two dozen calls a day between “corrective”
calls about my prescribing and suspicions about my patients that I
prescribe anything stronger than Ibuprofen, it gets ridiculous.
Pharm D? THAT is a fucking joke!

Two dozen calls a day? Okay, either this figure is way out of line, or you are prescribing some really shady shit to some shady people. “Just fill the fucking script” doesn’t quite work if the patient received 100 norco from another pharmacy yesterday.
You see Dr Dave, this whole situation really smells fishy. Most pain management clinics really have no problems with pharmacists and pharmacists don’t have a problem with them UNLESS a huge red flag comes up. If “two dozen” pharmacists are calling you about your “prescribing and suspicions” about your patients then obviously you aren’t just giving out Amioderone to a patient on Warfarin (which your ****10 YEARS OF SCHOOLING!@!@#!@$**** should tell you why that one is a biggie). So tell us Dr Dave, how many gallons of Norco do you write out on a daily basis to have all the pharmacists on alert? Have your Rx’s (and patients) been booted out of every pharmacist in town? Is that why you are so hateful?
You see, part of being a pharmacist is that you get good at sifting through the bullshit.

You’re either with us or … a huge douche!

As you have read before, California instated a 10% cut for its Medicaid Rx reimbursement.  However, last Saturday the courts overturned the ruling until 8/11/08.  Their computer systems still have the 10% cut, but they will let us know how they wish to deal with that ball of wax once the shit stops falling from the sky in the legal department.

Now, I don’t do this very often so you might want to bookmark/take a picture of this page.  The doctors have done a tremendous job in helping the local pharmacies keep their doors open and their paychecks from bouncing.  They have been more than receptive and more than helpful in switching their patients to generic drugs with little to no prior notice.  For how much shit I talk on doctors on here, they really helped us out.

However (you knew this was coming):

There seems to be a few doctors in town who did not get the memo.  You see, when we fax you a nice little note explaining the cuts and if we can switch our patients to something that cost less (so we wont lose money when we fill what the drug reps sucked you off to prescribe), and you write a big NO on it, that really upsets us.  Its not like you’re a cardiologist or writing for weird stuff like Tekturna.  Denying our request  from Nexium to OTC Prilosec isn’t rocket science, and obviously you must of slept through that class to realize how much power pharmacists have.  In fact, blanket denying everything that we send you to switch with a NO means that you are either:

1. Lazy
2. A dick
3. Think so little of us that you don’t give two shakes of a mouses dick what happens to us.
4. Have some ill-gotten god-complex that fell out of fad about 20 years ago when managed care/insurance companies snipped off your scroatum and dangled it in front of your face while saying ‘HAW HAW’
4. All of the above

Like I said before, this isn’t rocket science.  If I would of said that the insurance didn’t cover this medication you would of switched it in a hot second, but because we asked for a professional favor you decide to shit in your hand and rub it in our faces.

However, Pharmacists (believe it or not) like to take the high road.  So when your patient has a stupid medical question like what to take when they are constipated, we will not refer them to you and waste your precious doctor-time.  When potential new patients come and ask what we think of you, we won’t say that you are a flamboyant small-penis douche who hates pharmacists.  We wont make you wait an hour on hold or happen to forget to fax over that med list that one of your dropout front-end girls called and sorta-asked for in something-that-resembled-english.  I’ll look the other way when your minimum wage hired help totally fucks up.  Oh, and when you call me personally for a favor, I will (with a smile on my face), not bring up the time you totally FUCKED us when the cuts happened.  You see, we have professional courtesy, and even though you may bad-mouth us to your patients, we spend 10000x more time with them than you, so they’ll STILL come to us regardless what you say.

To all the doctors who stood up to help small pharmacies stay in business during the cuts, we love you.  We’ll refer patients to you, we’ll sing your praises from when the gates open until the gates close.  We’ll buy you drinks at the CE dinners (heh, they reps buy the drinks, but they dont know that) and run medication by your house late at night when your kids are sick.  We’ll cover for you when you write that Amoxicillin Rx to someone that you knew had a Pencillin allergy but just brain-farted.  We will drop everything to happily look up something that you just as easily could of looked up on your palm-pilot.  We’ll give you our cell phone numbers and open the store at night for those once-a-year emergencies involving a screaming grandchild, zithromax suspension and some auralgan (the original cheap one) drops.

To all the doctors who decided to not answer our pleas for help.  Eat shit.  The cards are down, and we know where you stand.  We will still treat you with respect, but excuse us always looking over our shoulder for the knife when the shit hits the fan.  We are more than just pill counters, and you are damn lucky that (unlike you) we have the moral and ethics to show you exactly how much influence over the patients we have.

Only the pain pills please

Photo_052208_001.jpg

This is a note that I get paperclipped by my clerks to an Rx on a somehwhat daily basis.  Gee, what other med would this person ever need when he/she is getting vicodin and soma?

For your information (and morbid curiosity), the “other med” was some lisinopril.  A whopping $6 worth of medication and although will not give the “buzz” that the vicodin and soma cocktail will give you, will obviously prolong your meaningless life.

I don’t even know why I put up with crap like this.  However at least this was only blood pressure medications and not antibiotics (or their child’s asthma medication).  If you want to screw yourself over by loading up on pain pills thats fine, however don’t subject your kids to your dependence and problems.

Thanks for letting me know you’re not an addict

Never fails.  I write a long rant about some addict and pain pills and no less than 3 months later I have 100 comments that all start with:

“I’m a chronic pain patient that takes 120 norco a month blah blah blah life story life story life story I dont think its fair that you say we are an addicts”.  That sounds about as smart as “Hi, I’m black, but I’m not a criminal”.  What the fuck people!

Where have I ever said “If you are on opioid x you are an addict”?  Seriously, point it out.  I’m tired of the whole “I have chronic pain so everyone thinks I’m an addict” pity party that I see more and more of.  So here is the post that sets the record straight.

Top signs that us pharmacists (or just me) that you are indeed need either some pain management consultation or just want to put gas in that escalade.

  • You cannot divide 90/3 to determine when you are due for your next refill.  90 tablets at 3 times a day is 1 month (30 days).  When you run out you are due for a refill.  Simple.
  • You appear to be either the most unluckiest (or stupidest) person on the planet.  Your house gets broken into every other day, your brother runs off with your pain pills, they are vaporized in an auto crash, flushed down the toliet, exploded, maimed, got wet, excuse, excuse, excuse.  Then, excuse excuse excuse.  “So heres what happened…. excuse excuse excuse”.  Not once, oh no, but every fucking month there is some drama or issue involving your pain pills being filled early, not late, but early.
    • Sometimes shit happens and you need an early refill once a year, thats cool, I understand.  No, this is every fucking month.  Get that everyone? Every month.
  • When I see your half-awake ass stumble into my store at 2pm and the very first words out of your mouth are “WHEN ARE MY SOMA DUE AGAIN” when you called me an hour ago and completely forgot you asked me the same thing.
  • You walk into my store loaded out of your mind.  Not just like “feeling good” loaded.  I’m talking about harvesting your blood to use in anesthesiology loaded.  Eyes are not supposed to roll back in your head or point in different directions when you are attempting to have a conversation with me.
  • When I see you walk outside the pharmacy, open up the pill bottle of soma, and GIVE A FEW TO YOUR FRIENDS OUTSIDE THE DOOR. Enough said right there.
  • When I say they are too early to be filled, you say “Well I’ll pay cash for them! I’ll pay double cash price!”  No way, bribing your pharmacist is not going to get you the pain pills early.

So the take-home message is, unless you obviously make it known that you have an issue, you have no issue. 🙂

California Medicaid Cuts – Ground Zero

Yesterday the California Medicaid system (Medi-Cal) cut reimbursements by 10% across the boards for Doctors, Dentists and Pharmacies.  For pharmacies this was both the dispensing fee AND the drug cost reimbursement.

Yesterday is also the day where if your MediCal Rx costs over $150, pharmacies will lose money due to the state reimbursing below the dead net cost.  See that Risperdal prescription that cost the pharmacy $200? The pharmacy lost $30 on that deal (reimbursed $170).  What makes this obvious clusterfuck more amusing, is that the state has under the table “rebates” ie: kickbacks that mandate certain trade drugs.  See generic prilosec? The state only reimburses for Nexium and Prevacid (now at $30 BELOW NET COST per Rx!).  If the state and Big Pharma would stop space-docking (go look that one up), maybe the state would not be in such a money-hole.  Wait, that makes sense.  What also would of made sense is a 5% cut on trade name drugs and a 15% cut on generics.  Hold on, does the state have any actual “real” pharmacists working for them or are they just “advisors” (ie: couldnt cut it in the ‘real world’ so they had to ‘advise’) who shake hands at the APhA meetings while giving back-room handjobs.  Was this 10% cut just an arbitrary figure by some suit in Sacramento who obviously doesn’t have to deal the fallout? Sure is.  Again, retail pharmacy is the human shield for the idiots in power.

No doubt that California is in a money-hole, but instead of sucking up some form of balls and a backbone and kicking people OFF of the welfare system who obviously should be out working (and contributing to the society that they gleefully suck the life out of (and make more babies for)), they just cut the reimbursement to the people who actually take care of them.   Is there a real legit reason why the 27 year old male who walks into my store should be on the state system with his car stereo blaring the bass out in front?

The state probably thinks that pharmacists and doctors are all rich, they can just work for free!  Yeah, fuck you.  I didn’t put the time and effort to go to school and make something of myself to work for free.  At this rate I should of just been on welfare like everyone else.  California’s tried-and-true idea of a “solution” is to just throw money at the problem and hope it goes away.  Well, I’m sorry, it didn’t and now people EXPECT the state to hold their cock while they pee, wipe their asses when they shit, and $0 copays for everything!  You created this situation and now you expect US to take it in the ass for you.  Again, fuck you.  Its common knowledge that you don’t shit in your own bed, and you dont cut down the trees that provide you with food.

Oh, and because shitting in the faces of the working professionals wasn’t enough, the other insurance companies will look at us and say “Well, if the State can pay you shit, and you deal, then WE can pay you shit and you can also deal”.  Can you all see where this is going?

Heres something else that the State obviously didn’t consider.  What are the highest dollar medications we have.  Ones that there are next to zero generics and people obviously cant switch to something else:

  • Retrovirals (HIV baby!)
  • Cancer/Chemotherapy
  • Atypical Antipsychotics (sorta, haldol is always an option. We can always bring back Clozeril! heh)

So the state now have put pharmacies in a very very tough spot.  Does the pharmacy lose $100 on that $700 HIV medication for their patient, or do they tell the patient “sorry bud, you up shit creek”.  Do those fucked up politicians need to look at that patient in the eyes and tell him/her “Sorry.  You cannot get your medications to prolong your existance because the store cant afford to lose $300 on your 4 HIV meds”.  No, they dont.  Maybe they should though.   Pharmacies (and their patients) that do a ton of mental health/HIV/Chemo drugs are absolutely fucked beyond belief.  Not just a little fucked, but full-on bend-over-bubba fucked. 

So to the California representives who made this clusterfuck:
I refuse to fill an Rx for below cost.  You know those expensive psych meds like Risperdal, Zyprexa, etc? Those aren’t going to get filled.  Maybe you should use your powers of penile stimulation on Big Pharma or just grow a pair of balls and start booting people off of the system.  Doctors aren’t going to take MediCal anymore, pharmacies are going to refuse to fill (ie: not stock) expensive trade name drugs and these people are going to go to their nearest ER at $500/visit to get care.  You shit in your bed, YOU think of a different way to fix it other than letting the shit roll downhill on retail pharmacy.

I forsee many MediCal patients not recieving their medications unless the State pulls their collective heads out of their asses and do something.  Stay tuned for more F-Bombs directed at the People’s Republic of Kalifornia.