Category Archives: Doctors and Stuff

The FDA obviously hates the public and needs to lay off the crack pipe.

Submitted by a shitpot full of people, the FDA has gotten this wonderful idea to allow people (read: idiots) to buy Rx prescriptions OTC using a kiosk rather than a Doctor to issue the Rx.

The jist of the article (for those too lazy to read it), is that you would go to a kiosk, and via a handy flow chart be able to obtain an Rx for antibiotics (!!) hypertension medication, cholestrol medicine, etc without seeing a doctor.  Your helpful pharmacist would help you from then on out.  Yeah, as if that’s going to magically make you become more compliant.  I’ll get right on that after my job as the vicodin-police, insurance agent, and your personal fucking nanny are done.

Lets take a journal into sarcastic TAP-land:

I think this is a completely fucking great idea!  We all know that Rx medications are completely safe, require no professional monitoring, and can cause no harm to the patient.  I mean who in the fuck cares if your potassium goes through the roof when you’re on an ACE-I, or if you get rhabo while on that statin.  This whole Rx concept is obviously a cartel plot by the medical industry to milk you out of copay money to line the pockets of BMW driving doctors as they light their cigars with your crisp $100 bills gotten from your copays.  Its not like those doctors know any more than the crackhead off the street…..

Shit, this whole idea of people just making shit up at kiosks to get a truckload of antibiotics is such a good idea!  We all know that antibiotic resistance is just a big fucking lie made up by the pharmaceutical industry so they can push their ‘newer’ expensive antibiotics to leech the consumer dry.  In fact, all of medicine is a big fucking lie meant to milk you out of your hard earned cash.  See this MD/PharmD degree? Thats just made up letters that we got from a mail-order school.

Travelling back to real-life common-sense land:

This whole clusterfuck was meant to save the patient money they would have spent seeing a doctor.  Because thats SO MUCH FUCKING LESS than say a hospital admit because your potassium shot up to 12, your kidneys stopped working because you have renal issues and had to get that ACE-I, or because MRSA is eating your face off.  Not to mention the tons of other issues that come with taking A CONTROLLED FUCKING POISON that externally influences certain enzymes and receptors in your body thereby circumventing your body’s own natural regulation pathways.  Oh shit, you didn’t know that most (if not all) drugs did that? Actually I’m sure you probably thought medications were made from unicorn farts that magically made you better.

Here is a fucking great idea, why don’t you use your doctor to DIAGNOSE whats wrong with you, and have the pharmacist PICK OUT THE RIGHT MEDICATION.   I mean we all know that 90% of our time is just faxing the doctor for a drug change because its the insurance company, not your doctor who decides what drug you get.  Tell us whats wrong with you, any lab values that we might find useful, and let US pick out the most effective and affordable drug.  Pharmacists are immune to the drug-rep masturbation, we (for the most part) know our shit, and our ass is on the line with you by default if the shit goes south.  The hard cold fact is that MD’s are good at figuring out whats wrong with you, and WE are good at what drugs to use.  Same coin? Different side? Sound familiar?  Obviously not to the FDA.

If the APhA is all about this, its just more evidence that they are focused at planting new pharmacy trees while the retail pharmacist forest behind them is burning to the ground.  Why are they always ignoring what needs to be fixed in lieu of added work for no added money for us?

Oh, and if you are thinking “Well it works in Mexico”, take a second and think about what happens if you take something and die in Mexico.  Do you get to sue someone? Do you get compensation from the manufacturers? Nope, you get a dirt-nap and a “Oh thats too bad”.

But really, what the fuck do I know.  I just count by 5’s all day while watching Dr Oz and drinking coffee.

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.


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.

The MD’s guide to an RPh

Lets face it, part of our jobs is dealing with Doctors of all shapes, sizes and colors.  As you can see from this website, Pharmacists are a unique and special bunch.  I hope this guide helps our MD readers out there (you cant hide from us!) understand and interact with us a bit easier.  If some MD makes an “RPh’s guide to an MD” let me know and I’ll link it here.

Both MD’s and RPh’s need to drop the egos: Face the facts, MD’s aren’t the proverbial God of medicine anymore.  The whole concept of a pharmacist being an MD’s bitch died when Lanoxin went generic (no, I wasn’t around for that).  We both need to look at each other as allies against “to better the health of” the patient.  Fortunately the doctors who pull the “This is Dr OldFart, I need this for the patient, I don’t care if its not covered do what I say *click*” are either close to retiring or already dead.  Doctors can’t afford to stock their offices with $100k worth of expensive trade-name drugs, and pharmacists can’t prescribe stuff.  Its mutual destruction if one of us goes under, so lets stick together and drop the egos. (me, the biggest pharmacy ego on the internet saying to drop the egos.  I’m talking about at work, not on the internet!)

MD’s need to stamp their prescriptions: If you don’t have a stamp (and your pads don’t pre-print your name) , print your name and DEA/NPI on every prescription.  Then spend the $4 and get a stamp after your pen explodes after the 4th Rx of the day.  Having the correct doctors name on the Rx saves a ton of time for refill requests, and prevents us from playing “guess the signature” as the patient sits there staring at us.  Oh, and you think the patient knows your name?  Unless your name is “that Indian doctor”, “the doctor who I cant understand”, or “that cute doctor on 4th street with the huge tits” (no, I’m not joking); get a stamp.

Allow us to substitute in the same class: Unless there is some HUGE issue with dispensing Aciphex instead of Protonix, please write “OK to substitute per formulary” on Rx’s that you write.  We went to school to dose drugs in the same class into ballpark ranges.  This is what we are taught to do.  Trust in our judgment!  If this doesn’t convince you, lets look at the time savings:

Drug isn’t covered.  We make a copy of the Rx and write down whats covered.  We fax it to your office where someone that you pay stops answering phone calls to take the fax and put it on your desk.  You need to look at the fax, roll your eyes at the bullshit that the insurance companies make us go through and write “OK”.  Your staff then faxes it back to us where one of our clerks pulls out the original (in case the fax was lost in transmission) and gives it to us.  All of this happens while the patient is cursing your name as to why you wrote for a drug that costs $150 when her copay should be only $15 (or $0, most likely $0) as if you know her shitty insurance formulary by heart.  By spending 10 seconds to give us permission to substitute, look at how much time everyone saves and makes you (and us) look like rock-stars to the patient.  The “Its not covered” speech turns into “What doctor wrote for isn’t covered, but he/she gave me permission to switch it to what is covered”.  I’m no longer the bearer of bad news, but your wonder-twin counterpart.

Obviously this wouldn’t apply to tweaky drugs, we (I hope) know when something is over our heads and wont try to wing a Depakote dose because Lamictal isn’t covered.  If this bothers you, we can even FAX you what we switched it to.  Trust us, seriously.  Trusting the insurance company (who is telling you what to write regardless of what you say) over us is pretty shitty.

Nobody’s shit smells any better than the other: Sometimes pharmacists fuck up.  Benazepril gets dispensed instead of lisinopril, a 4 turns into a 1, I misread your lamisil for lamictal, anything can happen.  We both make mistakes, and having a doctor throw me under the bus to the patient (or having him/her call me up and just give me both barrels) makes me more shitty than how I already feel when I make an error.  When you write for something that has a life-threatening interaction, we “fax you for clarification” not throw you under the bus and tell the patient that you almost killed him/her.  We are both busy, we both make mistakes.  Lets not finger point, because in reality when that happens we both lose.

We need to talk more: No, this isn’t a chapter in some relationship self-help book.  We need to stop using our minimum-wage staff’s as proxies and just call each other directly.  This is going to sound sappy, but I love it when a doctor call me and asks me if something is covered, or how much something costs.  Hell, even to bitch about this patient and what to give him/her to get them off of our backs.  This makes us feel like part of the “team” than just pill-pushing human shields to the medicine side of health care.  Yeah, we both are swamped all the time.  A 30 second phone call as to whats covered will save us 20 min’s (and lots of bitching) later on down the road.  You want to know the real scoop on a new drug that some big-titted rep is pushing?  Give us a call, we’ll tell you how the drug she was pushing a year ago is going generic soon so she’s pushing the “new version” to keep the sale.  Hell, even a simple “thanks” for informing you of a narc-shopper makes us feel like we did something good.  Remember, pharmacists are the underestimated fat-kid of the football team of medicine.

Show us you care by giving us lots of refills: Mrs Jones has been on Atenolol 50 since the day it first same out.  Why not give us 12 refills on that new Rx that you wrote for her?  Help us save time (and thereby saving you and your staff time) by giving a bunch of refills on drugs that the patient has been on for years (and you have no plans to change).  Obviously I don’t mean stuff that you need labs to monitor!

Med dosage/sig change? Write a new Rx: Telling the patient to take a medication differently without writing a new Rx is about as effective as giving a stripper $100 and asking for change (uh, don’t ask me how I know this).  Save us both a fax and just write/call in a new Rx for any dosing changes.  Our computer systems can put new Rxs on file for future fillings, so it just makes sense to make both of our lives easier.  Spend 30 seconds now or 20 mins (and lots of phone calls by the patient) later.

Want to know the scoop on a patient? Ask us! Patients will tell you what you want to hear so you’ll give them an Rx.  However we see when they are getting their refills, who they go to, and how they act.  The patient that complains of a 10/10 low back pain to you may waltz into the pharmacy like nothing is wrong.  You may not see how your patients act outside of your office, but we do.  We usually see your patients enough to get a good gut feeling if something fishy is going on with them.  If we don’t know, then their insurance company computers can tell us if they have been naughty or nice (like Santa!).

Hope this helps.  I’m sure other pharmacists will comment on points that I missed.

Why help those who refuse to help themselves?

There is a common saying that goes “You cannot help someone who will not help themselves”.  Pharmacists deal with patients like these day in and day out.  Patients who get prescriptions from their doctor only to have them sit unused on the shelves to be brought to you for refills months after months.  These are the patients who give you a bottle to refill that has 28 out of 30 tablets left in it (but the vicodin bottle is stone empty).  These are the patients who you see the drug dosages increase and increase then switched to something thats expensive (and not covered) only to sit there and expire on them.  We do the prior auths, we go through the filling procedure to RTS them a month later, we send refill requests to the doctors to have them waste money paying office staff to respond to them.  Its a big waste of time and money for everyone involved EXCEPT the patient.

What does a pharmacist do at this point?  Does he try to have a “Come to Jesus” meeting with someone who obviously has no regard for their health?  After all, healthcare is “free” to them, they can just take an ambulance ride to a cushy ER at some paid-for-by-tax-dollar establishment.  Or does he/she see the writing on the wall and just fill the Rx knowing full well it won’t be taken.  We all know that the moment you refuse to fill that Rx they are going to die and you’re livelihood is in jeopardy in some civil suit.

What does an MD do at this point?  Does he/she shit-can the patient only to have him/her die of some complication and get his life ruined by a suit brought upon by the family?  Does he/she write for more medication just to cover his/her ass knowing full well it won’t be taken?  Does he/she waste his/her time filtering the piss out of the ocean when there are other patients out there who need the help?

What does a healthcare professional do when the patient really doesn’t give two shits about his/her own health?  Tough question, no real cut-and-dry answer.  If the patient dies, someone is getting sued; be it me, the doctor, the hospital, someone.  Even if the patient’s family loses the suit, you still have to deal with the mental/financial bullshit that goes along getting sued.  After all, its everyone’s fault but the patient.

A big contributor to this problem is that the patient really isn’t forced to care about his/her health.  Like I said before, the medication is free, hospital visits are free, and the proverbial “You can’t get blood out of a rock” comes true when the bill arrives for services rendered for their irresponsibility.  These patients have nothing but what the state gives them, and have nothing to lose.  So what if I’m 500 lbs and my HbA1c is around what my IQ is, I know that if the shit hits the fan I can go to the ER and get treated for “free”.  Theres no burden/penality on the patients to take care of themselves, and (much like everything in life) the responsible people end up paying the price.  People in other countries would cut their testicles off for just a smidgen of wasted care that is taken for granted here.

I hate to say it, but I think know the healthcare system is going to implode on itself in the next 15 years (if that).  There are way too many irresponsible people sapping the resources that the responsible people produce.  Nobody cares about their health anymore, and the people that do are the ones paying out the ass for services that cost a truckload to compensate for the loss accrued by the irresponsible.

You may think that I’m blowing smoke out up your ass, but take a look around next time you are in a public place at the amount of morbidly obese people are mouth-breathing around.  Look at their kids and the crap they stuff into their face at an alarming rate.  Its not ignorance thats fueling this, its the simple fact that when push comes to shove they will get treatment without payment.  We are afraid to say “You did this to yourself, you deal with it” because of some bullshit excuse like “its not their fault”.  You may think that sounds uncaring and callous, but take a second out of your candyland outlook and look around you at the people who are pissing their health down the toilet on your dime just because they can.

Healthcare is a business, All of us; doctors, pharmacists, nurses, PAs, NPs, and the staff that help us all have bills to pay and families to provide for.  Charity won’t put food on the table, and the sooner you realize this the better off you are.  If you want charity and “helping those in need” then work for free and see how far that gets you.

I hope you link this jaded-yet-true article on your website/forums/whatever, because I’d really like to know how this problem can be fixed/should be fixed or what we can do short of just making as much money as we can before the entire system explodes and we’re all out of work.

Most complex concept in medicine – the Do Not Substitute box

I’ve ranted about how DAW-1s in the past, however a good chunk of “doctors” out there cant seem to understand exactly what it means when that “Do Not Substitute” box is checked.  I use the word “doctors” in quotes because I am also referring to people who write prescriptions such as NP, PA’s and the extremely clueless Dentists and Certified Nurse Midwifes.

In California (and pretty much every state), pharmacist have the authority (which are few and far between, trust me) to switch from a brand name drug (Prilosec) to an FDA rated generic alternative (Omeprazole).  We can do this all by ourselves!  7 years of college and a doctorate degree and doctors have trusted us with the power to switch the Brand to the Generic of a SINGLE DRUG without their all-knowing permission.  I’m sure that when this law was snuck under the doctors nose they shit all over themselves!  In fact, most pharmacists love it when doctors write the old brand name because I’d rather see “Adderall” than “Mixed Amphetaminescribblescribbledontknowwhatcomesnext”.

Now here is where the confusion comes in.  That little box that says “Do Not Substitute”, that is to prevent us from switching from the BRAND name to the FDA approve generic FOR THAT DRUG.  Idiots seem to think that we have the authority to switch from a Brand name to ANY GENERIC, we don’t.  Unless you work for a hospital, have some P&T committee overseeing you, or have some collaborative practice agreement; pharmacists CANNOT switch to a completely different drug (even in the same class) without the doctors approval.  We can just switch from the BRAND to the GENERIC of the SAME CHEMICAL.  See how simple? Obviously not.

What blows my mind is when Dentists (*sigh*) check that box and write for Amoxicillin and Ibuprofen.  So I read that the Dentist (*double sigh*)  does not want me to auto-substitute a generic for… the… generic that he/she… uh.. just wrote for…. yeah.  Certified Nurse Midwifes (uh, yeah, they can write for Rx’s and we cant, how’s that kick in the nuts towards our profession) LOVE to forbid me from substituting Docusate.. uh.. for docusate… hmm..  These people have prescriptive authorities?  They don’t even understand what that damn little box means!  “Oh, I don’t want this pharmacist substituting a generic alternative for this GENERIC THAT I’M GOING TO WRITE FOR!”  I’m sure that DDS’s and CNM’s have their reasons for needing prescriptive authority, they could at least do their profession some justice by not sloppily abusing that privilege.

The other end of the spectrum is when MD/NP/PA’s write for Lipitor and check the little idiot “Do Not Substitute (DNS)” box.  Uh, is there a generic out for Lipitor?  Why are you preventing me from switching to a generic that hasn’t even come out yet?  Do you even know what that little box does?  Obviously not.  Single-source drugs (meaning drugs that come from one source, hence the name) doesn’t require you to check the little “DNS” box because there isn’t anything to substitute them for (hence, single source)!

Then you call the doctor up and call him on it because obviously the insurance company is NOT going to pay for a brand name that costs 100x more than the generic just because he checked a little box.  What response did you get?  “Oh, the generic is fine.”  I really feel like answering “WASTE MORE OF MY TIME BY CHECKING THAT MOTHERFUCKING BOX YOU ASSHOLE!!”  Doctors can be so damn frustrating at times.  All that college and they can’t understand a simple concept like the DNS box on their Rx pads.

Don’t get me started on OB/GYN’s and checking that fucking box on prenatal vitamins or iron tablets.

If the state allowed us to switch a non-covered brand to a class-equivalent brand/generic (meaning switch the whole drug to another in the same class) then I can see them checking the box for everything.  However we can’t switch drugs, so checking that box just because you have no idea what it means just makes yourself look like an idiot.

This has been a Public Service Announcement by The Angry Pharmacist.

Phone-in Rx’s for Dummies

Dear Staff of Doctors Offices Everywhere,

There is an obvious lack of common knowledge in Doctors office as to the “proper” way to phone in an Rx.  So I have taken upon myself to give you all a little guideline to hang up in your office so you and/or your office staff don’t become a target of an angry rant on this site.  Consider it my gift to you.

The Angry Pharmacist Guide to Phone In Prescriptions
The Angry Pharmacist (c) 2009

  1. Before you pick up the phone, you must ask yourself a few simple questions:
    1. Do I speak LOUD and CLEAR English and do not mumble (you might need to ask a few office people their opinion of this)?
    2. Do I have the patients full name and date of birth?
    3. Can I read what the doctor has written?
    4. Do I know MY NAME and THE DOCTORS NAME?
    5. If I read what the doctor has written (see 1.3) , can I make out exactly what drug it is, what strength it is, how often is it to be taken.  Even if you have no idea what the drug is, you should be able to use your high-school education to deduce (that’s fancy-talk for figure out) how to take the drug.  If you are unable to determine this, consult the doctor or find someone in the office who can.
    6. Try to sound out the drug name.  Ask someone how to say it if you are confused.  Most drugs names sound similar, so if you are hopelessly confused just be prepared to spell it.
    7. Is there anything here that I might get confused about if asked questions.  Such as a possible 0 looking like an 8 or a 6, or why someone would need #400 Norco with 10 refills.  Giving Ambien (that everyone knows is for sleep) twice daily is obviously wrong as well.
  2. Having your pre-NewRx checklist, you are ready to call:
    1. Double check with the patient as to the pharmacy of choice, and also double check to see that you are calling the correct pharmacy.  In most phone books, the name of the pharmacy is on the LEFT and their number is on the RIGHT.  Use a piece of paper to keep a straight line if you are cross eyed and can’t seem to follow from LEFT to RIGHT.
    2. If you are calling a chain or any pharmacy with an automated system, go to the menu entry for a new Rx.
    3. If you are calling an independent and a LIVE PERSON answers the phone, you are most likely talking with a clerk who CANNOT TAKE YOUR NEW PRESCRIPTION.  Kindly ask to speak with a Pharmacist and state that you have a new prescription to call in.
    4. If you call it in to the wrong pharmacy, CALL THE WRONG PHARMACY BACK AND CANCEL THE PRESCRIPTION!  DO NOT CALL THE CORRECT PHARMACY UNTIL THIS IS DONE!  What happens is the wrong pharmacy processes it, and blocks the correct pharmacy from processing it through the insurance.  We would rather have you CALL and CANCEL THE RX vs having to deal with having another pharmacy return-to-stock and backing the prescription out.
  3. Speaking with the pharmacist:
    1. When the pharmacist answers, speak LOUD and CLEAR.  There is a lot of background noise in a pharmacy and softly mumbling will get your ass hung-up on.
    2. Tell them immediately what YOUR name is and WHERE YOU ARE CALLING FROM.  Nothing pisses off pharmacists more than when someone is giving a new Rx and they have no idea where they are calling from (hey, they could be the patient calling in a phony).
    3. Say the patients name in a way that we can understand.  You may be proud of your Mexican accent and the way you say Mexican names, but the non-Mexican pharmacist on the other end of the phone has no idea how to spell your ooplahs, n-yays and tongue-rolls.  Most pharmacists will want you to spell the name anyways due to the outrageous and stupid names people are making up for their kids now-days.  Say it like a white-boy and you should be safe.
    4. Immediately give the date-of-birth.  We shouldn’t have to ask for it because you should give it automatically.  You should already know where it is and don’t need to hunt/change screens for it.
    5. Give the first drug, strength, and directions.  Speak SLOW, AND CLEAR.  You can say it a whole lot faster than most of us can write it.  Calling in an Rx is not a race.  If you cannot pronounce the drug, just straight out say “I’m spelling this for you”. 
    6. If at any time you use the phrase “This looks like…” or “I think this is…”, you should re-read the section about preparing for the call in, and contemplate having somebody else call in Rx’s who can actually read and follow directions.
    7. When finished with the last drug, say “That’s all”.  This is not the time for awkward silence as the pharmacist patiently awaits another drug and you just sit silently waiting for the pharmacist to magically read your mind.
    8. Be prepared to give your name again, since we forgot your name a long time ago, and feel free to ask the pharmacist his name if you have to record that down.
    9. If the pharmacist has any questions (or the drug isn’t covered) be prepared to write down what /is/ covered and give the pharmacist a call right back.  We don’t expect you to give us an answer right away, and honestly we’d rather get a call/fax back than sit on your shitty hold music while you waddle your ass down the hall and ask the doctor in slow motion.

Following this guide will provide many happy memories with dealing with hard-working and stressed out Pharmacists.


The Angry Pharmacist

Brain between your ears, not in the palm of your hand

This entry is dedicated to all of the PA’s and NP’s out there who use a hand-held device (palm pilot, iphone, whatever) to dose medications.


Lets be completely honest here. We are both professionals so we can have this conversation.  Do you really think a welfare mother of 4 is going to have the mental horsepower to measure anything other than what is clearly marked on a measuring spoon?  Do you think they can comprehend the idea of anything smaller than 1mL?  Do you really believe in their ability to use a dosing syringe and draw up liquid to a big black line which I draw on there with a sharpie?


If you cannot use some common sense and round up or down dosages of amoxicillin or Prelone to either 1/2 or 1 full teaspoonful, then please save us both the trouble and write for something else which can.  Seeing dosages of 435mg tid of amoxicillin suspension just makes me wish that you didn’t have prescriptive authority.  I’m just going to round up to 500mg, and when you call me to bitch, I’m just going to tell you to use a little common sense and less calculator.  I’m also going to tell you that the idiot mother in front of me (who has yes to realize that penis + vagina = kid) doesn’t have a snowballs chance in hell in measuring what dose you initially wrote for.

Idiots who write super-precise dosages like that are the retards in college that score 100% on the tests, but can’t apply that knowledge to any real-world situation to save their life.  Unless you are dealing with a hospital staff with very narrow therapeutic drugs, whats the point of writing dosages like that?  Are you proud that you can do math using mg/kg units?  Are you proud that you have a program that figures out the dosages for you?  Have you ever in your life seen the thick pink amoxicillin death that you wish to be dosed out to .004mL digits?

When you write for those dosages, think for a whole 2 seconds knowing that amoxicillin comes in 125mg/5cc (1 cc = 1 mL in case you didn’t know), 250mg/5cc, and the ever not-used 400mg/5cc.  Now, use your math skills and shoehorn the dose that the stupid palmpilot program gives you into one (1) of those dosage bottles so the twatmuffin mother will give 1/2 or 1 teaspoon.  If you can’t, then just round up.  If some kid dies from getting an extra 25mg of amoxicillin, then obviously your diagnosis was so far off you shouldn’t be practicing.

Finally, please, when the pharmacist comments on your dose over the phone, don’t just blow him/her off with a “uh huh” and proceed to write again for stupid dosages.  That just makes us angry (and you get a rant written about you).

Truth about DAW-1

I really get angry when I see a DAW-1 on a prescription.  To me, a DAW-1 without a good reason is like saying “Hey pharmacist bitch, do what I say right now because I’m the doctor and I know whats best in drug-land”.  Bzzt, welcome to AngryPharmacyLand.

For those who don’t work in medicine, a DAW-1 means “Dispense as Written code 1” (There are a bunch of DAW codes to signify different things like “Generic not available”, “Brand dispensed as generic”, etc).  However a DAW-1 is doctor speak for “I want this Rx to be exactly how I want it, I don’t want any changes/substitutions made”.

Now some doctors are confused.  Lets indulge ourselves into what a DAW-1 means from a pharmacist standpoint.  You see, DAW-1 (to us) is meant to be used when a doctor wishes a BRAND NAME medication used instead of a FDA approved generic.  Most (if not all) states allow the pharmacist to auto-substitute a generic when the Dr writes the brand name on the pad.  This is great because I’d rather have doctors write Maxide instead of  triamterene/HCTZ.  Brand names are shorter and (especially with birth control) a whole lot easier to deal with. 

If a Doctor gets a wild hair up his/her ass and wants trade name Maxide (HAHAH!), they would write Maxide (DAW-1) while checking and initialing the little box by where they sign their name (which NO doctor can seem to get right) to prove that they indeed want the brand name dispensed instead of the generic substitution.  This also can be noted by putting “DNS” for “Do Not Substitute”.  Again, the checking & initialing the little “Do Not Substitute” is beyond an MD education.  If you cannot get this right, then obviously there should be some question as if the DAW-1 is education driven, or some big-titted drug-rep driven.

Whats funny, is when doctors (but mostly PA/NP’s) put DAW-1 on EVERYTHING thinking that it means something.  Diovan (DAW-1), Lipitor (DAW-1), Zyvox (DAW-1).  Now you (and only you) may feel like you are doing the world a favor by putting DAW-1 on a bunch of Rx’s for brand-name-only products, but you’re just looking like an idiot to us pharmacists.  You may think you are actually doing something via the DAW-1 code, but I hate to tell you, most states do not allow us to substitute completely different drugs, only a brand name drug to its FDA-approved generic.  So you are telling us DO NOT SUBSTITUTE a generic for a drug you wrote that has no generic out.  Way to go! You’re a winner!

Wait, you think that the patients insurance company will give 2 fucks about your DAW-1? Hate to tell you, but for all they care you can take that DAW-1, roll up really right and shove it straight up your ass.  99% of the insurance companies laugh at your DAW-1 and make your ass fill out prior-auth paperwork in lieu of putting DAW-1 on the Rx.  Even if they do take the DAW-1 code, they just make the patient pay full price (or just flat out refuse to cover the medication).  Now the patient gets no medication because you are too hooked on the pharma-pot-pie to “settle” for a generic (and the patient cant afford the brand name).  A winner is you! Thats patient care right there!  Remember, patient care does not start with you, it doesn’t start with me, it starts with whoever is footing the bill.  Who pays for the drug makes the rules for the drug (unless your patient wishes to pay for it, but we all know the F in Pharmacy stands for “Free”).

All kidding aside, I’ve seen loads of doctors do DAW-1’s for really stupid shit (like psycho endocrinologists for Glucophage, Glucovance, Amaryl, Glyburide, etc) only to have the patient be SO noncompliant that I could fill the vial up with cow-shit and get more therapeutic response than your DAW-1’d drugs.  Is it my job to make sure they take their medications? Sure, I blow them shit when they are 2 weeks late getting it filled, but I’m not their fucking nanny.  Teachers are also notorious for wanting trade-name stuff because they “deserve it” (and know SO MUCH MORE THAN WE DO).

Really, if you prescribers in the audience really want to get your point across with this DAW-1 bullshit, you are better off telling us WHY the generics cant be used or WHY the formulary cannot be used (brittle blood levels with warfarin/tegretol).  It’ll make it seem less bossy than DAW-1 (bitch!), but maybe (just maybe) we can save you a ton of time by faxing you the proper forms to sign or point you where to get that prior auth.  Give us more “here is why I want this” vs “I just want this because I can”.

So what do we do when a patient brings in a DAW-1 Rx that the patient cannot afford, and the doctor refuses to change it to something else?  The patient is now put into a position where he/she feels they need this super-expensive medicine that their “Obviously” intelligent doctor wants for them.  Never mind the fact that the pharmacist has about 3 alternatives up his sleeves that might not work quite as well as what the reps spout, however its affordable and wont take food off of the patients table.

Here is something else to consider.  Patient brings in a prescription for Drug-X that is DAW-1 for some reason.  Patient cannot afford the $200 cost and the doctor (being an ass) refuses to change it to something else that costs less.  Now the patient either forgoes treatment because the doctor wants THIS and ONLY THIS (even though a $12 generic might not work as well, but its better than nothing) or forgoes buying Xmas presents for their children or some other Quality of Life lowering factor due to the $200 they dropped for this drug.  Or worst case they just go without and get nothing.  Pisses me off when I call the doctor asking to change, and him/her (or one of their front end ‘staff’) says “Nope, we’re not going to change”.  My response is “Good idea, the patient can’t afford this, so now they will take nothing.” Asshats.

There is /always/ some sort of drug alternative in medicine. Sure it may not work as well or be exactly what you are looking for, but having the patient not take/cant afford the medication due to some drug-rep telling you that “this is new and better” when you had been using drug x for the last 20 years before it went generic last week is (to me) bad medicine.

The woes of new prescriptions

Lets face it, pharmacists are between a rock and a hard place when it comes to new prescriptions.  To be more blunt like this, we get bent over and the only choice is between what brands of lube we do (or dont) get.

Verbal Call Ins:
Usually from someone who has close to zero medical knowledge, these abortions of our profession are littered with “I think that’s….” or “Does … exist?” by some high-school student who is trying to decipher the same handwriting that took us a college degree to learn.  Add onto the fact that most doctors are notoriously cheap (or foreign) thereby hire the bottom of the barrel staff who either know nothing, don’t speak English clearly, mumble, speak softly or all of these.  Although I thought that having Methotrexate 0.2 mg called in by an OB/GYN was a mistake, it however didn’t take the office staff to say “Well I couldn’t really read it” when I called back to make damn sure they meant Methergine.  Now only an idiot can confuse MTX with Methergine, but the point is still there.

Now there isn’t a good way to handle this short of having the prescriber him/her/itself call in.  However, there are a TON of doctors who I cant understand what the hell they are saying, so we’re back to square one.  The prescriber can however hire people who speak CLEAR and LOUD english on the telephone.  However if their girls misspoke on the phone and someone dies, unless pharmacies have call recording software nothing will happen to the MD and his marble-mouthed liability.  They will just show on the chart it was written correctly, taken verbally by Pharmacist-X and that’ll be the end of their accountability.  Pretty sad to know that your career/livelihood is being held by some idiot who cant point to where her rectum is.

So, solutions?  One is pretty damn good that I came up with all by myself (go me).  If a doctors office has someone call in an Rx that you cant understand what the fuck they are talking about, tell them “Excuse me, but I cant understand a word you are saying.  Is there someone there who can call in the Rx for you?”  Sure you’ll offend the person on the phone, but both herself and the Dr should KNOW BETTER.  If the Dr gets pissed, ask if you would like that person calling in Rx’s for his/her family.  See, Dr’s like to get pissed off about things, but most of the time if you hit them with the logic bat (ie: ITS UNSAFE) then they can be pretty receptive.  I’d rather hurt the feelings of some young “nurse” who cant speak the English than hurt the feelings of an entire family because she called in something incorrectly and killed someone.  If we stand up and address the problem then it won’t be as big of a problem.  If we just accept it and let them vowel-guess us to death then it’s just going to get worse.

Now not to belittle techs, but lets imagine a time when a Tech can get a New-Rx over the phone by one of these marble-mouthed idiots.  Yikes!  That right there is pharmacist double-penetration with no lube.

Because today’s society we are so afraid to say to people that they cant speak clear English. Some company (and computer programmers who have NEVER EVER EVER stepped foot in a pharmacy for more than 20 min) created ePrescribing (such as SureScripts)

I’m not going to go into how absolutely EASY it is for anyone who has ever worked in a doctors office to call in phony Rx’s.  Hell, with how substandard the people calling in Rxs have gotten I would take a new one from an autistic dog for Norco without any suspicion (that’s if they actually called it by Norco, instead of Vicodin 5/325 *sigh*).

Seriously doctors, make your life and mine a whole lot easier (and safer for your patients), hire someone who knows what the fuck they are doing.

Touted as the next best thing since prepackaged drugs, the ePrescribing system is going to become mandatory in a couple of years.  All doctors will be able to go to their computers, click away and have their Rx magically zipped to the pharmacy of their choice!

Like taxes and welfare, this is a system that looks better on paper than how it really is.  Take this example to my right. 

Now I’m not sure about you, but if I were some tech who didn’t know any
better and was just hammering out the Rx’s while my pharmacist sat around and drank coffee, I would fill that as Levaquin 750 #5 – 1 tablet 4 times daily.  Thats what it says right?  Now all of the pharmacists reading at home are giggling, the doctors are sighing, and the dentists are wondering what the problem with this Rx is :).   Now I’ve been out of school for a while, so there might be some indication for 750mg of levaquin 4 times a day.  Wait, there is.  Its called WRONGITITS.  Its called the QD and QID drop-down boxes were so close together that someone clicked the wrong fucking one and the Rx was verified and sent out (by the “Dr”).  If a tech filled that and the pharmacist wasn’t on his game, that would of went out vs having the pharmacist on the phone saying “4 times a day? You’re on crack girl-who-cant-speak-english!”  How would their software even allow that to go out with such a blantant mistake?  This isn’t rocket science folks, certain drugs are commonly taken either once or twice daily.  Its very RARE we see a modern (ie: still trade name only) drug that has to be taken 4 times a day.

Is there a cut and dry solution to this problem? Yeah, give pharmacists prescriptive authority like you’ve given everyone else with letters after their names. 🙂