Signs of the times
I thought this was cute. It's today's Adam@Home:
iPhoto/iTunes for your digital medical library
I got an email from a Mac software developer this morning. He had seen a post I had made on another message board, and he was asking me to try his app. It's called Yep, and I must admit that I really like the it so far. (It's so pretty!) You can tag documents with your own custom tags, or let the app do it for you — if you've got them organized the way I do by directory.
It'll scan your entire hard drive for PDF documents, which to me is not really useful, so I narrowed its search parameters to only search my medical library, which up until now, I have kept organized by hand.
Yep will continue to watch a directory, and automatically add any new PDF to its index. Naturally it is searchable, and you can manage the documents from within the app itself. You can also configure a custom menu item to access an external website for a given search term. (It defaults to Google Scholar.)
My only complaint about Yep — and it's incredibly shallow — is that the logo is terribly ugly and non-Mac-like. And the name, I suppose. I guess we Mac users are a superficial group, on the whole…
Click the thumbnail for full-size.
For the harder core life scientists out there, Jonathan at Nobel Intent reviewed Papers (also for Mac OS X), and it's got some nifty PubMed functionality that Yep does not have. (And which I don't need, as I am not a researcher.)
[tags]Digital library, Yep, PDF management, Mac OS X, OS X[/tags]
Anecdotally: demographics, adult ADHD, and atypical psychotics
I worked in a pharmacy in a very wealthy community last night. First time. It was a huge change from both other pharmacies that I spend most of my time in. (One very poor, and one very middle class.) The thing I noticed most was the sheer number of adults (mostly men) filling prescriptions for Adderall XR and Concerta. I must have had maybe 7 or 8 in one hour. No Strattera or Cymbalta, interestingly enough. And most of the scripts were accompanied by other scripts for benzos, mostly for bedtime use. No surprise there.
Contrast this to my "home" pharmacy where we get maybe one or two adults filling these types of scripts per day. Then there's the other pharmacy in the poor section of town: I've never seen a prescription for an adult ADD med. Ever.
The correlation between wealth and adult ADD diagnosis is very interesting to me. I could draw some other conclusions about the relative intelligence of the people coming into each pharmacy, but I haven't worked at the wealthy pharmacy enough yet.
This is in contrast to the number of atypical antipsychotics used in children in the poor area. Lots of children on Zyprexa, Seroquel, and Risperdal. Almost none in the wealthy pharmacy. Again, the middle ground in my home store.
New suggestions for the disposing of old prescription medications
Back in May of last year, I wrote about disposing of old medications. I drew my conclusion from an EPA suggestion that stated the best method of disposing of old medication was to simply flush it down the toilet.
Last month, the White House Office of National Drug Control Policy advised people to "take unused, unneeded or expired prescription drugs out of their original containers and throw them in the trash." They also advise mixing the meds with kitty litter or used coffee grounds and putting them in "impermeable, nondescript containers, such as empty cans or sealable bags"
Now Harvard Med has taken this advice one step further:
- Ask your pharmacist if he or she can take back medications.
- Call your city or state to ask about disposal programs like those mentioned above.
- If you need to put your medications in the trash, keep them in their original childproof and watertight containers. Leave the label on, but scratch out your name to protect privacy. Add some water to pills, and put some flour in liquids. Conceal the vials by putting them in empty margarine tubs or paper bags before throwing them out.
Like I said last year, we do take back old meds, but they just go in our PHI trash to be destroyed back at the home office — or wherever that stuff goes. I think I like the third suggestion the best, though. Good common sense seems to apply pretty well in this case if you're paranoid.
Incidentally, I don't think press releases and suggestions like these are a waste of time and money. With our increasingly medication-happy culture, I think they're timely and poignant. You don't get taught in pharmacy school how to dispose of medication. Not at my school, anyway.
[tags]Medicine, pharmacy, prescription drugs, pollution[/tags]
MTM and the community pharmacist
I've seen a lot of hesitation on the part of community pharmacists over the last couple of years to interface with doctors, and to suggest therapy changes. When asked why, many of them have responded that they feel that it's not their place to do so.
I think this is bollocks. I think they're afraid.
It IS in your purview to make therapy recommendations. This is especially true for elderly people on Medicare Part D. For the first time (ever?) we have a system that indirectly rewards a large segment of the patient population for using fewer healthcare resources. (You don't hit the donut hole, so you save money.)
But what about those people who legitimately consume large amounts of healthcare dollars? They need an advocate. And that's YOU. The community pharmacist. When situations like this arise, you're the one that should go to bat for the person on the other side of the counter, because no one else can.
Interfacing with a doctor
Some pharmacists are hesitant to interface with a doctor's office. Maybe they're worried that they'll get stuck on the phone all day trying to make a change to a less expensive drug. But there are ways around this.
It's called asynchronous communication. And it's more efficient and less demanding on both your time and the doctor's time because it allows the both of you to communicate when you each have time rather than employing The Interrupter — AKA the telephone. This is the difference between urgency and importance. What you have to say is not usually urgent in this context. But it is important.
Last November and December, I made 25-30 suggestions for drug therapy change during the course of my Medicare consulting — all of them via fax — and all of them were accepted. This saved my patients an average of $500/year. This is serious money for someone on a fixed income.
Speak their language
Not all of these changes are silly little things like switching from one drug in a class to another. Or trying an ACEi instead of an ARB. Some of these changes were broad, tackling a given medical problem (or even multiple co-morbidities) from a different angle. Many of your elderly patients — particularly those with chronic illness — see multiple doctors, and lots of times there's no communication going on. In these instances you are the FOCAL POINT for their drug therapy. You are the gatekeeper, you see everything they take on your little computer screen. (Unless they're one of the relatively few people who enjoy playing Musical Pharmacies.)
In these cases you've got to speak their language. Don't even bother making a suggestion unless you are familiar with the latest treatment paradigms. If you want to change someone's insulin from a hojillion-dollar version to something more reasonable, be sure you're aware of the pharmacokinetic differences between the two. In your note to their endocrinologist, mention that you ARE aware of these differences but that you've spoken to Mrs. X and she is willing to try something new, and that this something new will save her $2000/year if it works.
Doctors listen, and they're usually willing to experiment if the patient is.
There are two types of "best drug"
You bring knowledge to the table that doctors don't have: how much things really cost. Most doctors have access to formularies if they want them, and they can relatively easily found out what kind of copay a patient will have if they prescribe X.
That used to be enough, but not anymore.
For Medicare Part D patients, the backend cost that the doctor does not have access to is a significant factor. Something might be a $28 copay, but UHC might be kicking in $250 behind the scenes that will quickly eat through someone's drug benefit.
There are two types of "best drug": the drug that is best from a therapeutic standpoint, and the drug that is best from a hybrid therapeutic-financial standpoint. This is the most pertinent concept of "best drug" for the person reaching for their wallet. Why reach for the Norvasc when you haven't tried felodipine?
Make it easy for yourself
You're a pharmacist. You're busy. You're machine-gunning prescriptions as fast as you can. The phone's ringing and one of your techs called out. Today is not the day to be making therapy suggestions. (If you find yourself in this situation often, you need to attend the RJS School of Pharmacy Management.)
But even bad pharmacies have good days. Make a template with your pharmacy name, fax and telephone numbers, with a section for the patient's information, and your notes. Personalize it with your name and titles. If you've got a system where you can type a note to the doctor, great. If not, don't insult insult them with bad handwriting, even though they may not return the favor. Be the bigger person and have someone else write it if you have to — bad handwriting does nobody any favors.
Take out as much of the repetition as you can. You have better things to spend your time on than redundancy.
Battles
There's this misconception that many pharmacists have that they're going to have to have a battle with the doctor to make XYZ changes. First of all, this rarely happens. Second of all, if YOU are battling THE DOCTOR, there is a problem, and it's not with you, if you are speaking on behalf of the patient as their advocate. No battles should occur; it should be a discussion. You know something the doctor doesn't, and maybe he knows something you don't about why s/he chose X drug instead of Y drug.
If you do end up having a battle, stick to your guns, but only if you know for a certainty that the patient will benefit if you do. Compliance issues due to money, dosing, etc. These are legitimate. Having a pet drug that you prefer is not. Conflict is not necessarily bad. Good relationships and mutual respect have been known to grow out of past conflicts.
Closing thoughts
These are the basics in effecting change as a community pharmacist. It is possible to take many of these ideas further, if you choose. Stepping on toes is never wise: step in when you see a patient is having difficulty with money, or if you can see they're otherwise unhappy. Many patients will come right out and ask if there's something else they can use. Some are unhappy with their doctor for any number of reasons, even though they've been seeing him for years. You may have an opportunity to save this patient-doctor relationship, and we all know how important good relationships are when it comes to healthcare, and how long they can take to build from scratch. They're not something to be thrown away lightly.
[tags]Medicine, pharmacy, MTM, community pharmacy, pharmacy practice[/tags]
RJS unmasked
Here's me being a nerd.
[Props if you can identify the compound on my shirt.]
Untitled
As an intern, I have worked with a *very* strong mentor who runs his store the way he wants to. He's become a friend over the years as well. One of my closest friends, actually. Our numbers are always consistent, it's not crazy busy, and I have had the time to develop the ability to become a darn good pharmacist.
I know because I fill in at other stores and wonder:
1) Why pharmacists are behaving the way they do.
2) How an intern could possibly learn anything of value in such an environment?
It seems to me that a lot of pharmacists, especially the women, don't seem to understand something. YOU ARE THE PHARMACIST. The chain does not exist without you. You have as much power as you think you do. If you think you don't have any power, then you don’t. If you think you can run the store whichever way you choose, then you can.
It's really that simple. Chain or independent, it doesn't matter. The buck stops with YOU. Not middle management. It really is a matter of deciding to take back your profession and ultimately, your life. The pharmacy does not exist without you. It CAN exist without middle management. Never forget that.
The first time you say "No" to your manager is an empowering experience, no matter how trivial it seems in retrospect, whether you’re saying no to an extra shift or simply saying you can't "just stay till closing."
[tags]Pharmacy, pharmacy practice[/tags]