If you have Parkinson's, you probably shouldn't try to alter your own prescription
This past week, we had a guy gentleman come in with prescriptions written for some usual suspects in the treatment of Parkinson's, one of them being Klonopin. His symptoms were relatively obvious, too. What was funny in a "Haha, this is really pathetic" sort of way was that the prescriber had signed them in blue ink with rather normal (even neat!) handwriting.
In the no sub box, this guy had scrawled "no substitution" in handwriting that looked like calligraphy done with a squiggle pen. And of course the ink was black.
Yeah okay, buddy. I mean, I don't really care if you want the brand name, just drive up the road to New Hampshire and request it. Don't alter the damn prescription and think I'm not going to notice. There are two parties that should be writing things on the prescription, and you are not one of them.
I didn't rake him over the coals for it. It wasn't worth the time and emotional energy, and he seemed like a nice enough fellow. I hope it doesn't happen again.
The ending is that the insurance (Tricare) wouldn't cover brand name if there was a generic available. Big surprise. So he ended up with his clonazepam, generic Sinemet CR, and generic something else. What a bunch of idiotic hoops to jump through to end up back at square one.
But seriously, what person — who knows they can't write due to a medical condition — alters their own prescription? In the wrong colored ink, no less?
Never ascribe to malice that which is adequately explained by stupidity.
Speaking of things that suck: waking up during your own autopsy
This man, Carlos Camejo — seen holding his own death certificate — woke up during his own autopsy after a car wreck:
Carlos Camejo, 33, was declared dead after a highway accident and taken to the morgue, where examiners began an autopsy only to realize something was amiss when he started bleeding. They quickly sought to stitch up the incision on his face.
"I woke up because the pain was unbearable," Camejo said, according to a report on Friday in leading local newspaper El Universal.
Ouchies. I guess they're not as thorough in other countries when it comes to pronouncing someone dead…
He should go as a vampire for Halloween. 
(Images preserved in order to stave off the inevitable Reuters link rot.)
Lasagna and heartburn
Today's Close to Home reminded me of something we used to do to take the edge off the sauce when my dad was having heartburn problems: a small amount of baking soda into the sauce while it was simmering.
Baking soda is sodium bicarbonate, also available in tablet form for — you guessed it — heartburn. Certainly though, Tums (calcium carbonate) are far more common than soda bicarb tabs. I suspect this is due to marketing more than anything else.
I wonder if McPherson knew he was unintentionally close to a mark?
[tags]Lasagna, heartburn, cooking[/tags]
"I've never learned anything at a CE"
The Ole' Apothecary writes:
I believe that the continuing education (CE) requirements for U.S. pharmacists are woefully inadequate. They should be increased, in both number and difficulty.
To start with, the number of required CE hours should be doubled in every state. They have not been changed in 30 years. Also, at least half of these hours should be live, at least to get us to interact with educators, and, at most, to get us to interact with our peers in the profession.
I couldn't agree more. I think pharmacists should have to take a periodic exam to assure basic clinical competence as well. I've had pharmacists ask me to do their CEs for them, which I find appalling behavior. It is my opinion — and after 6 years behind the counter, I'm not as naive and enthusiastic as I once was — that you should take pride in your profession, and that you should want to keep up with developments in the field of medicine. Even non-drug therapies, in my non-humble opinion. You didn't go to school to learn to count to 30 and slap a label on a bottle. Any jackass can do that, and every jackass with half a clue learns the necessary behavioral tricks to survive standing behind that counter, too.
(Well, maybe you did go to school to learn to count to 30 because you thought that since you planned on standing behind that counter, you might as well make some money while doing it. That's alright, I guess, but I wouldn't want you as my pharmacist. No offense or anything.)
What boggled my mind were some of the comments left on TOP's entry. By pharmacists. The vitriol that follows isn't directed at these people specifically, but rather at the lackadaisical attitude in general that many pharmacists have towards keeping up with their profession.
Even if you cheat like I do and go straight to the questions without reading the program, you still get SOMETHING out of it because you still have to look for the answers.
Well I am a 63 YO RETIRED Pharmacist and honestly I never learned much, if anything, from any of the CE courses I have taken over the years…
All were a total WASTE of time..
Look, I know CEs are seen as an onerous chore. ("OMG! It's December and I haven't finished gotten all of my credits yet! … Will you do this CE for me?") Maybe you've got kids, and your family takes up your free time. In retail there's that fantastic work-home life divide. Work stops as soon as you leave the pharmacy, and the retail environment isn't the place to try to learn anything, unless you work in the slow store. Frankly, this divide between work and home is no excuse to not stay current. You're a professional, for fuck's sake, not a factory worker. This is one of the things that sets professionals aside from non-professionals — you have to make some effort on your own to stay current. Whether or not you are paid for the time you spend is not even a question. It's just something you do.
I don't believe for one minute that you actually retain anything that you "go back and find" to get the correct answers. Not for more than a day or two, in any meaningful detail.
I'm bringing this up now because one of the pharmacists I work with recently gave a patient the wrong answer. (Which may breed another entry for later about stepping on toes.) It was a basic question about statins — and she got it wrong. It wasn't even a hard question. It was "When is the best time to take simvastatin?" It doesn't matter how busy your pharmacy is. If you can't answer the most basic question someone could ask about the most popular HMG-CoA reductase inhibitor in America, you're doing something wrong. And she's in her early 30s — nowhere near retirement age.
I cringe at the thought of the 63 year old retired pharmacist who never learned anything doing CEs. Unless you're reading journals, and staying current of your own accord — which you're probably not — you probably didn't know much about modern medicine while you were still working. How many major classes of drugs came out since you graduated pharmacy school?
Well let's see. There'd be the PPIs, statins, quinolones and fluoroquinolones, macrolides (things have changed a lot since erythromycin), atypical antipsychotics, SSRIs, COX-2 inhibitors, AIDS drugs, the entire field of asthma management, ARBs, T2DM management… I could keep going. Without even going near the biologics. ALL of the drugs in these classes have their basic similarities, but equally importantly, their differences.
Wait a minute! That's basically the entire list of the top 200 drugs prescribed in America! You learned about all these things when you were in school? Are you up on them? Even the basics? Gee, a statin's for cholesterol… whoopty freakin' do. You're a goddamn genius.
Do you even know what cholesterol actually is?
And not to mention that our understanding of the mechanisms of action of some older drugs have changed since you were in school. Theophylline is an old drug that springs readily to mind as a drug about which our understanding has changed over time. Perhaps since you first learned about it all those years ago.
For shits and giggles last night, I went back to some older issues of the clinical publication my chain puts out. My mind was boggled at how much our understanding has changed about even "basic" problems like ADHD and depression in just 8 short years. Almost nothing is hammer -> nail anymore.
Just like formal schooling, you get out of CEs what you put into them. I have no doubt that a great many of them are useless. CEs may not be an ideal answer, but they do serve, if you make the effort. Some of the information is undoubtedly redundant. Some of it you undoubtedly learn by osmosis. But I guarantee you that if you pick up a CE and really read it, you will learn something.
Plagakis would probably say that "we're all clinical". The Ole' Apothecary asks if some are more worthy than others.
The answer is "yes" but it doesn't matter if the letters after your name are "RPh" or "PharmD". Some are inevitably more clinical than others — and that's okay. But there needs to be some basic standard of clinical competence, otherwise you're just a glorified pharmacy technician with some extra liability padding and a key to the safe who takes home a fat paycheck every other week.
And if you've never learned anything at a CE, you should be looking in the mirror for the reason instead of pointing a finger at the system.
The patient with two names
One of TAP's bullet points made me chuckle. It also jogged a memory.
The patient who you thought you filled that Rx correctly for ended up having another last name and the same birth-date as someone else in your system. Of course they don't tell you this until after they have received the Rx and loudly proclaim that you filled it for the wrong person with a store full of people. I mean aren't we supposed to know that her full name is Maria Consuelo Rodriguez Maravilla Hernandez Guadalupe AIAIAIAIA ARRIBA?
We have one patient in one of my pharmacies — yes, they're mine — that has two names.
Two completely different names. No motifs. No variations on a theme. One day she's Maria Gomez and the next day she's Elisa Rodriguez. It's fucked up. What's even more fucked up is that Maria doesn't know Elisa's name, and vice-versa. She has to read it from the bottle that she wants refilled, and God help you if she doesn't have the bottle that day. But even more mind-blowing than this is that I'm the only person in over a year to actually put the other name in each of her two profiles. Yeah. Wrap your brain around that one, if you can.
This woman takes an SSRI, but that's it in terms of psych meds, so I have no idea what her deal is. I wouldn't even want to guess. Naturally, she can't speak English except for "15 meenoo? O-K," so I'll never find out, but she is terribly nice, which does get her some brownie points. I'll take a nice idiot over a smart asshole any day of the week. Not that she's an idiot — I strongly suspect she has some untreated psych condition. (Surely it can't be undiagnosed? We can't be the only ones who haven't figured out that something's not quite right.)
Thankfully she is starting to prefer one name over the other, so I guess we're making some progress. Or maybe it's a seasonal thing? Now that it's after Labor Day she'll go back to being Elisa… :suicide:
Try to be a *productive* nuisance next time
Scenario: Person calls up to see if their doctor has responded to the refill request that was sent the day before. We're going on 24 hours and still we've not heard back from the prescriber. (Oh, the horror!)
That first phonecall is okay. But then there's the second. And the third. And sometimes the eighth.
"WHY HASN'T MY DOCTOR CALLED YOU YET??"
How in the seven hells should I know, lady? Yes, it is almost invariably women that ask this question; men, in general, seem to be more interesting in getting to the root of the problem than complaining about it. (Insert off-topic discussion about gender differences here.)
I DO know one thing, though. If you've called us twice, and your doctor hasn't gotten back to us, and it's been 24 hours, and oh my god you will absolutely die if you don't get your simvastatin five minutes ago, you need to start calling the right person. The gatekeeper. The person who — hold onto your socks now — writes your bloody prescription.
I am not your goddamn therapist.
I don't understand the mental disconnect between dialing the pharmacy versus dialing the doctor's office. Is it because you're calling a retail establishment where someone actually answers the phone? Somehow I think the answer is YES. In the last two days, I have waited on hold with a doctor's office for 10 minutes or longer six times. One of those times was actually 23 minutes(!).
But back to consumer idiocy for a moment: Pharmacies are not required to do refill requests for you. There's no law saying "Pharmacist must request refills for patient upon request." It's just something that's done as a service to remain competitive with the other retail pharmacy outlets. Way back in the day — before unlimited long-distance phone service — many pharmacies would add the price of that telephone call into the cost of the prescription. Back before there were third parties. The average person would shit a brick today if that was done. (Back in the Good Ol' Days, there was also the Asshole Tax, which I'd like to reinstate for the habitual offenders.)
Newsflash: the pharmacist doesn't decide whether or not to refill a prescription — we'd LOVE to fill it for you because you're being a pain in the ass, and it'll get you off our back. Not to mention that mo' scripts = mo' money. Maybe sometime down the road, when s/he has access to complete medical records and lab results, a one-time refill ability will be within the pharmacist's scope of practice. But as of now, it's not.
So why don't you go bother the person with that authority?
And incidentally, if you're a provider, I'm not particularly interested in why your customers — yes, customers — wait on hold for eons before they get to talk to someone. I don't care how busy you are. I don't care how busy your office staff are. I don't care that it takes you an hour to get a diagnostic test approved. I don't care that your reimbursement rates are declining, and gee wouldn't it be nice if you could bill for time wasted on the friggin telephone.*
I AM interested in not being the cathartic outlet for your patients' frustration at you and your office's inadequacy.
…I totally just went there, didn't I? Feel free to vent your frustrations at and about pharmacists and pharmacies in the comments — and yes, this post was very cathartic. 
You know I still love all of you. 
* Actually, I do care quite a bit about that. Just not within this context.
"Oops, I picked the wrong one."
That's not a phrase you want to hear a doctor say when you call up and ask if he really wanted $random-obscure-drug-that-no-one-has-ever-heard-of after he's sent an e-prescription over to you from his fancy-schmancy new EMR. You know, the EMR that lists every single drug ever made from the beginning of time up until now, regardless of whether or not that drug still exists, and doesn't use any sort of Bayesian analysis — yes, the same technology that sorts your email — to suggest your drug of choice based on past prescribing habits, or to sort drugs based on their probability of usage or (Heaven forbid!) to suggest that just MAYBE, doctor, you really wanted something else when you picked that whacko drug from the drop-down box.
So anyway, the bogus prescription was for extended-release lovastatin. Yeah, it really does exist, but hilariously enough, the prescribing doctor had never heard of it. And neither had the pharmacist, thankfully, because she might have ordered it, and then the patient would have gotten the wrong medication.
Christ, people. Proofread your goddamn prescriptions. To make sure that gibberish that your EMR spits out is REALLY what you want. And that you've actually heard of the drug you are prescribing. It ain't rocket science, and even if it were, I'm sure you'd be equal to the task.
Yeah, yeah. We all make mistakes. Proofreading a friggin' prescription shouldn't be one of them. But yet, somehow, I see anywhere from 4-20 crap prescriptions Every. Single. Day. All because they weren't proof-read before they were handed to the patient or sent to the pharmacy.
What's the most fun part of all this is that when you get the doctor on the line, he cops an attitude because he thinks he's the Second Coming of Christ even though he's the bonehead who made the mistake. Get over yourself, dude. <Internet toughguy>I swear, one of these days, I'm going to drive to a doctor's office and put my foot up someone's ass.</Internet toughguy>
No, I don't hate my job, but I do hate people sometimes. It gets tiresome saving other people's bacon when all you get is grief for your troubles. Grief from the patient because the prescription took more than 30 seconds to fill ("Well, can you just fill it anyway?"), and grief from the doctor because you deigned to bother him.
And no, not all doctors are like this. Many of them are awesome, nice people. But just as the vocal minority often gives the silent majority a bad name, the types of doctors that are most likely to come to the phone themselves are the ones who want to pick a fight. And they often do everything in their power to make you feel like a piece of shit, even when they are in the wrong. Needless to say, that does neither themselves, nor their profession any favors. The same holds true for bad behavior no matter who you are, or what you do.