I would have a lot of questions for both the prescriber and the patient. On the surface, with no details, this really smacks of diversion.

One of my chronic pain patients, “Alpha,” moved to Florida. About a year before that,  I had received notification from the pharmacy chain management where I worked that it would be prudent for me to do a bit of CYA for myself and the company. I was to speak to the prescribers for my chronic pain patients and make notes in their profiles as to their diagnosis. In other words, why are these patients taking so much pain meds? When Alpha found out about this, she accused me of calling her a drug addict and causing her doctor to question her need for the meds. [Not her Rx shown above]

About two weeks ago, I received a phone call from Alpha. She was having trouble finding a pharmacy that would fill her prescriptions in Florida. I referred her to my successor at the store where we had become acquainted. I’ve been gone from that pharmacy for two years. Her daily dose would be fatal for a patient who had not built a tolerance for such high doses. Her doctor requires regular lab tests to ensure she is taking the medication.

Yesterday, I refused to fill a prescription for a “patient” who is on a similar regimen of drugs. We’ll refer to him as “Beta.” His doctor doesn’t do blood or urine tests to confirm compliance.  His doctor requires cash payments for office visits at the time of the visit. This patient drives a new Mercedes. Yesterday, as he often does, he wanted his prescription filled a week early. He became unruly when I pointed out that the doctor himself had put on the prescription when it could be filled.

Pharmacists from around the country report similar occurrences in their practices.

10,000 Baby Boomers reach age 65 every day.

Both scenarios are commonplace now as baby boomers turn gray and average from  three to five prescriptions (not all pain meds) as daily maintenance. It’s apparent that boomers have a lot of pain. This point was driven home by two noteworthy events:

1. pain management clinics began to spring up around the country and…
2. The government made it easier and quicker for pharmacists to order schedule two controlled drugs. (Amazing, isn’t it? The government made something easier?)

Then I met Betty Lou (my favorite generic name) but to be consistent here, she will be “Gamma.” She’s been my patient now for a couple of years. When she first started doing business at my store, her doctor confirmed that she was a terminally ill cancer patient. She’s been terminal now for over two years. She takes three different narcotic pain meds, Ritalin® in the morning, and sleeping pills at night. She takes meds for nausea and constipation. She’s obese.

And this represents only three of the hundreds of patients we see on a weekly basis.

Now meet patient “Delta.” Delta comes in regularly with prescriptions for 240 Ultram®, 180 Percocet®, and 90 Dilaudid® tablets(all generics.) Every month, Delta presents that month’s prescriptions a few days early. Delta’s chief complaint is “Every time I come into this pharmacy there’s a problem.” The recurring problem is that Delta wants early refills every month. Delta’s doctor writes the date each prescription can be filled into the instructions.

Some of the patients who seem legit, take so much, I wonder. Are they really taking that many tablets?

Finally, patient, “Epsilon.”  Epsilon sees a different doctor every week. Sometimes the doctor is from out of state. I’m not aware of any pharmacy in our area of the state that will fill an out of state prescription for schedule two controlled substance.

It’s disheartening to see bona fide long term pain management patients become addicted to drugs and then watch that dependence change their behavior to the point that we cannot deal with them rationally.

Another day in the life of a pharmacist.

To be continued tomorrow, HERE.

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Acknowledgement: Free lance writer and investigative reporter, George McGinn contributed to this article.

“Fire in the sky” Copyright Dan Gregory
used with permission

This week, we welcome retired pharmacist, Dan Gregory as our guest blogger.

He was born and raised in Louisiana. His interest in photography and painting blossomed in his teenage years, continued through his era of earning a pharmacy degree from Northeastern University in Monroe, Louisiana. He routinely practiced pharmacy until his affliction from MS became apparent in his fifties. He retired and now devotes his full attention to photography, writing, and oil painting.
What many would consider a handicap he has turned into the realization of a dream: full time attention to his visual arts and the expression of it. He currently resides in Lakewood Ranch/ Sarasota, Florida where he is happy with camera, pen, and brush in hand. He sees the world through new eyes. His renderings are sought by collectors through out the United States
and world, and he is the proud father of two sons, and a daughter.

Dan presents his thoughts on how and why he merges photography and oil painting.

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The world is quite the wonderful and startling place; discoveries are everywhere with infinite possibilities. All you have to do is open your eyes.
But for some just to see is not enough. Time must be frozen. But how to do that? Again in a myriad of ways, some more complex but satisfying through the magic of accomplishment.
I’m a retired pharmacist, not by choice, but thanks to Multiple Sclerosis, so I have all the time in the world now to discover it.
I’ve always painted since a child, almost always been a photographer from back in the days when everything was manual. I bought a Leica because it’s such an incredible tool to take photos that beg to be translated into paintings, not because I’m a snob. After several months with it, it FORCES me to arrange and compose artistically, unlike my other cameras which have
whittled photography into point and shoots. I’m still learning it, and it never fails to surprise or disappoint me. Much the same as life.
I like to travel the backroads with it, the blue highways so to speak. Here I can find the dichotomies between the past and present. There’s an abandoned motel, truck graveyards hiding in the tall weeds, archaic old general stores. Strange sites as compared to the glass and steel so commonplace today, the hurried pace. They scream in anguish to be remembered, for
once they stood proud and strong, rolled the roads in hubris. And now they just want to be thought of one final time.
And I have that power. Through my viewfinder I carefully compose my trophy within the lines of a grid. I bring the LEDs to a correct exposure, let the auto-focus do its thing by lightly depressing the shutter release. Then I press it all the way. The capture is complete; I have rendered my prey timeless, and, like magic, it is given immortality.
I like to photograph the serene beauty of the female form with it. From the release of that button, a woman who strives not to age will never do so. In decades to come, when the flesh has dried and withered, an ever-young face will stare from that screen or piece of paper. She will always be there, back when she had the power to enchant a man just with a coy smile which has vanished like a ghost. She has gained the prize of forever. And she will never lose it.

Copyright Dan Gregory

The photographs are good, but there is something better. The photographs are recordings which require no interpretation. Physics is physics. They can be personalized a bit with Photoshop or some such program. But more than anything it just depends on how the light strikes the sensor. The quality of a photo depends on the compositional and functional talent of
the photographer.
And what is something better you may ask? I take those images, and I interpret them in paints. I take tubes of pigments made from earth and draw forth from a blank, white canvas the colors of the rainbow. I paint those relics, those graceful women. If the camera gave them a new life, the painting gives them a new interpretation. I am scarcely limited, if only by my imagination. All creatures of mythology, past and present, can be rendered and brought to glorious life. The dead can be brought back to life, the divided reunited .The camera, the Leica, cannot do that. The elegant woman can still be captured by the unfeeling sensor, but it takes the pigments to give her the touch of the artist’s soul. He can see every mark, every crease, on that woman’s body, and he can love them because they are part of her uniqueness. He can appreciate that she is a child of God and render her as such. The camera cannot do that. It is merely a tool. It is like saying the painting exists solely because of the brush, no matter how fine.
The artist can return life to the abandoned building beside the unremembered road. A forgotten store that has seen many decades between the dark and light is suddenly ablaze once more. The song of crickets is replaced by the cries of merriment. The dead have been redeemed. The moon and stars above have seen it all since time began, but like the alloy and glass of a camera they are uncaring. They are not human.
But the camera and the brush are both only tools wielded by a human. A cheap Instamatic wielded by Ansel Adams can hardly be bested by a child with a Zeiss Ikon. A Waterhouse rendered by a cheap dime-store set of pan watercolors can hardly be surpassed by a child with all of the finest Winsor and Newtons in the world. Experience is the best, and harshest, teacher. So it is up to you to embrace it. Go into a world wracked by strife and wars, and cherish all of what you see there. It all exists for a reason, and it is up to you to find the latent beauty that lurks everywhere.

And it is up to you to show it, display it, and better yet, teach it.

Pharmacy student, James Herbert joins us today.

Our guest blogger this week is James Herbert, a Pharm D Student at South College School of Pharmacy, Knoxville, TN. He is a Husband, Father, Doctor Who fan, science fiction fan, philosophy-theology aficionado, and ex-IT guy with dreams of using informatics and technology to enhance pharmacy’s role in improving patients lives. He says, “I’m just a regular guy livin’ the dream because in the end aren’t we all?”

His topic addresses a situation begun decades ago and is now coming to a head. We introduced this subject last week with an article regarding the re-branding of patients to customers. Herbert believes there’s more to it than just semantics.

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James Herbert

A paradigm shift in healthcare begun years ago, speeds toward the downgrade of the patient to a statistical economic construct.
Patients are now being referred to as customers.
This is a dangerous shift that moves the focus of the patient’s medical needs towards the consumption of goods and services. Consumption of services does not require the relationship between patient and healthcare provider necessary for patient care. The purpose of healthcare is to provide appropriate care to patients. This shift away from the fundamental principle of personal attention is detrimental to the public health.
“Customer” is an economic term: A party that receives or consumes products (goods or services) and has the ability to choose between different products and suppliers.1 A patient is a person who has a medical need. In times of an emergency a patient does not have the luxury of choosing who provides their care. In cases of extreme emergency they have no say what so ever. Patients do not consume the “goods” and “services” of healthcare in the same way they would in a traditional retail environment. You will not see patients lined up at a hospital door on black Friday for example.
Dorland’s Medical Dictionary (2008) defines patient care as the services rendered by members of the health profession and non-professionals under their supervision for the benefit of the patient
Taking care of customers is commonly called customer service. “Customer service is a series of activates designed to enhance the level of customer satisfaction –that is, the feeling that a product or service has met the customer expectation.”2
Customer satisfaction is measured by the satisfaction survey. Here is where the disconnect begins
A survey, by its very nature, limits itself to the chosen parameters. That is to say that there are “buckets” that are being weighed as they are “checked off” in the survey. It is in this way that the customer is reduced to a set of statistics. In surveys, the person is irrelevant, it is the data that is important. Chosen members of management chose the parameters.
Data identifies trends and trends can be impacted by a series of scripted efforts. These efforts are called metrics. Metrics reduce customer service to a series of equations. CVS uses Triple S and KPM metrics3 in order to quantify and improve service performance. Customer expectations can be manipulated in scripted measures. Sitting down with a customer influences their perception of the amount of time spent with them4. Adding key words or phrases to encourage additional purchases is another scripted method of providing customer service (See CVS Pharmacy Business Metrics Paper)
Pharmacy may be measured by its Triple S and KPM or similar metrics but for hospitals to be reimbursed for providing care to those with Medicare/Medicaid, HCAHPS is the golden standard. Press Ganey is the leading provider of patient satisfaction surveys designed to help meet the HCAHPS requirements.

The manipulation of satisfaction scores may have nothing to do with providing safe and ethical healthcare. In one case a physician was able to achieve a 7% improvement in his satisfaction scores by prescribing an antibiotic to all his patients who complained of a cough, sore throat or sinus headache5. Managing low scores can lead physicians to prescribe powerful opiates for toothaches6. Healthcare professionals under pressure to meet metrics, forego patient care to perform customer service. The result is that most satisfied patients tend to be those who have higher healthcare cost, drug expenses, and most shockingly, have higher deaths rates than those who do not feel satisfied with their care7. The customer purchases their “good” but they may not get care for their health.
The retail pharmacy chain is the end game when customer service once and for all trumps patient care. In the retail setting, “wait times”, scripts per hour, and profit margins are king7. The pharmacist as healthcare provider is no longer part of the business model. Overwhelmed with hundreds if not thousands of script per day and skeleton staffing the pharmacist’s role is reduced to that of a dispensing machine. The result is they are not perceived as healthcare professionals. One woman demanded: “Please just do your jobs and fill what you see and stop trying to make yourself something you are not”9. In retail chain pharmacy healthcare is not important. Customer service is. Customer service quantified by metrics.
When results are all that mater then there is no “person” behind the customer or patient. They have been dehumanized. All that is left is the data. People do not get treatment. Data gets manipulated. Customers are not getting service. Data gets manipulated. When all that matters is the data, then the ends justifies the means. Metrics and surveys, by their very nature, dehumanize people.
The future of healthcare is freighting if the focus does not turn back to personal patient care. A therapeutic relationship addressing a patient’s medical need with personal and individual care, trust, and understanding. This includes a healthcare provider who has a specialized set of knowledge and skills that are not available on website, a television ad, or a talk show.
When raw, sterile numbers take precedent over warm flesh, people are no longer in the equation.

Without people there is neither health–nor care.

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References:

# http://www.businessdictionary.com/definition/customer.html
# Turban, Efraim (2002). Electronic Commerce: A Managerial Perspective. Prentice Hall. ISBN 0-13-185461-5.
# CVS Pharmacy Business Metrics: http://s3.documentcloud.org/documents/472510/250510-rx-tg.pdf
# Simple tips to improve patient satisfaction http://www.medscape.com/viewarticle/743875?src=mp&spon=25#vp_2
# Patient Satisfaction is Overrated: http://www.medscape.com/viewarticle/821288
# Why rating your doctor is bad for your health: http://www.forbes.com/sites/kaifalkenberg/2013/01/02/why-rating-your-doctor-is-bad-for-your-health/
# Patient satisfaction linked to higher health-care expenses and mortality http://www.ucdmc.ucdavis.edu/publish/news/newsroom/6223
# Pharmacists: Corporate greed putting patients at risk http://www.khou.com/story/news/investigations/2014/11/06/iteam-prescription-errors/18591573/
# LETTER: Pharmacists aren’t doctors http://www.courierpostonline.com/story/opinion/readers/2014/11/17/letter-pharmacists-doctors/19044977/

February 20 of next month will mark the fortieth anniversary of my liscensure as a pharmacist. I’ve been counting tablets and capsules by fives, for four decades.

I earned a B.S. in pharmacy at Northeast Louisiana University [now known as the University of Louisiana–Monroe] and graduated in December of 1974.

It’s been an interesting forty years, including a seven year hiatus in which I left pharmacy for Dale Carnegie Training and New York Life. I returned to pharmacy in 1992.  For “About Me” descriptions in the social media, this is what I list: “Husband, father, grandfather, pharmacist, photographer, and published author.”

Over the next twelve months I’ll post a few blogs with reflections on my career along with some guest blogs by other pharmacists and health care folks I’ve met along the way. In addition, there will be a few blogs to chronicle the my evolution from small town farm boy to small town pharmacist.

Maybe someone will find them of interest.