Pharmacy Forecast 2016-2020

The ASHP Foundation released a "Pharmacy Forecast: 2016-2020" Strategic Planning Advice back in December. My first thought is a pause thinking how long I have been out of pharmacy school. I start counting on my fingers from '99 and think, wait, what? SEVENTEEN years. I am officially the pharmacist I stood beside in one of my first pharmacy jobs. I considered him wiser. Maybe I am wiser, but I still sometimes feel like school was not too terribly long ago.

This is the fourth edition of this particular report, and I generally try to read every edition. This one somehow slipped by until this past week when I found it and read it rather quickly. There are some applicable topics for today's healthcare pharmacist that I want to dive into.

Strategic Planning versus Reactive Planning

I have not seen a lot of strategic planning within the hospital pharmacy model. We do a lot of reactive planning based on other departments mostly in line with cost management and saving money. We plan operations in how we staff our departments based solely on how many patients are in the hospital but do not use other metrics such how complicated medically is the patient? What if the patient comes in with a chronic infection versus the patient who comes in as a first-time infection? What if the patient has 20 or more home medications on board? Census is more than just number of patients. What if it is measured by a formula of disease states both acute and chronic along with number of hospital admissions in the past 5 years plus number of medications? A patient doesn't equal a patient. Maybe this applies in a surgical patient, but not in a patient with COPD, ARDS and decompensating on a ventilator due to a hospital-acquired infection.

Opening the report is a timely introduction:

"Since the start of the pay-for-performance movement1 and passage of the Patient Protection and Affordable Care Act (ACA), there has been intense pressure on healthcare organizations to improve quality while reducing costs. The stress created by this pressure has been exacerbated by proliferation of expensive specialty medications, egregious price increases for some sole-source drug products, and the escalation of generic drug prices. In response to this environment, many healthcare organizations are pursuing mergers and acquisitions in an attempt to create economies of scale without the cost of new construction. Another tactic is to partner with outside entities such as chain pharmacies."

Specifically what caught my eye this time was the section on work force. Change in practice models claim a shift from inpatient to ambulatory type practice.

"THE SHIFT TO AMBULATORY CARE As healthcare organizations respond to payment reforms that aim to lower costs and improve patient outcomes, health-system pharmacy practice leaders are challenged to optimize the role of the pharmacy work force in new models of care. One area of challenge is the shift in emphasis from inpatient to ambulatory care.1 Reflecting this change, three-fourths of Forecast Panelists (FPs) agreed that over the next five years, in at least 25% of health systems, patient care pharmacists will have umbrella responsibilities for both inpatients and outpatients (survey item 1). Further, 69% agreed that at least 25% of health systems will reallocate 10% or more of inpatient pharmacy positions to ambulatory-care positions (item 2). Consistent with anticipated growth in ambulatory care, 65% of FPs predicted a vacancy rate of greater than 10% for ambulatory-care pharmacy leadership positions over the next five years (item 5). Pharmacy staff development programs should ensure that there are adequate opportunities for education and training in management of ambulatory care pharmacy practice, transitions of care, and medication management of chronic illnesses. "

How do we lose money? Readmissions, using more inpatient days than necessary due to reasons in and out of our control, and not following certain standards that are attached to payment or removed when standards are not met while in-patient. 

Did you notice one thing? The salaries of newly hired entry-level pharmacists will decline by 10% while pharmacist technician salaries will increase?

You know I get excited about this one:

"PHARMACISTS AS PROVIDERS Nearly 80% of FPs predicted that at least 25% of health systems will have a formal plan for including pharmacists, along with nurse practitioners and physicians assistants, in advanced roles that allow primary-care physicians to care for more patients (item 4). Supporting the high level of agreement with this statement is the shortage of primary-care physicians, proposed federal legislation to grant provider status to pharmacists, and the large number of states that authorize pharmacists to establish collaborative practice agreements with physicians. 2 Recent changes in reimbursement rules related to complex chronic care and transitional care management3 support the addition of pharmacists to primary-care teams. Many health systems will be establishing a privileging process for pharmacists to ensure that those with expanded patient care roles have the necessary competence for those roles."

I suggest you read through the report. It is mostly put together through surveys, but has some very timely information for the next 4-5 years in pharmacy.

PHARMACY FORECAST 2016-2020

Why Hospital Pharmacy Struggles

It is no surprise to hospital pharmacists that there is an internal battle going on. I cannot outline the struggle without first describing how hospitals get paid. Hospitals are a business and businesses cannot continue to function without money to pay its employees and generate profit.

Hospitals are paid by different methods depending on who is paying the bill.

Medicare: the federal program for the elderly usually pays the hospital a flat fee per case depending on the case. There are around 750 different diagnostic related cases (D.R.G.'s) that can be billed and each command a flat rate regardless of what happens in the hospital. These flat rates are changed due to lobbying and advice from commissions and other methods. Many times hospitals claim the payments received are below cost which causes the hospital to lose money.

Medicaid: the federal-state program for the poor, blind and disabled hospitals receive the same D.R.G's or a set amount of dollars per day (per-diem) or fee-for-service (F.F.S.) payments. These are set by state governments. Again, many times hospitals claim the payments received from Medicaid are below cost which causes profit loss.

Private insurers: purchased by consumers and pay hospitals on the basis of per-diems or fee-for-service. These usually exceed hospitals' costs and help override the losses from Medicare and Medicaid. Private insurers also help with net profits for the hospital and are negotiated yearly.

Breaking down the particular fees agreed upon, it's fairly evident that the pharmacist's role in billable services is on the distribution aspect: the medication provided and the rest is dollars saved but not billed. For example, if I dispense 2 bags of IV vancomycin, the hospital can bill $XX for the medication. If I recommend changing vancomycin to an oral antibiotic, the savings are due to medication and delivery costing less. I am not billing the other aspects of the IV to PO change. The patient has less chance of infection with an antibiotic given by mouth than IV and is easier to administer. Maybe even the cultures drawn show equal sensitivity and the choice of by mouth antibiotic is an ideal choice over choosing IV. There are cost savings for the drug (still distribution in nature) and costs in drug delivery, but the consult itself to change a medication has no billable service to the pharmacy department but indirect savings to the hospital as a whole. There are also cost savings with preventable adverse drug errors in regards to length of hospital stay billed, but nothing billed on catching anything amiss on a patient's profile, rounding with physicians, billing a "consult" or anything tied to a clinical pharmacist directly as a provider.

In other words, pharmacists command high salaries but do not have a way to bill for the same amount in return. Pharmacists and pharmacies cost the hospital a lot of money.

Hospitals are starting to learn that using pharmacists to cut medication errors cuts down on readmission (financial penalties with reimbursement). They are learning that there are costs tied to a patient experiencing an adverse drug reaction and other indirect cost savings, but the hospitals still need a return on their investment. Perhaps that is where provider status for pharmacists will fill in the gap?

Not only do we struggle with what we bill and what we cannot bill, we also struggle with being segmented within our own pharmacy departments. Distributive pharmacists (order entry pharmacists) are looked upon as aging dinosaurs out-of-touch with the clinical aspect of rounding with physicians and making real-time recommendations at bedside and new graduates state, "I don't want an order entry job. I want to be a clinical pharmacist." There is a division that seems to be encouraged with residency programs, fellowships, and board certification leading to "clinical" jobs and none required for order entry jobs. Maybe you are one of the lucky ones in a more progressive hospital that tries hard to incorporate both models into staffing with pharmacists decentralized on the hospital floors interacting "clinically" with nursing, physicians and patients. Maybe you are still stuck to a computer monitor in the basement of a hospital barely interacting with anyone directly. The models are all over the place because of the lack of being able to bill for what pharmacists provide besides a bag of medication.

Another struggle is that clinical pharmacists do not want to be bothered by pharmacy operational problems or regulatory issues. Operational problems affect patient care as well and translates into costs for the department and hospital. 

The last struggle that I have observed over the last fifteen years is the lack of excellence in leadership. I do not have many peers who strive for leadership roles in pharmacy but are fine to sit back and just work as a pharmacist rather than a manager. There are not a lot of strong leaders teaching and mentoring others on how to lead within the pharmacy and because of that pharmacists do not have a lot of power or clout to make change happen inside the pharmacy. This also translates into the lack of leadership and power where change happens on a government level.

What is the answer? I am hopeful that provider status will open the door to pharmacists becoming a return on investment for hospitals rather than a huge expense, but I also believe that there should be more meshing with understanding the business side of hospital pharmacy with clinical pharmacy because the two together would benefit what should be the ultimate goal of a hospital: patient care and minimizing costs.

Rejection Can Be a Good Thing

Have you ever thought of rejection as being something that can be utilized for greatness? While no one actively enjoys rejection on the job or in life, it is at least something that can propel you to another level in how you view its role in your expertise and willingness to continue moving forward despite what is usually considered a personal failure with the usual negative results.

Usually when most people face rejection the first impulse is to withdraw and criticize the methods; however, what if we turned it into an opportunity to learn? What if we sought out opportunities to be rejected to learn how to minimize the emotional reaction and criticism and turned it into something else?

Take for example the issue that comes up with a medication where you have to make the phone call to the prescriber about a prescriber’s choice in medication. How does a pharmacist approach it to not look like someone who is pointing out mistakes the prescriber made and at the same time can convince a change if you really believe it? I hear pharmacists in the field make comments about physicians’ personalities and how one physician always says no to any recommendation and another physician is just plain “not nice.” What one pharmacist may think as “not nice” another pharmacist may interpret in a different way. Hospitals many times are using clinical pharmacists to manage medications with a cost savings plan in mind and that aspect can sometimes clash with what the prescriber believes when medicine was more of an art and less money, or it could mean that the pharmacist is bringing a valuable piece of knowledge to the table that the prescriber will appreciate. Whatever the reason, learning how to approach the physician and using it as an opportunity to improve the approach and delivery can make rejection turn into a positive rather than a negative.

Overcome the fear of rejection: One of the reasons why we have such fear of rejection is that we take rejection personally. Rejections are not personal. The prescriber or manager did not reject YOU but the proposal or effort was rejected. Of course rejection should not make you feel less, but it somehow can. Don’t let it, dive in and ask why the recommendation isn’t accepted, move on. The more you ask and are rejected (or accepted!) the less it will sting. If a pharmacist can learn how to detach emotions from the results, whether a yes or a no, it will help gain real confidence in the face of possible rejection. Building a relationship with the prescriber by actually being physically on the floor and picking up the phone helps as well. Leaving a note on a chart doesn’t help build a relationship and can easily be ignored but asserting yourself helps not only improve your relationship with the prescriber but also gives the prescriber a chance to hear and respond in real-time to a request. And the more you are rejected, the less it will sting and in the meantime the prescriber is getting to know you better.

What if a prescriber responds with a no? What if you asked the right questions to find out about the no? You could learn a lot as to why your idea to change something was rejected or you could just learn it is the prescriber’s prerogative. If all of this is handled well, you could use that no to help build a relationship and eventually trust.

This is a study that reviewed inpatient pharmacy recommendations and their acceptance rate. Perhaps if we focused a little more on approach and building a relationship with the prescribers, the number of acceptances would increase and make more of a difference. In the meantime, don’t let a rejection keep you from asking and asking well. Those rejections help teach you how to handle rejection better which could be the very thing keeping you from excelling as a clinical pharmacist.

Pharmacists in the ER Equals Better Patient Care

One of the biggest impacts a pharmacist can make in the hospital setting is in the emergency department (ER). There has been a growing interest and trend in placing pharmacists in the ER to review medications, both reconciliation of home medications and medications administered in the ER to ensure correctness and cut down on medication errors and drug interactions that contribute up to 7,000 yearly deaths in the US. A pharmacist in the ER can review real-time orders that are typically bypassed by staff pharmacists due to the urgency of an ER patient.

Pharmacists can also improve flow of patients through the ER, educate prescribers and staff development about medications and their costs and also utilize the ER as a place to precept and mentor students and residents. Pharmacists can participate in codes, help with admissions in home medications and help with discharge medication reconciliation. Pharmacists in the ER can also be involved with the ER department in providing presentations, publications and other activities to the department. Pharmacists can monitor the use of expensive medications to make sure use is consistent with approved criteria (Factor VII, alteplase, etc.) and conduct MUEs in the emergency room setting. These pharmacists could also be involved with microbial culture follow-up. The emergency department is usually a place of unpredictability in acute illnesses and patient volume. High risk medications are used more often and a greater chance of a medication error reaching the patient.

Currently in most hospital settings, hospitals use a clerk to fill out a home medication sheet which typically can include errors in drug name, drug strength and directions. Many times staff pharmacists are clarifying home medications days later than what is optimal. I have personally witnessed mistakes in high-risk medications like warfarin that are discovered days later. In short, when a patient is admitted, they are prescribing for themselves with no oversight from a pharmacist, and physicians do not want to take ownership of what the patient takes at home since they are presenting with something acute that may have nothing to do with the herbals they take on the side.

The American Society of Health-System Pharmacists (ASHP) believes every hospital pharmacy department should provide its emergency department with the pharmacy services that are necessary for safe and effective patient care. The Joint Commission also has compliance requirements that can be met with a pharmacist in the emergency department (MM.4.10. which requires that all medication orders be evaluated by a pharmacist prior to administration of the first dose and MM 7.10 which identifies high-risk or high-alert medications and all the processes involved from procuring to monitoring and medication reconciliation). One of the National Patient Safety Goals is to accurately and completely reconcile medications across the continuum of care which would include the first stop in the emergency department.

One of the most common reasons most hospitals do not employ emergency room pharmacists is due to cost. Small hospital pharmacies are staffed at a bare minimum. Most hospitals do not realize that pharmacists working in the emergency room can reduce readmissions, medication errors and drug interactions to save money but more importantly increase patient safety while being treated for an acute illness.

1.       Impact of a prescription review program on the accuracy and safety of discharge prescriptions in a pediatric hospital setting. J Pediatr Pharmacol Ther. 2008 Oct;13(4):226-32. doi: 10.5863/1551-6776-13.4.226.

2.       Levy DB. Documentation of clinical and cost saving pharmacy interventions in the emergency room. Hosp Pharm. 1993;28:624-627,630-634,653.

3.       American Society of Health-System Pharmacists. ASHP statement on the role of health-system pharmacists in emergency preparedness. Am J Health Syst Pharm. 2003; 60:1993-5.

4.       Cohen V, et al. Effect of clinical pharmacists on care in the emergency department: a systematic review. – Am J Health-Syst Pharm. 2009;66;1353-1361

National Patient Safety Goals: The Joint Commission

Pharmacy Distractions

Yesterday, I decided to record the number of distractions I faced on a regular work day. This proved to be a distraction in itself considering the pharmacy where I worked is in an open plan where technicians, phones, cubicles and door to the hospital hallway are all within ten feet of where I sit. There are four or five telephone lines which ring regularly. There are usually one to two other pharmacists sitting within five feet and two to three technicians in the same vicinity.

Yesterday I recorded over 150 interruptions. I even faulted myself for starting personal conversations which distracted others. 

What are some things we can do to make the pharmacy workplace have less distractions? Interruptions contribute to medication errors and having a dedicated space where interruptions are not allowed should be implemented. Chemotherapy entry, preparation and checking definitely falls into this category. The Institute for Safe Medication Practices found that each interruption is associated with a 12.7% increase in errors. I have personally attempted to enter new chemotherapy on a patient in the noisiest place where phones are ringing consistently, technicians are interrupting the workflow with issues on the phone that they cannot handle and other staff are just walking by to chat, all while the TV is reporting the news and a radio in the back is piping out 80s music. It is enough to cause me to go into panic mode. Ask for a dedicated space with less distractions or a no-interruption zone. You may not get it but it is on the record that you asked. In the meantime, one tip I have tried is headphones with something soothing to completely block out all noise when concentration is key. Bose makes great noise-canceling headphones that work! Though I would love to work in silence, blocking out everything but one sound is better than ten sounds all interrupting and distracting what you are trying to do safely. 

Another source of interruptions is when a medication is out-of-stock. This issue can completely lead a pharmacist into a rabbit hole of issues. First I have to ask if we have the medication which leads to comments of inventory failure and what process is to blame. Second we have to call other hospitals and ask to borrow a medication which interrupts them as well. We also have to call a courier service to deliver the medication which leads to delay in delivery of treatment to the patient. If we could reduce missing medications, we could reduce distractions and phone calls. This type of interruption falls under system distractions along with medication timing and other issues that causes distractions on how we handle system failures or deficits.

Alert fatigue is another source of distraction. It is common for me to receive five or more alerts per order when entering a medication with the majority being unnecessary. For example, when entering a sodium chloride IV fluid, I will routinely be alerted that the chloride in the IV fluid will be a duplication with the potassium chloride (chloride duplication). I will also receive an alert that sodium chloride is on national backorder. Most of the times medication alerts include what is formulary, nonformulary, to notify IT staff when medication is depleted, duplication of class that isn't clinically significant, insignificant labs that can include a time period longer than current hospitalization and even how to enter medications differently for a new process that can change quite often. It is used more times than not as an email to communicate inventory issues that should be saved for another time and not when entering a medication where the most important issues are drug, strength, indication, directions and allergies. All of the important stuff can be diluted quickly by things that are nowhere near as important than the task at hand.

Educating the staff is very important in handling distractions and improving patient safety. Educating the staff to know when to interrupt with something important that cannot wait a second and when to write a note for the pharmacist to handle a few minutes later is important. Placing phones with multiple lines in a separate area to lower distractions while the pharmacist is entering orders or checking orders and/or having a designated technician to answer phones and not filling is an idea to consider. Also educating a technician on how to answer the phone and troubleshoot is invaluable!

The Institute for Safe Medication Practices has looked at this issue and has an invaluable write-up about things that can be done to help pharmacists and technicians focus on what matters most... patient safety.

A.S.P.E.N.'s Parenteral Nutrition Handbook, 2nd Edition

Click on image to order A.S.P.E.N.'s Parenteral Nutrition Handbook, 2nd Edition (no paid link on this, just for your information)

            As a pharmacist and a clinician at my local hospital, there have been times where I am starting a new PN (total parenteral nutrition) and needed help beyond the usual formula or write-up that we use. In the information age, we have a diverse amount of information online at our fingertips; however sometimes this information can be from sources that are not legitimate. I can google PN and a disease state and hope for something relevant, or I can seek out material that is tried, true and tested.

            The A.S.P.E.N. Parenteral Nutrition Handbook, 2nd Edition is a pocket-sized handbook or quick reference that covers many parenteral nutrition topics with students in dietetics, nursing, medicine and pharmacy in mind. There are 10 fully revised chapters from the 2009 1st edition including: 

1.  Chapter 1: Nutrition Screening, Assessment, and Plan of Care

2.   Chapter 2:  Overview of Parenteral Nutrition

3.   Chapter 3:  Parenteral Nutrition Access Devices

4.   Chapter 4:  Parenteral Nutrition Formulations and Managing Component Shortages

5.   Chapter 5:  How to Prescribe Parenteral Nutrition Therapy

6.   Chapter 6:  Review and Verification of Parenteral Nutrition Orders, Preparing Parenteral Formulations, and Ordering

7.   Chapter 7:  Parenteral Nutrition Administration and Monitoring

8.  Chapter 8:  Complications of Parenteral Nutrition

9.  Chapter 9:  Medication-Related Interactions

10.  Chapter 10:  Home Parenteral Nutrition Support

These chapters cover many of the relevant topics for the patient receiving parenteral nutrition (PN) including some newer topics on order review, compounding, and drug shortage management. Also this handbook contains evidence-based guidelines from the A.S.P.E.N. Parenteral Nutrition Safety Consensus Recommendations (JPEN, March 2014) and A.S.P.E.N. Clinical Guidelines: Parenteral Nutrition Ordering, Order Review, Compounding, Labeling, and Dispensing (JPEN, March 2014).

I have taken the time to utilize this handbook while dosing PNs in the past few weeks and have found this reference accurate while covering many of the topics I needed.  I especially enjoyed the chapter on parenteral nutrition complications.  I found the topics succinct and spot-on for finding quick information on a couple of questions I had on a patient’s PN.

If you are looking for a guide with a broad range of topics related to PN that will help your student, resident or even new pharmacist managing PN, this guide will help you tremendously.

Meet Mr. MRSA

I thought I would introduce you to an infectious organism every week!  Today, the lucky "bug" as they are referred to in the medical community is methicillin resistant staphylococcus aureus (MRSA). If I was a common layperson in the field of medicine, I would view this microorganism as a very nasty flesh eating entity.  I thought I would shed some light about MRSA.  Whether you are dealing with a soft tissue infection, pneumonia, central nervous system infection, endocarditis (heart), or bone and joint, the treatment differs.

Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterium that causes infections in different parts of the body. It's tougher to treat than most strains of staphylococcus aureus -- or staph -- because it's resistant to some commonly used antibiotics.

The symptoms of MRSA depend on where you're infected. Most often, it causes mild infections on the skin, causing sores or boils. But it can also cause more serious skin infections or infect surgical wounds, the bloodstream, the lungs, or the urinary tract.

Though most MRSA infections aren't serious, some can be life-threatening. Many public health experts are alarmed by the spread of tough strains of MRSA. Because it's hard to treat, MRSA is sometimes called a "super bug."  Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterium that causes infections in different parts of the body. It's tougher to treat than most strains of staphylococcus aureus -- or staph -- because it's resistant to some commonly used antibiotics.

The symptoms of MRSA depend on where you're infected. Most often, it causes mild infections on the skin, causing sores or boils. But it can also cause more serious skin infections or infect surgical wounds, the bloodstream, the lungs, or the urinary tract.

Though most MRSA infections aren't serious, some can be life-threatening.  Many public health experts are alarmed by the spread of tough strains of MRSA.  Because it's hard to treat, MRSA is sometimes called a "super bug." 

Also just news today... an almost instant test in detecting MRSA.

Skin and soft-tissue infections

1.  Abscess  - incision and drainage
2. Purulent cellulitis
   • Clindamycin 300-450 mg PO TID (C diff)
   • Bactrim 1-2 DS tablets BID (pregnancy category C/D)
   • Doxycycline 100 mg BID (pg category D and not recommend for children under 8)
   • Minocycline 200 mg x 1, then 100 mg PO BID
   • Linezolid 600 mg BID (expensive)
3.  Nonpurulent cellultis
   • Beta lactam (cephalexin and dicloxacillin) 500 mg QID
   • Clindamycin 300-450 mg TID
   • Beta lactam and/or Bactrim or a tetracycline – amoxicillin 500 mg TID
   • Linezolid 600 mg BID
4. Complicated SSTI
   • Vancomycin 15-20 mg/kg/dose IV every 8-12 hours
   • Linezolid 600 mg PO/IV BID
   • Daptomycin (cubicin) 4 mg/kg/dse IV QD
   • Telavancin 10 mg/kg/dose IV QD
   • Clindamycin 600 mg PO/IV TID
5. Bacteremia
   • Vancomycin 15-20 mg/kg/dose IV every 8-12 hours
   • Daptomycin 6 mg/kg/dose IV QD
6. Infective endocarditis, native valve – same as bacteremia
7. Infective endocarditis prosthetic valve
   • Vancomycin and gentamicin and rifampin – 15-20 mg/kg/dose IV every 8-12 hrs,                                          i.      1 mg/kg/dose IV every 8 h,  300 mg PO/IV every 8 h
8.  Persistant bacteremia
9. Pneumonia
   • Vancomycin 15-20 mg/kg/dose IV every 8-12 hours        
   • Linezolid 600 mg PO/IV BID
   • Clindamycin 600 mg PO/IV TID
10. Osteomyelitis (Bone and Joint Infections)
    • Vancomycin 15-20 mg/kig/dose IV every 8-12 hours
    • Daptomycin 6 mg/kg/day IV QD
    • Linezolid 600 mg PO/IV BID
    • Clindamycin 600 mg PO/IV TID
    • TMP-SMX and rifampin – 3.5-4.0 mg/kg/dose PO/IV every 8-12 h
11. Septic arthritis
    • Vancomycin 15-20 mg/kg every 8-12 hours
    • Daptomycin 6 mg/kg/day IV QD
    • Linezolid 600 mg PO/IV BID
    • Clindamycin 600 mg PO/IV TID
    • Bactrim 3.5-4.0 mg/kg/dose PO/IV every 8-12 hours
12. Meningitis
    • Vancomycin 15-20 mg/kg/dose IV every 8-12 hours
    • Linezolid 600 mg PO/IV BID
    • Bactrim 5 mg/kg/dose PO/IV every 8-12 hours
13. Brain abscess, subdural empyema, spinal epidural abcess
    • Vancomycin 15-20 mg/kg/dose every 8-12 hours
    • Linezolid 600 mg po/iv BID
    • Bactrim 5 mg/kg/dose PO/IV every 8-12 hours
14. Septic thrombosis of cavernous or dural venous sinus
    • Vanc same
    • Zyvox
    • Bactrim same

How to Make the Transition from Retail to ANYTHING Else

You've finally reached the end of the line in retail.  You've had enough of the rude public, the non-pharmacist managers, and the corporate cuts.  You are ready to have an hour lunch (maybe) and normal bathroom breaks.  You are ready to feel a little more professional.  Sorry, retail pharmacists, you know it's true.  Yes, you probably make more money than me, but at least I'm not worried about my health.  (I was working retail in a terrible part of town.  All of the good areas were full with waiting lists of pharmacists ready to transfer out just like me.  I just chose a quicker path). The first thing that is entering your mind as I'm noticing on a couple of comments here is that you think a special amount of training is required.  Let's first think about hospital pharmacy.  You can transfer from retail to hospital pharmacy fairly easily.  Hospitals can train you.  There is a lot to learn, yes, but I was up-to-speed in two months.  I worked five years in retail, if that helps at all.

You will have to learn about the hospital's formulary, allergy list, and perhaps coumadin and pharmacokinetic dosing again.  You will certainly have a lot of pharmacists willing to help.  There will be no more jerks in line waiting on you to hand them their papersack with drugs; you will merely have a function to be a part of the team that helps to heal the acutely and chronically ill.  You will revisit sterile technique to mix IVs, chemo, and TPN. (I hope, though it seems the hospitals I worked in didn't observe this at all!)

And most importantly... you will have a life back.  No more driving home from work in retail and a customer follow you home.  No more jerks waiting until 3 minutes before close to get 10 prescriptions filled... all new.

I don't regret leaving retail at all.  I do regret losing the knowledge of some of the new drugs since graduation, but it's worth it for peace of mind and life.

I hope that helps.

Are You Kidding Me?

My mouth just dropped open.  It's obvious to me that physicians do NOT read medication reconciliation forms for home meds at all.  The ones that do, kudos, but the ones that don't make my job more interesting and at times really get to me. Case-in-point:  50-something presenting to the hospital with lower GI bleed.

The doctor signed off to CONTINUE HER HOME MED OF PHENTERMINE FOR WEIGHT LOSS.  Are you kidding me?

I guess the nurse could have written "Purina Dog Chow - take one cup by mouth daily" and the physician would have signed off on it.

Way to go Joint Commission on putting in a requirement with no means of adhering to any sort of THINKING for anyone involved.

Except for the pharmacist of course to wade through the BS and find what is really needed.

I really like the one where the physician wanted to continue the patient's viagra while in the hospital.  THAT should keep the nurses on the floor on their toes running from a man who is looking for some fun.  Not good.

Medication reconciliation forms.  The bane of my existence.

Is It That Bad?

A potential pharmacist student commented on my blog here asking me if pharmacy was really that bad... he said he was reading blogs about the medical profession and all we do is gripe and complain. Got me to thinking this early morning about that question... "Is it that bad?" For me, no way it's not that bad or I would have already gone back to school to do something else. I believe it's human nature to complain some and especially to complain anonymously. Things about pharmacy that I have loved... This is a list probably needed to be completed to tell you guys and gals the GOOD stuff.

1. If you loved science and you loved biology in high school and college then pharmacy could be the career for you. Not only did I have the opportunity to learn about chemicals, etc..., but I learned the various ways they are changed, metabolized, and excreted by the human body. Not only that, but the different ways they can be broken down by DIFFERENT human bodies - some with renal issues, some with hepatic issues, etc... Everyone can be truly different. Drugs can react differently. I found this one single point of pharmacy to be quite fascinating.

2. If you want to graduate in 6-8 years and start out making six figures (potentially) this may be the job for you. I found in 1999 when I graduated that I was making close to six figures, but a lot of the older pharmacists were really ill about the new guys on the block because they knew we were making the exact same pay. It wasn't pay based on performance but LICENSURE. For the new guy, this is great; for the old guy, it can be disheartening to think that little youngin' next to you is bringing home the same bucks. I'm almost 10 years out of pharmacy school now (unbelievable time flies!) and it STILL DOES NOT BOTHER ME. I don't get wrapped up in petty stuff, and I figure if you really want a dollar more per hour, you could have negotiated up front. BE A SHARK when you negotiate - ASK FOR THE IMPOSSIBLE. If you do not ask, you will NOT RECEIVE. Vacation... they say we'll give you 3 weeks. Tell them that you want 4 weeks. Go up on pay by at least 5-10K per year. Why not? They want you and they will negotiate just like if you are selling a house.

3. Options other than retail. When I tell people I'm a "pharmacist," the majority think retail. What is great about pharmacy is that there are MANY MANY options in different jobs. Of course coming out of school, retail is the most lucrative in pay, but over time other positions can be just as tasty. There are the hospital pharmacists (me), the home infusion pharmacists, the nuclear pharmacists, the retail pharmacists, the professors in a pharmacy school, the long-term care pharmacist, the consultant pharmacist, and the specialty pharmacists within other settings. You can do a residency, make yourself a little different than Joe PharmD next to you, and land a Critical Care Specialty Pharmacist position at a big city hospital, make rounds with a physician that actually respects you if you know your shit and drink Starbucks coffee everyday leaving for home at 5pm like the rest with bankers' hours. The CHOICES ARE ENDLESS really.

I've been out of school, like I said, for 10 years almost. I have tried retail, home infusion, long-term care, and hospital. I love little bits of all of them... but I find hospital to be the most comfortable for me.

I would never tell someone to NOT pursue pharmacy. It's a great career for anyone... BUT you will find some complaining out there... even from me.

Blogs have to be funny after all, right?