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?

What advice I would give students graduating from pharmacy school

Seems others are doing the same, so I'll put in my 2 cents. 1.  Don't assume that all of pharmacy is retail.  Yes, you will make the most bucks in retail and if you have gone the way of borrowing your way into a huge hole, then it may be your only way to make it out and then find something else.  Perhaps retail is your goal, and you love it, but personally, I found 3 years of retail to be enough pharmacy prostituting that I could do.  The bucks WERE nice, but the abuse to my body from standing 14 hours a day, lack of bathroom breaks, treatment from STORE managers who have barely any sort of education, abuse from patients, and abuse from non-caring technicians, I look back now and say RUN -- no I SCREAM RUN!  There are some great jobs out there that don't involve retail at all.

2.  If you DO choose retail know that the longer you stay IN retail, the less likely you'll ever get out.  It's like getting hooked on a drug.  You keep doing it saying you'll quit, but by the time you are ready to leave, it's almost too late, unless you are lucky and some poor sweet manager in a different realm of pharmacy sees the pain you have experienced and wants to throw you a lifeline.  I had one of those - a female pharmacist that I am forever indebted to.... thanks J!

3.  Make pharmacy a hobby somehow.  Read and read and read.  The only difference between you and the girl (since girls are taking over ;)) standing next to you is that you somehow have made yourself marketable... you are reading publications and keeping up.  You are giving a rats ass about pharmacy and all the crap going on...  You know how to find anything FAST...  you can think on your toes.  Who care what you made in Biochem.  No one cares.  But do you know the difference between using Primaxin/Fortaz vs. Tygacil in different situations?  Can you think critically?

My top advice... DO NOT GO INTO RETAIL!!!!!!!!!!!!!!!!!!!!!!!!!!!

Night Shift Pharmacists

Looks like working the night shift is carcinogenic.  Can't you hear it now?  The lawyers on TV asking, "Have you been working the graveyard shift for such-and-such years?  It's not called graveyard for nothing!  Call 555-5555 and file your claim today against your company!" Article here and here.

Brain Shivers... Brain Zaps... Brain Shocks...

I do not know if many in the medical community are aware of this term that is thrown out there for such offenders as venlafaxine (Effexor), duloxetine (Cymbalta), paroxetine (Paxil), fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro), but it is a very real phenomenon. Unfortunately, though many in the medical community have not had to rely on any of these meds in their own personal lives, I had a 2-3 year stint with venlafaxine from 2002-03. Basically, I presented with the inability to sleep due to anxiety of some personal issues (which we all have from time to time), and did not want a controlled substance. I tried paroxetine first and absolutely despised the drug. I quit cold turkey. Very smart for a pharmacist, right? (You can't just stop cold turkey and expect to not endure some uncomfortable sensory disturbances.) I found venlafaxine, at 75 mg extended release, to be a very good drug for its purpose of 9 to 12 months. However, what I didn't expect was that weaning from the drug would be so uncomfortable. 75 mg in itself is not even a moderate dose, falling more into the lower dose category. I've seen higher doses much more than the lower doses.

To explain what I felt, I will do my best to try to break down into words the feelings. Initially, there was a sinking feeling in my brain. If you've ever been to the Grand Canyon or a very tall building and looked down, there is a falling feeling that your brain sometimes throws at you though you are not falling at all. That feeling would happen for very short bursts, 2-3 seconds, enough to disrupt my thoughts, my work, and my being. I would just think, "What was that?" If I tapered over the recommended taper schedule (usually a week at a time step down, but keep in mind there's only one strength lower than the 75 mg XR - the 37.5 mg XR. Then where do I go? Literally it didn't matter. The big divide between the 75 mg and the 37.5 mg was enough to cause the "shivers" in my brain - a disorientation, falling, weird, and uncomfortable feeling.

"Brain zaps" are said to defy description for whomever has not experienced them, but the most common themes are of a sudden "jolt," likened to an electric shock, apparently occurring or originating within the brain itself, with associated disorientation for a few seconds. The phenomenon is most often reported as a brief, wave-like electrical pulse that quickly travels across the surface of (or through) the brain. Some people experience these "waves" through the rest of their body, but the sensation dissipates quickly. They are sometimes accompanied by brief tinnitus and vertigo like feelings. Immediately following this shock is a light-headedness that may last for up to ten seconds. The sensation has also be described by many as a flashbulb going off inside the head or brain. Moving one's eyes from side to side quickly while open has also been known to trigger these zaps and sometimes causing them to come in rapid succession. It is thought to be a form of neuro-epileptiform activity.

As withdrawal time increases, the frequency of the shocks decreases. At their peak, brain zaps have been associated with severe headaches. They may last for a period of several weeks after the last dose and usually resolve completely within a month or two. However, anecdotal reports of "zaps" during a protracted withdrawal are known to last a year or longer.

My remedy was to open the capsule and to count the tiny beads and literally make capsules with less and less tapering over a 6 week period rather than the usual 2 - 3 weeks at this dose. It did eliminate the feeling, but it definitely helped. One could go as far as asking the physician for a 37.5 mg immediate release tablet and maybe breaking it up into pieces and tapering at the very end that way. Any way you dice it, venlafaxine was a pain and taught me right away a bigger lesson in remembering the side effects than any package insert ever could.

10/31/12 - update and fitting it is Halloween! Guess what? Add Cymbalta (duloxetine) to the list. It has been given approval for pain, both arthritic lower back and cancer. Withdrawal when you miss a dose.

I did take Vitamin B Complex, and maybe it helped.  Others have mentioned other vitamins.  Would love to hear remedies that worked if you can email me at theblondepharmacist@gmail.com

Hospice Care

When I'm entering/reviewing orders for someone with terminal cancer and the last "D/C to hospice" order.  A lump will come up in my throat and then I start thinking about life.  What will I die of?  Will someone enter my last orders someday?  Will I die of a terminal cancer or something else?  I know I shouldn't think about it, but the last few decades of life have passed rather briefly.  Will the rest of life be the same?  Quick and so fast you don't take the time to enjoy it? Anyway, that's what those orders do to me... and then I have to clear my thinking and my mind and get back to work.

I just wonder sometimes if others are affected by it in the same way.

One of the most profound rotations in my last year of pharmacy school was with a hospice nurse.  To this day I still remember each and every patient we visited at various stages of dying.  The man whose terminal wife was hours if not a day from death but yet he seemed so stoic and in denial.  That one was the worst.  They had this gorgeous custom home with all the fine details and obviously had planned retirement together in this space.

Life had other plans.

 

NAPLEX is Suspended

Prof. accused of sharing licensure exam questionsQuality of University not in doubt KRISTEN COULTER

Issue date: 8/30/07 Section: News

Shirley Zhang, a graduate student from China studying biochemical sciences, walks past the Pharmacy Building located on South Campus.

A University pharmacy professor is a defendant in a federal court case, in which he is accused of collecting and disseminating pharmacy test questions to students, according to court documents obtained by The Red & Black.

The National Association of Boards of Pharmacy filed the case Aug. 3 against the Board of Regents and Flynn Warren Jr., citing copyright infringement, misappropriation of trade secrets and breach of contract, according to the documents.

NABP has investigated Warren twice for these allegations.

The North American Pharmacist Licensure Examination and Georgia Multistate Pharmacy Jurisprudence Examination are tests required to obtain a license to practice pharmacy. The NAPLEX is used by all 50 states’ boards of pharmacy, and the MPJE “combines federal and state specific law items to serve as the state law examination in 46 participating jurisdictions,” according to a NABP news release.

At an Aug. 23 meeting, the executive committee of NABP decided to suspend all administrations of the NAPLEX and the Georgia MPJE beginning Aug. 25 and will not administer the test nationwide.

NABF said in the news release it has not decided when to reinstate the test.

“I cannot comment on this, given the current investigation,” said University Provost Arnett Mace Wednesday afternoon.

Warren, who was reached at his home Wednesday evening, also refused to comment.

The College of Pharmacy referred calls to Tom Jackson, the associate vice president for public affairs. Jackson wrote Wednesday in an e-mail, “parties have been ordered by the court not to comment on the matter while it is in litigation.”

While he would not comment on the investigation, George Francisco, associate dean of the College of Pharmacy, said Warren has taught the board review course at the University “for several years.” Francisco said the class lasts three days and is available to both University pharmacy students and students at other institutions.

Warren is accused of copyright infringement because NABP owns the copyrights on the exam questions. Court papers say he asked students to memorize NAPLEX test questions and share them with him. He collected the tests’ contents and created a review packet.

Warren is faced with these accusations because he was never “granted a license … to copy, sell, distribute, prepare derivative works from, or otherwise offered to transfer the ownership of the copyrights of the NABP Examination Questions, to which NABP has exclusive rights,” the court papers read.

Warren is accused of misappropriation of trade secrets because: “the NABP Examination Questions are original lists of questions containing technical information used for evaluating the competency of a candidate in the field of pharmacy,” and the questions “derive economic and evaluative value from not being generally known and not being readily ascertainable by proper means,” according to the documents.

The breach of contract charge stems from a 1995 settlement agreement, in which Warren and the University said they will “cease and desist for profit or otherwise from all past, present and future copying, transcribing or other infringing use of NABP copyrighted materials, including but not limited to patient profiles, sample questions, or other copyrighted information.”

Francisco said he was unaware of the 1995 settlement, and the pharmacy school was not monitoring Warren’s classes.

Last year, the BOR offered to pay $40 million for an addition to the College of Pharmacy.

Professors at other schools exposed exam study guide

According to a biography on the University’s Web site, Warren has been a pharmacy faculty member since 1985. Before his July 1 retirement, he was a clinical professor and the college’s assistant dean for student affairs.

Though he retired last month, Warren still is teaching elective classes for the pharmacy school, Francisco said.

This case arose after Warren offered an annual exam review course at Samford University.

Alan Ray Spies, an assistant pharmacy professor at Samford, said in an affidavit that he learned Warren was giving NAPLEX questions to students. Spies said he first found out this information in May 2007.

“Specifically, I learned that Mr. Warren’s course materials include, among others, a series of questions, some 2,700 in number, that appear to be very similar, if not verbatim, to questions asked on the NAPLEX,” Spies said in the affidavit.

Spies said he talked with some of his students about Warren’s course in the affidavit.

“It soon became apparent to me that individuals who had just taken the exam were sending Mr. Warren questions which he in turn was forwarding to students who had not yet taken the NAPLEX.”

Spies said he sent the information he found in an e-mail to Steven Pray, a pharmacy professor at Southwestern Oklahoma State University.

In his affidavit, Pray discussed his view of the importance of exam security for the NAPLEX.

“The knowledge base required to become a competent pharmacist is vast, taught via hundreds of hours of lectures, laboratories, and practical experiences,” Pray said.

In the affidavit, Pray also discussed his thoughts about the extensive consequences for the exam if the questions have been compromised.

“A loss of hundreds or thousands of items, as it appears, has occurred through the activities of Mr. Warren, will force NABP to endure a loss of millions of dollars and will necessitate a radical overhauling of the examination pool,” he said. “If this is required, the nation’s pharmacy graduates cannot be licensed until a new, uncompromised NAPLEX can be created.”

As he further researched the issue, Pray said in the affidavit that he found an online forum where students discussed Warren’s course.

“This Web site also discussed an individual named ‘Flynn,’ who offered a review course and notes on passing the NAPLEX,” Pray said in the document. “One correspondent on the Web site suggested that prospective examinees review the comments sent to ‘Flynn’ by other students, and another provided his address at the University of Georgia.”

Pray declined Wednesday to speak for attribution about the case with The Red & Black.

Professionals feared news would ‘impair confidence’

According to court documents, Pray sent the information to Carmen Catizone, executive director of NBAP.

In his affidavit, Catizone said Kerri Hochgesang, a lawyer for NABP, bought Warren’s course materials on July 31. In her affidavit, she stated, “a true and correct copy of my payment receipt from the ‘UGA Pharmacy Cont ED, Pharmacy Building’ for the course materials” was given to her for $100.

According to Catizone, the materials contained at least three PDF files. On the NAPLEX REVIEW 2007 disc included in the materials, the files were labeled “NAPLEX MATERIAL PART 2, 2006 INFO FOR NAPLEX, and NAPLEX SAMPLE TEST W ANSWERS.”

Catizone reported his analysis of this material “revealed at least 633 ’sample’ questions contained in Warren’s ‘review course’ and/or were made available by Mr. Warren to candidates who gave him their e-mail addresses.”

He also discussed his concerns about the value of the test if the allegations against Warren are true.

“The extent of the forgoing breach in the confidentiality of NAPLEX exam questions calls into serious question the integrity of the exam,” Catizone said in the affidavit.

Efforts to reach Catizone Wednesday were unsuccessful.

According to an Aug. 6 NABP news release, “United States’ Marshals seized materials and computers from the University of Georgia College of Pharmacy and the offices and home of Flynn Warren, Jr.”

“NABP is disappointed and appalled that the

public trust and health were victimized, the security of the NAPLEX and MPJE breached, and the integrity of the licensure process compromised,” Catizone said in the news release.

On Aug. 3, NABP motioned to file the case under seal, citing potential public panic as a result of the case.

“If the facts of this case are covered in the media or are otherwise publicly available, there is a significant chance that the confidence of the general public in pharmacists and the dispensation of pharmaceuticals will be impaired,” NABP stated in the document.

“This case involved copyright infringement and misappropriation of trade secrets in highly confidential testing materials used in the licensure of pharmacists in many jurisdictions, and reproduction of the testing materials is required in order for Plaintiff to prove its case. Making this information publicly available will further compromise the licensure of pharmacists.”

Warren filed a motion to stay Aug. 21, citing a lack of subject matter jurisdiction.

On Aug. 27, the court “provided the parties with a limited opportunity to conduct discovery related solely to the jurisdiction issue,” according to court documents.

The court also stated, “there have been no final factual determinations by the court and no findings of liability on behalf of any defendant. Furthermore, the court has made no findings that would question the quality of education provided by the University of Georgia College of Pharmacy.”

- Alexis Garrobo, Juanita Cousins and Brian Hughes contributed to this report.

Magic Mouthwash (the vague term for a concoction of ANYTHING)

When I worked in retail pharmacy, a physician would write a prescription for "Magic Mouthwash" and the patient would hand over the prescription with this look of "magic."  This special blend of WHATEVER would be the cureall for their sore mouth and throat caused by thrush or radiation or any other mouth/throat pain condition.  The physician rarely would include what he/she "thought" to be their special recipe.  So, we would have to call and clarify. "What would Dr. Doe like in his magic mouthwash?"  I would ask simply.

"Magic Mouthwash?"  asks the nurse, "I don't know.  What do you normally put in it?"

Sigh.  "Well we could start with diphenhydramine, lidocaine, and nystatin all at a 1:1:1 ratio or we could do tetracycline and throw in some mylanta with the formerly mentioned ingredients at all different ratios.  There are probably a 100 different magic mouthwashes out there.  What is the doctor treating?"

And it would end up that I could pick whatever I wanted.  That made me think... hmmm  placebo effect.

So what exactly should you put in Magic Mouthwash?

The usual concoction contains equal amounts of viscous lidocaine and diphenhydramine for analgesia...and Maalox or a similar antacid to enhance coating of the ingredients in the mouth.  Some also include nystatin to prevent or treat fungal growth...a corticosteroid to reduce inflammation...or tetracycline to prevent secondary bacterial infections.

 

Who knows if this stuff even works and is worth the money since we pharmacists usually tack on a compounding fee.  I say get a prescription for lidocaine viscous and buy your own benadryl solution and mylanta and make your own... for less.

Teamwork and Positive Attitude!!!

There was this cheery orientation video that we all had to watch with the rest of the newbies during the Human Resources' led introduction. I cannot remember the exact name of it, but it had phrases come across the screen of what staff members should NOT say to other members of the staff or patients in the hospital. Rather than: "No. I don't know." Say: "No... but let me find out for you."

There were twenty or more of them, and oh... what a perfect world it seemed for that 10 minutes of listening to those positive and helpful statements. In the real world, I remember the first three weeks of work. I heard them all.

"No... it's not my job."

"Sorry, I don't know."

Or just ignored me. I felt like the biggest idiot asking question after question but considering there was no real formal training program, I guess I got by after four weeks of it.

Andy gave me a brand-new shiny white notebook filled with a 5 week training schedule, a page to write down all my usernames and passwords... (um... doesn't that defeat the purpose?), and blank pages to write notes. OK.

A few words about the training schedule.

I don't know how many of you pharmacists out there have specialty pharmacists, but it's this new phenomenon of further separating the pharmacists from those with residencies and fellowships. We have a few female specialty pharmacists: critical care, infectious disease, pain management, and a couple of others. And their boss, Ann, who has about a month left before she moves away. Most of the regular staff (non-residency pharmacists) cannot stand Ann because they say she forced more work on them and our boss Andy didn't stand up for them. OK. Whatever. Now we have to calculate creatinine clearances for Vancomycin, etc... Big deal. Doesn't matter to me.

Part of the training schedule included meeting with every single one of the specialty pharmacists, etc... and discussing what they do and taking me up on the floors to see them in action. One of them did her job with that setting up the meeting and showing me what she does, etc... One of them mentioned setting something up in three or four days but never delivered or remembered it later (That would be Jessica, who seems nice enough)... is that MY job to remind her? It's THEIR TRAINING PROGRAM! Another one of them, Kimmie, never mentioned it or anything. Geeze. So I didn't see any of it.

The third week, I saw my boss Andy completely ass out. We have automatic orders that can be ordered in group by physicians and we don't have to see the actual written orders... they are pre-approved orders. They print off all day as the orders are being entered along with the scanned and written images we see. Sometimes we get a little bit behind on the pre-approved orders. Andy waltzes into our little room and asses out one day as we are behind on them but also severly understaffed. I saw the real Andy. He's passive aggressive.

Also the third week was when it was discovered by me that although we are in one department, we are severly divided. Staff vs. Clinical. I'm staff. Ann, Kimmie, Jessica, and management with some others are clinical. They have private celebrations for one another without including the staff and don't have the decency enough to take it off site but rather leaves us out. Like I care... but I remember the terms used in my interview...

"Oh Blonde Pharmacist...." Andy says nicely, "We have the best team attitude and everyone is positive and we are making sure that all new hires fit with us and vice versa."

Um. OK. I see what's going on here. He's hiring one person at a time to try to change the culture.

I don't want to be a part of the revolution!