Jim Plagakis

The voice on the other end of the phone line seemed distracted. First, she had to finish up with a prior conversation before she could talk with me. I could tell that she was not holding the phone near her mouth.

When she finally got to me, she said, “I want to call in a prescription for mumble mumble mumble.”

“I’m sorry. I do not hear you very well.” I had the phone pressed to my ear, but I still could not make out everything she was saying. My 67 year old badge has dents in it, but it is still shiny. Most of me is in pretty good shape, but there is a sizeable nick on the medal for EARS. They are 67 years old and an investment in an expensive sound system would be wasted on my ears. Saves me a bunch of money. My aural acuity is compromised.

I am not alone. There are plenty of pharmacists out there who do not hear as well as they did a few decades ago. But get us on a conversation where the information imparted is critical to a patient, we better get it right.

This is what happened when I could not understand what this doctor was trying to order for a patient named mumble mumble mumble.

“I can’t hear you,” I repeated.

She sighed a frustrated sigh. I could hear that. She tried again to get the same result. I knew what the problem was.

“Please put the phone closer to your mouth,” I said, “I can’t hear you.”

“I know how to use a telephone, honey.” Those words I heard very well. She DID put the phone closer to her mouth for the “honey” sentence, but the rest was mumble mumble mumble.

“Please, doctor. Cooperate with me. I want your patient to get exactly what you want, in the correct dose with the correct instructions. I can’t do that if I cannot understand what you are saying.”

“I’ll go slower,” she said with another sigh. “Mumble mumble mumble.”

“Slower doesn’t matter,” I squealed. “You just have to put the phone closer to your mouth.”

“I don’t HAVE to do anything. You HAVE to listen.”

“I’ll listen as best as I can. So far, I don’t even know who the patient is.”

“I told you twice.”

“But you did not have the phone near your mouth. I did not get the patient’s name.”

There was a silence. “Oh forget it,” she said and hung up.

Now, I do not know what happened next. Did she whine to the patient about the pharmacist and suggest a second pharmacy? Did she call back later WITH THE PHONE CLOSER TO HER MOUTH? Perhaps she called when I was at lunch and talked to a pharmacist with 50 something ears. Did the patient have to go without?

All of those possibilities would have caused her time and effort. All she had to do was PUT THE DAMN PHONE CLOSER TO HER MOUTH. Stubbornness is an alternative ONLY when the result is not that important. We are talking about pharmaceuticals. Controlled poisons! Put practically ANY pharmaceutical on a plate and take enough of it often enough and you are dead. We are not talking about an expensive floral display. With controlled poisons, we absolutely have to get it right. You would think that getting it right would always be the goal of the prescriber.

I got that this was a youngish doctor. Her manner was imperious. Her voice was haughty and bossy. Nothing she did made me respect her. She failed in her most important job. ACT SO THAT THE PHARMACIST WANTS TO HELP YOU.

There is enough in this little essay to keep us talking for awhile. In the end, however, it is patient care we are talking about. If the patient did not get the medicine that was needed in a timely manner, is it my fault? I know that I might have sounded impatient, but I raised two daughters and trying to get this doctor to cooperate with me was like getting my daughters to cooperate when it came to their chores.

My contention is that she exhibited gross impatience. She put her opinion of herself right at the top of the list. Her ego is what said, “Oh forget it.” I

I wonder how long it will be before she grows up a little and makes things easier for herself. They can’t be that effortless with the attitude she shows. I’d bet that the nurses make her pay. Women can do that. Men will tolerate her attitude, but nurses (mostly women) will trash her trail with glass.

I would have loved to help her out, but she never even gave me her name.

Monday, July 28, 2008

Next week the House of Representative will vote on giving the FDA its first real power to regulate tobacco products, much as it now regulates food, drugs and medical devices. This is an important bill. If passed and implemented, this bill can finally bring the renegade tobacco industry under regulatory control.

The Bush administration is against it. Bush people say that it will cost too much money. Bullshit. The FDA has been hamstrung by the Bush administration slashing the budget. FDA oversight will be funded by designated USER FEES and no other FDA funds. The Bush people say that giving FDA control of tobacco will pile new responsibilities on the FDA and stretch the FDA too thin.

The only downside I can see is the big tobacco weasels putting ‘FDA APPROVED’ on the tins of Copenhagen that get into the hands of kids.

My question is this: Will CVS & Wal-Mart & Rite-Aid still sell tobacco products when the FDA condemns their use? We are 45 years out since the Surgeon General’s report that denounced tobacco use and labeled it “A CANCER CAUSER”. When the FDA pointed at Vioxx, Merck voluntarily pulled the drug from the market. When the FDA finds no compelling health benefit in tobacco and, indeed, repeats what the Surgeon General said in the early 1960, will Phillip Morris pull all Marlboros?

The tobacco companies and the state of North Carolina will be okay. Big tobacco is going all over the world to get people addicted. They are succeeding.

Drug store companies have continued to sell them because they represent a “PROFIT CENTER”. This behavior is a big turd in pharmacy’s punchbowl. Perhaps a progressive pharmacy organization can come out and express strong disapproval.

Since 1989, I have written about the unethical marketing of tobacco products at the front of the store and dispensing albuterol puffers and ipratropium nebs in the back.

We are frikkin’ hypocrites, you guys. Hypocrites. Name another health professional that does this.
Give it a shot.

This is the best, you guys. The prize-winning example of how we are perceived by some other health professionals.

This time it was a doctor’s office nurse. You come into the conversation right now:

“You want me to do what?”

“Please call our patient and see if she was satisfied with the samples we gave her.” The nurse was pleasant enough and ignorant. She had no clue as to know to navigate the territory she was getting into. She did not know it, but I wait at work for chances like this, for a good gem to write about.

“Then what happens?” I asked, “After I find out if the patient is satisfied?” I could feel it. I tensed a little. I so wanted her to make an idiot out of herself….. for you.

“Call and tell me if she liked it and I’ll give you a prescription.”

“Doesn’t your office have one of those phone things where I have to keep listening to messages and keep pushing numbers and wait ten minutes before I even talk to the receptionist.”

“We call her our “patient care specialist”, not “receptionist”.

“Oh, excuse me, but aren’t I correct? It will take me awhile to get you?”

“Not ten minutes.” She argued.

“How can you know if the drug is right for this patient if all she took was a sample?” I already knew her answer.

“We gave her enough. She’s been taking it for almost three months.”

“So you took food right out of the mouth of my kids by giving her 90 days of an expensive drug free when you could have had me fill three prescriptions.” I could not help myself. My daughters are 24 & 34 and long on their way, feeding themselves, but you gotta have fun with these people.

“Well… uh… well, that’s not how we look at it. We want to make sure a drug works and the patient is satisfied before we actually prescribe a drug.”

“What drug did you give a patient 90 days worth? I will call the head office and tell them that if they continue to give you samples, I’m going to boycott them.”

An important note here. A good lesson for you. Threats work. Just be judicious. I can guarantee you that this nurse, probably a nice girl, had my take-away-your-Pfizer samples intimidation right up front on her cerebral cortex for the rest of the day. How was she going to tell the doctolr that Pfizer was gonna cut them off and it was her fault?

“You can’t do that.”

“Try me. Samples are not meant for 90 days.” Of course, I can’t do that, but she doesn’t know it.

She couldn’t let it go. Her friendly tone had become tense and cold. “Just please call and tell me if she is satisfied.”

“I don’t know how to tell you this, young lady, but you are not going to find any pharmacist who will do what you have asked me to do.”

Silence. Then, “Are you sure?”

“Who gave you this idea?” I tried to sound paternal. I made my voice as soothing as I can make my rusty, deep voice.

“I just thought that you could do that for me since you will get the prescription. I am very busy and I thought you could help me out.”

This is getting too long. Of course, I gave her a quick lecture on how busy pharmacists are. I named a list of things that doctor’s do or do not do that gets in the way of patient care and takes up the pharmacist’s time. Bad handwriting. Prior authorizations. No refills on maintenance drugs. That kind of stuff.

“Oh, I didn’t know.” She sniffed. “I will take the time to call the patient myself. Will you call me around three o’clock to see if I have a prescription for her.

Shit. Didn’t she learn anything? “No, I won’t call you. Geez, girl.”

“Don’t call me girl.”

“Okay. Geez, maam.”

There is a Wal-Mart pharmacist living and working in one of my favorite places in the world.

The Pacific Northwest. The Puget Sound area. You young ones with sand in your shoes, you cannot find a more exciting place to live. You will not find such a population of young, vibrant, progressive thinking people who are your age anywhere on the planet. The pharmacist shortage is acute in Tacoma, Seattle, Bellingham, Whidbey Island (where I lived for 16 years) and there are sign-ons available. I would bet that moving costs are available. You may even want to look into working in a clinic on an Indian reservation. I loved living there.

Victoria and I left only because we wanted a new place for our new marriage. Also, I was old. 59. To really suck up the velocity, the rhythm, the drumbeat, the panache of Western Washington you need some youth. That was my take. I’ll tell you about Vermont and Galveston some time if you want.

This post is about Jeannette and how my viewpoint has been altered a bit.

Jeannette loves working for Wal-Mart. Like many institutions in the state of Washington, the Wal-Mart pharmacy operation there looks to be very different from a Wal-Mart in.. say.. Tennessee. Jeannette is treated very well. She doesn’t like her good experience being diminished and disregarded when a pharmacist who has been embittered tells her that she is not justified in feeling good about her company. She feels fenced in. She gets her back up. She gets her self-righteous muscles exercised. She feels on the outside looking in. This is not good, my friends. We don’t need to be mean.. ever!

The majority of us may feel that the $4.00 Rx is nothing but predation. Wal-Mart contending that constitutes a revolution in medical care is upsetting. That is all beyond the point. I don’t think that Jeannette feels attacked by our disgust with the $4.00 Rx. She is rightfully upset by seeing her good experience devalued.

Jeannette and Peon and all of the other Wal-Mart pharmacists are full-fledged members of the community that is pharmacy. As Jeannette pointed out, a handful of Florida Wal-Mart pharmacists had the chance to kill this monster when it first hatched. It is far too late now. The $4.00 Rx is now a cornerstone. It is part of the landscape. I do not see that opposing it is helpful.

Parenthetically, The Publix free antibiotics is really a disgrace. Is $$$ zero now their Usual & Customary?

We will have to hold the $4.00 Rx as part of our reality now as we examine just what our DUTY is as an American pharmacist. I contend that we have a duty to uphold the profession of pharmacy. I think we need to get a little attitude. I think that every pharmacist should participate in MTM if he/she wants to. Payment is a must. I think that it is a scandal that pharmacists are still managed by non-pharmacist managers who are green with jealousy about what pharmacists make. This is not helpful. When you have a Doctor of Pharmacy sat down for the dreaded “write-up” by a guy who barely got his associates degree, you have a situation that is degrading and dangerous.

We have a duty to be honorable, generous and helpful with patients. We have a duty to our colleagues. The days of cutthroat competition must be ended. Again, parenthetically, the $4.00 Rx is not competition. It is a quantum distance from the pricing wars of the 1970s when everyone still made a living. I think it is predation.

In the end, we have a duty to ourselves. By attacking Jeannette and her relationship with Wal-Mart (one person was inappropriate in his personal attack and use of bad language) you push to the side a talented young woman who can help. You have diminished her dignity. You have left her self-respect stained. She speaks up about her experience and therefore, her dignity is intact.

So, be nice. The $4.00 Rx is really no longer the issue. The matter at hand is our DUTY. Trust me. If every pharmacist felt an obligation to the profession and acted in a dutiful manner, things would look a helluva lot brighter.

Talk about this. My best regards to you, Jeannette.

Triage:

The process of prioritizing sick or injured people for treatment according to the seriousness of the condition or injury.

Tuesday, around 2:00 PM, a woman interrupted what I was doing and begged me to help her find some “butterfly” bandages. Her neighbor had told her that “butterflies” would hit the spot. She was a little flustered and I had to settle her down.

“Who needs the butterflies?” I asked. “How deep is the wound? How long is the cut?”

She couldn’t stop stuttering. “I.. uh.. I.. there is a lot of blood.”

“Relax,” I said. “Tell me more.”

“My son. He was cutting a big chunk of Parmesan cheese into little chunks so I could shred it.”

A very rude customer butted in and asked me where the Huggies were located. I turned my back on him. “Where is your son now?” I asked.

“Huggies?” The guy was persistent. “I’m looking for Huggies.”

The woman gave the Huggies man a look. “My son is in the car bleeding.”

The Huggies guy turned and walked away on the word bleeding.

“You better bring your son into the store. I’ll look at the cut.”

Two minutes later this kid around fifteen years old came in with his mother. He had his hand wrapped in a terry cloth towel. I couldn’t see any blood until he released the towel. There was the wound, a cut to the quick of the ham part of his right palm. An inch and a half gash that was wide open. He had managed to get through the yellowy fat layer. He had gotten right down into the meat.

I gave my usual disclaimer, “I am not a doctor. I do not diagnose. But it looks to me that he will need some suturing and you better get him to the emergency room at UTMB.
”
“I’m just visiting my sister.” She stuttered again. My advice about the emergency room made her as jumpy as a bug on a hot pan.

“Go right down 4th Street to Harborside. Take a left and keep looking to your left. The entrance to emergency is less than a mile from 4th.”

“Okay.” They started to leave.

“Just a second,” I added. “I have some advice. You will have to wait in emergency. I think you better buy some Betadine Solution and squirt it all over that hand before wrap it up again.”

“You think?”

“Will it hurt?” A whine from the fifteen year old.

I told her that this Betadine step was very important. She followed my advice. I watched her apply the solution liberally. The kid cringed, then looked at me. “You’re right. It doesn’t hurt.”

This is TRIAGE. This happens thousands of times a day in pharmacies all over the United States.

Triage is a three point thing at the pharmacy.

1. ” THAT’S MOST LIKELY NOT A PROBLEM. I WOULDN’T WORRY ABOUT IT”. or 2. “I CAN HELP YOUR SYMPTOMS WITH AN OVER-THE-COUNTER PRODUCT”. or 3. “YOU BETTER GET YOUR ASS TO THE DOCTOR OR THE EMERGENCY ROOM”.

Have you noticed that #3 doesn’t happen that often? With numbers 1 & 2, pharmacists save the medical system millions of dollars… possibly every day. Otherwise, most of the #1 or #2 will end up in the emergency room to the tune of a few hundred bucks each.

What we do saves a ton of money and what do we get? We get absolutely NOTHING. And we keep on doing it. I like doing it. It has always felt good to use my knowledge to make a difference for someone. Is this perseveration? A bona fide mental condition. Where you keep on doing the same thing over and over expecting a more satisfying result.

THEY ARE NEVER GOING TO PAY US WILLINGLY… NEVER!

So, talk to me. What do we do?

I suggest you look to the right and click on the link to “The Pharmacy Alliance” website.

That’s the best advice I have. Individually, we can get nothing done.

Do you have your personal NPI# yet? Paul Trusten can tell you how. He is the person who got me started in the right direction. It will take only minutes.

An hour ago, I stood at the customer service desk of a department store and waited while three women, who spoke a language I did not recognize, returned a shopping cart full of bedroom goods. Pillows, sheets, blankets. They were, I would guess, not native Americans.

My grandparents were immigrants. They all came funneled through Ellis Island from four points in Europe. Spain, Switzerland, Finland and Greece. None of them spoke English right off the boats. They brought their treasures with them. A small suitcase, the clothes on their backs and whatever money they had saved. None of them were highly skilled professionals. I’m telling you that because I think that immigrants are okay.

The three women at the counter acted like they were afraid of being cheated by the store or they were out to cheat the store. I just know that I had to wait while they finished up their business. I thought to myself, “These women certainly aren’t acting like they are Americans.”

Last week, I got a copy from a pharmacist in Illinois. He had a thick accent and a name that indicated that he was a Bengali from India, probably Mumbai.

After all of the business was done, he said, “What are you doing the fourth?”

“Pardon me?” I didn’t understand.

“The fourth of July,” he said, “Independence Day.

“Oh, that fourth,” I said. I hadn’t realized. It had crept up on me. “I don’t know, man. Probably have a picnic on the beach or something.” The fourth of July had become just another day off. I was not really charmed by it.

“What are you doing?” I asked.

“All of it. A parade in the morning, a town picnic in the square, a baseball game.”

“Who are you going to see play?”

“Me. I’m playing. I pitch for the Red Birds. I was a cricketer in India. I threw a wicked googly.”

“Maybe I’ll go to the fireworks,” I said.

“Oh, for sure. I will take my wife and kids for the first time. This will be their first fourth. I am a citizen now and am sponsoring them.” There was a lilt to his voice. Like a man who had lived a long time with his family half a world away.

“Well, I wish you a great fourth,” I said, thinking, “He is certainly acting like an American.”

“The same to you, my friend, the same to you.”

After that phone conversation, I made it a point to find out about the Fourth of July parade in Galveston. My daughter-in-law, Ivana, has been here for only six weeks. My son-in-law met her in Afghanistan. They both worked for KBR. Their six month old son is an American citizen, born in Macedonia, with a USA Passport. That leaves Ivana on the outside.. for a little while… Frosty (my son-in-law’s real name) is sponsoring her and has hired an attorney for the job.

Next year, Ivana will be a Yankee, but this year will be her first fourth. We will make it memorable. We’ll do the parade, the picnic, the beach and the fireworks. People will say about Jim Plagakis, “He’s certainly acting like an American.”

Winston Churchill said that success is moving from failure to failure with enthusiasm. Elvis, Michael, Dr. Suess and Henry Ford all failed dramatically. Michael was cut from his high school basketball team. “Green eggs and ham” was rejected 23 times before a publisher said, “What the hell. What can I lose?” Elvis got an “F” in music and Henry Ford went bankrupt twice. Their vision was clear. It just took the rest of us a while to see what they saw. That dream of owning your own pharmacy? Protect it. Guard it. Wait until the time is right. Don’t ever give it up.

There are “self-corrective” forces at work in American pharmacy. Pharmacists are “pushing back” and asking that there be changes. After many years of never having an uninterrupted meal break, I now work for a major chain two days a week. My shifts are eight hours and I take 30 minutes to eat. This is routine policy. Nobody bothers me. The forces at work may be subtle, but they make any and all efforts to continue any repressive schemes very difficult. “Self-corrective”. That is how it should be.

There was a time not long ago that life could be very difficult for a single or divorced mother who was the sole support of her family. Not long ago, the only job Sandra Day O’Connor could get at law school graduation was the job of legal secretary. The days of the Age of Pisces is over. It is the Age of Aquarius and women will take their spots near the top of the pyramid. You are a pharmacist. You make enough money that if the bastard cheats on you, you can kick his ass out and never miss a beat.

The real battle is conquering yourselves. Think about it.

Don’t smoke. Don’t drink too much. Don’t text while you are driving. Do find a sport or exercise. I suggest yoga. These are your “yamas” and “Niyamas”. When you get together in ten years, take a look. You will know who took my advice.

Be present all the time. Stay wide awake. I think that you can do a whole day of pharmacy and never notice what is going on around you. You are the pharmacist. When that little old black lady who still believes that her red, white and blue Medicare card will get free prescriptions starts to cry from desperation, it is your job, not the technician’s job, to go out and serve her with all the compassion you have in your heart. Keep a soft heart, an open heart. A hard heart is very dangerous.

Get the hell out of the world of virtual reality a couple hours a week. Go to the beach and leave the cell phone at home. Virtual reality may seem to be huge, but, trust me, the real world is infinitely larger and infinitely more interesting. Drop to your knees in the surf and feel the waves surround you. Experience the power of nature and, please, take your kids with you. An hour or two , sitting on a bed of cedar needles, during a rain, in a hollow cedar tree in a Pacific Northwest forest, silently with your ten year old daughter, waiting for Raven, the creator, to appear is sublime. The bonds that grow from a silent experience will never be broken. Raven, by the way, did appear that day.

Just remember that the profession of pharmacy is fine. It is perfect just to way it is. It is the JOB of practicing pharmacy that can be a problem at times.

Of course, you will have people who don’t know, come to you and say, “Get real!” They will want you to march to the same drum beat that everyone else marches to. Very dangerous. You are young. You may think that you want to stretch out and do it your way. That is very good. I just have one thing to say:

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