I’m going to tell you a story about retail pharmacy. This story will overlap and intersect other aspects of our healthcare system like insurance companies and prescribers. It will also overlap and intersect with who we are as people and as a society. Not many jobs involve interacting with such a broad cross section of people. Even other retail jobs see a smaller section of society. If you work in a restaurant or bar, not everyone likes that kind of food or goes to that type of bar and some people don’t even drink. But in pharmacy, so many people are on a daily medication. If you don’t need a daily medication, you might need a pain medication for an injury or an antibiotic if you’re sick or something prior to or after a surgery. You might come in for a vaccination or you might be coming in to pick up a medication for someone else, because even if you’re not on a daily medication there’s probably someone in your household who is.
This story starts long ago, way back when there were so fewer medications. Pharmacy was truly about the preparation and dispensing of medications and remedies. That is still part of today’s pharmacy and it’s obviously an important part because if someone doesn’t have access to the medication they need then it’s not going to help them. I call this part of pharmacy the assembly line. That’s what it is. A prescription comes to the pharmacy, one way or another, the prescription is typed, checked, and a leaflet prints with all the information to fill the prescription. The prescription gets filled and checked one more time then it’s ready for pick up. It’s an assembly line.
That is now just one of the many tasks in pharmacy. The only task in the assembly line process that requires any knowledge of medications and health care is when the pharmacist checks to see if the prescription has been entered correctly and if it makes sense. The rest of the assembly line is busy work. Because pharmacy started as an assembly line and because it’s hard to fight inertia or change the status quo, everything else in pharmacy has just landed on top of the assembly line without fundamentally changing the way pharmacy works. This is a problem.
When you call your doctor’s office, who answers the phone? Not your doctor, not a nurse and probably not even one of the medical assistants. When you call the pharmacy, who answers the phone? Could be the pharmacist and if not the pharmacist, then it’s a pharmacy technician.
When you call to schedule an appointment at your doctor’s office, who do you talk to? It’s either the receptionist or someone who deals primarily with scheduling. When you call the pharmacy to schedule something, who do you talk to? It’s the pharmacist or technician again.
When you call your doctor’s office to discuss a bill, who do you talk to? You talk to the billing department. There are people there who work exclusively with billing. When you call the pharmacy to discuss a billing question, do you talk to billing specialists? Nope, you talk to the pharmacist or technician again.
Even if you’re not great at noticing patterns, you’ve caught onto this one by now, right? In retail pharmacy, the same people do EVERYTHING. Not only are those people expected to be good at everything but they’re expected to jump from task to task with no warning as to what’s coming next and while dealing with constant interruptions.
Most routine shots are administered in pharmacies now. Giving a shot is easy. It’s not like drawing blood, which I’d say takes some real skill. Most immunizations are given intramuscularly and there’s nothing to it. It’s not that it’s hard to give immunizations, it’s that immunizations were just dumped onto the pharmacy assembly line. The same assembly line that is also the receptionist, the billing department, and the scheduling department. Not only do pharmacies have the extra task of immunizations, they have the task of discussing with people, counseling them, and deciding which immunizations are appropriate.
You see, pharmacists have to follow rules. Just because “your doctor told you to get the shot” doesn’t mean you should get the shot. Doctors are treated like gods in this country. Congratulations to their lobbyists for doing a kick ass job. A doctor can prescribe any medication for any reason, even if that’s not the reason the drug was approved. But pharmacists have to follow rules. So, if it’s not appropriate to give the shot, the pharmacist can’t give you the shot. That’s not just extra work, that involves some arguing coming back at the pharmacy staff and maybe even a little bit of shit getting dumped on them. Because, remember, pharmacies are dealing with the public and everyone isn’t as polite and well-behaved as you are, dear reader.
Pharmacy staff also tell people where the light bulbs are, where the bathrooms are and answer lots of other random questions. Pharmacy staff usually answer those questions while they’re already in the middle of talking to another person because when it’s just a little itty bitty question like “where can I find the laundry detergent?”, you shouldn’t have to wait your turn, right? It’s ok to just butt into the conversation a pharmacy staff member is already having as long as you say “excuse me”.
< For the record, starting your question with “excuse me” does not make you polite if you’re still interrupting. >
Pharmacists are also asked to call patients and go over ALL their medications to determine if the patient still needs to be on all the meds, if everything still makes sense, if the patient has any questions or if the patient might have a condition that is not being treated. This is called a Comprehensive Medication Review. The pharmacist doesn’t go to a quiet office and close the door to make those calls. Nope, those calls are just part of the assembly line. There’s other calls that are part of the assembly line too. Calls to follow up on new medications, calls to see why someone is late to refill a medication (the medicine only helps if you remember to take it), and calls to see why we bothered to fill a medication ten days ago when you still haven’t come in to pick it up.
What else? Pharmacies don’t have an ordering department. If a pharmacy need supplies or more medication, the same pharmacists and technicians who answer the phone are responsible for placing those orders.
Oh, here’s a good one. In most retail pharmacies there is only ONE PHARMACIST ON DUTY AT A TIME. Often, that pharmacist will be the only pharmacist working from the time the pharmacy opens until the time the pharmacy closes. (What happens if the pharmacist has to poop?)
Covid has been lots of fun for everyone and pharmacy staff aren’t left out. Pharmacies get to give Covid vaccines! And even though there are a lot of headlines about the anti-vaxers, trust me when I tell you that the people who want the vaccine are just as intense as the people who do not. Only one of the Covid vaccines is a one dose shot which means for every person who gets a Covid shot, the pharmacy is really giving two shots. Twice the work, twice the fun! But wait, now there’s booster shots, triple the fun!
More vaccinations aren’t the only gift that Covid has given pharmacies. Pharmacies also administer Covid tests. Again, the tests are just thrown into the assembly line. The same people, who answer the phone and fill your prescriptions and solve your billing problem and run the cash register and give you your vaccination, are administering Covid tests.
With the same people doing everything, what could go wrong?
And I haven’t even told you the part of the story that explains how we fit into the rest of the health care system or the part of the story that explains how the interactions with this large cross section of the public go. The bottom line is that retail pharmacy is planted firmly in the middle of everything. Which sucks.
Pharmacy is in the middle of you and your doctor. You are mad that we don’t have the prescription from your doctor but you aren’t at the doctor’s office. You are at the pharmacy so you yell at the pharmacy staff.
Pharmacy is in the middle of you and your insurance company. You are mad that your new prescription is not covered, but you are not at your insurance company’s office. You are at the pharmacy so you yell at the pharmacy staff.
Pharmacy is not in the middle of your doctor and your insurance company, but everyone hates insurance companies, so your doctor’s office will call the pharmacy to ask which drug is covered by the insurance. Pharmacists all know exactly which medications are covered by which insurance companies for which copay so that’s always an easy question for the pharmacist to answer right off the top of their head while they are also checking a prescription to see if it was typed correctly and telling the guy who is yelling at the counter which aisle the paper towels are in.
It’s also really common in pharmacies for people to lose touch with reality. Have you ever been in line at a grocery store and had someone farther back in the line yell that it’s taking too long? How about at the bank? I have never experienced that, but if you work in retail pharmacy you have experienced it multiple times. There could be a dozen people all waiting outside the pharmacy counter for their medications and vaccinations and someone will come up to the counter and want to know what’s taking so long. Or the next person in line really can’t understand why it’s going to take an hour for their medication to be ready that was just sent over from the doctor’s office. “Please turn your head and observe all the other people who were here before you.”
If the morale of the pharmacy staff hasn’t been beaten down sufficiently by everything already discussed, there’s one last thing that happens in retail pharmacy. It’s all the numbers that the corporate overlords look at and keep track of. No one up the corporate ladder will ever come into a retail pharmacy and congratulate the staff for keeping their patients safe and for having so few errors. They will ask why the phone hold time was 90 seconds. Or why only 68% of patients are signed up for text messages.
Our American healthcare system is broken. No doubt. But while a lot of the system could just use a little tweak here and there, retail pharmacy needs to be burned down and rebuilt. The assembly line model is dysfunctional with all the extra tasks currently demanded of the pharmacy staff. The assembly line staff should not also be the receptionist, cashier, billing department, ordering department, scheduling department, and vaccination department. Retail pharmacists need to be acknowledged legally as healthcare providers who can make their own judgement calls not only because that’s what a doctorate in pharmacy program is designed to teach but also because it’s what’s already being asked of pharmacists. And maybe just be nice to the pharmacy staff and show a little respect too. Pharmacists are already in the middle of so many relationships in our healthcare system. If empowered and used properly, pharmacists can smooth out and solve so many problems on a daily basis and improve patient outcomes. But that’s not going to happen if pharmacists are stuck telling people which aisle the batteries are in.
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