Nov

Professional courtesy

Posted by The *Angriest* Pharmacist as Work Sucks

I got an email from “The Chick in the White Coat” asking me about professional courtesies and my take on them. She was asking about things such as the loaning of pills, calling doctors for refills, and how they have become expected of pharmacy rather than something a pharmacy does as a courtesy for patients. These things have become the rule rather than the exception.

I’ve never worked in pharmacy when these things weren’t the norm. I’m sure once upon a time, these things were done by a few pharmacists as a way to keep customers, gain new customers, and go above and beyond what was expected….as a way to expand business. Yet, now they must be done to merely keep business and ensure people are happy. I personally think it’s kind of bogus.

Loaning of Pills. I do it. We all do it at one time or another. Most pharmacy statutes allow pharmacists to dispense an “emergency” 3-day supply to a patient when a doctor cannot be contacted (and a patient had been taking the medicine for an adequate amount of time). These statues also allow pharmacists to use their professional judgment in these situations — meaning that we wouldn’t give little Timmy another bottle of Amoxicillin but we would give Grandma Johnson a few more lisinopril. Most all of us do this on a case-by-case basis. I will usually give the person three days worth if they have been on the medicine for longer than three months. If a person is a really good customer and thought of by my staff in good regard, I will give them the benefit of the doubt and front three days after only one-month of therapy. That’s not exactly fair, but me giving anyone any pills is not required by law. I personally think that the patient’s should take more responsibility in their healthcare and actually read the fucking bottle. When it says ZERO REFILLS, don’t wait until there’s 1 pill left in the damn bottle to call your doctor (or pharmacy — see below). If a patient wants a week’s worth because they are going on vacation, they are shit out of luck in my pharmacy. As a reader has said in the past (and now I say all the time): “Lack of planning on your part does not constitute an emergency for me.” You can either call your doctor’s exchange/emergency line or take your bottle to a pharmacy at your final destination. They can call your doctor from there. [It goes without saying that no one fronts controlled meds to any patient under any circumstances.]

Contact doctors for refills. Again, this has become the norm. Each morning, we all have a tech chained to the phone making the daily, “doctor calls.” I’ve handled this in a few different ways. Sometimes, I come in a little early to make the calls — before the pharmacy opens. Most MD offices open earlier, and I can get them done before my staff even arrives. Over the past 6 months or so, I’ve made a huge push to convert all of my calls to faxes. I’ve got a pretty decent relationship with most of the nurses around town (and know most of the doctors), so I’ve gotten them to either buy a fax machine or allow me to fax in refills. I still have one doc that absolutely refuses to accept faxes for some weird reason — but I am down to making only 4-5 actual calls each morning. I merely told them like this, “When I call you, I get a receptionist who makes me wait on hold before she actually inquires to what I want. Then she sends me to your extension where I have to listen to your obscenely long voicemail explaining the same thing over and over again that I hear 20 times a day — what information to leave, how to do it, and to spell everything out. Then I have to leave the message and wait for you to get back with me later in the day — at your convenience. Why don’t I just send you a fax, save my time, and you can still get back to me at your convenience. The fax will have all the info on it and will add to patient safety. It will also reduce the amount of prescriptions called in by non-medical personnel that have little to no training in medicine.” — No one has ever told me to fuck off because I’m trying to increase patient safety. I even made one trip to a doctor’s office to meet with him about it. He, of course, listened to reason — regardless of how his nurse wanted it done.

I also do my best to try and get the patient active in the process. I’ve tried telling them that, “Hearing from the patient that they need a refill usually gets them in gear,” after we’ve contact the physician once. I’ve also flat out told other patients to call the doctor themselves in instances of early refills or for refills of antibiotics and drugs that usually do not have refills for a reason. The patient’s standard response is always the same — “I just talked to them. They said you need to call.” — Well, I don’t play that game anymore. As I said above, enough of my time and my staff’s time is wasted on the phone holding for a nurse. Let’s waste your time, dear patient. “You need to call the doctor and tell them to either call or fax me, because if I call, all I’m going to get is a voicemail line instructing me to leave a message — after I wait for 5 minutes for someone to answer the phone to transfer me to the voicemail.”

I’ve also recently installed a TTY-type device which connects me to a nearby medical group which houses something like 30 doctors. I just type my message, the doctor’s extension, and it’s done. They still get back to me whenever they damn well please, but it’s convenient and really fast. I just take the receipt-paper printout and staple it to a blank Rx and it serves as my prescription.

I still haven’t addressed the issue yet — should we be doing this? Honestly, I think not. I think that patients should take a more active role in their healthcare. I believe that when they are out of refills, rather than depending on us to loan them pills and/or call their doctor, they should call the doctor themselves and state that they need more refills. I also think that doctors should ACCEPT THIS! Many doctor’s voicemail lines boldly state, “If you are a patient, have your pharmacy call us.” — Why? I have no clue. If the doctor wants them to continue the therapy, what’s the fucking issue? I understand that the office may want to know when the last fill date was, but that can be easily ascertained by even a technician when they call in the new prescription. At that point, the nurse can note that date (to track compliance) and decide whether or not the patient is actually due for a refill based in the sig and quantity dispensed. I think the nurses can handle that much…

There will be those out there that say our loaning of pills and calling MDs for refills does a lot in terms of ensuring patient compliance. I call this a load of bullshit. If a patient is not compliant with their therapy for themselves, why should I give a flying train full of antelope shit? The answer is, I don’t. Here’s what I think. I will help those that cannot help themselves — the sick, the dejected, the broken, and the poor. I will not help those that refuse to help themselves. I will not care about you if YOU don’t care about YOURSELF. Your health should be enough initiative to remain compliance with drug therapy. You took the time (and perhaps paid the money) to go see the doctor, bring the prescription to me, and get it filled. If your compliance depends on whether or not I give you three pills and call your doctor for additional refills, not only are you pathetic, you are doomed to have poor outcomes from your therapy.

Or Print it...

WAGslave says November 4th, 2008 at 11:06 pm

Lending of pills drives me nuts… once in awhile, okay. But we have some pinheads who expect this EVERY month. What really pisses me off is when they get a 3 day loaner, and then switch pharmacies. It’s not the cost … usually it’s just HTCZ or lisinpril. But if I’m going to bail you out with the courtesy of loaning you a few pills, at least have the decency to pick up the rest from the same pharmacy!!! And regarding controls… absolutely not. I’ve never met a single pharmacist who budges on this point. The only time I’ve done this was for a kid who was on phenobarbital for seizures. I lent mom 2 days worth … I couldn’t risk little Jimmy having a seizure. Besides, I figured the DEA wasn’t going to come after me for that. Mom is still our patient and is grateful for the assist.

crazyjane says November 5th, 2008 at 12:05 am

i have been a tech at A Large Chain Pharmacy for 13 years. we have recently been required to call customers and remind them to fill due soon and past due rx’s. i have a list every weekend of at least 60 people i am required to attempt to contact a minimum of 3 times. there also a wednesday list, usually about 35 people who need to be contacted mid-week. this is supposed to help these people be more compliant. please. i have, on no less than 3 occasions, called the number on my list and asked for a recently deceased family member.
i have explained to all my bosses that when (not if) the day comes when i have a daily list of people who “might forget” that i need to call and remind them to take the pill and/or ask if they need me to bring them some water, i am out of there. that day will come. i have no doubt.

dm says November 5th, 2008 at 12:15 am

yeah, i don’t like the direction this is all going. the goal it appears is to make patients have to deal with their healthcare the least. fuck it. they need to be involved otherwise bad outcomes will happen. every time my mother did not go with my grandmother to a doctor’s appointment, my grandmother ended up in the hospital. granted she’s a special case, but the point is clear. using all of our clinical markers and targets for therapy are bull shit if it’s not treating the disease we are trying to treat. to know that, doctors have to know what patients are experiencing, and then they have to prescribe the drug to fix it. and we have to fill it. this is removing patients from the equation, and completely fucking up the system. patients should see the doctor, they should have to talk to the doctor. then they should have to come to the pharmacy, and see the pharmacist. when they are stable on something, that’s great. that doesn’t mean they shouldn’t see a healthcare professional.
the new deal at our store is automatic refills. not a day goes that we do not have a problem with automatic refills. i’ve taken to saying our automatic refill system is messed up. we end up returning to stock 2 or 3 of them a day, we have people complain because the automatic refill wasn’t done early, and that they didn’t need that drug on the automatic refill. it’s more fucking work than it’s worth. it should only be used for those individuals that are so compliant with their medications, they get it on the same day every month. they should be patients who come in at the same time every month, and for ones that ask for it. ugh

Jean Poole says November 5th, 2008 at 7:30 am

From the “consumer” side I would love it if my doctor’s office would switch their screwed up policy and let me call in my own damned refills when needed. My pharmacy is an indie that I have been a faithful customer of for 10+ years. The head pharmer owns the store. My doctor recently became corporatized and where I used to be able to call in requesting my own refills, they are now “pharmacist call only” per corporate policy.

I don’t like being infantilized. And it rankles when I contact my pharm 3 days before I run out on a scrip and the doctor’s office has not called back a refill 3 days later when I am down to that last dose. And then you cann the damned doctor and the “customer service” tron tells you that your pharmer, who you trust as much as a person can trust another, probably didn’t fax it in. So you have to get the doctor group’s receptionitron annoyed enough that they put you on the phone with a nurse if you are lucky. And you get to explain it again. And then you have to call back to your pharmer and ask them to please refax the request. I’ve been with the same physician group for 15+ years from the time it was a one-man country doc show. I only put up with being treated like a moron by the trons because there are no more country docs around these parts. But at least I have my country pharmer.

Stan says November 5th, 2008 at 1:36 pm

Long time customers at our counter most times get the benefit of the doubt. I’m lucky in that I’ve trained most customers to give 3 days notice for refills and 4-5 days if a refill request needs to be phoned in to the doctor.
One question I’d like to toss out for reply: In this state (midwest) a pharmacist can dispense a C-V cough preparation w/ cod. at his/her discretion. How does this stack up with other states. I will only do it with customers that have a lengthly history with our store and rarely, if ever ask for something like this.

PrePharmNC says November 5th, 2008 at 2:53 pm

I have two questions (I’ve only be in Pharmacy a few months)

What’s the reason behind not giving a child a refill on their Amoxicillin? You don’t refill amoxicillin (an antibiotic) because if 10 days of therapy didn’t clear up the infection, it’s unlikely another course of the same drug will help. You have to switch to another drug because it’s obvious at that point that the infection is an organism that amox doesn’t hit. Of course, there are certain circumstances where people take Amox for long periods of time (acne) in which case it’s obvious — 30 caps #1qd-BID — at this point you can front them caps with no worries.

What is the story behind the nurse not wanting you to do it your way? I have no idea. It must be because the fax machine is far away from her desk and she doesn’t want to walk to it — or perhaps she has a receptionist to take her voicemails for her and do all the work and if faxes come in she has to do it. It’s something to that affect when they refuse to change — it creates more work or something. It’s usually laziness — because the additional safety provided by faxing (and removing non-medical personnel from trying to get involved) is really beneficial in my opinion.

Also, on the note of early refills. In the past week I have had two patients (one walk in, the other called) wanted a refill. The first one was for Seroquel and said she had been taking it twice daily, on a 1qd sig. We told her the situation, she went bezerk and said “if I lose my mind, it’s all your fault” as she was walking away. The pharmacist noted that she already had. We chuckled. The second person called in and asked to refill a prescription (it escapes me right now). I told her it was too early, another 1qd sig. She told me that was wrong, saying she had been taking 2.5qd. As I repeated back to her the difference on the sig, the lady’s eyes in line waiting to drop off got huge. The caller was nicer though, if a little think. She eventually agreed to call her doctor.

aligirl says November 5th, 2008 at 5:43 pm

I especially luv it when the customer calls in for a refill on her antibiotic and says that she thinks she is still sick so we need to call her doctor for more medicine. Who will try explaining to this lady that if after ten days of an antibiotic you are still sick than obviously it is not working for you, so of course maybe you should be seen again. But no, the patient does not want to hear that,they want you to call the doctor for more pills. So here I go faxing a doctor, because that is what we do first, we always fax first. Then I get a faxback with a big DENIED written across it because the doc wants to see the patient. Now I have to call this lady and explain to her what I had originally explained in our first conversation only to hear her get pissed off that she has to make another trip to the doctor.
Another thing that pisses me off is when customers call in their refills and then ten days later never come to pick them up. Every ten days our pharmacy does a delete list that is the size of me basically. About ten pages long with prescriptions that were never picked up. Oh so Mr. Smith really needed his heart medication that day he called them in, but my goodness here it is on my list. Or how about Little Timmy Jones antibiotic that is still here for a $O copay(medicaid) and has not been picked up. I wonder if Little Timmy is feeling any better since he hasn’t even started his ten day therapy of antibiotics ten days later!
Its like everyone else has said, patients need to take responsibility for their healthcare. They can not just expect others to do it for them. I wonder if I just left the paying of my car loan to someone else if I would still have a car.? People need to get off their lazy asses and not expect everything to be hand fed to them.

I love your reply.

aligirl says November 5th, 2008 at 5:50 pm

How about when you get a customer from out of town and another pharmacy. When they show up at your counter and expect you to fill their medication because it is your “duty”. Here it is a weekend and no way to get a hold of the pharmacy because they are already closed. So what we do at our store is only give them one pill to get them through the night and keep their bottle to make sure to transfer in the morning. We also explain very clearly that if the patient is going to go tomorrow to their own pharmacy than we will not transfer the prescription. If the patient does in deed still go to the pharmacy after we have transferred it to our pharmacy and get a call from them to reverse it, we wont because we already lent out the medication. This way the patient has to come back to our store of risk paying out of pocket for her medication at her own store. People think a pharmacy has to give them their medicine, but if it is not a medical emergency than you can go a day without it. Especially love it when the young girls call up sunday morning to refill their birth control that of course has no refills. Sitting on the phone and listening to them whine about how now they have to wait on having s** and even about having to use another form of protection totally makes my day. If ya really were so worried than maybe you should have called us thursday or friday even. No birth control is not a medical emergency and we will not lend you a few pills to get you through.

Ali, Contact me about writing a guest post. I’m interested in seeing what you can come up with.

Pharmacy chick says November 5th, 2008 at 9:23 pm

Many moons ago I worked with a pharmacist who practiced in a different state. When he moved to this state he was amazed at how the refills were handled here. In his first town, the patient was held responsible for his/her refills. The patient called the dr, the dr charged a refill fee to the patient (blows your mind doesn’t it?) and then the dr reviewed the chart and called in the refills. Rarely did the pharmacy call refills in because the Dr couldn’t collect a refill fee from the patient.
Since I dont have that option here, I have heavily pushed for fax refill auths on everything. First of all, leaving phone messages is a waste of time, especially when some long winded message preceeds the beep. I KNOW how to leave a message.
Second of all, when they are faxed back there is no second guessing. The name is right there. You may not be able to decipher the signature, but its there and thats what the board likes…signatures. Stamp it, fold it, file it. done. Lastly, I spend enough time on hold, with fax machines, I can fax and forget it. I also empty my fax box every 24 hours. I dont care how long the dr wants for auth’s, I send it every 24 hours until they call back. Period. After 3 faxes the customer gets a call…

Loaning pills is another story. we are stuck doing it, but it creates stupid patients, who become so accustomed to the loaners they expect it every month. some get a little pissy when they get the lisinopril but not the lorazepam.

every courtesy we do becomes an entitlement over time it seems…

No good deed goes unpunished :-)

aligirl says November 6th, 2008 at 10:58 am

In cannot agree more with what pharmacy chick stated. The customers start coming in every month, knowing fully well that they have ZERO refills on their medications. But since you lended them some last month and the month before that means that you have to do it again. HELL NO IT DOESN’T MEAN THAT. Our pharmacy system has a page that shows all the faxes that have been sent in the computer for refills. If a patient shows up and has no refills and need a few we will automatically send the fax and do an emergency supply for them. However our computers keep track of how many were given and the date they were given on each medication in their file. So when we see that it is starting to become something usual for the patient to come in and ask for a supply we start denying them. When we pull up their names and see how many emergency supplies we have given them, we tell them that we have already told them before not to wait until the last minute and to call us before they ran out. So no, this time they will not be getting an emergency from us.If the customer sees that you are not going to fall for their every wimb and cry than they might start to think about calling in their refills ahead of time. Somewhere, somehow these patients really need to learn…

Shalom (R.Ph.) says November 6th, 2008 at 1:53 pm

I always try to fax refill requests when possible. Back when I worked the overnight shift for a certain Chain of Very large Stores, I used to go through the pile of refill requests, delete the ones that were taken care of already, and resend the faxes for the ones that hadn’t been responded to. I used to do this around 1:30 AM, after most customers were asleep and I’d cleaned up the day’s mess.

So one night I get an irate phone call. “This is Doctor A., why the hell are you sending me a fax in the middle of the night?” Me: “Because this is when I have the time to do it, and it’ll be waiting on the machine in the morning when you get there.” Her: “But the fax machine is right next to my bed!” Oh, what I wanted to say… but I restrained myself.

OMG. I just pooped a little after reading that…

What pisses me off beyond anything else is when the patient calls me and tells me I “need” to call their doctor for a new prescription. I don’t mind calling on refills, but that’s too far. What, have they got a pay phone in their office…? First of all I disagree with their terminology. I don’t need to do squat, _you_ “need” _me_ to do this. But what that doctor is saying is that their time is valuable and mine isn’t worth shit.

(What’s even worse is when I give in and do it, and they say they’ll call me back. So WTF did you have me call you in the first place for?)

Helpful hint for those of you with internet access in the store: most doctors have their fax numbers on the NPI lookup website (https://nppes.cms.hhs.gov/NPPES/Welcome.do).

This is very valuable! THANKS FOR THIS!

We had one guy in the abovementioned Chain of Verylarge Stores location who was always looking for advances on his refills. We’d loan him the tabs, call for a refill the next day, and of course he never came back to pick them up. I finally noted his profile: no advance. Next time he came, I told him nothing doing. “Why not?” “Because you never come back for the prescription.” He didn’t even blink. “Oh, okay. So let me have a refill on my $OTHER_MED.” (for which he did have refills). Not even embarrassed that I caught him out.

On the topic of calling doctors and advancing tablets: One old lady was visiting from who knows where and forgot her meds. I actually was able to get a hold of her doctor and got a week’s supply for her. When I went to ring it up, she looked at me in outrage. “What, you’re gonna *charge* me for that?” Well of course I’m gonna charge you for it, what do you think it’s free?

Another helpful hint: When the answering machine/voice mail starts yacking at you, if you hit the # key it often skips right to the beep.

Regarding birth control, one sunday I was called by an OB/GYN who’d been paged by her patient, she thought it was some emergency but the patient only wanted a refill on her OC. This triggered a rant. “The manufacturers all put that they should start on sunday, so they always run out on saturday and call me on sunday every time. Why the hell can’t they tell the patients to start on Monday?” I had to agree with her.

A staffer of mine allowed one patient to get in the habit of using our computer system to “partial fill” an Rx for one specific person (as if we didn’t have enough tablets). So, the computer charges the person ZERO for the 3 days supply and throws the copay on the remainder. The person gets a few days for free — because they say they didn’t have the money for them — then they come back 2 weeks later to pay for and pick up the remainder.

This pissed me off to no end and I put a quick stop to it. What really burned me up was the fact that the person was in the store every other day buying beer, but he didn’t have the money for his 10 dollar or less prescription(s).

walgreens drone says November 6th, 2008 at 1:54 pm

I kind of digress here…but Pharmacy Chick’s post reminded me of a question I would very much like to “throw out” to the universe. How come when I call a dr’s office, I have to listen to a bunch of BS about how EXACTLY to call in a refill request correctly, but when a nurse/receptionist from the same office calls in a new script, it sounds like it’s in Farsi/Spanish/some other friggin language and is missing all kinds of pertinent information/qty/strength/mds NAME?

Just one of those questions that has no answer. I feel better bitching about it though.

Excellent point. I cannot believe I haven’t bitched about this shit before. Absolutely drives me bat shit crazy.

thetwitchytechnician says November 6th, 2008 at 7:30 pm

I don’t question the pharms on their judgment calls, but there are those times I want to just smack them upside the head because I know they just created another demon and I’ll have to try and exorcise the demon at least three times before they come to their senses and purge the creature from our store.

VaTech says November 6th, 2008 at 10:05 pm

I’m that tech who spends an hour every morning trying to get ahold of doctor’s offices that require us to fax them…yet put no fax numbers on any prescriptions. 90% of the doctors that we deal with in our pharm actually do require us to fax..I have actually been interrupted by a nurse, right in the middle of my “hello, my name is X and i’m calling from Y for a refill authoriza…” and they jump in with the fax number and hang up. there are a small number who require us to phone and leave the message after listening to that voicemail that makes me feel like i’m 5 and need my hand held.

of that 90% that require us to fax, 89% of them get back to us right away.

What really gets me is when the patient comes back after 3 days and then says “oh..well I moved offices and now see him over here on blah blah street” they never told us when we verified info and this now requires more phone calls, waiting on hold, and getting a fax #, and in some cases..getting hung up on and starting all over.

The thing that irks me the most is when the patient comes in and says “My doctor said he called/faxed you…” One patient was getting very, very angry and had the audacity to call me a dumb bitch…i politely told her that there are three ways a doctor can send in a prescription…1) fax 2) call and leave a message on the voicemail or 3) call and talk to someone in person. At that point I was in the middle of a 10 hour shift and told her that I apologized, i’d been by the phone and fax machine all day and the pharmacist just checked her voicemail, so apparently I was not only dumb, but also blind and deaf…then i walked away and promptly cried. I refax automatically after 2 days, and I call to verify fax number every time…i am sick and tired of doctor’s passing the blame to us just because they can’t get off their asses and use the damn phone or fax. We actually had one office try to send us a fax back after the patient flipped out on me, and they hand stamped that it was sent 3 days prior…too bad our fax machine timestamps the exact time it’s sent on the bottom. Good try, assholes, way to show your maturity.

V-tech says November 10th, 2008 at 3:43 am

We tell patients it is their RESPONSIBILITY to get refills. Also we will send a COURTESY fax once. Those key words put the ball in their court.

Jill says November 25th, 2008 at 3:29 pm

I respect pharmacies and pharmacists. I honestly see them put up with a lot of rude, direspectful people. I have a question. I don’t want to irritate my pharmacy in any way. they are a large chain and I am not the only customer who needs help. I have a family member in their 80’s who needs a refill on hydrocodone..sp ?. and there are no refills. We called in the request yesterday morning and the pharmacy said they are waiting to hear back from the doctor. We are going out of town for Thanksgiving and the medicine did not actually run out until today. Would there be a reason why the doctor would not call back or fax back or whatever the procedure is? I don’t want to irritate them. And I know our family member will not need this medication after this refill. They were hit by a car 4 months ago and have gone through therapy, etc. But they are too afraid to tell the doctor they hurt. There have only been 2 refills requested since that time.
What would be your best advice for us?

Regardless of the situation or time frame - the best advice is always the same:

PATIENTS CALL DOCTOR’S OFFICE

If the patient calls the doctor’s office, it truly makes the office give a shit. They hear from me EVERY DAY — they here from you every other month…and you pay their bills! I won’t call that office and raise hell, but you will! So, do it…you fucking call me raising all kinds of hell, why not them too?

Patients like to say that “their doctor is so slow”, “he always does this”, “I can’t believe he didn’t call in the refill!” News flash, you can go to any doctor you like — so do it! Find a new doctor that runs a better office — one that will take care of you when you need it and not when it’s convenient for THEM.

I guess all this boils down to is YOUR RESPONSIBILITY. Yeah, it sucks that you have some, but I cannot be expected to do everything — I can’t call your doctor every 2 hours asking for your refill. You gotta take some initiative of your own rather than floating through life like lumps of crap expecting everyone else to powder your ass.

Patients - call the doctor yourself | The *Angriest* Pharmacist says November 25th, 2008 at 4:28 pm

[...] got this comment in response to PROFESSIONAL COURTESY. My response is below in bold. Now, I’m not trying to single this person out or make them [...]