What did I do for 31 years?
Yesterday I read an article by a fellow Hive member. Greetings to 
For the past seventeen years I've been at Medical Tower Drugs in Abbotsford, BC. That might seem like a long time to some but my manger has been there for probably 28 years. That might seem like a very long time but let me highlight the picture in the background.
That's an artists rendition of the building when it was built way back in 1970. The artist was the owners son when he was in high school. He became an architect and his brother took over the Pharmacy after the father retired. His son is still working there as a manager. A family owned business for 56 years.
But
Different standards
Let me start with a story from Surabaya. Unfortunately I ate something I really shouldn't have and got a wicked case of stomach distress. As a Pharmacist I knew what I had was viral and I knew that my life would be unpleasant without Loperamide. I looked it up and it requires a prescription in Indonesia. Luckily there was a doctor's office with a pharmacy right beside it near the hotel I was staying. I went in and there was a doctor available for a nominal fee. They checked me out and agreed that it was likely viral and said I would be fine. I got a prescription from the doctor but it didn't actually say I needed loperamide. I went to the pharmacy and asked if I could buy loperamide and they said no problem.
I chuckled to myself...
In Canada: No Prescription : No Medication
In Indonesia, at least at that pharmacy and for loperamide, apparently no problem.
Well, there was one problem and it is a problem I never once considered.
I had money. I had a credit card. I had a translator (ChatGPT). I had a pharmacist willing to sell me the loperamide. But I almost wasn't able to buy it.
Reason? I had 100,000 Indonesian Rupiah. Cost for 10 tablets : 700 Rupiah. The medication was very cheap and the pharmacy didn't have change for 100,000. I wanted to use my credit card but the purchase price was too small for a credit card.
For those who don't know the value of the Rupiah?
I had a bill valued at about $6 HBD (8000 Naira) and the medication cost $0.05 HBD (65 Naira) for ten tablets.
I mention this because in Canada I know with absolute certainty that it would be much much more expensive.
(image is mine)
$8.97 Canadian for 12 tablets VS $0.08 Canadian for 10 tablets.
100 times more expensive in Canada
The message is that things are very different
The main message isn't that one country is less expensive. It isn't that medication is more available in one country than the other. The reason I included this is :
Different country, different rules, different prices
What has MY job been
The role of a pharmacist in Canada (British Columbia) is simple to state:
To ensure that a pharmacist has the knowledge to safely distribute medication a lot of schooling is required.
For me?
- Two years of university sciences
- Four year Bachelor of Pharmacy course
and for new pharmacists it is even longer as a PharmD course is required. Basically my course plus an additional two years of research and clinical experience
Of course schooling isn't enough. The university course requires students to intern in multiple pharmacies as part of their schooling AND pass a national licensing test in addition to graduating their course to get a license. A pharmacy law exam and often test of spoken English are also required.
End result the guy in the white jacket behind the counter has a LOT of training before he gets to wear the name badge that identifies him/her as a pharmacist.
Following the rules
Now while my role is to safely distribute medication it often seems that my job is following a very long list of rules while acting as a intermediary with insurance companies and documenting everything on multiple systems before distributing medication.
When I say a lot of rules I mean it. Remember the name badge that I had to earn. Well, it is a legal requirement for the pharmacist to wear it. There are lots and lots of laws governing the position... from my license and registration requirements, insurance requirements, confidentiality requirements, having a time delay safe, having a fridge that needs its temperature monitored twice daily, keeping records for multiple years for every medication dispensed and many many many more.
Break the rules? Lots of potential penalties:
- Lose your license
- Restrictions on your practice
- Go to jail
But sometimes if you don't break the rules? Lots of penalties:
- Lose your license
- Restrictions on your practice
- Go to jail
What do I mean by you have to follow the rules and have to break them?
Here is a scenario:
A long term customer gets a very high dose narcotic prescription. They need more of it as they are running out. Their Doctor is unavailable to prescribe it. The hospital doctors won't prescribe the dose they need (its very high). Walk in doctors and family physicians won't prescribe it (the dose is very very high). In fact the dose is so high that their one day usage has a street value of about $2,000
My options are :
- Give the medication or
- Don't give the medication
Give the medication?
...I'm distributing narcotic medication without a prescription. Same as a street level drug dealer. Sure I'm a pharmacist but my license doesn't protect me if I break the law.
Don't give the medication?
...I'm refusing to give necessary care to a patient. I'm causing pain, discomfort and ignoring a medical need.
What does College of Pharmacists say?
--Document everything in case it goes to court.
My job sucked on that day. However, most prescriptions are a lot simpler than that one. Let me tell you the regular routine.
Filling Prescriptions, Information Requests, and Expanded Role
Mostly my job is doing three things: Fill Prescription medication. Provide information about medication to patients and practitioners. Do "expanded scope of practice"
Fill a prescription:
Simple: A patient has a prescription from a doctor they need filled.
Step #1: Accept the prescription
- Check the name.. Is it the patient or agent picking up for them
- Get spelling of name, date of birth, phone number, verify if they are new patient or not
- New patient? Get insurance information, get health care, get details like drug allergies, medical conditions and so on
- Quick scan of prescription to make sure it looks complete
Step #2: Data entry and verification.
This is where things can go quickly or slowly. All prescriptions I receive have to be entered into a province wide database. No exceptions. Every drug must be tracked directly to the patient and their care card number. If they don't have a care card I have to get more information, contact the province and get them a care card number AFTER I verify they don't already have one that they forgot.
What do I need to enter?
- Name
- Medication
- Quantity
- Directions
- Refills
- Prescribing practitioner (usually a doctor)
If anything is missing? I have to verify before I can fill.
Step #3: Verify it is appropriate and safe
Giving the patient what the Doctor ordered isn't an acceptable minimum bar. I am responsible for any Doctor error I don't catch. Before it is given out I have to be certain that :
- the dose is appropriate for someone of their age, sex, condition, etc
- the medication is appropriate to treat the condition they have
- the duration is sufficient for their treatment
- but the duration is not so long to prevent them from getting proper follow up
- that the medication will not interfere with other medications
- that the patient doesn't have allergies or other reasons they can't take the mediation
Step #4: Bill insurance
Making the medication affordable is also important. If a patient can't afford to take it then the treatment will fail. In that respect I'm required to inform the patient of their options and work in their best interest to get the best treatment. As an example: If the Doctor prescribes Dexlansoprazole which is expensive and rabeprazole works in much the same way with similar benefits but a price tag 90% cheaper its my job to make sure the patient is getting the best treatment. That means asking questions about prior treatments and failures and figuring out why the expensive treatment before an equivalent treatment that is much less expensive. Certainly there are times when more money is worthwhile and other times? Not so much. Of course there is insurance to deal with as well. Sometimes they pay for X but not Y. Sometimes they pay for Y but only if certain steps are followed first. My job? Explain options, help with paperwork, do billing, ensure that the patient understands and gets the best treatment at the best price.
Step #5: Consult with the patient about their treatment
I am also mandated to explain the medication and treatment to the patient as part of the process. My job would be so much easier if the doctor prescribed a medication, I grabbed it, gave it to the patient and got paid. But that is the model of 40 years ago.
These days I am expected to go to the patient and explain the medication to the patient and give them details on how to get the best treatment from their medication.
- Benefits and side effects
- Storage
- Missed doses
- Expected outcome
- How to deal with possible adverse reactions
are all things I'm expected to relay to the patient before they leave
*** Information requests
In addition to filling prescription medications I get lots of questions about medication that is not prescription. Has a cough...ask a pharmacist what to take. Have a headache? Have diarrhea? Have dry itchy skin? Have itchy eyes and nose? I get questions all day long.
The advice I give? Considered professional advice and if I give bad advice that makes someone sick I'm legally liable. That's why I ask questions to do the best I can to give a medication that will be safe and effective. I can't just say: diarrhea? stomach remedies are on aisle #1. Nope. How long has it been happening? Blood in the stools? Signs of dehydration? Other medications (dehydration causes other medications to have issues)) and many more questions.
Sometimes the questions aren't medication related. I get questions about medical products, herbal remedies, basic health and nutrition, even insurance questions and of course the question I get asked a lot : "Do you have a public washroom"? Even unrelated questions like "Can you send a fax for me?". "Where is a good place to eat near here". "Do you know how to get to the doctors office". or "Why are aliens sending comedy to my brain"? (yeah that last one required additional follow up with the physician).
And sometime its requests from a practitioner. How to get medication covered. Is a certain medication available in the country. What is the best alternative to XXX medication and many many more.
Expanded roles
As time has gone on pharmacists have been given additional responsibility in the community. Some of the best known are things like:
- Administering vaccines
- Prescribing mediation for minor ailments
- Adapting prescriptions
- Medication reviews
Quick version of each?
Vaccines: need a flu shot. Talk to your pharmacist. Need travel vaccines? Need Pneumonia vaccine? Need Shingles vaccine? Pharmacists can give them.
.... but they have to verify they are appropriate first
.... and some old timers like myself (who needles make queasy) don't do themMinor ailments: Yes. Pharmacists who do additional training can prescribe.
.... But we have to do an interview and assessment just like a doctor. We have to document the visit and give rationale just like a doctor. We have to give a prescription that you can take to any pharmacy. Just like a doctor. Yes. If things go wrong? We are liable just like a doctor. However, "minor ailments" are things that will likely last a week or less. If it is something more major, that's a doctor visit.Adapting prescriptions: This simply means modifying what the Doctor wrote. If the doctor prescribes a dose that is too high or too low? I can change the prescription. If the medication is too expensive? I can change to a different medication. If there is a dangerous interaction? I can change the medication. The catch? I have to have the patients informed consent. I have to notify the doctor of the change and the follow up protocol. I have to document my reasons to make the change. Plus I have to put my name on the change and take full responsibility for any problems or failure.
Medication reviews? Those are audits of a patients entire medication profile as well as all over the counter and herbal remedies a patient takes. It is a 15-30 minute sitdown to look at everything on the list and review if it is working, appropriate and so on. By the end all interactions found, all side effects documented and patients response looked into followed by contacting the physician or other practitioners if deemed necessary.
And lots of other stuff
While that is the main part of my job there are always other things going on. I make sure we package things to make it easier for elderly to take their medication. I call doctors and other practitioners when there are issues with treatment, no refills, medication shortages and more. Calling insurances is commonplace. Following up with audits from insurance companies is commonplace. Giving medication request for lawyers for legal issues is commonplace. Checking expiry dates and following return procedures. Logging medication that comes into the pharmacy. Narcotic counts to verify it isn't being stolen from the pharmacy. There is a lot of stuff going on in the pharmacy moment by moment and day by day
Is it different in different countries?
Absolutely.
I worked in the USA for almost a decade. The difference between Canada and the USA? In Canada the laws are there to correct and being sued is possible but for sane amounts of money. In the USA? lawsuits can reach insane amounts of money and if you don't follow the rules? They are out to punish the pharmacist.
How about Indonesia and the Philippines?
I have never worked behind the counter in either country so I will not say for certain. However, in rural areas I get the impression that it is more providing medication to patients as the doctor prescribes than acting as a patient advocate for optimal therapy.
Then again I could be totally wrong so I'm looking forward to hearing from a Nigerian Pharmacist about how their job is different (or the same) as mine.
Now I could ramble along even longer but this is already far too long. Thanks for reading, Thanks for dropping by and if you have comments or questions I would love to do my best to answer them.
After all answering questions is exactly what my job has been for over 3 decades :)