The Plight of the Retail Pharmacist

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She wanted me to call in an antibiotic.

My sister, a lawyer, often tells me how the ethics of her profession govern even her extra-professional acts. She feels that when she was sworn into the New York State bar, she lost the freedom to bend the truth. She would never, for example, attempt to smuggle a Cuban cigar into the country for our father, because she might be required to falsely represent herself to a customs official.

Given this, I am perplexed that she does not see the irony in asking me to bend medical ethics to diagnose and treat my nephew over the phone.

I should explain—my mother is a pediatrician. When we were growing up, all of our medical care came in the form of house calls. The downside? I would have needed an oxygen requirement to skip a day of school. The upside? No waiting rooms. All of our medical care was prepared à la minute. When my mother retired and turned in her prescription pad, the role of family doctor fell to me.

My nephew seems to have inherited the family impatience with the medical ritual. When I tried to conduct a medical review of systems over the phone, my nephew interrupted—Uncle Phil, why are you asking so many questions? Just concentrate on the throat.

I decided he was right. He probably had strep throat. In truth, I wasn’t sure if an antibiotic would help. From what he described, it sounded like his symptoms were already starting to resolve. That said, I thought a short course of amoxicillin was not unreasonable and, almost as important, would satisfy my avuncular obligations, so I could return to the work for which I am paid.

I called his local pharmacy and asked to speak to a pharmacist. It was a bit of a novelty. As a trainee, I spent a good part of my life listening to Vivaldi’s The Four Seasons, or some equally inoffensive piece of music, while waiting for a pharmacist to pick up the phone. Now, I largely communicate with pharmacies electronically, sending prescriptions with a few clicks of the mouse.

This brought back old memories, however. I spoke to someone at the front desk, to let them know I was a physician who wanted to call in a prescription. I was dutifully transferred to another line, but after about six or seven minutes of listening to Spring, my call, again, rolled back to the front desk, where I, again, explained that I was the same physician wanting to call in the same prescription.

Someone finally answered the phone in the pharmacy, who then asked if I would mind being placed on a brief hold to speak to a pharmacist. I actually had objections to several parts of that sentence, but I assented. I was just starting to listen to the first few bars of Summer when the pharmacist picked up.

I knew immediately that she was having a bad day.

She spoke in the clipped tones of someone who did not have time for this conversation. I tried to communicate the information as efficiently as possible, using the lingo sig and dispense to linguistically reassure her that I was a physician. She still wanted my bona fides, starting with my office phone number, then my office address, then my NPI number. At some point, I wanted to point out that all of that information should be in her system from prescriptions I had called in previously. But I know what it’s like to be in the weeds, and I did not think that now was a good time to ask whether she could be using her computer system more efficiently. I thought the greatest kindness I could show her would be to answer all of her questions, quickly, so she could return to the work for which she was paid.

After I got off the phone, I did find myself thinking, I wonder if she has enough time to make sure my nephew is receiving the right drug?

In 2000, the Doctor of Pharmacy degree became the entry-level pharmacy degree. This clinical degree gives pharmacists education & patient experience they would be eager to put to work—if only they had enough time to do so.

To Err Is EMR

Traditionally, prescribing errors are the fault of the prescribing physician. A multi­disciplinary panel of physicians, surgeons, pharmacists, nurses and risk managers, defined a prescribing error as “when, as a result of a prescribing decision or prescription writing process, there is an unintentional, significant 1) reduction in the probability of treatment being timely and effective or 2) increase in the risk of harm when compared with generally accepted practice.”¹

The increasing use of electronic medical records (EMRs) and electronic prescribing has removed a major source of prescribing errors—physician handwriting. I remember as a senior resident doing handwriting consults for interns, helping them interpret the instructions the attending physicians scribbled in the paper chart. I am certain most pharmacists have the same experience. Electronic prescribing has removed the uncertainty that used to come from trying to distinguish the abbreviations for magnesium sulfate and morphine sulfate.

This was no mean feat. On Dec. 1, 1999, the Institute of Medicine released a report on medical errors. The report estimated that 1.5 million adverse events and 7,000 deaths occurred in the U.S. each year as the result of prescribing errors, many of which could be traced back to poor handwriting.² This report, titled To Err Is Human: Building a Safer Health System, was designed to increase awareness of medical errors and was largely responsible for the push to transition to electronic prescribing.

For the most part, this transition accomplished what it was supposed to. One study demonstrated a 70% reduction in errors following a transition to electronic prescribing, largely attributed to elimination of errors due to illegibility, inappropriate abbreviations, and incomplete prescriptions.³ And were it not for the law of unintended consequences, the transition to electronic prescribing might have been an unequivocal victory. Unfortunately, EMRs, perhaps predictably, gave rise to a new generation of prescribing errors, which include the following:⁴

• Autopopulation: Most EMRs automatically suggest a list of potential matches as soon as you start to type the first few letters of the drug name. Only a few millimeters of space may separate penicillin from penicillamine, or azithromycin from azathioprine;
• Alert fatigue: Clinicians face a high burden of automatically generated alerts. Some of these are valuable, but are buried under a deluge of nonsensical or repetitive warnings, which dilute the potential of this feature; and
• Default values: EMRs may default to specific quantities or doses, which may be incorrect.

An illegible prescription, while annoying, was easy enough to flag. Who is responsible for catching this new generation of subtle prescribing errors? The pharmacist.

Pharmacists on the Front Lines

EMR-associated prescribing errors are just one of a number of new stresses that retail pharmacists on the front lines face. Many pharmacy chains now track pharmacist productivity, tying bonuses tightly to the number of prescriptions filled.

A community pharmacist may work a 12-hour shift, during which they may be asked to fill 30 prescriptions every hour. If you do the math, that means the pharmacist must fill one prescription every two minutes.⁵ That includes the time needed to counsel patients, which is mandated by law.⁶ If we factor in the time the pharmacist needs to check the insurer’s formulary, look for drug interactions, speak to physicians calling in prescriptions and counsel patients, the amount of time left to fill prescriptions drops precipitously.

Some pharmacies tie pharmacists’ bonuses to other activities, such as the number of patients agreeing to automatic refills or the percent of 30-day prescriptions converted to 90-day prescriptions; each of these activities, in aggregate, leads to increased revenue.⁷

Many pharmacies now rely heavily on pharmacy technicians, who may help fill prescriptions without a solid understanding of the potential interactions and risks of the drugs they are placing in the bottles.⁸ In many states, pharmacy technicians must be registered, licensed or certified by examination. That said, because these technicians must be supervised, their presence does not necessarily decrease the stress placed on the pharmacist.

Not surprisingly, these higher workloads are associated with a higher rate of dispensing errors. In 2015, Christy Gorbach, PharmD, et al. conducted a retrospective study of medication errors by 50 pharmacists who worked in a tertiary care hospital. Among pharmacists who verified fewer than 200 prescriptions per shift, 2.58 errors per 100 shifts were noted. Pharmacists who verified more than 200 prescriptions per shift had a threefold increase in errors.⁹

These errors have the potential to affect our patient’s lives: In 2016, the Chicago Tribune had reporters walk into 255 pharmacies in the Chicago area with prescriptions for both clarithromycin and simvastatin. Over half of the time, the reporter walked out with both drugs in hand, without anyone warning him about the potential drug–drug interaction.¹⁰

Also not surprisingly, these higher workloads are associated with a higher rate of burnout among pharmacists. A 2017 survey found that nearly half of health system pharmacists had symptoms of burnout, on par with the rate of burnout experienced by physicians.¹¹ In the 2014 National Pharmacist Workforce Study, 66% of respondents characterized their workload as high or very high, and 45% indicated this workload negatively affected their emotional and mental health.¹²

Where is all of this increased pressure coming from? The answer, in part, may be pharmacy benefit managers (PBMs).

For the uninitiated, PBMs started as middlemen between insurers and pharmacies, taking a small fee for processing claims. Now, three PBMs manage the drug benefits for 85% of all Americans.¹³ With this ubiquity comes the ability to influence all aspects of drug delivery; PBMs now have a hand in determining which drugs are included in a plan’s formulary, which pharmacies are included in a plan’s network and how much to charge pharmacies for their services.

That last point is the key: PBMs squeeze pharmacies to increase their profit margins; in turn, pharmacies push pharmacists to do more with less. So how can patients protect themselves from pharmacy-generated errors?

The Government, Here to Help

Articles on this topic begin with the same piece of advice: Talk to your pharmacist. I imagine every time pharmacists hear this sort of advice being given, they must sigh. It’s not that they don’t want to talk to us. It’s just that between filling prescriptions, fielding phone calls and administering vaccines, they don’t have enough time.

Ronald Reagan famously said, “The nine most terrifying words in the English language are, ‘I’m from the government, and I’m here to help.’” In this case (and perhaps in others) he may have been wrong. Having the government turn a regulatory eye toward PBMs is a good thing.

The inner workings of PBMs are famously opaque. Ohio State Senator Dave Burke makes the following analogy: “If you knew how much a yard of concrete costs, you know how many yards are in a mile and you can estimate how much you should spend on concrete … When the person who is doing that work isn’t telling you how much they paid for the concrete—they just tell you how much it costs for a mile of road—that gets to be a very expensive highway.”¹⁴

Increasingly, both state and federal govern­ments are noticing the tremendous role PBMs play in the delivery of nearly 6 billion prescriptions in the U.S. every year.¹⁵ Greater transparency in this industry should benefit all of us.

This won’t be enough, however, to extricate pharmacists from their current situation or allow them more time to provide vital clinical services. For pharmacists, it’s hard to imagine anything but a legislative solution. With this in mind, in 2018, Illinois established the Collaborative Pharmaceutical Task Force, which was “charged with discussing and making recommendations on how to further advance the practice of pharmacy in a manner that recognizes the needs of the healthcare system, patients, pharmacies, pharmacists and pharmacy technicians.”¹⁶

The task force has made several recommendations to the Illinois legislature, including mandatory work breaks and penalties for pharmacies who fail to give their pharmacists an adequate amount of time to do their jobs properly and safely.

In 2000, the Doctor of Pharmacy degree became the entry-level pharmacy degree. This clinical degree gives pharmacists education and patient experience they would be eager to put to work—if only they had enough time to do so.

Even legislating pharmacists’ time may not be enough. Notably, the task force elected not to set a maximum number of prescriptions that pharmacists could be expected to fill in an hour, deeming such thresholds arbitrary. The task force was also silent on what sort of penalties should befall a pharmacy that sets unreasonable productivity goals for pharmacists.

That said, it’s a good start. I hope other states follow suit, because it’s important that we acknowledge pharmacists for what they are—a vital link in the delivery of healthcare for our patients.

After all, my nephew is counting on them. 

Philip Seo, MD, MHS, is an associate professor of medicine at the Johns Hopkins University School of Medicine, Baltimore. He is director of both the Johns Hopkins Vasculitis Center and the Johns Hopkins Rheumatology Fellowship Program.

Author’s note: I would like to thank Tim Hinze PharmD, RPh, and Michele B. Kaufman, PharmD, BCGP, RPh, for their helpful comments on this column.

References

1. Dean B, Barber N, Schachter M. What is a prescribing error? Qual Health Care. 2000 Dec;9(4):232–237.
2. Institute of Medicine To Err Is Human: Building a Safer Health System. Washington: National Academy Press, 1999.
3. Devine EB, Hansen RN, Wilson-Norton JL, et al. The impact of computerized provider order entry on medication errors in a multispecialty group practice. J Am Med Inform Assoc. 2010 Jan–Feb;17(1):78–84.
4. Graber ML, Siegal D, Riah H, et al. Electronic health record-related events in medical malpractice claims. J Patient Saf. 2019 Jun;15(2):77–85.
5. Jaret P. Avoiding pharmacy errors. 2020 Jan 1.
6. Scott DM, Wessels MJ. Impact of OBRA ’90 on pharmacists’ patient counseling practices. J Am Pharm Assoc (Wash). 1997 Jul–Aug;NS37(4):401–406.
7. Gabler E. How chaos at chain pharmacies is putting patients at risk. The New York Times. 2020 Jan 31.
8. Benavides S, Rambaran KA. Pharmacy technicians: Expanding role with uniform expectations, education, and limits in scope of practice. J Res Pharm Pract. 2013 Oct;2(4):137–137.
9. Gorbach CG, Blanton L, Lukawski BA, et al. Frequency of and risk factors for medication errors by pharmacists during order verification in a tertiary care medical center. Am J Health Syst Pharm. 2015 Sep 1;72(17):1471–1474.
10. Roe S, Long R, King K. Pharmacies miss half of dangerous drug combinations. Chicago Tribune. 2016 Dec 15.
11. Jones GM, Roe NA, Louden L, Tubbs CR. Factors associated with burnout among US hospital clinical pharmacy practitioners: Results of a nationwide pilot survey. Hosp Pharm. 2017 Dec;52(11):742–751.
12. Gaither CA, Schommer JC, Doucette WR, et al. 2014 National Pharmacist Workforce Survey. Midwest Pharmacy Workforce Consortium. 2015 Apr 8.
13. The Council of Economic Advisers. Reforming biopharmaceutical pricing at home and abroad. 2018 Feb.
14. New drug pricing analysis reveals where PBMs and pharmacies make their money. 46brooklyn Research. 2019.
15. IQVIA Institute. Medicine use and spending in the US. 2019 May 9.
16. Collaborative Pharmaceutical Task Force.