We have met the enemy, and he is us

November 17, 2015

Article

You want to see change in the way pharmacists are treated? Change what you're doing - and start with incorrect Rxs.

In a recent Drug Topics column, Ken Baker referred to a classic POGO comic strip by Walt Kelly, the one that launched the saying “We have met the enemy and he is us.” Turns out, the Cynical Pharmacist has plenty to say on that subject.

We pharmacists are our own worst enemy. We need to change that, and we need to do it ourselves. We need to police ourselves. We need to band together. And we need to do it now.

Back in the day

Not long ago, pharmacists were respected. We went out of our way to help people in every imaginable situation. After years of our being the go-to good guys, who would bend over backwards to help our patients, we created a perception that now simply expects us to bend over as a regular practice.

Back in the day, if patients had no refills, pharmacists, who usually had a great rapport with nurses at physician offices, would call to request refills, and they would often get them in the same phone call.

If patients had no refills and it was the weekend, pharmacists would front patients "just a few for the weekend," because we knew the patients would call their doctors, who would send in the Rx when they returned to their offices.

What is the upshot of all this kindness today? Patients berate and complain about us unless or until we accede to their every demand.

Think about what you’re doing

While the issues and expectations cited above are more corporate-driven and attributable to loathsome “customer service” programs and metrics, my biggest complaints pertain to the problems we pharmacists bring upon ourselves every day without stopping to consider the ramifications.

For starters, laws. We go to school and have a law class. How important is pharmacy law? It is actually one of the two tests we have to pass in order to receive our license. That’s how important it is.

Prescribers also must pass this exam, but as they enter the real world, they are not held accountable anymore. We are.

If a prescriber forgets anything on a prescription, what do pharmacists do? We call.

Some things are minor infractions in circumstances where this is acceptable, such as missing strength, quantity, directions, refills. The areas that concern me are the ones that may draw the attention of the DEA and state board of pharmacy: missing DEA on a control prescription, missing CTP from a non-doctor prescriber, missing the spelled quantity next to the written quantity on controlled prescriptions, etc.

Whose job is it?

What do we do? What should we do? These are two very different questions.

What we actually do is call the prescriber and get the missing information so that we can fill our patient’s prescription. What we should do is send the incorrect, invalid prescription back to the office so the prescriber can fix it. If we send back enough Rxs, perhaps prescribers will learn to write correctly. It is not my job to fix their errors.

I know what you are going to say: “It’s not the patient’s fault their prescriber wrote it wrong. They’re standing here in pain and you owe them professional courtesy.”

Do I? Let’s think about this for a minute.

Over the course of my career I have tried to be the bigger, better pharmacist. What happens when I send prescriptions back with a patient?

1. The patient says: “I don’t have that problem with ‘[competitor across town].’ I’ll just take my prescription there.”

2. The patient takes the Rx back to the physician office and the office fixes it.

3. The patient takes the Rx back to the office and doesn’t return with it, so I lose a prescription.

My problem is with item 1. Even though we know the prescription is not legal, there is a pharmacist out there who will fill it. Is he scared for his job? Does he have to meet his metrics this month? Is he really old-school and doesn’t care? Did he just not notice it?

Until we can put an end to “the other pharmacist will fill it,” we cannot ask patients to respect us or our profession. Basically, in the eyes of the public, we are whores who do anything for a buck.

We need to fix this. But how? Better yet, why?

Do the rules apply?

A correspondent forwarded me a letter received from his pharmacy’s corporate office. Their state requires that a non-physician prescriber must provide his/her Certificate To Prescribe (CTP) Number on all prescriptions. This includes e-scripts, handwritten prescriptions, and prescriptions that are phoned in. It is a legal requirement. It says so right in the state law under “Manner of Issuance of Prescriptions.”

This section is a how-to guide for prescribers as well as pharmacists. I believe that both groups of people have to read, understand, and follow the same set of rules. Why then does it fall on the pharmacist to play cleanup when the prescribers ignore - that’s the only word for it - their legal obligations?

The letter I received encouraged the pharmacist to check the national database online, look up the prescribers’ CTP numbers, and then write them on the hard-copy prescriptions.

Yes. Somehow it has become our job to fill in the blanks for the prescribers. I fail to understand why, when the prescriber failed to write this one little number on the prescription, that I should have to do all this extra work.

How about a big fat “no”? I say, send them back. Let’s start with missing CTP and DEA numbers.

Who ends up on the hook?

“But what about the poor patients? Don’t put them in the middle of a pissing contest between you and the prescriber. It’s not their fault their prescriber was in a hurry/forgot/is a moron.”

This is the most common plea I have heard from other pharmacists and staff, and all of you are absolutely 100% wrong. The only people who can walk all over you are the ones you allow to take the first step. In this case both the patient and the prescriber are doing a tango down your back.

The State Board of Pharmacy used to be on the pharmacists’ side on this issue. They used to believe in the tenet “the patient comes first.” As long as you used your professional judgment, you could justify filling a noncompliant, illegal prescription.

A recent visit with a friendly inspector led to a change in this practice. The new answer is: “This is not valid in court.” With DEA agents now investigating more cases, just because you’re filling for a regular patient or for a regular prescriber is not enough to get you off the hook.

Simply put, whether you telephone the prescriber or not, continuing to fill these prescriptions with errors is likely to lead to more trouble for you - not for the prescriber.

Why are we risking our licenses for prescribers who are responsible for errors time and time again, yet will face no repercussions with any agency?

We’ve stuck our necks out like this many times, without considering the professional consequences. We did what was in the patients’ interest. Rarely did we face legal ramifications. And in so doing, as I said in the beginning, we dragged our profession down a rabbit hole that we must now find a way to escape.

Stand up for pharmacy

I ask that we band together. Let’s stop accepting prescriptions that lack legally required information. Pharmacists have to know the laws to accept prescriptions. Prescribers should have to know the laws to write them.

Send the prescriptions back. The worst prescribers can do is complain.

The worst I can do is make copies, send them to my local state board agent, and ask him to pay a visit to the office.

I’ve done it. It’s amazing how quickly physician offices change their tune when facing legal repercussions. I give them the old three-strikes-and-you’re-out. If they haven’t fixed it by the third time, it’s time to call in the professionals.

Let’s not forget how prescribers like to throw work back our way. Refill requests? The new office policy states that you must call your pharmacy and it will request the refill either electronically or via fax.

Did I mention that we also pay for the privilege of receiving all those incorrect e-scripts, e-scripts we must call to get corrected? I know we won’t be getting a return-to-sender button any time soon, but we still have the power to send back prescriptions that are brought to us by the patients.

Just stop

As I have said many times before, we are great complainers. We also shy away from conflict. Patients yell at and abuse us all day long and we complain - after they’ve gone. Prescribers take advantage of us because they think to themselves, “It’s okay. The pharmacy will fix it” -and we let them!

Stop permitting abuse. Stop being that pharmacist who turns a blind eye to everything. Stop being the one pharmacist everyone knows will take the forged prescription, the unsigned prescription, the illegally post-dated prescription, the one prescription every other pharmacy in the county refused because the state database lit up with red flags when they all checked it. Just stop.

Better yet…just send them back.

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