Contributing Editor Jim Plagakis is a community pharmacist in Galveston, Texas. You can e-mail him at jpgakis@hotmail.com and cc us at drugtopics@advanstar.com. You can also check out his website at jimplagakis.com.

Jim Plagakis, RPh, Contributing Editor

Two years ago, Cleveland Clinic stopped hiring smokers. Recently, Doctor Delos "Toby" Cosgrove, the CEO of the Clinic, announced that if he could get away with it, he would stop hiring obese people. He noted that our national fat problem has huge costs, both medical and economic. 

What makes pharmacy run? The scent of profit, or the chance to make a difference as a healthcare professional? If we keep going like this, "Too much, I'm lovin' it" will overload the prescription mill. Universal access to healthcare will mean fat people too. Thousands of obese people, uninsurable today, will get full coverage, and expensive prescriptions for obesity-related illnesses will clog the tube. Obesity may become a millstone on an already overloaded system.  

Overweight and obese people constitute a majority in the United States. There is a growing fat-acceptance campaign. Fat pride. Books are published claiming that obese is beautiful. Take 

, written by Marilyn Wann. Ms. Wann and others are pushing hard against the idea that obesity is unhealthy. They project the idea that fat is healthy and beautiful. This is revisionist propaganda. Overweight, fat, and obese = harmful. Period. 

Fat-pride proponents claim people can be healthy at any size. This is not a productive argument in any conversation about healthy lifestyles in the 21st century. Adults can choose for themselves, but any group or book or video that glorifies obesity to children is a disgrace. Obesity has been an increasing epidemiological nightmare for years. It is getting to be a crisis. Our culture needs to take action. Perpetuating a myth that obesity is healthy is morally unacceptable. 

Peggy Howell is the public relations director of an outfit called the National Association to Advance Fat Acceptance. She said, "We believe that fat people can eat healthy food and add movement to their lives and be healthy." Peggy Sue, girl, it's called diet and exercise. Keep it up and you won't be fat anymore.  

We are bipolar about this. Profit sits on one side. On the other is the health professional. Linda Bacon (

) says we should refrain from giving a clear and direct message that there is something wrong with being fat. Sorry, Linda, there 

 something wrong. It is simply not healthy. Obesity is often a death sentence. Can you look your patient in the eye and somehow, gently, tell Brenda that 5' 2" and 300 pounds is going to kill her? She may miss her daughter's wedding. 

In the past, Big Insurance deemed thousands and thousands of obese people uninsurable. Big insurance is not stupid. Brenda becomes a walking drugstore cash cow at the drive-through when she gets prescription coverage. I can envision the author of 

 sending a handful of prescriptions through the drive-through tube. The manager starts salivating. He gets cross when the pharmacist counsels on her weight.  

 author Wann is self-employed and uninsurable right now. She recently said this about what she termed a humane and health-enhancing medical-care system: "We're all in this life raft together." 

 is a community pharmacist in Galveston, Texas. You can e-mail him at

Articles

Overweight and obese people constitute a majority in the United States. Universal access to healthcare will mean fat people, too. Thousands of obese people, uninsurable today, will get full coverage, and expensive prescriptions for obesity-related illnesses will clog the tube.

Fried Twinkies

At this store, all profits go to the employees. All shifts are double-staffed. Greatest Pharmacy pays for leased cars. The lead technician drives a BMW roadster. (I said 

I don't need to work for a living. I only come in when I want to have some fun. When the staff sees me coming, it's embarrassing. The adulation. The applause. The kisses on my cheek. The party in the opulent staff lounge. The cook who prepares the staff's meals gets to work on a vegetarian lasagna. The old-fashioned ice-cream counter starts giving away ice-cream sodas.  

So I quit. The exchange rate was so good in 1976 that my hotel room in Athens, with a private bath, was less than $4.00 a night. I spent evenings on Mykonos with an archeologist from New Zealand. Thanksgiving I drank vin ordinaire and ate bread and cheese on the train to the French Riviera. I spent Christmas in a hotel in a snowy Swiss village. 

. That gave me confidence for the next dream. I would be a novelist. I never worked more than 20 hours a week for 5 years. I wrote novels. Bad novels. When I published one in 1982 I was royally cheated when the publisher sold the book in Europe without my permission. The best one was written in Vermont. It is on a disk, in a drawer. Agents are hard to get. I didn't try hard enough. 

My pharmacy dream is latent now. The Greatest Pharmacy fantasy is more fun than should be allowed to a guy whose first drugstore job was as an apprentice in 1956. What about your dream?  

A girl in Washington State said, "I want my own store, Jim, but my student loan is so big that I just don't dare." Bingo! Student debt. The savior of CVS! How many kids would bail out of Wal-Mart after a few years if they were debt-free? 

The period we are entering will be a renaissance for the private drugstore. The number of prescriptions to be filled will increase exponentially in coming decades. The chains saw this coming years ago. Two words. Baby Boomers! They refuse to get old. They want to stay youthful, vibrant, and sexy for the whole ride. That means lots of drugs! The first drug designed just for them was Viagra. There will be more.  

I don't see success in starting a store under the old prescriptions-first model. It will take a paradigm-busting vision. You'll need a niche business that provides something valuable that is not available at Rite-Aid. Compounding is nothing novel, but a choice.  

My friend Elliott started in the 1920s and did well. Cosmetics and then photography were better profit centers than Rx. RxJoe in Boston left CVS and now has it his way. Rick and Marge on Lopez Island in the San Juans have their dream. My friend Nathan is a smart rat. He left Seattle and went home to North Dakota, where pharmacies must be majority-owned by pharmacists. That's the law. 

There is a chance for you. Your dream can come true. But not if you stay anesthetized. All you have to do is wake up. Trust me.  

 is a community pharmacist in Galveston, Texas. You can e-mail him at 

One man's fantasy of the ultimate pharmacy leads him down memory lane.

Commentary: The greatest pharmacy in the world

I know scuz when I see it. After all these years, I have a well-tuned scuz-o-meter. My ability to discriminate between just plain scuz and exceedingly scuzzy has been developed in the run-as-fast-as-you-can sweepstakes during numerous late-night shifts at a deep-discounter in Everett, Wa. They rushed me between nine and 10 at night.

I worked for an independent owner in Texas who preached, "If it is a legal prescription, we fill it." Cash prescriptions in the scuz market are very profitable. When word got out, some of them drove 50 miles. Four in a car. All with the same prescriptions. Finally I just said no. 

Scuz alarms clang when I see a couple at the drive-through drinking from a paper bag, cigarettes dangling from their lips, while their 1989 Cadillac Coupe de Ville spews stinky plumes of gray exhaust. The "prescription" is an 8.5x11 sheet of paper with boxes checked off: 360 hydrocodone/apap, 180 carisoprodol 350 mg, 90 alprazolam 2 mg, and a pint of promethazine w/codeine as a chaser.  

I have heard pharmacists lie to the drive-through fiends, "We don't carry any of these drugs." Not me. I am intrepid. "This prescriber isn't even a doctor. I'm not filling these ... I understand your bad car crash in 1978. I'm still not filling pain-clinic prescriptions." 

It takes decades to calibrate your scuz-o-meter. I recently worked with a very young floater pharmacist. There was no gray area for Lee; it was all black-and-white. I was doing busy work at the time; she was  the leader of the pack.  

"I'm not filling these prescriptions," she said. This was a challenge for her. Her eyes were wide and her lips were pressed together tightly. She wanted to be strong. 

"Why not?" They were for hydrocodone/apap and zolpidem. They were written by an orthopedic surgeon in Houston and looked good to me. 

"Well, look at him," she said with distaste. "He hasn't shaved for days. His T-shirt is old and his shorts are dirty. Look at his hair. He hasn't showered."  

"Lee, this guy lives on the Bolivar Peninsula. He probably doesn't even have a shower. Those folks are mostly a bunch of old hippies, free spirits, and artists. They don't have to shave if they don't want to." 

Bolivar is a beach environment that's a 15-minute ferry ride from Galveston. The first retail store from the ferry dock is where I work. The Bolivar Peninsula was ground zero for Hurricane Ike. They got the dirty side of the storm. Heavy bombing could not have caused more damage.  

I went with Lee to the counter. I asked the guy how he was doing. How was his home? 

"What home?" He managed a laugh. "Before the storm, I owned three businesses. Now all I have left is my RV park. There's nothing to do these days except fish." 

Lee lightened up. "Do you catch much?" I don't think she had ever seen a beatnik before. 

"Baby," he said, "We get our limit of 24-inch trout before nine in the morning." He looked at her. "Do you like seafood?"  

On his next visit, he brought us both enough filets for dinner for a family. We broke the rules and stored them in the Rx refrigerator. 

I studied her. "Scuz is as scuz does," I said. 

Unkempt appearance is often the pharmacist's first clue that a drug-chaser has entered the store.

A pharmacist's toolkit should include a well-tuned scuzz-o-meter

Going to the bathroom is priority ONE at this point. "I don't care if the doctor's line has been holding." You practically trot to the bathroom and THE DOOR IS LOCKED. You do a little jig, holding it tightly, but, ARRRRRGHHH. By the time the mother and her four children unlock the door, you...well...little accidents can happen.

Recently, I turned to the technician and said, "I'm all caught up. What is there for me to do?"  

"I can't help it," I said. I was looking through the problem box for something to do. "This is the way I have always worked." 

"It must be a pharmacist addiction. You all race like you'll get a whuppin' if you dare to slow down." She was laughing at me. "Hurry up and wait," I said, still looking for something to do. 

All occupations have intrinsic hazards. In an article in 

, I read about a group in Buffalo who worked in the plants supplying pumped-up radioactive materials to the nuclear weapons industry. This was in the 1950s; now they're getting sick with cancer. Because of poor record-keeping, some of them are not able to take advantage of a medical program specifically designed for them. Some are just dying. 

Pharmacists don't have to worry about glowing in the dark at night. Fifteen years ago, when you noticed the corpses piling up, you did the hardest thing you have ever done. You quit smoking tobacco. You are a smart rat with your diet and you get regular exercise. You even moved the family to the country to escape the nitrous oxide that spewed from the plant upwind from the fashionable subdivision you thought was heaven.  

Imagine this, Mister Ar Pee Aitch, you warned your co-workers: "America is too good at promoting death." You preached about food additives, rush-hour traffic, and unprotected teen sex. In return, they gave you a nickname they only used behind your back.  

You may not glow, but you are probably unwell. Of the 230,000 pharmacists out there, I'd bet that 90 percent of them have suffered from this condition at one time or another during their careers. It can be debilitating and dangerous. It can harm marriages and relationships. Health can suffer. So why not address it? Because it is part of the job and too expensive to recognize as a health issue.  

We suffer stomach difficulties, hypertension, and other insidious troubles because of this problem. It is a thoroughly modern ailment that, frankly, is not recognized as a source of trouble. It is probably the condition most prevalent among pharmacists.  

There is a name for it. You can find it in numerous reference sources. 

A modern malady caused by constant rushing. A compulsion to do everything quickly, or a chronic feeling of being short of time, attributed to the fast pace of modern life, which causes symptoms such as anxiety and insomnia. 

How about adding divorce, alcohol and drug abuse, adultery, depression, child neglect, and nervous collapse? A thoroughly modern scourge, from which we all suffer. Think your insurance will cover treatment?  

And we spent all of those years studying and preparing for a nice, comfortable life. 

The one condition that is probably shared by most pharmacists can harm marriages, health, and jobs. But it comes with the job, so what do we do about that?

Commentary: Too many pharmacists suffer from hurry sickness

Last week I was talking with a pharmacist in Michigan. After the transfer, we chewed the fat awhile. I really like my job, I said. He said he hated his. My PIC is terrific; his is a seven-letter word that starts with "A" and ends with "E." He said that where he worked, Billy Bill's Car Wash and Pharmacy, the store manager butted in all the time and told him how to practice pharmacy. 

"Customers know that they can complain to this guy and he will jump all over me when I have to refuse a refill." His voice rose in pitch. "It's too stressful." 

"I've been here 20 years," he said. "I wouldn't know where to start looking for a new job." 

"Start with your buddies," I suggested. "Your pharmacist friends in town." 

There was an awkward pause. He blurted, "I don't have any pharmacist friends." 

Holy Moly, Batman, has it gotten to this point? I shuddered as I realized that I don't have any pharmacist friends either. I have a network of 700+ pharmacists, but they are readers of this column. Real people, in real time, in Galveston, whom I see on occasion? None!  

There was a time when I played golf with pharmacists. We put on a winter holiday dinner dance. Maybe it would be corny in 2009, but it was fun to get dressed up. And there was the Fourth of July cocktails and barbecue in a fellow pharmacist's large backyard.  

There were all the times we met for after-the-store-was-closed restaurant meals. This was before Big Pharma and CE; one detail man or another could be counted on to write a check. We laughed and joked. We had a hell of a good time, but we would be serious if one of us needed help, like finding a new job.  

Divorce? The first person I told about my toxic first marriage was an older pharmacist. Early one Sunday morning we were on his boat on the Sacramento River delta, fishing. I talked. He listened. He asked all the right questions. Twelve hours later, his wife served comfort food. Meatloaf, mashed potatoes. She asked me how I could continue living with an alcoholic.  

			The pharmacist said, "Jim, that's enough." 

In the 21st century, something is missing in our profession. We have reached the point where we, as individuals, are on our own. We are rudderless. We are spinning almost out of control. Whoever heard of a profession in which the individual practitioners have no well-established support system?  

Don't talk to me about the big pharmacy organizations. We both know what it feels like to be abandoned. 

Pharmacy network sites, where I call myself jpgakis, are where I get to interact with pharmacists who give themselves monickers like Rxbabe and SmoothPharmD. My own Web site has its share of incessant nattering about a $4 professional embarrassment and other assorted whines and complaints.  

The Drug Monkey uses adult language and pharmacists love it. That's telling them, goddammit. But telling whom? Nobody who counts is really listening.  

You can visit Pharmacy Forum UK and see that pharmacy in England is no better. The Pharmacy Alliance maintains a more dignified conversation. Discussion there can actually offer constructive dialogue, but it is not the same as six pharmacists eating an early breakfast around a table in the local coffee shop.  

We must rediscover the center we lost about 20 years ago - to the benefit of outfits like Billy Bill's. It's an easy task to smack-slap one pharmacist who's twisting all alone in the wind. Not so easy when there are 10 of us talking on a regular basis. Not so easy!    

Before the concept of "networking" became necessary, professional colleagues were often friends as well as peers, gathering regularly to compare notes, have fun, and support each other through difficult times. The loss of that connection has impoverished today's practice of pharmacy.

When pharmacy meant community, we showed up for each other

"I got a brand-new pair of roller skates. You got a brand-new key." 

The voice was pretty good. High-pitched. In tune. A playful touch that I liked. "

I think that we should get together and try them on to see."

 Her smile was brilliant and her eyes lively. 

 out of luck." She turned around. "Look at me. Look at the sweat." 

"Not so hot. Maybe 85 degrees. I walked from the clinic as fast as I could to get here before you closed." 

She was soaking wet. Her lightweight tie-dyed cotton dress with the spaghetti straps clung to her. She couldn't have been more than 100 pounds and she was probably 5-foot-8. Her prescriptions were for 120 tablets of Norco-10 and a course of Levaquin.  

I rode my bicycle past your window last night." 

She winked and posed as provocatively as a rail could pose. 

"I roller-skated to your door at daylight." 

Okay. This doesn't happen very often, but it has happened enough during my career that I know how to laugh it off without embarrassing anyone. I smiled my best smile and said, "You are a very sexy woman and your voice is beautiful." 

She laughed. "You are a liar about the sexy part, but I know my voice is good. I made my living with it for 40 of my 64 years."  

"Baton Rouge and Houston. I'm here now so I can be near my doctors." She patted her hot cheeks and made a puffing sound. She was sweating profusely.  

She nodded, and I took a bottle of Aquafina from my personal stash and handed it to her. 

She drank a fourth of the bottle in one gulp, wiped her mouth with the back of her hand, smiled, and said, "Thanks. How much?" 

"I'm not selling," I said, "I'm giving." We had been talking for a few minutes and I had taken a good look. This woman was in very rough shape. Her hair was matted and dirty. Her dress was very old, but clean. She had given me a Medicaid card when I asked about insurance. 

"Thank you." She was not smiling. "I have pancreatic cancer," she blurted. "I'm a dead woman walking, but, baby, I can still sing.  

"I asked your mother if you were at home. She said yes, but you weren't alone."

 This woman was a torch singer - and a damned good torch singer. Her eyes. Her mouth. The way she moved. She 

was sexy. All of her belied the body that was dying. 

As many a pharmacist can testify, sometimes a momentary encounter makes an impression that will last a lifetime.