When business clashes with patient care

October 24, 2005

Have you ever worked in a setting where you felt you were set up to fail as a pharmacist—a place where there was a large gap between the standards and expectations of the organization and what you perceived to be the needs of your patients? After having worked for several different pharmacy establishments, I recall one employer in particular.

The job interview seemed relatively harmless, and the manager even quelled my doubts about the pharmacy computer program. The manager simply stated that learning the computer would be intuitive. This particular program had been around since before the computer mouse. The company apparently believes that with such an intuitive program, who really needs a modern device? A manual certainly would have been helpful, if only there was one! In fact, nothing was written down; the policies and procedures existed only in the form of lore passed down from one generation of pharmacist to the next.

Patient safety, including screening for drug interactions, should be pharmacists' primary concern. Unfortunately, the drug interaction reports at this pharmacy interfered with this important activity. For instance, if a female patient took a short course of penicillin two years ago and was picking up a prescription today for oral contraceptives, the program would generate a warning despite the two-year time lag between the prescriptions.

The idea of a "Fast Mover" section for more frequently dispensed drugs seems reasonable as a means to improve operational efficiency. However, it can become a parallel universe rather than a step-saver if it includes more than half the inventory of the pharmacy. Much like the Grand Canyon, the Fast Mover section of this model pharmacy was both vast and deep. The problems with the Fast Mover section were really two-fold: the Fast Movers were not physically closer to the R.Ph. than the Slow Movers, nor were they in any logical order. For example, generic drugs were organized by brand name rather than the name on the container.

My appreciation for everything I was taught in pharmacy school was shattered within the first two hours on the job. The manager told me to avoid leaving the pharmacy counter to assist customers with OTCs because of time constraints. The manager also explained that OTCs were separate from the Rx business and, thus, did not contribute to the pharmacy's bottom line. Since pharmacy managers' bonuses are partly based on Rx sales, there was no financial incentive to counsel patients on OTCs.

The incessant focus on the bottom line also affected the availability of tools essential to the practice of pharmacy. I wish that the hiring manager had warned me to bring everything I might need to work with me on the first day. This pharmacy was equipped with one spatula, one counting tray, two broken tape dispensers, and one prescription pad with just a few sheets remaining.

The pharmacy also had in its possession an Erlenmeyer-like flask and was in desperate need of more accurate measuring devices, such as graduated cylinders. It would have taken a miracle to measure an accurate amount of water for reconstituting oral suspensions using this piece of medieval lab equipment. For fun, try pouring 72 ml into a 500-ml flask with calibrations 25 ml apart using a 1-gal. container of water. Again, the managers of this chain were probably so focused on their weekly sales performance, that no money was allocated for basic supplies, upkeep, and, dare I say, automation.

Needless to say, it quickly became clear that pharmacy management concerns were at odds with practicing pharmaceutical care. This particular chain had some of the highest Rx volumes in the area, yet its approach to management of the pharmacy operation was penny-wise and pound-foolish, with multiple impediments to pharmacy efficiency that precluded R.Ph.s from talking to their patients. Clearly if management was unwilling to provide the pharmacies with adequate supplies, then implementing a new computer system or introducing pharmacy automation was not even on its radar screen.