Where is the line between patient service and disservice to self?

August 22, 2011

Pharmacists have reached into their pockets to assist needy patients on many occasions. But when the patient makes no effort to take responsibility and the cost to the pharmacist becomes painful, where should the line be drawn?

I'm just a simple man. I go to work. I go home. I love my wife. Lather, Rinse, Repeat. We don't yet have any kids of our own, but as my one and only top-notch technician would tell you, I'm a softie for kids. I can't stand to see children suffer harm, hunger, or half-hearted care. I have always done whatever possible to protect those who cannot protect themselves.

Not long ago I found myself taking a prescription for Malarone Pediatric Tablets (Atovaquone/Proguanil 62.5/25 mg) for a 40-kg child. The physician kindly asked me to figure out the dose, duration, and quantity, and relay that to “Dr. Mom.” In case you don’t have Facts and Comparisons open and handy right now, I’ll save you some trouble. He needs 3 tablets daily, starting 1 or 2 days before entering endemic area and continuing for 7 days after return.

“When are they leaving?” I asked the doctor, praying it was weeks away.

“I’m pretty sure they’re hitting a plane early tomorrow morning for Andhra Pradesh, India,” he responded.

“That’s going to be a problem,” I said, knowing how things work in a community pharmacy, “We will be hard-pressed to find it in a local pharmacy, and the soonest I could get it into my hands is tomorrow afternoon.”

“Well, do the best you can. I just heard about this little trip minutes ago, myself,” he muttered, seeming a trifle perturbed.

I foresaw several different places that this could all fall apart. Luckily, the first, their commercial insurance, didn’t pose a problem. The family had a higher, but reasonable, copay (considering the cost of an international flight ticket). Could I get the drug before they left? Unlikely.

I’d be willing to do anything in the world as long as it isn’t illegal, immoral, or unethical to get this medication for this child. Much to my dismay, but just as I expected, no pharmacy within any reasonable distance had it in stock. I had to resort to my last option, overnight ordering. I didn’t doubt for a second it would get there. But I knew exactly when it would get there - hours after their flight leaves. The final hurdle was the actual dispensing of the drug.

It was just after midday when the parents came into the pharmacy to - as they thought - pick up this medication. I had nothing but bad news for them. We knew that the child should have begun taking the medication the day before, and I made the parents painfully aware of how shortsighted and immature their process of procuring this prescription had been. Nonetheless, we decided that they would go ahead and pay the copayment, and I would mail the medication to them in India. The child would start it immediately, they would be sure to follow up with their physician, and they would be mindful of ANY symptoms.

The next day came, and so did the Malarone. Mailing address in hand, I logged into the website my company uses to mail/ship parcels. That was when I realized I’m not equipped for international shipping. The website, while amazingly proficient, just won’t recognize a 6-digit zip code. I wasn’t going to give up though. Not yet.

I sent my technician to one of the parcel services on Tuesday early afternoon, my personal credit card in hand, to get this thing taken care of. She called me minutes later with an edge of concern in her voice.

“The good news is that they recognize the address and will get it there this Saturday with tracking and signature delivery. The bad news is that it is $144.50!”

That is certainly blurring the line of great customer/patient service and a good-sized personal disservice. I’m two years out of school - still paying off loans and a mortgage. Hard pill to swallow for a stranger I may never see again. Even without tracking and signature confirmation, it’s still nearly $100.

Next, my technician headed for the United States Postal Service. I knew they would be more reasonable. She called once more to say that “$49.95 will get it to the border. They can’t promise anything once it is funneled into the country’s postal service. To their knowledge, it would not be a good idea. Considering it’s an expensive antimalarial agent being sent into an endemic area, she thinks it might be ‘confiscated’ before delivery, and we’d never know.”

“Bring it back,” I told her. I can’t ship it. I can’t mail it. I surely can’t deliver it. I didn’t charge them any postage beforehand. I tried their cell phone, and it doesn’t work. While I could surely pay for the shipping, the cynic in me questions whether the family will ever pay back the cost. We’ve all known a patient to “borrow a few bucks” and then switch pharmacies to avoid paying back an insignificant amount of cash. In this situation, the sum was a bit more significant.

I had reached a point where my beliefs and perceptions about myself led me toward a positive, desirable outcome, yet that outcome was significantly affected by my own beliefs and perceptions of the world in which we live. The worst part, besides the inability to get medication to a child, is that no less than 24 hours before this dilemma arose, I had made these parents aware of their shortsightedness and immaturity. Maybe next time, I’ll show a little less of both myself.

Brandon Eldridge is a practicing community pharmacist in Missouri and Illinois. He can be reached at brandon.eldridge@gmail.com.