Wednesday, December 5, 2007

Pharmacy is Not a Commodity!

Pharmacists and Corpo-Drugstore are intertwined in a sort of Faustian bargain.

There's not a lot of glamour in community/retail pharmacy. CorpoDrug pays pharmacists lots of money to stand behind a counter. The fact that "patient" and "customer" are used interchangeably to refer to patrons of CorpoDrug's pharmacy is very telling; I find it most interesting who chooses to use which word. As an informal observation, most pharmacists prefer patient. Most technicians and store managers use customer. Sapir and Whorf may be onto something here. Patient sounds a lot more "medical." Calling patients customers reinforces the idea that CorpoDrug is a store. I would quip about portraying pharmacy as the equal of the Big Box retail business here if it weren't for the fact that such a comparision is pointless; Wal-Mart, Meijer, Target and CostCo all have their own pharmacy departments.

The problem is not that CorpoDrug is turning pharmacists into glorified store managers who coincidentally have medical degrees. The problem is that pharmacy started that way and that it has failed to break free of those chains. CVS retail outlets originally did not include pharmacies; the "CVS/pharmacy" nomenclature grew out of a need to inform consumers which locations had pharmacies and which did not. Walgreens began as a drug store, but this was back in the era where the drug store was a place to get malted milkshakes and tobacco products. The history of community pharmacy suggests that with the advent of pharmaceutical manufacturing and the downfall of compounding that pharmacists filled no clear niche in the healthcare field. Now, pharmacy is rapidly evolving into a profession of drug information and medication therapy management experts. Pharmacists in hospitals and managed-care facilities have the opportunity to work with other healthcare professionals to optimize patient outcomes by contributing their unique skills and knowledge as drug experts. Physicians can rely on pharmacists as valuable allies.

But CorpoDrug is still living in the stone age of pharmacy, perhaps with fewer mortars and pestles. It is two-faced, talking out of both mouths simultaneously about the value of its pharmacists. Surely it "values" pharmacists in the sense that CorpoDrug is willing to pay them a median salary of $90,000. And the American public, at least, considers pharmacists to be among the most ethical professions, just behind nurses. It is clear that people think that pharmacists are ethical. And if my experience is any indication, they think pharmacists are knowledgeable, too. Pharmacists get asked some pretty crazy questions, like whether or not sodium benzoate is safe or which urinary tract infection test strips are more reliable. This is in addition to the more traditional queries like "can I take these two medications together?" and "how much Tylenol should I give my four-month-old?" A big part of why pharmacists get used so frequently as a source of information, aside from the public's assumption of their ethics, is their accessibility. I can think of few doctors who have time to take phone calls about sodium benzoate, but pharmacies do it all the time.

A district manager for the retail pharmacy that employs me stopped into our store one day and was conversing with the pharmacist. "We're here to help people," he said, "but pharmacy is a business, too." In the most base sense, this is true. It isn't wrong to want to make money; it's a necessity of living in a capitalist society, and there is nothing immoral about that in itself. From a marketing perspective, prescription drugs are a commodity. The time and advice of a pharmacist is a commodity. These are goods and services for which there is a demand and only a limited supply. But healthcare professionals, the dedicated, honest, ethical ones at least, don't see their services as commodities, not in the same way that businessmen do. Can you imagine a physician offering to push people to the front of his waiting list for appointments if they volunteered to pay higher fees? Would an ethical doctor provide patients with prescriptions for whatever they asked for on-demand as long as the patient was a paying customer? These might be very profitable business moves for a physician. Assuming he evaded prosecution, a physician willing to "sell" prescriptions for drugs of abuse could make a huge fortune. But it would be illegal, and more importantly, unethical.

Pharmacists, like physicians, take an oath. Nowhere in that oath is "I will uphold a committment to the idea that the customer is always right" or "I promise to provide the lowest prices for antibiotics in town." The first point is "I will consider the welfare of humanity and relief of human suffering my primary concerns." Pharmacists are professionals.

The mechanisms that CorpoDrug use to secure customers are insulting. Gift card coupons that encourage patients to bounce back and forth between retail chains whenever they get a new piece of junk mail. My chain is currently offering as much as $50 in gift cards for filling a new or transferred prescription at our chain instead of somebody else's. "Ten minutes or less" guarantees that any reasonable pharmacist will recognize as total bull; if your insurance company is being a pain or your doctor's handwriting is illegible, I'm not going to uphold some fast-food speedy service ideal at the expense of patient safety. Drive-through windows are perhaps the most appalling of all; they suggest that the time and expertise and pharmacists aren't even worth getting out of your car. I'll be amazed when a physician's office puts in a drive-through and volunteers to diagnose patients through the window. Once you've got your diagnosis, you pull up to the second window to pay and get your prescription. Absolutely absurd.

CorpoDrug treats pharmacy like a commodity, and the public has picked up on the idea. Pharmacies, like McDonalds' outlets, are interchangeable. I have dozens of stories about patients who were in my store and thought they were at a different retail chain. All pharmacies have the same drugs, right? Perhaps pharmacists are interchangeable, too, like grill cooks, as long as the product is the same. CorpoDrug uses one mouth to say that pharmacists should take the time to counsel patients and verbally slaps them on the hand for "unacceptable" wait times that cause loss of profit margins with the other. It becomes the job of individual pharmacists to uphold high standards of care--with or without the support from their retail outlets. Many find it impossible to keep up and have simply folded.

A lot of patients on chronic therapies, namely insured patients, will pick one pharmacy and stick with it, giving the pharmacist or pharmacists who work there a greater degree of access to their medication history. Programs to encourage these patients to stick with one pharmacy, or at least one chain, have been largely successful. On the other hand, there are the patients who comparison shop, bouncing back and forth between outlets based on who has the cheapest prices for each particular medication. This spells disaster when the patient winds up on two drugs that should never have been taken together.

Which brings us to universal healthcare. Pharmacy wouldn't have to be a commodity in the face of universal healthcare--we could have universal pharmacies, too. Instead of walking past displays full of toilet paper and office supplies on the way to the pharmacy "department," the whole structure could be dedicated to health. With adequate staffing, patients could make appointments to speak with pharmacists about their medication--a service that is already being promoted for Medicare patients. Imagine if every corner drugstore offered the same service and advertised it as heavily as they do sales on toothpaste! The sort of competition CorpoDrug engages in with PharmaMart is bad for patients, whether they realize it or not; they become sources of revenue rather than sick people, permitting greed and capitalism to steamroll good health practices in the face of profits. CorpoDrug doesn't sell dietary supplements because they help people. They're on the shelves because they add to CorpoDrug's profit margins.

My absolute least-favorite "pharmacy" publication is Drug Store News; sure, they talk about clinical issues from time to time, but a huge portion of Drug Store News is things like "which brand of lip balm sells the best?" and "how can I add proprietary vitamin blends to my inventory to boost earnings?" It's positively revolting. If drug stores were really focused on being healthcare providers, this sort of crap would never propagate. Physicians don't distribute coupons through the mail. That's the shady realm of chiropractors. Would physicians subscribe to publications suggesting that they add in-office plastic surgery or proprietary herbal blends to their services to supplement their incomes? Absolutely not, and most physicians would be offended at the idea. Why do pharmacists put up with it? The short answer is that most of them feel that they don't have a choice. Independent pharmacies really do need to go to extremes to keep from being washed away by the tsunami generated by the chains. And pharmacists employed by those chains are essentially being bribed into silence with high salaries.

Pharmacy is not a commodity. Medical care is not a commodity. Medical care is a necessity, a basic human right. And if pharmacy is going to contribute to overall human health for our communities, it's going to be necessary for pharmacy to distance itself from "business" as much as is humanly possible. Pharmacists need to support themselves and their families, and it's easy to see why a desperate pharmacist, buried in debt and student loans, would sign on with CorpoDrug in order to dig their way out. But if CorpoDrug really had any respect for their pharmacists and their clinical expertise, they wouldn't treat them the way they do.

Corpo-Pharma's assault on pharmacist ethics persists.


Δρ Νικος Kanakas said...


it is a very nice adn good post adn I like it.

Νίκος Κανακάς said...


It is a very nice abd beautiful post and I really impressed to it.