I'm done being quiet.

Updated: Feb 2, 2019

Yet I can't speak out publicly, for reasons any pharmacist could tell you. I care about getting the best care to patients, providing access to digestible information, and showing empathy to the patients who are only seeking me out because they trust me with their health by trusting me to select, provide, and educate them with the proper medications. But the US pharmacy industry just doesn't allow for this in the vast majority of American community pharmacies. The lip service is loud. Large chain pharmacies preach about how much they care, how they are here to help, how they decrease costs and improve patient care. The lip service becomes louder still when you realize how silent the pharmacists actually providing that care are.


If pharmacists could speak freely, they'd tell a different story. They'd tell you about standing for 14 hours, verifying prescriptions at lightning speed. About shoving 3 bites of a sandwich down, racing to beat the timer on the endless stream of prescriptions flowing into their work queue. About holding their urine so long they develop UTIs from lack of access to proper breaks. About their milk supply drying up early and having to stop breastfeeding earlier than intended because there is no time to pump. About developing varicose veins and plantar fasciitis from long hours of standing with no rest. About passing out in the floor of the pharmacy from lack of food, or developing stress-related hypertensive crises (yes, these are real-life examples). And most pharmacists aren't even complaining about this because they worry for themselves. They're complaining because these conditions make them more likely to make a mistake - a mistake that could harm YOU, or me, or an unborn child, or someone's grandmother.


Why does the pharmacist worry about this? First and most of all, because most pharmacists are compassionate people. We started on this path wanting to help people. Many of us became disillusioned along the way, but our gut still clenches at the thought we could be at fault for harming anyone. Emotional factors aside, why does the pharmacist worry? Why not the pharmacy companies that create this type of labor environment? This is a multi-factorial problem I will try to break down, but I am only one pharmacist with one set of experiences. Other pharmacists PLEASE chime in in the comments about anything I've missed, and I'll try to include it in the future.


1. Pharmacy law

Pharmacy law places the responsibility for the provision of adequate patient care directly in the hands of the pharmacist. This was good, in the days in which pharmacists were independent providers of care and had control over their own work environment and productivity demands. Many states mandate that pharmacists "counsel" or educate a patient thoroughly with every new prescription issued. When that doesn't happen, the chance to catch a medication error at the final point of issuance is lost. And when that doesn't happen, the violation falls on the pharmacist, not the employer, even if the employer knowingly set up conditions that would not allow the pharmacist to fulfill this vital duty. In the case that the employer is implicated, for the large companies dominating the pharmacy industry, the cost of settling a lawsuit is simply part and parcel of what they do. It costs less to handle those as they arise than it does to appropriately staff their store locations.


2. Student loan debt

In the pharmacy world, many people see us as "overpaid technical workers." In truth, many ARE attracted by the seemingly high salary of pharmacists, without recognizing what are colloquially known as "golden handcuffs." The pay looks high when you check the list of salaries and see that even the lowest paid pharmacists are usually making six figures a year. The context that is missing though, is the astronomical cost it takes any one person to become a pharmacist, and the liability resulting from the duties they fulfill. The cost includes financial costs, opportunity costs, and personal sacrifices. Pharmacists generally attend at least 6 to 8 years of post-secondary education, and all newly licensed pharmacists since 2006 have been required to attain the doctoral level degree of PharmD. Since the financial cost is the easiest to see, let's look at that first. As of 2017 the average debt of graduating pharmacists was over $160,000. From personal experience, if you try to pay that amount of debt off in the standard 10-year period, you end up with a student loan payment of over $1700 per month. That's before the cost of housing, liability insurance, transportation, or any other general living expenses. And this kind of debt leaves us living in fear, due to the next item on the list...


3. Oversaturation

In the early 2000s, the pharmacy industry experienced a widespread shortage of licensed pharmacists. Demand was high, and wages rose sharply. Pharmacists were treated well and were receiving large sign-on bonuses to bring their services to a company. In the rush to correct the market shortage, many colleges found it extremely profitable to open a pharmacy school, and sell the chance at a >$100,000 salary to fresh-faced undergraduates looking for a career. Unfortunately, this trend continued long after the market shortage was accounted for, and still new pharmacy schools were being opened, resulting in a gross over correction of market conditions. The accrediting body for schools, the ACPE, is either unwilling or unable to stop this trajectory. Due to exorbitant oversaturation, now pharmacists are aware that if they have a problem with the ethics of their company's demands, there are surely 3 unemployed new pharmacy graduates waiting to take any job that can pay their massive student loan bills.


4. Inadequate Representation

Aren't there organizations out there to prevent this kind of abuse, you may wonder? Unfortunately the answer for community pharmacists employed by chain pharmacies, the answer is essentially NO. Pharmacy organizations are essentially impotent in comparison to the representation and lobbying power held by physicians via the AMA and by nurses in their professional organizations. Associations that represent the interests of chain pharmacies are there to represent the companies, not the employees (practicing pharmacists and technicians). What about the government? Don't they care? Isn't there a Board of Pharmacy in every state? Why yes! There is! But the Board of Pharmacy is charged with protecting CONSUMERS (patients), not pharmacists. So shouldn't they take action concerning working conditions dangerous to patients? You'll find the answer to their inaction by checking the list of your state's pharmacy board members and their affiliations with major pharmacy chain companies. A board member in Texas, no wait, the EXECUTIVE DIRECTOR of the Texas Board of Pharmacy, famously claimed in 2014, "I don't believe any company in Texas is using metrics to say a pharmacist has to fill so many scripts," claiming complete lack of awareness of an obvious truth to anyone who has ever worked a day in a chain pharmacy.


5. Unfair Business Practices

This is a topic best suited for its very own blog post. The gist of the situation is that due to consolidation, vertical integration, and conflicts of interest being allowed to flourish freely, the community pharmacy landscape has essentially turned into an oligopoly with a few major players controlling the vast majority of the industry, and gradually forcing all other competitors to sell out or close their doors. Is this a result of their superior services simply out-competing the rest of the market? Not at all. Secretive and convoluted contracts and insurance mandates force patients to use their services, or face lack of insurance coverage for their medications. Unfair reimbursement practices pay some pharmacies more than others for same medications, often far less than the price it costs the pharmacies to actually acquire the medication (much less the overhead, supplies, and labor it took the pharmacist to provide the medication to the patient). In just the state of Ohio, 165 community pharmacies went out of business over a short 2-year span. Some pharmacists publicly announced that a certain large company that influenced their reimbursement rates cut their payments even further, then almost immediately issued letters offering to buy out their business.


So why don't pharmacists just organize? Make their own association and speak out? Look back at number 3. The ones employed in community pharmacy are afraid to speak out for fear of losing their positions. Not only that, but the profession of pharmacy has the unfortunate tendency to splinter into its numerous subgroups. The hospital pharmacists, compounding pharmacists, nuclear pharmacists, academia pharmacists, and veterinary pharmacists all have their own issues to attend to, and the working conditions of their old school-mates are not of the highest priority. But someone has to fill the role of the daily dispensing community pharmacist, and it shouldn't just be people that can swallow a questionably ethical work environment.


*Nothing in this writing is intended to imply that non-community pharmacists or other healthcare professionals are not sympathetic or helpful to the problems of community pharmacists. There are simply numerous problems facing healthcare and healthcare workers in the United States and all of us have our own problems to struggle with.


Reference links for relevant news stories listed below:

https://www.verywellhealth.com/what-is-a-pharmd-1736265

https://www.khou.com/article/news/investigations/pharmacists-corporate-greed-putting-patients-at-risk/285-259208744

https://www.ohiopharmacists.org/aws/OPA/pt/sd/news_article/152198/_PARENT/layout_interior_details/false

http://www.pharmacyerrorlawfirm.com/blog/fda-estimates-1-3-million-injured-by-pharmacy-errors-yearly.cfm

https://www.pharmacytimes.com/contributor/timothy-o-shea/2017/10/4-tips-to-pay-off-pharmacy-student-loans-faster

https://www.businessinsider.com/cvs-squeezing-us-mom-and-pop-pharmacies-out-of-business-2018-3

#pharmacy #medicationerrors #patientsafety #pharmacist

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