Near Riot In A 24 Hour Pharmacy

This is a true story.

Not too many years ago, my father-in-law and mother-in-law came to town for Thanksgiving.  They had to drive about 6 hours to get here and in their haste to leave town, they forgot some of their medications.  We were able to get the scripts filled at a 24 hour pharmacy, but the pharmacist said: "You can come down and wait - but it will take a while."  I drove down around midnight and there were about 15 people standing there.  "Not too bad I thought" and took a seat.  Over the next 30 minutes the crowd started to build.  This was the Wednesday night before Thanksgiving, but we were already into Thursday.  I could see the pharmacist and noted he was a PharmD.  He was also working furiously.  He was literally filling prescriptions at the rate of 1 - 2 every 5 minutes while taking telephone calls.  I noticed at the 30 minute mark he was starting to break a sweat.  The next time I looked up there were over a hundred people there, pushing back through the aisles.

The pharmacist's work ethic was not enough to appease the crowd and it was getting ugly.  It started out with the kind of atmosphere you find on an airplane when a passenger does something to delay take-off.  A lot of irritable people grumbling under their breath and rolling their eyes for the most part, but the occasional well enunciated expletive.  "Great" I thought: "Here is a guy who has a PharmD working as fast as anyone can work and it is not fast enough for the growing mob."  To make matters worse, a very crabby middle-aged women sat down right next to me.  As the crowd got angrier, she started to ridicule them.  It was hard to believe at first, but she would lean over to me like we were best friends and make incredibly crude remarks at the people in the front of the crowd.  Even though she leaned toward me, she projected her statements right at the front row.  I thought about whether I should intervene and talk with her but instead, I just dissociated and hoped that my prescription would come up soon and I could get out of there.  Besides, the angry young men in the crowd had already made the decision that there was probably nothing to be gained from arguing with an irritable middle-aged woman much less pummeling her.

I thought back to the pharmacists I knew well.  Working mostly in a hospital setting you get to know a lot of pharmacists.  They are a critical part of just about very level of care that involves medications.  They participate in Pharmacy and Therapeutics (P&T) Committees and provide most of the hard data for discussion.  They sign off on all physician orders and call that physician if there is a problem.  They provide education for physicians, patients, and nursing staff.  These days they monitor and change the orders on warfarin and some antibiotic therapies and do the phrmacokinetics.  In many cases they work with Infectious Disease teams on monitoring antibiotic and fungal resistance as well as antibiotic selection for drug resistant bacterial infections.  They used to work in teams with inpatient units and discuss drug interactions and pharmacokinetics.  For years they would come in person to my unit to trouble shoot all things in person on my unit every day.

At least until managed care decided that pharmacists should just crank out prescriptions.  Clinical pharmacists disappeared from their consulting roles.  Initially just a few units.  We still had a pharmacist to consult with, but eventually that person (who specialized in psychopharmacology) also disappeared.  I would drop by the pharmacy to pick up scripts and see my old colleagues all working furiously - just like the PharmD I was watching through the window in the 24 Hour Pharmacy.  They were so busy filling prescriptions they barely had time to look up.

For anyone who thinks that only physicians have been marginalized by the management that goes along with managed care, it really goes across the board.  Pharmacists, nurses, and clerical workers are all put on the same production plan.  I always wonder how we survived doing things in a collegial manner before all of the management geniuses showed up.  Is it an artifact of managed  care that there now seem to be billions of prescriptions more than before we were in a managed care environment?  Is it the logical outcome of of widget production?  The prescriptions in the 1980s all got filled and I still talked with the clinical pharmacists in person every day.  There were no near riots in the pharmacy.  When physicians and pharmacists are talking and networking - the quality of care is better.  As an interesting sidebar, I consulted my most recent text on management of healthcare systems (copyright 2008) and there was no mention of pharmacy services or pharmacists, but plenty of references to the pharmaceutical industry.

Back to the all night pharmacy.  My name was finally called and it was not a moment too soon.  The woman in the seat next to me had just made a loud and incredibly crude remark to the mob.  Several people had noticed and seemed ready to say something.  I turned to her and said:

 "If I told you that you had to be cool would you know what I meant."
"Yeah - I suppose so"
"Well good because you really need to be cool here.  You are starting to make some of those people angry and they are already angry about waiting at 1AM to pick up prescriptions."

I picked up my prescription and left.  As far as I know there were no further incidents.  At least I did not read about anything in the papers.

I was burned out from my job at the time.  I think I was covering an entire 20 bed inpatient unit.  I had taken a week off to recover.

But I was very glad to not be a pharmacist.

George Dawson, MD, DFAPA