What the pharmacist (probably) isn’t saying…

If you’ve come to this page hoping to find information to fuel your conspiracy theories about “Big Pharma” and the “evil medical fraternity”, I’m afraid you’ve come to the wrong place. This blog is written by a pharmacist for other pharmacists and pharmacy personnel to make light of some of the issues that we have to deal with when we work in the retail pharmacy sector. But that’s not to say that a non-pharmacist would not to be able to appreciate some of the commentary below, in fact you might just learn something about the inner workings of the mind of your legal dealer and how to avoid annoying, upsetting or infuriating him or her in the future… or at least to minimise such reactions! To my friends and colleagues, I hope you’ll enjoy this posting as much as the last! Now, let’s go through a list of common occurrences which you probably experience regularly and, most likely, do not (externally) express your feelings and thoughts related to such occurrences.

Schedule 4 creams

You’ve heard it, I’ve heard it, I’m sure we’ve all heard it…

“But why do I need a prescription for a cream? I mean, it’s not like I can overdose or abuse a cream!”

Despite being sorely tempted to respond with something witty such as “It’s really just because we’re in cahoots with the doctors and we know that these products work better so we know that you’ll be desperate enough to see the doctor to get them. When you get the prescription, they give us a kickback!”, that’s probably not the best idea. It would probably would only spur the patients on in believing some of the delusional things that they actually, strangely enough, do believe so it’s usually best to employ the “smile and wave” tactic. Because that’s easier than explaining complicated concepts such as bacterial resistance to antibiotic creams and the horrors of topical cortisone abuse such as hirsutism or thinned skin.

The skills required to read prescriptions

How often do you hear this witticism or similar versions?

“Joh! Do you guys attend a special course to read these things?”

I think most patients would be scared by the actual answer, being a combination of different things such as

• familiarity with certain doctors’ handwritings following a lot of exposure to said doctors’ prescriptions
• guesswork based on what the prescription words look like and what the patient says is wrong with them
• guesswork based on the given dosages and product combinations
• knowledge of different products available and figuring out if what is written resembles any known product
• remembering that the rep for that product has been doing the rounds and a whole load of doctors have been prescribing that one lately.

Addictive substances

Here’s a little known fact, when a patient says things like:

“I want some Adco-Dol, one hundred. Two boxes.”

“Just give me Adco-Sinal (Co).”

“I want Benylin with Codeine (OR Phensedyl OR Bronkleer).”

“I want my sleeping tablet, but DON’T claim it on the medical aid, I’m going to pay cash for it.”

…my first instinct is not to trust them. Wanting large quantities of Adco-Dol is an easy warning, the subtler person with a problem usually tries to buy packs of twenty, very frequently and possibly at different pharmacies. The number of people that I have spoken to who use Adco-Sinal Co just to manage the “blockage” as opposed to pain associated with sinusitis is alarming, especially since it’s “the only thing that works”. Patients who don’t even say what is wrong with them and simply ask any one of those cough medicines without batting an eyelid are über suspicious, especially if they ask for a second bottle as soon as you acquiesce to give them one. As far as the “don’t claim, I’ll pay” when it comes to Schedule 5 anxiolytics, tranquilisers, painkillers or sleeping tablets, I often still submit the claim “accidentally” just to see if a DUR rejection pops back because my suspicion is that there is another prescription at another pharmacy where this person also picks up that medication. It’s actually rather sad how much of a cynic one becomes when working in a retail pharmacy.

How to queue

I think this image sums it up. I cannot even.

The converse of this is when the person knows where to stand, but messes the fantasy of human evolution up completely by immediately coming to stand in front of you as soon as the person you have just served has left without you actually indicating to them that you are ready to help them (or a patient arrives to stand in front of you because you’re working at a terminal and there’s doesn’t appear to be anyone that you’re helping). Because it’s not like there’s even the remotest possibility that you might need to go sign an order, check a prescription, go on your lunch break or that you’re actually busy with someone else’s prescription and that person called the request in for their medication to be made up or has gone to browse or there’s a problem with the medical aid claim that you’re trying to sort out. But it’s fine, I can drop whatever I am doing and do what the (im)patient wants me to do… People should come when they are called. And they should know where to stand while they’re waiting.

What “the other pharmacist” does

As much as it pains me to say it, there are a lot of unethical and unprofessional pharmacists out there. The things one hears when listening to patients is alarming, especially when you know that they’re under a certain supposition based on the actions of a member of your profession.

“Is it really true that you need a prescription for Stilpane? Because the other pharmacist just gave me some over-the-counter”

“Just give me the [whatever product the medical aid is rejecting] and claim some Corenzas.”

“I’ve been getting this medication for six years, I’ve never had to bring in a new prescription for it.”

To respond to each of these involves explaining why medications are scheduled and why these LAWS should be adhered to, making a patient understand that that rather “simple” request actually involves committing fraud and as far as continually taking a medication without following up with a doctor, it’s scary to think about how long that condition has gone unchecked and whether or not is has worsened or resulted in other comorbidities that the patient is completely oblivious to. When faced with such situations, unless there is a very serious problem which requires a sympathetic ear and intervention, the simple way to deal with these issues is to say: “That pharmacist is not here, you’re dealing with me and I’m not prepared to do that. If you don’t like that then by all means go to ‘the other pharmacist’”.

The pack size drama

Patients act as though it’s the end of the world if the pack they’ve received contains 28 tablets instead of 30. Is it really so difficult to simply refill all of the medicine that little bit earlier? Is it going to kill someone? The truth is that this issue is probably more annoying for pharmacists than it is for patients because this issue really depends on how picky the patient is. Some will be happy to simply receive their packs of 28, while others will insist on having those extra two tablets put in and often you won’t know what kind of patient you’re dealing with until they start to moan and bitch about those precious two tablets. Even more confounding is when the client having the tirade is a woman in her 50s who is also receiving a pack of 28 HRT tablets. Logic? There is none. And we do this to “keep the client happy”, but the price we pay for their convenience to simply not have to come a mere two days earlier is to possibly end up having however many broken packs that need to be accounted for come stock take time. The joys.

“But why do they make them in 28 packs? No month has 28 days.”

Well, actually February has 28 days for three out of every four years. And if you’re going on the lunar cycle, every month has 28 days. And often the 28 day packs are “calendar packs”, the days of the week are printed onto the foil to aid patient compliance: “It’s Tuesday, did I take my blood pressure tablet this morning? Let me see. No! The tablet for Tuesday is still in the blister, I’d better take it now.” In a perfect world...

But if you work in the public health sector, the 28 packs have another purpose, it’s to try keep the patients coming back on the same day every four weeks, especially for clinics that have their specific conditions being treated per day (diabetic day, hypertension day, arthritis day, etc.). Sadly though, this system is also flawed because human nature seems to go against the systems designed to make life easier.

If you really want to bend your brain, though, in some countries you get pack sizes of 25 tablets. For chronic medication. How does that work??

Blood cleaning

Cultural beliefs aside, I’d really like to know how taking a massive dump is, in any way, going to clean out your circulatory system. I think a lot of people spend an awful lot of time worrying about their bowel movements, I honestly think that watching reality television, as in the kind featuring Kardashians and women smothered in fake tan, is more exciting, possibly even more pleasant. If a person is constipated, by all means have a good colon blow out and enjoy the relief of not being bloated, uncomfortable and gassy, but I’m sure that the wonderful placebo effect does more than a dose of Mist Alba does for “detoxing” a person’s blood. I often feel, and sometime do tell people, that if they want to detox, they should change their diets and drink a lot of water, as opposed to risking dehydration and developing lazy bowel syndrome. But what do I know, I’m just a pharmacist.

Doctors and HCPSA cards

I’ve had so many varied experiences with this matter, some very willing and cooperative doctors as well as some very egotistical jerks who seem to feel that being asked for proof of their authority to write a prescription in your dispensary is an affront.

For the latter variety of doctor, the following is an example of the kind of thing I would love to say:

“Maybe you have a God complex and maybe your aunt, related to you through marriage to your father’s fourth cousin, likes to go around telling people that her nephew is a doctor, but the rest of the world doesn’t actually know and probably doesn't really care. The universities don’t send out lists of graduates, complete with your pictures, to all health care institutions and facilities with instructions for staff members to roll out red carpets and bow upon your arrival. Sorry, you’re not that important. If I happen to visit your place of work, I am a patient and you are the supreme ruler. When you are in my dispensary, I am the ruler and I’m perfectly happy to assist you in whatever way possible, as long as you’re prepared to acknowledge that the rules to be followed are mine. So I will ask you for your HCPSA card to verify your qualification and I will refuse to sell you most medications which are Schedule 5s (or higher) because I am a custodian of medicine and I need to ensure that you aren’t supporting either your own or your family member’s addiction."

The end.

Nurofen Period Pain

I sincerely hope that the person who came up with the concept to market “Nurofen Period Pain” got a huge bonus. Really, it has to be one of the most successful marketing ploys which has taken advantage of people’s naivety to sell huge volumes of an overpriced product. So many women think that that is the only medication which is going to help their menstrual aches, and so few are prepared to listen to reason and end up saving themselves about R30 odd Rand by buying some good old Adco-Ibuprofen 400mg or Inza 400mg instead. And the facial expressions you’ll see if you tell men that they can take the medication too is hilarious!

Clotrimazole creams

Much like Nurofen Period Pain, I also have to smother an internal snigger when men are horrified by the suggestion that they should buy the vaginal clotrimazole cream instead of the topical one. In instances where the area to be treated is rather large or the infection is of a severity that will likely require longer than normal treatment, I’ve made this suggestion. It’s amazing how much a packaging description can affect a person’s common sense. The product inside that tube is exactly the same as what’s inside the tube which is marked for topical use, it’s just in a larger quantity and works out to be cheaper than buying several “topical” preparations.  

Package inserts

I’m sure most pharmacy personnel loathe and detest those instances where they find themselves having to refer to a package insert. Because as if the process of trying to unfold the insert and actually find the information that you’re looking for isn’t bad enough, you’ll inevitably have to try to refold the damned thing and, quite possibly be subjected to this “oh so clever” comment:

“Do you guys have special classes to learn how to fold those things?”

Much like the prescription interpretation issue. It’s not funny, it’s annoying. Those inserts are folded by machines and are often done so intricately and with a huge number of folds in order to reduce a piece of paper which could be almost as big as an A3 sheet of paper into a tiny little insert for a small package that trying to fold it back into the same shape is often next to impossible.

Does this product REALLY work?

Worse than the “Dr Google” patients are the ones that are equal parts desperate, ignorant and paranoid. Because whatever you recommend for them, they’ll want to ask a whole lot of questions about and will likely repeat their symptoms at least once each time they think of a new question to ask. But they don’t want to see a doctor, for whatever reason, and YOU have to help them. And after attempting to answer every question that they've thrown at you, it will end off with the above question. And then you need to try to explain to a desperate, ignorant and paranoid person that no drug is guaranteed 100% to resolve the problem that they are experiencing. Based on available data, you can recommend a product which is probably going to sort out the issue, but you can’t put your head on a chopping block if it doesn't work… and unfortunately these kinds of people are usually wanting that kind of reassurance. It’s a jungle out there.

Weight loss

Much like the scenario above, negotiating the tricky terrain of the would-be weight loser is challenging at the best of times and just about impossible at the worst of times. Because so many people want to lose weight, but so few people are prepared to put in real effort to do so and everyone wants a “magic pill” to make it easier for them. And all those products available without a prescription promise such wonderful results, while the products available on prescription are so expensive that one assumes that they must work. It doesn't really matter what product a person uses, if they decide to go that route, if they’re not prepared to adjust their eating habits and get some exercise, no pill is going to solve the problem and even if it does help, it will only be a temporary solution.  

Medical aid scheme rules: exclusions, MMAPs and the almighty chronic regulations

I often wonder whether medical aids are a blessing or a curse and more often than not come to the conclusion that they can be varying parts of both of any given day. Because it’s lovely when the medical aid pays for everything without any issues and without any co-payments, but as soon as there’s any kind of glitch, you as the pharmacist (or assistant) are responsible for the problem. And it gets that much worse when the person you’re helping doesn’t even have the faintest clue regarding how their medical aid scheme actually works or what medication of theirs has been approved for chronic benefits. Because when they’ve been getting their Foxair every month without fail and suddenly their day-to-day funds have become depleted by July, it must be your fault. Why didn’t you claim it correctly? Why didn’t you get the chronic authorisation sorted out? Why didn’t you get the chronic authorisation sorted out? Why didn’t you fight with the medical aid to accept the drug as chronic? Why didn’t you ask the patient if you should do this for them (and offer to wipe their butts while you were about it). And that’s just the tip of the ice burg really, because there are so many different medical aid schemes out there with so many different rules, benefits and scheme types that it’s actually impossible to know what is going on with all of them, but you’re expected to know why [insert medical aid name] will pay for Mrs Smith’s simvastatin on chronic, but still only pays for Mr Smith’s simvastatin on the acute benefit. Or why Mrs Benecke’s chronic funds have been used up because aren’t chronic funds unlimited? The list of potential problems, off-pissing complaints and sheer ignorance on the part of scheme members is endless. And no matter what happens, for some reason they all seem to forget that their broker or Human Resources representative is the person to actually direct these kinds of questions to, the person who actually gets paid to answer these kinds of questions. But no, you’re the person who gets screamed and/or sworn at and called stupid when they couldn’t be bothered to actually confirm for themselves what benefits they’re entitled to from this scheme that they probably pay several thousands of Rands to every month. FML.