Why pharmacy continues to fail

I’ve been a pharmacist since 1997. The profession of pharmacy, and therefore the basic principals of the practice, haven’t changed in that time. During my career I’ve worked in six different hospitals (1 in operations, 2 as a clinician, 2 general practice, 1 informatics), one long-term care pharmacy, once as a consultant pharmacist in long term care, in retail for two different retail chains, one community pharmacy and as a relief pharmacist for about a year. Looks pretty bad when I put it in writing. What can I say, I get bored.

I’ve recently been following a thread on one of the ASHP Forums about tech-check-tech (TCT). For those of you that may not know, I’m in favor of it. Why? It’s a tool. A tool to get pharmacists more of what they want, and that is less time spent in direct distribution functions and more time spent working with other healthcare professionals on patient care. I see it as a no-brainer, but there are many that are fearful of such a simple practice change. Of course everyone has their reason for not wanting to use TCT – too difficult, regulatory requirements, “risk”, liability, and so on – but that’s not really the issue. To me the failure to universally accept and use such a powerful tool represents the professions inability to make adjustments to age old practices that will ultimately lead to the failure of the profession. I hope I’m wrong, but unless things change drastically over the next couple of decades, pharmacy will simply vanish under a sea of massive changes in the healthcare environment. There will come a time when a pharmacist, in their current practice model, will be obsolete. Most people don’t like to admit it, but we’re on the edge of such a catastrophic failure right now. Pharmacists are beginning to look for alternate career paths in alarming numbers. I know several bright pharmacists that have moved, or are contemplating a move away from traditional pharmacy practice. Why? It’s hard to say. All I can tell you is that I left pharmacy because it became clear that what I was doing would never make a difference in the overall scheme of things. The practice was so deeply rooted in tradition and fear that alternate theories and concepts were looked upon as blasphemy or akin to voodoo. And, I was bored.

With that said, I have hope for pharmacy. My hope is fading quickly, but it’s there in the back of my mind. Things like ASHP’s Pharmacy Practice Model Initiative (PPMI) are encouraging, although the enthusiasm for the initiative seems to be fading just as quickly as it rose. The PPMI Summit, which was held in November of 2010, pulled together some of the brightest minds in pharmacy to ponder the need for changes to the profession. The result of the Summit was a long list of recommendations designed to help transform pharmacy practice. You can read all about it in the June 15, 2011 issue of AJHP if you’re interested.

More than a year has passed and I still run into pharmacists across the country that have no idea what the PPMI is or that an initiative for practice change even exists. How is that possible? Some blame ASHP, but I hardly think that’s fair. It’s not their responsibility to change our practice environment. It’s yours and my responsibility to do that. Change has to come from the trenches. If you don’t like your situation, then change it. If you’re expecting pharmacy organizations to take you by the nose and drag you into the future, then you’ve got it all wrong. You have to create the pharmacy practice you want. For the record, I do believe that pharmacy organizations can help. They have resources to make changes to laws and regulatory processes that will go a long way in improving the profession’s chances of changing how we practice, but ultimately it’s not up to them to force a change.

My words may lead some to believe that I don’t like pharmacy, but that’s not the case. I love the profession and I like being a pharmacist. I just don’t like the practice of pharmacy. There is a difference. Sometimes I jokingly tell my daughter that I love her, but I don’t love her behavior. It’s an important distinction. Pharmacy is like that for me. And even though I complain about pharmacists, I have great respect for them. There are some really smart people in pharmacy. I often feel quite small when gathered with some of the big names in the profession; they cast a big shadow.

People don’t become pharmacists because they can’t do anything else. They become pharmacists because they want to be pharmacists. What that means is different for everyone, but the pharmacists in the audience understand what I mean. Even though I no longer practice traditional pharmacy, I’m proud of the fact that I went to pharmacy school and have a license to practice in the state of California.

Regardless of my opinion, pharmacy has ultimately defined an endpoint, which is “to significantly advance the health and well being of patients by developing and disseminating a futuristic practice model that supports the most effective use of pharmacists as direct patient care providers.” Unfortunately it’s clear to me that we’ve failed to create an infrastructure strong enough to reach that endpoint. Pharmacists have been talking about what they want for years, and this new round of “change” appears to be little more than talk as well. To paraphase Theodore Roosevelt, “Rhetoric is a poor substitute for action, and we have trusted only to rhetoric. If we are really to be a great [profession], we must not merely talk; we must act big.”

Some healthcare systems have taken the plunge and started the process of investing in the future and changing how they practice. As a result they have become examples for the rest of us. But those examples are few and far between. The ideas necessary to make wide-sweeping changes to our profession have failed to take hold. It’s difficult to say exactly why, but some of the barriers are evident.

The profession is segmented
Pharmacy is a segmented profession. All you have to do is look at the different practice settings to know that I speak the truth. Retail practice seems to focus more on the business, i.e. the money of pharmacy. Acute care, i.e. hospital pharmacy tends to over focus on the clinical side of things. And long-term care pharmacies tend to focus on operations, i.e. how can I make this more efficient. Of course the focus of long-term care is designed to squeeze money out of the process, but nonetheless the result is a highly effective distribution process. There really is very little common ground among the practice settings.

By itself, the difference between practice settings matters little, but when it spills over into everything we do it creates dissension between pharmacists. In fact, I would go as far as to say that most pharmacists stick to “their own kind”. I was taught early on in my professional education to look down on retail pharmacists (not to be mistaken with community or outpatient services). I find myself doing it today even though I make a conscious effort not to. I have friends in the retail world and I find it difficult to feel compassion for them when they talk about their working conditions, the lack of help, the lack of time to consult with patients and all the troubleshooting they have to do with insurance companies. I don’t understand why they do what they do. I’ve tried working in retail a couple of times during my career and each time I’ve quickly discovered that I hate it. That’s why a vast majority of my career has been spent in the hospital setting.

With that said, hospital pharmacist have their own issues. Hospital pharmacists are so focused on being “clinical” that they often forget about everything else. “Clinicians” don’t want to be bothered with operations. “Clinicians” don’t want to be troubled with regulatory affairs. “Clinicians” don’t want to have to deal with billing and business practices because they’re nothing more than a nuisance. Unfortunately the result is an incomplete practice environment. I’m as guilty as the next pharmacist of contributing to this failure. Until quite recently my beliefs were as described above. Even as an informatics pharmacists I always felt inferior to the clinicians. After all, clinicians are the jocks of pharmacy practice, and who doesn’t love jocks.

And what about long-term care pharmacists? There are two types of “long-term care pharmacists”: those that work in operations and those that act as consultants to the care facilities. I won’t talk about the consultants as it’s a fairly unique niche. I did the whole “consultant thing” for a while and quickly became bored by the redundant nature of the job. The consultants could probably be lumped in with the “clinicians” in terms of desires and personalities, but I won’t go there.

Long-term care pharmacy is all about distribution; getting as much product out the door as quickly as possible. And let me tell you something, it ain’t no joke. I spent a year working in a large long-term care pharmacy and it was amazing to witness the efficiency of the distribution process. It would make any retail or hospital pharmacy green with envy. And why are they so good at distribution? It’s really quite simple. They operate on razor thin margins so they have to be as efficient as possible. They make good use of technology and great use of their pharmacy technicians. Hospital pharmacy could learn a lot from a long-term care operations model. As a pharmacist, however, the job is terrible. I spent hours simply standing in one place verifying the contents of punch cards using bar code scanning. Beep-beep. Beep-beep. Beep-beeeeeep! Oops, that one doesn’t match. Send it back through. Beep-beep. Beep-beep, Beep-beeeeeep! Oops, that one doesn’t match. Send it back through. And so on, ad infinitum….. Hours felt like days.

Ultimately if you combined the three different practice environments you would probably end up with a complete “pharmacy model”; clinical, operations, business. I doubt that will ever happen, but integration across the continuum, changes in laws and the automation of many processes are ultimately what’s needed to bring pharmacy together into a global practice model.

Regardless of how things look in the future everyone has to decide on the practice setting that best suits their interests and needs, and that has to be acceptable within the profession.

Lack of strong leadership
Pharmacists are, by their very nature, introverts. I don’t know if the profession attracts them or creates them; chicken and egg argument. Pharmacists tend to work better alone, standing in the corner with a calculator and a pencil working on one difficult problem after another. It’s not simple shyness, but rather the desire to stay away from the masses in healthcare. Like many other pharmacists I prefer to work alone. I don’t like relying on other people to get things done because they will ultimately come up short and let you down. Don’t look at me like that. It is what it is. I didn’t create human nature.

In and of itself being introverted isn’t a bad thing, but it ultimately keeps the profession from progressing; out of sight, out of mind. I don’t like to admit it, but nurses and physicians are much better at cultivating leaders capable of making change inside a healthcare organization. This is evident when looking at the hierarchical structure in a large healthcare system. It’s not uncommon to see physicians and nurses in positions of power, while it is rare to see pharmacists in similar positions. Do pharmacists fear the responsibility of making decisions? Certainly not. Pharmacists make countless decisions every day that directly impact patient care. They take on great responsibility. Nonetheless, it is uncommon to see pharmacists striving for leadership roles, which creates a conundrum because the most effective place to implement change is from a position of power. Pharmacy needs a pulpit from which to preach the message. Without it, pharmacy change will likely not occur in my lifetime, nor will it likely change in the direction of our choosing.

Pharmacy Education
Let’s face it, people that chose to attend pharmacy school aren’t typically looking for a career in finance, business or administration. By in large, people attending pharmacy school want to be healthcare providers. At least that’s what I wanted. Unfortunately pharmacy schools fall short of giving students a realistic view of pharmacy practice. Everything in pharmacy school is sunshine and butterflies. Transitioning form the role of pharmacy student to full-fledged pharmacist is difficult. The reality check brought on by real-life pharmacy practice can leave freshly minted pharmacists bitter and frustrated with a job that is clearly not what they expected. There are ideal practice settings to be sure, but they are rare and do not accurately represent the majority of pharmacy work environments.

So how do we fix the pharmacy education issue? That’s a very good question, and I don’t have the answer. It certainly won’t be an easy fix as one wouldn’t want to give up the current crop of didactic courses and clinical focus in exchange for something else. It will take years to make the necessary changes. Do we have years? Only time will tell.

Failure to understand the business of pharmacy
Ultimately pharmacy is a business. Pharmacists provide two products: information and medications. Unfortunately pharmacy doesn’t get paid to provide information, and thanks to a poor job by retail pharmacies and healthcare systems, pharmacies don’t earn much from the distribution of medications. And that leads to a fundamental problem: pharmacists cost healthcare systems a lot, but they don’t make a lot of money for the healthcare system in return. In other words, our profession has failed to provide a ROI, which makes it difficult to justify potentially costly changes.

As much as I hate to say it, money is power. Pharmacy doesn’t make enough money, and therefore has little power inside the structure of a healthcare system. How many times during your career have you, as a pharmacist, had a problem with a department inside your hospital only to be told nothing could be done “because they make a lot of money for the hospital”? There are people reading this right now nodding in agreement with a smirk on their face because they’ve been there.

Fortunately all is not lost. We have opportunities, but until recently have missed the mark. Pharmacists aren’t trained or educated in the way of the busy savvy executive. Quite the contrary. Most pharmacists I know, including myself, are quite ignorant about business practices. I’ve gone out of my way to avoid the business side of pharmacy. Why? Because I’m a pharmacist. I didn’t get a degree in finance or business, I got a degree in pharmacy. I’m not alone, and that has ultimately resulted in pharmacy leaders that don’t have a clue.

It’s time for pharmacists to embrace the business side of pharmacy. As silly as that sounds it must happen for us to be successful. Without it the profession is likely to end up with “business men” making decisions for pharmacists instead of pharmacists making business decisions for the profession.

Complacency
The mantra of pharmacy should be “if it ain’t broke, don’t fix it“, and that’s not a good thing. The process of making an IV admixture hasn’t changed since we began mixing IV’s. Pharmacy distribution, whether it be in retail or acute care hasn’t changed since its inception. And so on. Sure, we use better technology and have managed to make slight improvements here and there, but ultimately the nuts and bolts of the process remain relatively unchanged over the past 20 years; possibly longer.

We should be asking ourselves what we want the practice to look like and work backward toward a solution. I guarantee you that solution won’t be what we have today.

No players at the table
I’ve been part of several pharmacy projects. Nothing strange about that. However, in a majority of those projects the person in charge wasn’t a pharmacist; that’s a little strange. Why would a non-pharmacist be in charge of a pharmacy project? The only thing that makes sense is that pharmacy has little to no power inside a healthcare system. The reasons are basically what I’ve outlined above, i.e. lack of strong leadership, incomplete educational structure, failure to understand the business of pharmacy and complacency. When pharmacists aren’t making decisions that impact their practice environment there’s a problem.

Lack of communication
There are basically three ways that pharmacists communicate: 1) conferences, 2) through literature, and 3) directly with one another through email or other electronic means (texting, social media, etc).

Conferences are great for gaining new practice insights, but they fail to muster the right atmosphere to talk about change. When pharmacists attend the ASHP Midyear Meeting, for example, they are there to learn. They go to see what’s new to the practice; most commonly clinical practice. To drive change organizations like ASHP would have to create something like an annual PPMI Summitt and make it open to anyone that would like to attend. I’m not sure that would actually do much good, but it might be worth a try.

Literature is quite possibly the most poorly designed method for communication in the digital age. Journal articles are often out of date by the time the information is published. The process is too slow to be an effective means of communication. In this day and age I find it incomprehensible that journals can’t push out information more quickly. In addition to the glacial pace of journal publications a subscription is typically required for access. This creates yet another barrier to the information. Information should be readily available for free (we need an open source pharmacy information movement – discussion for another time). Plenty of information can be found online, but you have to be willing to dig, and most people aren’t.

And finally, pharmacists communicate directly with each other…on occasion. There are two problems with such a strategy. First, your information is only as good as the smartest friend you have. Don’t get me wrong. Some of my pharmacy friends are brilliant, but there’s always someone smarter and odds are I don’t know them. And second, you tend to befriend people that have like opinions and thoughts, which ultimately limits the scope of one’s search for enlightenment. Introverts, remember?

Unwillingness to be bold
The theme throughout much of the PPMI Summit was to “be bold”. Unfortunately the profession has not only failed to be bold, but they’ve crawled under a rock since the initial flutter of activity following the PPMI Summit. I hear things about the PPMI occasionally, but it’s less and less often as time goes by. We don’t have to constantly talk about the PPMI, but it would be nice to hear a lot more about change.

I follow a lot of pharmacy discussion on various forums, websites and social media platforms and I don’t hear much about radical changes. It is increasingly rare when I see real thought provoking discussion about expanding the practice and moving toward the future. A majority of pharmacists are simply trying to find better ways to do the jobs they have. I certainly can’t blame them because that’s all most people want. But then again we’re a profession in search of significant change.

And there you have it. All we need to do is develop strong, well spoken, charismatic, highly educated, business savvy, well-rounded, bold pharmacists. Sounds simple enough.

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