I’ve seen a lot of hesitation on the part of community pharmacists over the last couple of years to interface with doctors, and to suggest therapy changes. When asked why, many of them have responded that they feel that it’s not their place to do so.

I think this is bollocks. I think they’re afraid.

It IS in your purview to make therapy recommendations. This is especially true for elderly people on Medicare Part D. For the first time (ever?) we have a system that indirectly rewards a large segment of the patient population for using fewer healthcare resources. (You don’t hit the donut hole, so you save money.)

But what about those people who legitimately consume large amounts of healthcare dollars? They need an advocate. And that’s YOU. The community pharmacist. When situations like this arise, you’re the one that should go to bat for the person on the other side of the counter, because no one else can.

Interfacing with a doctor

Some pharmacists are hesitant to interface with a doctor’s office. Maybe they’re worried that they’ll get stuck on the phone all day trying to make a change to a less expensive drug. But there are ways around this.

It’s called asynchronous communication. And it’s more efficient and less demanding on both your time and the doctor’s time because it allows the both of you to communicate when you each have time rather than employing The Interrupter — AKA the telephone. This is the difference between urgency and importance. What you have to say is not usually urgent in this context. But it is important.

Last November and December, I made 25-30 suggestions for drug therapy change during the course of my Medicare consulting — all of them via fax — and all of them were accepted. This saved my patients an average of $500/year. This is serious money for someone on a fixed income.

Speak their language

Not all of these changes are silly little things like switching from one drug in a class to another. Or trying an ACEi instead of an ARB. Some of these changes were broad, tackling a given medical problem (or even multiple co-morbidities) from a different angle. Many of your elderly patients — particularly those with chronic illness — see multiple doctors, and lots of times there’s no communication going on. In these instances you are the FOCAL POINT for their drug therapy. You are the gatekeeper, you see everything they take on your little computer screen. (Unless they’re one of the relatively few people who enjoy playing Musical Pharmacies.)

In these cases you’ve got to speak their language. Don’t even bother making a suggestion unless you are familiar with the latest treatment paradigms. If you want to change someone’s insulin from a hojillion-dollar version to something more reasonable, be sure you’re aware of the pharmacokinetic differences between the two. In your note to their endocrinologist, mention that you ARE aware of these differences but that you’ve spoken to Mrs. X and she is willing to try something new, and that this something new will save her $2000/year if it works.

Doctors listen, and they’re usually willing to experiment if the patient is.

There are two types of “best drug”

You bring knowledge to the table that doctors don’t have: how much things really cost. Most doctors have access to formularies if they want them, and they can relatively easily found out what kind of copay a patient will have if they prescribe X.

That used to be enough, but not anymore.

For Medicare Part D patients, the backend cost that the doctor does not have access to is a significant factor. Something might be a $28 copay, but UHC might be kicking in $250 behind the scenes that will quickly eat through someone’s drug benefit.

There are two types of “best drug”: the drug that is best from a therapeutic standpoint, and the drug that is best from a hybrid therapeutic-financial standpoint. This is the most pertinent concept of “best drug” for the person reaching for their wallet. Why reach for the Norvasc when you haven’t tried felodipine?

Make it easy for yourself

You’re a pharmacist. You’re busy. You’re machine-gunning prescriptions as fast as you can. The phone’s ringing and one of your techs called out. Today is not the day to be making therapy suggestions. (If you find yourself in this situation often, you need to attend the RJS School of Pharmacy Management.)

But even bad pharmacies have good days. Make a template with your pharmacy name, fax and telephone numbers, with a section for the patient’s information, and your notes. Personalize it with your name and titles. If you’ve got a system where you can type a note to the doctor, great. If not, don’t insult insult them with bad handwriting, even though they may not return the favor. Be the bigger person and have someone else write it if you have to — bad handwriting does nobody any favors.

Take out as much of the repetition as you can. You have better things to spend your time on than redundancy.

Battles

There’s this misconception that many pharmacists have that they’re going to have to have a battle with the doctor to make XYZ changes. First of all, this rarely happens. Second of all, if YOU are battling THE DOCTOR, there is a problem, and it’s not with you, if you are speaking on behalf of the patient as their advocate. No battles should occur; it should be a discussion. You know something the doctor doesn’t, and maybe he knows something you don’t about why s/he chose X drug instead of Y drug.

If you do end up having a battle, stick to your guns, but only if you know for a certainty that the patient will benefit if you do. Compliance issues due to money, dosing, etc. These are legitimate. Having a pet drug that you prefer is not. Conflict is not necessarily bad. Good relationships and mutual respect have been known to grow out of past conflicts.

Closing thoughts

These are the basics in effecting change as a community pharmacist. It is possible to take many of these ideas further, if you choose. Stepping on toes is never wise: step in when you see a patient is having difficulty with money, or if you can see they’re otherwise unhappy. Many patients will come right out and ask if there’s something else they can use. Some are unhappy with their doctor for any number of reasons, even though they’ve been seeing him for years. You may have an opportunity to save this patient-doctor relationship, and we all know how important good relationships are when it comes to healthcare, and how long they can take to build from scratch. They’re not something to be thrown away lightly.

[tags]Medicine, pharmacy, MTM, community pharmacy, pharmacy practice[/tags]

Here’s me being a nerd.

[Props if you can identify the compound on my shirt.]

If you do a Google search for "Tylenol #3", the second hit on the page is this link. Looking closely at the page, you’ll note that we’re talking about "Tylenol #3" specifically. Why then, is the Common Name listed as "acetaminophen – codeine – caffeine"?

There is no caffeine in Tylenol #3. There’s just acetaminophen and codeine.

What form(s) does this medication come in?

Tylenol NO. 3 with Codeine®: Each round, hard, white, flat-faced tablet, bevelled-edged, engraved with "3" on one side and "McNEIL" on the other, contains acetaminophen 300 mg and caffeine 15 mg, in combination with codeine phosphate 30 mg. Nonmedicinal ingredients: cellulose, cornstarch, and magnesium stearate. This medication does not contain gluten, lactose, sodium metabisulfite, or tartrazine.

Who should NOT take this medication?

Anyone allergic to acetaminophen, caffeine, or codeine should not take this medication.

In the United States, when a doctor writes "T3" or "Tylenol #3" you’re getting 300mg of acetaminophen and 30mg of codeine. No caffeine.

However if you go to the Janssen-Ortho website and hit up their product information PDF for their Tylenol products, it indicates there’s caffeine in T2 and T3, but not T4. But the Ortho-McNeil website’s prescribing information (PDF), for T3 indicates that it’s 300mg APAP and 30mg of codeine. No caffeine.

So WTF is going on here? I called Ortho-McNeil (US makers of T3) and I also called Janssen-Ortho (Canadian counterpart). The US office told me what their website did: no caffeine. I have yet to hear back from the Canadians — they say they’ll return your call in one business day. I’m wondering if there’s a difference between Canadian T3s and US T3s? Maybe in Canada, they have 15mg of caffeine, whereas in the US, they don’t? If this is indeed the case, talk about a nightmare trying to track down accurate consumer information. Yikes.

Update: I just got off the phone with Janssen-Ortho of Canada, and Tylenol #3 in Canada has caffeine in it, which means that it is different than the US formulation of Tylenol #3. If I had trouble figuring this out, how much moreso would your average consumer struggle?

[tags]Medicine, pharmacy, drug information, T3, Tylenol #3[/tags]

According to a Reuter’s report, CVS plans to open 300 new Minute Clinics in 2007.

Is this going to change the way doctor’s offices fundamentally do business? In the long-term, I think so, because right now they can’t compete with retail convenience. In multi-doc office, I expect to see doctor/NP/PA scheduling altering to have a more or less constant presence in the office. This will be particularly true with NPs and PAs who can handle more immediate issues — the things that will be diagnosed at Minute Clinics.

There’s been lots of talk in the medical blogging community about how Minute Clinics are “bad” in the sense that a patient’s medical history will be spread out over multiple locations. That the treatment prescribed by the NP at the Minute Clinic will be sub-par, or not what one’s PCP would have chosen. These are valid complaints, so I expect to see doctors respond in the areas where Minute Clinic density is higher.

You don’t need a large medical practice to cover a lot of hours. Lots of hours = lots of availability. Sure it’s not as nice as a 7-7 medical practice, but it IS more convenient for the patients/customers. And it has unexpected benefits as well — 3 days weekends once a month and the like are not uncommon for pharmacists.

Realistically, a moderately-sized medical practice (3 docs, say) could easily cover 72 hours of availability per week. 8am-8pm Monday through Friday, and 9am-3pm on Saturday and Sunday. Start with one doctor in the morning, have the second come in later in the day, say around 11am or noon, and doctor #1 goes home around 4-5pm while his/her colleague stays until late. This is what retail pharmacists do, and I expect you’ll see variations on this theme for doctors once they start feeling the pressure from retail clinician availability. Get an NP or a PA to see the urgent cases, and I think you could probably cut down on ER overuse in your area.

Are there problems? Yes. Are the insurmountable? No. Will it happen in the next five years? Probably. Think about it. 300 Minute Clinics in 2007 alone. If they become big hits, expect to see that number grow yearly. That’s a lot of Minute Clinics. That’s a lot of lost, easy revenue.*

*I think it was Flea(?) who said that these types of visits are the bread and butter of pediatricians because they’re fast and easy. These are the types of visitors the Minute Clinics are catering to.

[tags]Medicine, pharmacy, CVS, Minute Clinic, retail medicine[/tags]

The University of Maryland School of Medicine has essentially come up with a spit test for lung cancer:

In the January 15 issue of Clinical Cancer Research, the researchers report that their fledgling test, designed to check whether two genes believed to be tumor suppressors are deleted in cells found in sputum, identified 76 percent of stage I lung cancer patients whose tumors also showed the same genetic loss. Existing sputum “cytology” tests, which look for changes in cell structure, identified only 47 percent of the patients, they say.

While no other simple sputum analysis has found such a high correlation with lung cancer, it is not yet good enough for the clinic, researchers say, and so they are now expanding their test to screen for up to eight genes.

This is pretty cool, and while it may not be good enough for the clinic, it does appear to have greater potential than say, the controversial PSA test for prostate cancer which misses 82% of tumors in men younger than 60, and 65% of cancers in men over 60. While you can’t yet make a direct comparison between the two, this spit test does seem like it will end up being more accurate than the PSA test.

The researchers are hoping to drill down to the genes that are specific only to cancer. Current cytology tests show the extend of cell damage, but this doesn’t correlate to lung cancer rates because most heavy smokers do not develop cancer. Looking for only the genes involved is a more precise approach to calculating lung cancer risk.

[tags]Medicine, cancer, lung cancer, oncology, genetics[/tags]

I saw this when it first came out, but unfortunately I didn’t give it a second thought. Details, unfortunately are scarce, but it’s good news nonetheless. The NYT has more on the fun backstory of the plant-based remedy:

In some ways, it is a wonder that the work survived at all. In 1670, at the age of 42, Rumphius went blind. In 1687, his still unpublished manuscript and all of his illustrations were destroyed in a fire that swept through the European quarter of Ambon. Undaunted, he dictated a new version and commissioned artists to draw new illustrations.

Fortunately, the second time around he kept a copy of the manuscript. The original was lost when the ship carrying it back to the Netherlands was sunk by a French naval squadron. Still unfazed, Rumphius continued his work, finishing the last volume shortly before his death in 1702.

The extract shows some efficacy against E. coli and MRSA. It was used in ancient times as a remedy for dysentery.

The seeds of the tree, Rumphius wrote, “will halt all kinds of diarrhea, but very suddenly, forcefully and powerfully, so that one should use them with care in dysentery cases, because that illness or affliction should not be halted too quickly: and some considered this medicament a great secret, and relied on it completely.”

Very cool story. I just wish researchers knew more about the active compound itself, and whether it is related to any other antibiotics on the market. I could see it being entirely new or being related to a current antibiotic: it could be from the seeds themselves, which would indicate that it’s entirely new, or it could be from a fungus growing inside the seed (think a moldy peach pit), in which case it could be related to current antibiotics. I guess we’ll have to wait and see — I don’t have access to the BMJ, so any details about the extract itself are hidden from me, if they are even known. Alas.

Geographic isolation can make for some very interesting evolutionary developments. It would be really cool if this was completely new.

[tags]Medicine, MRSA, pharmacy, antibiotics, MDROs, drug discovery, botany[/tags]

There is a small body of research out there that indicates that thiazolidinediones (TZDs) — specifically rosiglitazone (Avandia) — may inhibit angiogenesis. Without new blood vessels to feed fuel tissue growth, there is no tumor growth. There aren’t many researchers out there experimenting with these drugs, unfortunately, but new findings published in the International Journal of Radiation Oncology – Biology –Physics indicate that pioglitazone (Actos) may prevent brain damage in mice undergoing radiation treatment for tumors, which could mean more studies looking at the effects of TZDs on cancer and its management.

The study involved young adult rats that received either radiation treatment equal to levels received by humans or a “sham” treatment involving no radiation. Animals in both groups received either a normal diet or a diet containing the diabetes drug.

Cognitive function was assessed a year after the completion of radiation therapy using an object recognition test. Rats receiving radiation exhibited a significant decrease in cognitive function, unless they received the diabetes drug for either four or 54 weeks after radiation.

The researchers are hopeful that the findings may allow clinicians to give higher doses of radiation. There is a strong correlation between higher doses of radiation and longer lifespans, but there has always been some reluctance to prescribe these higher doses for fear of damaging healthy, surrounding tissues.

[tags]Medicine, pharmacy, Actos, cancer, radiation, oncology, pioglitazone[/tags]

Kevin asks “How to get more medical students interested in geriatrics?” and suggests tuition loan forgiveness. Or rather, the article he links to, does.

My question is, do you *really* need more geriatric doctors?

I’ve opined extensively on pharmacists as prescribers, and I’ve basically concluded that it’s not a bad idea, so long as they’re not making the diagnosis. (Because that’s not part of one’s curriculum in pharmacy school.) With things like the CCGP certification, do you really need doctors who specialize in old people?

I’m inclined to think yes… and no. Surely you need some, but probably not the numbers that have traditionally done so. In fact, most of the CCGPs I know can, and do, run therapeutic circles around the doctors when it comes to managing drug regimens for the elderly. And that’s not meant as an insult to the MDs, it’s simply a fact.

Let the pharmacist deal with adjusting dosages and fixing interactions and managing polypharmacy; let the MD stick to making diagnoses. Clinical pharmacists are generally more interested in the management of drug regimens anyway.

I have a feeling this is the way geriatric medicine is going to mostly go in the near future. I wouldn’t be surprised to see other, select fields do the same thing. Pharmacists are, after all, cheaper than doctors. ;)

[tags]Geriatrics, medicine, aging[/tags]

I had a physical last week that lasted an hour(!). My doctor (who I just started seeing) did two extra things that I’ve never had done before during the course of a routine physical: an EKG and a hearing test. Both of them made me scratch my head inwardly, and they were performed at the end of the physical by a nurse.

I’m a healthy male, in my mid-to-early twenties, with no history of heart problems, and I’ve not complained about anything hearing-related, save twice-a-year ear infections. I’m convinced the hearing test is part of what he does at every physical, because I mentioned my ear infection as an afterthought, after he’d already told me about the hearing test…

Is this normal for physical exams now? Or is it just so he can bill for a bit more from my insurance company?

Back in July, CVS bought MinuteClinic, thinking to get a jump on the coming retail health clinic boom. If you’re like me, and you oppose the fast-food medicine phenomenon, you’re probably against the whole idea.

What I can’t argue against is the convenience, and that’s what’s going to be the big thing. People aren’t going to utilize them for the management of chronic illness, they’re going to use it for the one-off things: Hey I’ve got an ear infection. Hey I’ve been hacking my lungs out for the last 3 days. Hey my sinuses are about to explode and I’m ready to go postal on anyone who f’n looks at me. That sort of thing. (“Zpak, next!” “Zpak, next!” “Amoxicillin, next!…” etc. etc. ad inifinitum) Anyways, what’s better than stopping by CVS, seeing the PA (or NP), doing some shopping, then stopping by the pharmacy to pick up your Zpak? One-stop shopping at it’s finest.

Anyway I spoke at some length with a CVS district manager two weeks ago about the MinuteClinic thing, asking for some details on how they’re run. Who are they staffed by? (An MD? Probably not.) He didn’t know, which sort of irritated me. He was thinking in terms of revenue, and I’m thinking in terms of what’s best for the patient. I guess my main question is how you’re going to have someone diagnosing and prescribing without an MD on staff. PAs and NPs, of course are able to prescribe, so long as they have a supervising physician. (In the two states I’m familiar with, anyway.) So where’s the incentive for the MD to “supervise” a clinician at a retail-based health clinic that’s taking revenue away from their own practice, regardless of whether they own their own shop, or are part of a bigger whole? From a pure business perspective, it doesn’t make sense to me, unless CVS plans to share part of the revenue from their health clinics with these practices. (Which I don’t see CVS doing.)

Maybe they’ll higher one supervising MD per district and have all their NPs or PAs report to him? That’s really the only way I could see a system like that working, but it would seem like a terribly kludgy system. Does anyone know?

In any event, retail health clinics will not be coming to New Hampshire or Massachusetts in 2007, according to aforementioned DM. There hasn’t been any money allocated to open clinics. They will be popping up in Maine, particularly in the uniquely urban-rural areas like Bangor. Apparently there’s more money to be made there than in southern NH and Massachusetts, which really isn’t terribly surprising given the relative density of clinicians to the general populace.

[tags]Medicine, pharmacy, CVS[/tags]