Author Beware: Medical Students

I’ve blogged here a lot about the trouble many authors have with scope of practice issues. Scope of practice is what the licensing board says you can and can’t do to a patient. Every licensed healthcare professional has a defined scope of practice. For nurses, it is managed by their State Board of Nursing. For doctors, it is the Board of Healing Arts.

You can find other posts I did about scope of practice herehere and here.

I recently came across a novel written by a doctor that had an interesting medical scenario. In short, a medical student was running amok killing patients by overdosing them on potassium. Below are a few highlighted portions from the novel. I’m using asterisks instead of characters names to further disguise the story to protect the author.

This portion is written from the medical student’s (the killer’s) POV:

I was helping them (nurses) with their work. I’ve fixed IV pumps, drawn blood, placed catheters, even changed bedpans. It’s got me into their good graces, and a lot of them now pretty much trust me with anything. Like giving medications. 

They’d pull the IV bag from the electronic medication dispenser, log it into the system, hand it to me, and go back to doing the twenty other things they were trying to do at the same time. They never gave me or my poor little bag of potassium a second thought. 

And why not? They’d seen me give IV medications to patients hundreds of times. Not one of the– not a single one– even bothered to check to see if the patient actually needed potassium, much less confirm that I’d actually given it.”

Honestly, it’s hard to know where to start with the medical inaccuracies this small piece of fiction highlights.

1. A medical student is not licensed healthcare provider. Therefore, they practice under someone else’s license. They are managed by their attending physician or resident. They are not monitored by nursing. A nurse is not going to let a medical student do these things to her patient. The most a medical student does is obtain a patient history, do a physical exam, and observe procedures by other physicians. If this author had made the medical student a resident– the scenario would be a little more plausible.

2. Every nurse is not that stupid. Sure, one nurse allowing a medical student to give her potassium I could believe. But, as in the novel, up to fifty? Remember, the nurse is likely more liable than the medical student under this circumstance. These nurses would all be fired. Nurses are not that blase about their licenses. Without one, even a license with a minor mark, and that nurse will not be working in nursing ever again. Medical students are learning. A nurse’s job is to protect her patient. We don’t trust medical students to be competent in what they’re doing for that reason alone.

3. The author also misses another layer of protection. Medical dispensing machines are another layer of protection. Hospital medications are approved for dispensing by the hospital pharmacist. So, a pharmacist can look up a patient’s lab results and check whether or not they need the potassium as well. All these medication orders on patients that don’t need potassium is going to raise some serious alarms. Can you override the medication dispensing system? Yes, but you better have a good reason. Many hospitals have removed concentrated forms of IV potassium because an error could be so potentially deadly to the patient. Also, patients who receive a bolus dose of IV potassium need to be placed on an ECG tracing (or continuous heart monitoring.) In this instance, they are generally in the ICU or on telemetry and not a basic med/surg unit.

The scenario could be plausible if written another way. Overall, the author needed a seasoned ICU nurse to review the manuscript.

The Art of Forging Prescriptions


I’m so excited to host future author and pharmacist, Amy Gale, who will be blogging on the topic of falsifying prescriptions.

Welcome, Amy!

Prescription drug abuse is rapidly growing. A large amount of popular “street drugs” are medications prescribed on a daily basis. It seems more and more people are trying to falsify prescriptions and the new trend is to “pop pills” to get high. Let’s hope this trend is short lived. So, how do you forge a prescription?

The most commonly forged prescriptions are Class III to Class V narcotics. Some popular examples are Vicodin, Valium, and Xanax.  These prescriptions are easier to falsify because they can be forged in two ways. 

First, a prescription can be called in to the pharmacy. As long as the caller has all the pertinent information and knows the physicians DEA number, the prescription is deemed valid. If a pharmacist feels the prescription is falsified, a call to the physician is warranted to verify the information. Some drug abusers are so good at impersonating a physician or office; they can fool even a seasoned pharmacist.
Second, a written prescription can be presented to a pharmacy associate. It must contain all pertinent information such as patient’s name, address, phone number, drug name, quantity, directions for use, refills, physician’s name, and physicians DEA number. A prescription can be written for any medication, but Class II narcotics (some examples are Percocet, Oxycontin, Morphine, Ritalin, and Adderall) must be physically written prescriptions with no additional refills. There are exceptions such as emergency supplies, but most fraudulent prescriptions are written for larger quantities than the emergency supply law allows.
How do I know if a prescription is fraudulent?  There are warning signs indicating a prescription may not be legitimate. The following are some common ones:
1. Prescription is written/or called in for an unusually high dosage or quantity.

2. Prescription is written in pencil or several different colors of ink.

3. Lack of standard abbreviations (every word written or spoken out completely).

4. Different handwriting styles or perfect handwriting.

5. Altered numbers in quantity and/or dosage.

6. Characteristics indicating a photocopy.

7. Out of state physicians. 
 
8. Paper is too smooth, no indentations from pen pressing on paper.

9. Part of physician’s signature is cut off. 

10. No perforation or residual glue at the top of paper.

11. Toner dust rubbing off or smudging on the paper.
Patients presenting fraudulent or forged prescriptions do not act like everyday customers. Here are some signs of unusual patient behavior that flags a pharmacist.
1. Requests early refills (some common excuses are vacations, lost medication, dropped in sink.)
2. Patient is willing to pay full cash price instead of using insurance or attempts to work around the days’ supply and quantity limits imposed by most insurance carriers.
3. A number of patients appear simultaneously, or within a short period of time, all bearing similar prescriptions from the same prescriber.
4. Patient is unusually anxious, out of proportion to the situation.
5. Unusually impatient for prescription to be filled and attempts to rush their prescription through ahead of others.
6. Attempts to persuade the pharmacist not to verify prescription with physician.
7. Drops off prescription right before closing and persuades pharmacist to rush it through.
8. Patient arrives within minutes of the prescription being called in by prescriber.
9. Verification callback number is cell phone or number other than physician office.
When a fraudulent prescription is presented to a pharmacist a few things can happen:
1. The patient fools the pharmacist and obtains the medication.
2. The pharmacist refuses to fill the medication.
3. The pharmacist fills the medication but alerts the DEA or local authorities and the patient is arrested as soon as the fraudulent prescription is sold.

I’d like to say I’ve never been fooled or that my patients would never try and falsify a prescription, but unfortunately that’s not true. I’ve seen it and heard it all! In my twelve years as a pharmacist I’ve even had a few people arrested. I hope you have a better understanding of how prescriptions are forged.  Feel free to ask any questions or pick my brain.

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Amy Gale is a pharmacist by day, aspiring author by night. She attended Wilkes University where she graduated with a Doctor of Pharmacy degree. Her dream is to share her novel, Blissful Tragedy, with the world. In addition to writing, she enjoys baking, scary movies, rock concerts, and reading books at the beach with her feet in the sand. She lives in the lush forest of Northeastern Pennsylvania with her husband, five cats, and golden retriever puppy. Her journey to publication is just beginning, let’s hope it has a happy ending. You can connect with Amy at her website at www.authoramygale.com.

Top Three Most Popular Posts: #2

Suspense novelists are a little consumed with finding ways to kill their characters. I’m guessing that’s why this post by Kathleen Rouser was the second most popular post.

Plants: Poisons, Palliatives and Panaceas

Then God said, “I give you every seed-bearing plant on the face of the whole earth and every tree that fruit with seed in it. They will be yours for food.” Gen. 1:29 NIV

Shortly after the time Adam and Eve were forced to leave the Garden of Eden, because of their fall into sin, human beings most likely began looking for relief from pain and sickness. Perhaps by God’s guidance or by what seemed like coincidence, they found that there were certain plants that not only nourished, but also relieved symptoms or cured illnesses.

Throughout the ancient world healers emerged, whether as a medicine man, priest, wise woman or physician. They were brave enough to search by trial and error to find the right cure for each malady. These practitioners, whether spurred on by superstition or curiosity, had to figure out which plants healed… and which ones harmed. The line between healing and poisoning was often quite fine.

A few of the remedies the Sumerians used were made from licorice, myrrh, mustard and oleander. The Code of Hammurabi, originating during his reign (1795-1750 BC), regulated medical practice. There, apothecaries emerged, since the role of preparing medication was considered separate from that of the physician.



Poppy Plants

Around 1500 BC, the Egyptians wrote a dissertation on medicine and pharmaceuticals. Among many plant sources they derived their drugs from were castor seed, spices, poppy and acacia. They imported some ingredients due to the limitations of what they could grow. The Egyptians developed ways to dry, ground up and weigh these materials. Those that concocted medicines were called ‘pastophors’ and were members of a priestly profession.


Seventh century BC clay tablets have been discovered revealing that the Babylonians used many plants as pharmaceuticals including castor seed, thyme, peppermint, myrrh, poppy and licorice.

Various theories of diagnosis and treatment arose through the Greek and Roman civilizations. Pedanius Dioscorides, who lived from around 50-100 AD, wrote Materia Medica, which listed various materials with their medicinal uses and also Codex Aniciae Julianae. This text on herbals, listed many plants and how to prepare them through drying and extraction. Dioscorides, a surgeon to the Roman armies, shared a philosophy with another famous Roman medical man, Galen. They believed that each plant’s shape, color or other physical characteristics left a clue as to which body part or ailment it was meant to treat. By the 16th century, this was foundation to one Christian viewpoint, which had expanded upon the Doctrine of Signatures, stating that it was the Creator who had marked each of these plants for their use.

During the Dark Ages, the Arab world and the monasteries of Europe, with their healing gardens, preserved much pharmaceutical knowledge.

Throughout history, many folk remedies, based on superstition, were supplemented with chants and rituals. Most often they missed the mark, perhaps imparting comfort if nothing else, considering man’s need to feel as though he is doing something! But apart from that, many plants continued to be used for healing and a large proportion of modern day prescription drugs are rooted in their derivatives. Some emerged to the forefront.



Cinchona Tree

During the 1600s, European Jesuit missionaries in South America sent a powder back home, derived from the bark of the cinchona tree. They’d been surprised to find out that the Native Peruvians knew how to successfully treat malaria, an illness spread by mosquitoes that has killed so many. In 1820, when French chemists extracted a chemical compound from the powdered bark of the cinchona tree, they called it quinine, based on the Peruvian name for the tree, quinquina.


William Clark and Meriwether Lewis took cinchona bark with them on their westward expedition. Lewis’s mother was an herbalist of some renown and imparted some of her knowledge to her son. While the men did not wind up contracting malaria, they found the bark useful for lowering fevers and as ingredient in poultices.


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Kathleen lives in Michigan with her hero and husband of 29 years. First, a wife and mother, she is “retired” after 20 years of home educating their three sons, who are all grown and have moved away. Since then, Kathleen returned to Oakland Community College to complete a Liberal Arts degree and a certificate of achievement in ophthalmic assisting. Last year the American Board of Opticianry certified her. Kathleen has been published in Home School Digest and An Encouraging Word magazines. She writes regularly for the local women’s ministry “Sisters” newsletter. She also contributes articles and author interviews to FavoritePASTimes.blogspot.com, a blog devoted mostly to historical fiction. Read about her fiction writing endeavors at: www.kathleenrouser.com


Top Three Most Popular Posts: #3

The one year anniversary of this blog was October 31st! Now that the zombies have been put to sleep for another year, it’s time to celebrate by taking a stroll down memory lane and looking at the top three most popular posts of the last year.

I love hosting Sarah Sundin. She’s a truly gifted novelist and I hope you’ll check out her books. This post, ranked #3, struck a chord with people and I think it’s the way Sarah painted the picture using her authorly ways to make this time period come alive.

Pharmacy in World War II—The Drug Store

In the 1940s, the local drug store was more than just a place to get prescriptions filled and pick up toothpaste—it was a gathering place. If you’re writing a novel set during World War II, it helps to have an understanding of this institution.
As a pharmacist, I found much about my profession has changed, but some things have not—a personal concern for patients, the difficult balance between health care and business, and the struggle to gain respect in the physician-dominated health care world. On February 14th, I discussed the role of the pharmacist in the 1940s, today I’ll describe the local drug store and how its role changed during the war, and on February 18th,  I’ll review the rather shocking role—or lack thereof—of pharmacy and pharmacists in the US military.
Welcome to the Corner Drug Store—1939
Perkins’ Drugs stands on the corner of Main Street and Elm, where it’s stood all your life. Large glass windows boast ads for proprietary medications and candy, and a neon mortar-and-pestle blinks at you. When you open the door, bells jangle. The drug store is open seven days a week, sixteen hours a day, so you know it’ll always be there for you. To your right, old-timers and teenagers sit at the soda fountain on green vinyl stools, discussing politics and the high school football game. The soda jerk waves at you.
You pass clean shelves stocked full of proprietary medications, toiletries, cosmetics, hot water bottles, hair pins and curlers, stockings, cigarettes, candy, and bandages. You know where everything is—and if you can’t find it, Mr. Perkins or his staff will be sure to help you.
The owner, Mr. Perkins, is hard at work behind the prescription counter with good old Mr. Smith and Mr. Abernathy, that new young druggist Mr. Perkins hired last year. Mr. Perkins greets you by name, asks about your family, and takes your prescription. He has to mix an elixir for you. If you don’t want to wait, he’ll be happy to have his delivery boy bring it to your house. But you don’t mind waiting. You have a few items to purchase, and you’d love to sit down with a cherry Coke.
Welcome to the Corner Drug Store—1943
Perkins’ Drugs still stands at the corner of Main Street and Elm. Large glass windows boast Army and Navy recruitment posters and remind you that “Loose Lips Sink Ships.” The neon sign has been removed to meet blackout regulations. The store is open for fewer hours since Mr. Smith retired and Mr. Abernathy got drafted. Mr. Perkins hired Miss Freeman. Not many people are thrilled to have a “girl pharmacist,” but if Mr. Perkins trusts her, that’s good enough for you. Perkins’ Drugs and Quality Drugs on the other side of town alternate evening hours so the town’s needs are met.
A placard on the door reminds you that Perkins’ Drugs is authorized by the Office of Civilian Defense as a pharmaceutical unit, meaning the store will provide a kit of medications and supplies for the casualty station in case of enemy attack. You pray the town will never need it.
Bells jangle when you open the door. The soda fountain is closed. Mr. Perkins can’t buy metal replacement parts for the machine, the soda jerk is flying fighter planes over Germany, and sugar is too scarce a commodity.
A barrel stands by the door. You toss in five tin cans, washed, labels removed, tops and bottoms cut off, and flattened. Mrs. Perkins at the cash register thanks you.
You pass clean shelves with depleted stocks. Proprietary medications, cosmetics, toiletries, and medical supplies remain, but rubber hot water bottles, silk and nylon stockings, hair pins and curlers, candy, and cigarettes are in short stock—or unavailable. Most of the packaging has changed. Metal tins have been replaced by glass jars and cardboard boxes. You pick up a bottle of aspirin and a tube of toothpaste, double-checking that you brought your empty tube. Without that crumpled piece of tin, you couldn’t purchase a replacement. Tin is too dear.
At the prescription counter, Mr. Perkins greets you by name and asks about your family. Miss Freeman gives you a shy smile and you smile back. There’s a war on and women have a patriotic duty to do men’s work so men are free to fight. Mr. Perkins frowns at your prescription for an elixir. He’s used up his weekly quota of sugar, and his stock of alcohol and glycerin are running low. Would you mind capsules instead? Of course not. Mr. Perkins phones Dr. Weber and convinces him to change the prescription. Mr. Perkins can’t have the prescription delivered—he doesn’t qualify for extra gasoline and he couldn’t find a delivery boy to hire anyway.
You and Mr. Perkins discuss war news as he sets up a wooden block with little holes punched in it, then lines the pockets with empty capsule halves. He weighs powders on a scale, mixes them in a mortar, then fills the capsule shells. After he sets the capsule tops in place, he puts the capsules in an amber glass bottle with the familiar Perkins’ Drugs label.
You buy a few War Bonds. Your wages are higher than ever with the war on, and with all the shortages there’s nothing to buy. Besides, War Bonds are a solid financial investment and your patriotic duty. On a poster by the counter, a smiling pilot leans out of his plane and reminds you: “You buy ‘em. We’ll fly ‘em. Defense Bonds and Stamps.”
Mr. Perkins thanks you for your purchase, and you thank him for his service. War or no war, you know Perkins’ Drugs will always be there for you.
Resources
My main source was this excellent, comprehensive, and well-researched book: Worthen, Dennis B. Pharmacy in World War II. New York: Pharmaceutical Products Press, 2004.
http://www.lloydlibrary.org (Website of the Lloyd Library and Museum, which has many articles and resources on the history of pharmacy).
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Sarah Sundin is the author of the Wings of Glory series from Revell: A Distant Melody (March 2010), A Memory Between Us (September 2010), and Blue Skies Tomorrow (August 2011). She has a doctorate in pharmacy from UC San Francisco and works on-call as a hospital pharmacist

Contemporary Pharmacy: Part 4/4

Today concludes Sarah’s four-part series on contemporary pharmacy. I’ve certainly enjoyed having her back and can’t wait for her return. Today she focuses on the hospital pharmacist.

Fiction writers do mean things to their characters. If those mean things require pharmaceutical care, you may need to introduce a pharmacist character or understand how pharmacies work. As a pharmacist myself, I want to help you get those details straight.
Today’s article discusses practice in the hospital setting. Previous articles discussed an overview of the profession, pharmacy education and training, and practice in the community pharmacy setting.
Hospital Pharmacy
About 22% of pharmacists work in America’s 5800 hospitals. These can range from the small community hospital with a few dozen beds, to large teaching hospitals with thousands of beds.

Setting

The traditional hospital pharmacy is “in the basement,” away from the main hospital area. As pharmacists have become more involved in patient care, some larger hospitals have opened satellite pharmacies on the floors. To deliver medications, hospitals use employees, vacuum tube systems, dumbwaiters, or even robots.
Access to the hospital pharmacy is restricted to pharmacists and pharmacy technicians, and briefly to nurses, administration, housekeeping staff, and delivery personnel under pharmacist supervision.
The typical hospital pharmacy is divided into work areas. One area contains computers and reference materials for pharmacists entering medication orders. A narcotics room contains all the controlled substances, usually in a secure cabinet accessible only by password or biometric scan. A “cart-filling” area contains medications as well as the large carts that will be filled with a daily supply for each patient. The IV room contains laminar flow hoods for sterile preparation of intravenous medications. There is also room for bulk storage and tables for breaks and meetings. Offices are provided for the director of pharmacy and others.
Work Conditions
In the inpatient setting, medications must be available twenty-four hours a day, every day of the year. Therefore, the largest hospitals are always open. Smaller hospitals may have off-site pharmacists enter orders electronically after hours, while nurses obtain the medications from automated systems.
On average, a hospital pharmacy employs ten pharmacists and about twice as many pharmacy technicians. Directors of pharmacy must be pharmacists by law, but they usually perform administrative duties only.
Opportunities for part-time or on-call work abound. Most employees work odd hours, including evenings, weekends, holidays, and graveyard shifts. Those in administrative or purely clinical jobs may work traditional hours.
Dress codes vary, but most pharmacists dress professionally—men wearing nice pants and shirt, with or without a tie, and women wearing a nice top with dress pants or a skirt. Technicians tend to more casual clothes, often jeans or scrubs. Lab coats may or may not be worn within the pharmacy, but are preferred when the personnel go to the floors. In the hospital setting, the long-sleeved knee-length lab coat is most common.
Work Flow
Physicians’ medication orders are transmitted to the pharmacy electronically or by fax. Many hospitals have the physicians enter the orders themselves to prevent errors due to illegibility. A pharmacist checks if the drug and dose are appropriate for the patient’s condition, age, and weight, and checks for potential problems due to allergies, drug-drug interactions, or drug-disease interactions. Many hospitals have protocols that allow pharmacists to adjust doses for certain drugs.
Technicians then pull a day’s supply of the new medications to send to the floors. Most medications in hospitals are “unit-dosed,” with each dose individually packaged in blister packs and labeled with drug name, strength, manufacturer, lot number, expiration date, and bar code.
Most hospitals supply medication on a 24-hour basis. Large carts contain drawers for each patient, which are filled with a 24-hr supply of medications and delivered once a day. Intravenous medications are batched, with a 24-hr supply sent up once a day. Exceptions are made for drugs with low stability or high cost. As medications are changed, only the new medications need to be sent up. Automated dispensing machines on the floors provide nurses access to emergency medications, stat doses, or after-hours doses. These machines are also used to dispense controlled medications, as they require passwords or biometric scans.
IVs and TPNs
One special function of the hospital pharmacy is mixture of intravenous (IV) solutions and total parenteral nutrition (TPN). These require calculations, training in sterile technique, and the use of a laminar flow hood.
Clinical Pharmacy
A growing and cherished role in hospital work is clinical pharmacy, the direct interaction with physicians, nurses, and patients to optimize pharmaceutical care. Pharmacists in a clinical role monitor lab values, read patient charts, analyze the patient’s condition and current care, and make recommendations individualized for the patient. Clinical pharmacists can improve patient care, reduce length of stay, decrease side effects, and even reduce costs.
The Hospital Pharmacy Experience
Hospital pharmacy personnel work behind-the-scenes in a fast-paced, often-interrupted, and frequently stressful environment. However, they take pride in working with complex medications for critically ill patients, knowing they do their best to improve patient care and reduce medication errors.
Sources:
Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2010-11 Edition, Pharmacists, on the Internet at http://www.bls.gov/oco/ocos079.htm (visited October 17, 2011).
American Pharmacists Association http://www.pharmacist.com/
American Society of Health-System Pharmacists http://www.ashp.org/
American Association of Colleges of Pharmacy http://www.aacp.org/
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Sarah Sundin is the author of the Wings of Glory series from Revell: A Distant Melody (March 2010), A Memory Between Us (September 2010), and Blue Skies Tomorrow (August 2011). She has a doctorate in pharmacy from UC San Francisco and works on-call as a hospital pharmacist.

Contemporary Pharmacy Practice: Part 3/4

Sarah Sundin continues her four-part series on contemporary pharmacy. Today she focuses on the community pharmacist. This series is providing a lot of great background information for these health care professionals and potential fictional characters.

Back to Sarah….

Fiction writers do mean things to their characters. If those mean things require pharmaceutical care, you may need to introduce a pharmacist character or understand how pharmacies work. As a pharmacist myself, I want to help you get those details straight.
Today’s article discusses community pharmacy practice. Previous articles gave an overview of the profession, and discussed pharmacy education and training, and the following article will discuss practice in the hospital setting.

Community Pharmacy

About 65% of America’s pharmacists work in retail pharmacies inside drug stores, supermarkets, or mass merchandisers such as Walmart, Costco, or Target. There are approximately 23,000 independently owned pharmacies in the U.S., and 39,000 chain stores.
Setting
In the typical American drugstore, the pharmacy is toward the rear of the store, with over-the-counter (OTC) medications stocked close to the pharmacy. A counter divides the pharmacy from the rest of the store, usually with prescription drop-off and pick-up in separate areas. The secure pharmacy area is set further back, usually behind bulletproof glass. Access is restricted to pharmacists and pharmacy technicians. Other persons are allowed inside briefly to make deliveries or for housekeeping, and only with a pharmacist present.
The pharmacy area includes a main counter with computer workstations. Shelves hold bulk medications divided by type—oral tablets and capsules, oral liquids, suppositories, topicals (creams and ointments), eye and ear medications, inhalers, and injectables, plus bulk storage. Each pharmacy has a refrigerator for temperature-sensitive drugs and a locked cabinet or safe for the most heavily controlled substances (C-IIs).
Traditionally, the owner pharmacist ran the complete store as well as the pharmacy, and this configuration still occurs in smaller independent stores. However, in most situations, a store manager runs the main store, while the pharmacy manager runs the pharmacy. The pharmacy manager must be a pharmacist and performs administrative as well as dispensing duties.

Working Conditions

Most community pharmacies employ one or two full-time pharmacists, plus on-call or floating pharmacists to cover absences. Several pharmacy technicians work each shift as well. Most pharmacies are open from morning to early evening to cover the after-work rush, as well as shorter hours on weekends. Therefore, most pharmacists and techs work odd hours—morning shifts, afternoon to evening shifts, and alternating weekends. Larger pharmacies may be open twenty-four hours.
Pharmacists and technicians work on their feet. Pharmacists are required to dress professionally—a dress shirt and tie for men, a nice blouse and dress pants or skirt for women. Technicians tend to dress “business casual.” The traditional pharmacist’s short-sleeved lab coat that buttoned up the side to a high neck is rarely worn nowadays. Most pharmacists and techs wear a white hip-length lab coat with short or long sleeves.
Work Flow
Pharmacy technicians are allowed to do many duties, but those requiring professional judgment are restricted to the pharmacist. The precise division of labor varies between stores.
The prescription is taken in by a technician, who checks to see if the prescription is complete and that the patient’s information in the computer is current. The prescription is then entered in the computer. A pharmacist checks if the drug and dose are appropriate for the patient’s condition, age, and weight, and checks for potential problems due to allergies, drug-drug interactions, or drug-disease interactions. Sometimes the pharmacist needs to call the physician due to illegibility, errors, clinical interactions, or to verify a controlled substance prescription. The correct medication is pulled from the shelf, and tablets or capsules are counted on special counting trays. Larger stores often use automated systems to count and fill. The pharmacist performs a final check, and the medication is dispensed to the patient.
Patient Consultation
As accessible and visible health-care professionals, pharmacists often advise patients on proper treatment of ailments needing over-the-counter medications, including when to see the physician. Also pharmacists consult with patients when medications are dispensed to make sure the patient understands the proper use of the medication and side effects to watch for.
Immunizations
Offering immunizations is a growing role for pharmacists, with 147,000 certified to give vaccinations. Pharmacists enjoy this chance to serve the community and improve public health.
Controlled Substances
Many of the medications used for legitimate medical purposes are also drugs of abuse with high street value. Therefore, pharmacists must balance two conflicting community needs—to provide health care to those who need it, and to prevent diversion, fraud, and theft. High security, locked cabinets, background checks, and multiple counts are used to prevent outright theft and in-house diversion.
However, fraudulent prescriptions are often phoned in or written on stolen prescription pads. The pharmacist must use professional judgment to determine if each prescription is authentic. Does the prescription use improper medical jargon? Unusual and large quantities? Is the patient paying cash for a high bill? Do they come in after the physician’s office is closed? A pharmacist can legally refuse to fill any prescription for any reason. However, recently patient advocates threaten lawsuits if they believe access to medications is blocked.
The Community Pharmacy Experience
Overall, working in a community pharmacy is fast-paced and often stressful, especially when dealing with insurance companies or when disgruntled patients or irritated physicians vent their frustrations. However, most pharmacists can overlook these issues, knowing they’re providing excellent health care and helping patients get better.
Sources:
Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2010-11 Edition, Pharmacists, on the Internet at http://www.bls.gov/oco/ocos079.htm (visited October 17, 2011).
American Pharmacists Association http://www.pharmacist.com/
National Community Pharmacists Association http://www.ncpanet.org/
National Association of Chain Drug Stores http://www.nacds.org/index.cfm
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Sarah Sundin is the author of the Wings of Glory series from Revell: A Distant Melody (March 2010), A Memory Between Us (September 2010), and Blue Skies Tomorrow (August 2011). She has a doctorate in pharmacy from UC San Francisco and works on-call as a hospital pharmacist.

Contemporary Pharmacy Practice: Part 2/4

Sarah continues her four part Wednesday series on contemporary pharmacy. Today, she focuses on education and training.

Fiction writers do mean things to their characters. If those mean things require pharmaceutical care, you may find the need to introduce a pharmacist character. Or if medications play any role in your story, you’ll need to understand how pharmacies work. As a pharmacist myself, I want to help you get those details straight.
Today’s article discusses pharmacy education and training. Last week’s article gave an overview of the profession, and the following articles will discuss practice in the community pharmacy setting and practice in the hospital setting.
austinisgreat420
Entry Degree
The first four-year Bachelor’s of Science degree in pharmacy was offered by Ohio State University in 1925. The four-year program became mandatory with the incoming class of 1932. The doctor of pharmacy (Pharm. D.) degree was first offered by the University of California, San Francisco in 1955. As the clinical focus of the Pharm. D. degree became more desirable, the bachelor’s degree was phased out. As of 2000, the Pharm. D. degree was required for initial licensure.
Pharmacists with a bachelor’s degree sign their names with an “RPh” afterward (Registered Pharmacist) and are addressed as “Mr.” or “Mrs.” or “Miss.” Pharmacists with a doctorate sign their names with a “Pharm. D.” afterward and are addressed as “Dr.” However, it is common practice in modern pharmacies and hospitals for pharmacists to be addressed by their first names—this is controversial within the profession. Please note, the degree is a doctorate in pharmacy not pharmacology. Pharmacology is an academic discipline not a clinical profession, and pharmacologists receive the Ph.D. degree.
Length of Education
To gain admission to pharmacy school, students must complete the prerequisite undergraduate courses in math and science. A dedicated student can complete the prerequisites in two years and apply straight to pharmacy school. However, most students obtain their undergraduate degree first. Common majors of entering students include biology, chemistry, and biochemistry, but any degree is acceptable as long as the prerequisites are filled.
Pharmacy school is a four-year program. Therefore, the typical time from high school graduation to receipt of the doctorate is six to eight years. At graduation, students attend the traditional hooding ceremony. The lining of a pharmacist’s doctoral hood is olive drab.
Course of Study
During those four years, pharmacy students undergo a rigorous course of study in basic science and clinical practice. Studies in the basic sciences include organic chemistry, biochemistry, physical chemistry, anatomy, physiology, and microbiology. More specialized courses include pharmaceutical chemistry, pharmacokinetics (how the body processes medications), and pharmacology (how medications act on the body). The highlight of the academic experience is an intense series of courses in clinical pharmacy, where students learn about disease states and the proper of use of medications. The final year of pharmacy school is spent in the clinical setting. Students work on hospital floors, rounding with physicians and medical students. There they monitor patient care and recommend changes in therapy. Students (called interns) work under the supervision of experienced pharmacists, called preceptors.
During pharmacy school, students also take part-time and summer jobs to obtain their required internship hours. Interns must fulfill a certain number of hours both in the inpatient (hospital) and outpatient (clinic or retail pharmacy) to sit for pharmacy boards.
Licensure
Upon graduation from pharmacy school, completion of internship hours, and a background check, graduates can take the NAPLEX, the North American Pharmacist Licensure Examination. Each state also administers an exam in pharmacy law, since regulations vary from state to state. Since the NAPLEX is now accepted by every state, pharmacists enjoy reciprocity. To move from one state to another requires sitting for a new law exam but not the pharmacy boards.
Pharmacy licenses must be renewed every year or two, depending on the state. Continuing education is required for renewal. Since pharmacists work with controlled substances, pharmacy licenses may be suspended or revoked for crimes involving controlled substances, including driving under the influence. Pharmacy licenses may also be suspended or revoked for other crimes, malpractice, or professional ethical violations.
Residencies and Fellowships
As medications and therapy become more complex, so does pharmacy education. Many graduate pharmacists choose to do a one-year general pharmacy residency—essentially a continuation of their fourth year of pharmacy school. Pharmacists may choose to take additional residencies or fellowships to gain more specialized experience, especially if interested in an academic career.

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Sarah Sundin is the author of the Wings of Glory series from Revell: A Distant Melody (March 2010), A Memory Between Us (September 2010), and Blue Skies Tomorrow (August 2011). She has a doctorate in pharmacy from UC San Francisco and works on-call as a hospital pharmacist.

Contemporary Pharmacy Practice: Part 1/4

I’m so pleased to have Sarah Sundin back. She’s going to give us a glimpse of her real life as a pharmacist in a four-part series.

Welcome back, Sarah!

Fiction writers do mean things to their characters. If those mean things require pharmaceutical care, you may find the need to introduce a pharmacist character. Or if medications play any role in your story, you’ll need to understand how pharmacies work. As a pharmacist myself, I want to help you get those details straight.
Today’s article is a general overview of the pharmacy profession. The following articles will discuss pharmacy education and training, practice in the community pharmacy setting, and practice in the hospital setting.
Meet Your Pharmacist



Sarah’s Graduation: UC San Francisco 1991

A pharmacist is the member of the health care team primarily concerned with the safe and effective use of medications. Although the profession of pharmacy is relatively small—268,030 employed pharmacists in the United States in 2010, according to the Board of Labor Statistics (1) —pharmacy plays a vital role in health care.

People drawn to pharmacy enjoy math and science, and tend to be detail oriented, methodical, and conscientious. Although many pharmacists are naturally quiet, they do tend to enjoy working with people. For the record, modern pharmacists strongly dislike being called “druggists.” Please don’t use this term in your contemporary novels. Thank you.

Demographics

Traditionally, pharmacy was a profession for white males, and even as late as 2004, 54% of licensed pharmacists were male, 88% were white, and only 7% were Asian and 2% black. However, the demographics of the profession have shifted dramatically over the past few decades, with extreme gains by women and Asians in particular. In 2004, 67% of doctorates in pharmacy (the entry degree as of 2000) were awarded to women, 23% to Asians, 7.7% to blacks, and 3.7% to Hispanics. (2)
One of the reasons pharmacy appeals to women is the ability to work part-time. Indeed, 24% of female pharmacists work part-time, primarily between the ages of 31-35 during the child-rearing years. Conversely, only 13% of male pharmacists work part-time, mostly over the age of 72.
Areas of Practice
About 65% of pharmacists work in a community pharmacy, filling prescriptions in either chain or independent drug stores. Another 22% work in hospital pharmacies. Others work as consultants for skilled nursing facilities (nursing homes), in pharmacy education, for governmental agencies, or for pharmaceutical companies—in clinical research or to provide drug information for other health care professionals.
Responsibilities
The traditional responsibility of the pharmacist is to purchase, store, compound, prepare, and dispense medications. Most medications are currently available from commercial manufacturers, leading to a diminishment of the pharmacist’s role in compounding—mixing ingredients to create elixirs, tablets, pills, suppositories, ointments, etc.
However, as the quantity and complexity of medications increases, pharmacists have positioned themselves as the medication experts. The practice of “clinical pharmacy” or “pharmaceutical care” involves working closely with physicians, nurses, and patients to assure the best possible care for the patient. Pharmacists are trained to watch for allergies, drug-drug interactions, and drug-disease interactions, and to adjust doses based on kidney or liver function, age, and weight. To increase patient compliance, pharmacists educate patients about their medications and answer questions.
Proper pharmaceutical care has been shown to decrease medication errors and the cost of therapy.
Pharmacist Shortage
A shortage of pharmacists has existed for several decades as the demand outstripped the graduation rate. This bumped up salaries significantly. In 2010, the average salary was $109,000, but this varies widely by geographic region. The shortage protected the profession from the recent economic downturn. However, many new schools of pharmacy have opened in the past decade, and the economic downturn has led pharmacists to postpone retirement and to work more hours. Anecdotally, fewer positions are open, and salaries are leveling off.
References
1)      Occupational Employment and Wages, May 2010: 29-1051 Pharmacists. United States Department of Labor, Bureau of Labor Statistics website. http://www.bls.gov/oes/current/oes291051.htm Accessed 29 Sept 2011.
2)      Report of the ASHP Task Force on Pharmacy’s Changing Demographics Am J Health-Syst Pharm. 2007; 64: 1311-9. American Society of Health-System Pharmacists website. http://www.ashp.org/s_ashp/docs/files/practice_and_policy/workforce/1311.pdf Accessed 29 Sept 2011.
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      Sarah Sundin is the author of the Wings of Glory series from Revell: A Distant Melody (March 2010), A Memory Between Us (September 2010), and Blue Skies Tomorrow (August 2011). She has a doctorate in pharmacy from UC San Francisco and works on-call as a hospital pharmacist.