Common Community Pharmacy Annoyances

It's funny how variable working in a community pharmacy can be. Nowadays, I locum here and there, and I tend to really enjoy it. I usually do evening shifts, so you have an hour or two of bedlam, followed by several hours of blissful calm and quiet, where you get to sort out all the outstanding things, do lots of other bits and pieces like checking owings, controlled drug stock levels, and cleaning. I usually also end up having bizarrely deep and meaningful conversations about life, love and philosophy with whoever I am working with. Usually when I leave a pharmacy it is as clean and tidy as possible, I've sorted out what I can, and have left notes for anything that I haven't been able to deal with fully.

I say all this because I lately did one of *those* locum shifts. The ones where it is constantly busy, no prescription is straightforward, the fax machine isn't working, and you seem to have to deal with every problem under the sun. On this particular locum shift, I think my colleagues and I encountered every single type of category of impolite customer possible in a 4 hour shift.

So, because the only way that we can cope with such things is to laugh about them, and because I fancy a self-indulgent rant, here is my compilation of the things in pharmacy that annoy me and that happened in that locum shift.

The Mythical Taxi

Some people do get a taxi to their local supermarket. I have done it myself. But it would appear that taxi companies must have an amazingly lucrative trade in ferrying people to and from pharmacies if the frequency of use of the phrase "Can you do it quickly please, I've got a taxi waiting" is anything to go by. These are not, as far as I am aware, magic words that will somehow warp the time-space continuum so that I am able to dispense and check a twenty item prescription in a mere matter of seconds. Whether or not you actually have a taxi waiting will simply mean that your prescription gets put in the queue in the same place it would have done anyway, and you will wait the same amount of time as you would have done anyway. Needless to say, I suspect that many of these taxis don't actually exist, but merely a tactic used by some people to attempt to "hurry their prescriptions along".

The Dry Chesty Cough

"What sort of a cough is it?" "Well, its a dry, chesty cough."
No, no it isn't. It's either dry or its chesty, its not both. And either way, there is little point buying anything for it given that there is no evidence that any cough medicines work.

The Evil Eyes

Glaring at me continuously for the entire time that I am dispensing your prescription will not in any way speed up my work, and in fact may have the opposite effect as I am more likely to lumber around in a sloth-like manner just to annoy.

"I Need To Be Somewhere"

At 6:05pm, a woman handed in her prescription of 4 items. At 6:07pm, having spent all of two minutes repeatedly sighing and tapping her feet, she asked to speak to the pharmacist. Off I went, leaving a prescription half-dispensed. She demanded to know how long her prescription was going to be (the one I left to go and speak to her), because she needed to be somewhere. I gave her an estimation, told her I was doing it now, then went off to complete it. She then asked to speak to me a further three times to find out how long it was going to be, each time meaning it would take a little longer. "But I need to be somewhere at 6:15!!" she told me each time. I handed her the prescription at 6:12pm, thanking her for her patience. She then proceeded to rant for several minutes about how long the prescription had taken and how it meant she was going to be late and she had to be somewhere at 6:15. She eventually stopped complaining at exactly 6.15, and I returned to the dispensary, whereupon I noticed out of the corner of my eye that she had taken the time to hang around to complain about how long it had taken her to get her prescription to some of her friends who she just happened to bump into in the shop. Goodness only knows what time she actually left.

Invading Privacy

If you have ever picked up a prescription from a pharmacy, you will have probably been asked to confirm your address. This is so that we can make sure that you actually get the correct prescription. This is not because we are evil assassins or because we want to sit in a bush outside your house and spy on you- we really don't- and you're address is written on the prescription so if we wanted to we could anyway. On this locum shift, however, we were accused of invading someone's privacy for asking for this information. "I don't need to give you that information!" he declared. The counter assistant advised him that this is a routine question to ensure that we give out the correct prescription. But this wasn't good enough, and he wanted to speak to someone in charge. Off I went into the breach. I told him that he could come into the consultation room to give us his address so no one could overhear, but this was "an inconvenience", apparently.

By this time, he was shouting and other people in the queue were staring at him.

Again, I advised that we routinely confirm the address to ensure that the correct prescription is given out.

He decided to prove that the prescription was his instead by giving out his name, date of birth, and by telling me every item that was on the script. Loudly. One of which was sildenafil (Viagra).

Magicking Up Medicine

Me: "I'm sorry, we don't have that item in stock. There is a manufacturing problem on it, so we can't get it from our suppliers"
Patient: "But I need it" 
Me (in head): "Oh I see. Well if you can hold on a few minutes, I'll just nip round the back into our large pharmaceutical manufacturing factory, dig out the raw materials, and whip you up a batch right now then" 
Me (in real-life): "I understand, but I'm really sorry, we can't get any in at the moment."
Patient: "But I need it."
Me: "Where is the nearest wall please, so that I can bash my head against it repeatedly?"

The Expert Customer

I'm advising a patient about how to manage their child's teething problems. Another customer waiting in the queue decides to chip in with "Those Nelsons Teetha sachets are really good." (Nelsons Teetha sachets are homeopathic, therefore contain nothing of use and have no pharmacological effect). From then on, I (and my many years of training and experience) might as well not exist, as nothing I say can steer the patient away from believing that Nelsons Teetha are simply THE best thing since sliced bread, and in her eyes I'm obviously a terrible pharmacist for not recommending them immediately.

Impatient Patient Questioning

You ask the patient all the usual questions. They're all answered with a loud sigh, vacant eyes, and a disinterested "yes" or "no" at all the bits that they think are right. I could be asking anything, and I'd get the same response. So sometimes, I like to mix it up a bit and throw in a question they're not expecting. If its something like Nytol or a codeine containing medicine, I'll ask "Do you take it regularly?" to which the response is usually a bored yes. In which case, I advise them that I can't sell them any, then swiftly duck for cover when they inevitably throw things at me.

A variant You ask the patient if they are taking any other medications, to which they sigh and say "no". It's only when they're about to hand over their money that they a) ask what would happen if they were taking medicines, then confess, or b) whip out an inhaler and proceed to take a couple of puffs right in front of you after they have just told you that they don't have asthma or COPD.


The patient can inexplicably only take one or two brands of generics for a product. You are, of course, expected to telepathically know this and dispense the right one, and woe betide anyone who doesn't. Now, I am entirely understanding of cases where a patient has specific requirements for one type of product- maybe an allergy to an excipient, say. But when there is not reason for it, and the patient is shouting at you for not giving them "the right medicine" despite them at no point telling you what "the right" one is, then I tend to feel a bit put out.

Mobile Misery

Now I am known for being attached to my mobile phone. However, one of the most annoying things when working in retail is having to deal with customers who refuse to hang up theirs whilst you are trying to have a conversation with them. Over a pharmacy counter, we often need to give detailed counselling, and of course we need to ask a lot of questions. I can't really do that if you are also listening to so-and-so discussing who was drunkest down the pub the other night. At this particular locum shift, I had to attempt to explain that there was an item owing on a prescription to a chap who was having just such a conversation. The icing on the cake was when he said to his phone-based friend "Hang on, I can't hear you, this stupid woman keeps talking about something and wont give me my prescription". Needless to say, despite me explaining the owing and handing him an owing slip, he returned a few minutes later demanding to know where the missing item was. This "stupid woman" then had to patiently and politely re-explain everything I had already told him.

How do I deal with situations like this? Politely, professionally, and with a smile on my face. I might have a bit of a rant and a laugh about it later in the back of the pharmacy, but outwardly in these situations I remain as calm as possible and attempt to be as helpful as I can. I've had many years of practice. The worst thing about this shift was that I was working with a new counter assistant and a newly qualified pharmacist, and I could see their morale slipping minute by minute. Their shoulders slumped, their smiles became more forced, and I found myself desperately trying to reassure them that this is just how some days go. Of course, we pharmacy types do make mistakes on occasion, and inconveniences do happen. I can understand that, when it comes to health, people can be scared and anxious, and that can come across as aggression. It is my firm belief, however, that a little bit of kindness and manners get you everywhere, and I am always much more likely to respond positively to calm and polite customers than those who default to outright rudeness, although I will do what I can to ensure that I help them all.



Homeopathic Harms Vol 7: Professional Ethics

In February 2013, my friend @EBMScientist and I delivered a Newcastle Skeptics in the Pub talk entitled Homeopathy: Where's The Harm? As a follow up to this, we decided to write a series of blog posts expanding on a number of points we covered in the talk:

"Ethics is the science of morals, or moral philosophy. The principles, written or unwritten, that are accepted in any profession as the basis for proper behaviour are the ethics of the profession" -Dale and Appelbe's Pharmacy Law and Ethics

As you'll know by now, I'm a pharmacist. And as such, I have to be registered with the General Pharmaceutical Council (GPhC) to practice in the UK. I'm therefore governed by the GPhC, and in particular their code of conduct, ethics and performance, which has seven main points:

  1. Make patients your first concern

  2. Use your professional judgement in the interests of patients and the public

  3. Show respect for others

  4. Encourage patients and the public to participate in decisions about their care

  5. Develop your professional knowledge and competence

  6. Be honest and trustworthy

  7. Take responsibility for your working practices.

If I-or any of my colleagues- were to act against this code of ethics, we could be held to account by our regulator and reprimanded accordingly. Other healthcare professionals- Doctors, nurses etc- all have similar codes of conduct produced by their regulatory bodies. They all have one thing in common- that the patient is central to everything you do, and if a member steps outside this code of conduct, there is a clear and organized route through which complaints or concerns can be raised. This is as it should be: healthcare professionals have the lives of patients in their hands, and need to be held to account if anything goes wrong. As I've written before in this series, homeopaths don't have to register with a regulatory body and anyone can set themselves up as a homeopath with no training whatsoever. Whilst some 'professional' bodies exist in the UK, they have no regulatory powers so are unable to reprimand anyone if they receive a complaint.

Health care professionals who also practice homeopathy still have a duty to ensure that they abide by their regulatory body's code of ethics. In my opinion, however, it is very difficult to reconcile some of the clear guidance with homeopathic principles. Let's take a look at what I mean, using some selected points from the  the first two standards of the  GPhC's Code of Ethics July 2012 as a guide. (I'll cover the rest of the points in another post)

1. Make Patients Your First Concern
Under this heading, the GPhC states that we must "Make sure the services you provide are safe and of acceptable quality". Given the lack of high quality information that homeopathy works, we are unable to guarantee that such a service is of acceptable quality. You'll also know if you've read the rest of this series of blog posts that there is a lack of evidence regarding the harms- both direct and indirect- of homeopathy- so how could we guarantee that it is safe?

2. Use Your Professional Judgement In the Interests of Patients and The Public
There are a couple of relevant points here. firstly we are told that we need to make sure that professional judgement is not affected by personal or organizational interests or incentives. If you're going to charge for a homeopathic service on the side of your usual practice, then there is already a clear personal incentive to promote homeopathy.  We can minimize the possibility of such things affecting our professional judgement by making sure that we use evidence to guide treatment decisions wherever we can: evidence-based medicine is not perfect, but its the most objective method we have at the moment. And, as you'll know, there is no good evidence at all that homeopathy works. 

We are also advised to:

 "Be prepared to challenge the judgement of your colleagues and other professionals if you have reason to believe that their decisions could affect the safety or care of others"

I myself-and other pharmacists-have done this: I've spoken out about Tony Pinkus, for example, a pharmacist who endangers patients' lives by promoting unlicensed homeopathic vaccines or sugar pills to prevent malaria. In Nancy's latest blog post, she covered some of this, and I know Adam at Dianthus Med has also been discussing this point on twitter and his blog lately. Its clear-from our own professional guidance-that where patient safety is in danger, we do not protect our own- we need to report, speak out, and denounce those amongst our colleagues who let the profession down.

Homeopaths, on the other hand, seem to have no such obligation. We've been struggling to think of one single example of where homeopaths have spoken out against other homeopaths where patient safety has been endangered. In a conversation on twitter, for example, no homeopath would say that it was inappropriate for a homeopath to have said that a homeopathic remedy could have saved someone who died due to injuries sustained in a horrific gang-rape and disembowelment.  I recently asked some homeopaths on Twitter whether they would speak out against a colleague who put patients in danger. The answer I received from one was shocking:

"When its so easy 2 wink at 1's own sins, seems impossible 2 find judge orjury before whom 2arraign the 1st law breaker. KENT" (sic)- @22VenkateshN

Admittedly this particular homeopath that responded (he was the only one) has a reputation for obfuscation, but this reply seems to suggest that no, he wouldn't report, in case someone did similar to him. I tried to clarify : "so to clarify: you wouldn't speak out in case someone else did the same to you? A yes or no would suffice, thank you". The reply:

"some questions can't be replied with a simple 'yes or no'. for example_ 'are you still mad ?'"- @22VenkateshN

I'm not sure what he is trying to imply by asking about being mad, but we'll give him the benefit of the doubt and ignore any insinuations he might have been trying to make. What is staggering is the reluctance to admit that he would put patient care first and report a fellow homeopath in a situation. As a health care professional-and a good person- the code of ethics  becomes deeply ingrained in your being. Its second nature- and pretty obvious- that you would put the needs of a patient first. I persisted further,  trying to make it easy for him to agree that you would report a colleague: "It's very easy, if you work under clear ethical guidance. homeopaths do have that, right?: patient safety comes first: therefore yes, you would report and denounce a colleague who endangered it." Again, the reply astounds:

"Its not that easy, every one accusing everyone else would result. That's why I tweeted the appropriate observations of Kent"- @22VenkateshN

Wow. So it would seem- on the basis of this sort of conversation and the complete radio silence from any other homeopaths- that no, they wouldn't report or denounce a fellow homeopath because some sort of petty slanging match would ensue. Instead of a clear referral process to deal with complaints, accusations would be flying all over the shop- and one very, very important aspect gets forgotten: patient safety. 

I'd love to be proved wrong here. I'd love to think that medical homeopaths or pharmacists who also practice homeopathy would do otherwise, in accordance with their code of ethics. But I'm currently deafened by their silence. If I were one of the more professional, caring homeopaths who really did want to do the best for their patients, I would be utterly horrified and disgusted by some of the claims and actions of others, and I'd want to-nay I'd feel obliged to- speak out against them for the good of my own practice. I'd be embarrassed to be associated with them.

So here's your chance, homeopaths. Speak up against bad practice and drown out the previous deafening silence. Go right ahead: I'm listening intently. And while you're at it, please do take a few minutes out to respond to Adam's Challenge to the Society of Homeopaths too


Amazon sometimes frightens me, if I'm honest.

A while ago @DianthusMed alerted me to the fact that Amazon UK are selling unlicensed medicines imported from the US via its Marketplace. Adam got in touch with Amazon, and the particular brand he bought are no longer available on their website, but of course there are still a whole range of other unlicensed loratadine brands available to buy with just one click.

I dug a little bit deeper and discovered that this could actually be more dangerous than some non-drowsy anti-allergy medicines- along with some problems selling licensed medicines as well.

Some inane browsing brought me to a page selling Syndol. I noticed it because of the price- its being sold at a whopping £39.99 for 30 tablets. I presume this is due to the fact that Syndol are currently on a long term manufacturing problem. Syndol do have a UK product license, and are sold over the counter in pharmacies. They're kept behind the counter for a number of reasons, and require quite a lot of patient counselling for appropriate use: they contain paracetamol, therefore shouldn't be used in conjunction with any other paracetamol products (they're one of those shiny combination products which people might not realize contains paracetamol). They contain codeine, which is very addictive and should be used for no more than 3 days at a time. They contain doxylamine, which causes drowsiness, making them even more abusable and dangerous. I use these occasionally myself if I get horrible, migraine-type headaches. They seem to work, but I also sleep the sleep of the dead for 5 hours, then wake up feeling zombie-like for a good few hours after that. If I sell these over the counter, I check that the patient isn't using them regularly, that they understand about the paracetamol, and that they will make me drowsy. Whilst the sellers do state they might need more information from you before selling them, they seem to me to be pretty inappropriate for an internet sale- sometimes you can tell if a patient is misusing them by their body language etc. the largest pack size it is available in is 30, for all of these reasons. And charging £39.99 for an addictive substance which is out of stock elsewhere just seems manipulative.

And here's the most horrifying thing: Amazon, trying to be helpful, suggest a package that we can buy, based on what other customers have bought together:

Umm, right. So Amazon have been selling Syndol + Syndol+ Sleep Aid, an unlicensed US product (doxylamine) together, and they're suggesting we do the same. This combination, if taken together, could well be deadly. There's the issue of paracetamol toxicity, codeine and doxylamine addiction, and the potential for self-harm to consider here.

This is, of course, just the tip of the Iceberg, Click on the Sleep Aid tablets and you're encouraged to buy Sleep Aid, Sleep Aid and Unisom. Click on Sominex (a UK-licensed product) and you're advised to buy it alongside Sleep Aid and Nytol. Any of these combinations have a huge potential to harm.

I'm going on about licensed and unlicensed products here. So what am I on about? Well, in the simplest terms, a product that is licensed in the UK, and used according to the manufacturer's instructions, is guaranteed to have met certain standards of quality, efficacy and safety. If it hasn't got a license, you haven't got that guarantee. It might be fine, or it might be made of rat poison and brick dust, you just don't know.

I know I get taken in by these packages on Amazon all the time, when I'm buying DVDs or books, or other items. At least none of these are going to have that much of an effect on my health (although I'm sure some would argue that my love for Korean extreme horror must be having some effect).

This sort of multi-product purchase encouragement goes against many of the reasons why products are sold through a pharmacy in the first place.

Amazon have been through the mill lately, what with the Keep Calm and Rape T-shirtsand their selling of unlicensed cancer medicines. Well, I'm going to add my little chirp to all that noise too. I'm sure there are complicated technical reasons behind why they have this frequently bought together sections on medicines, but frankly I don't care.


The troubled life of a community pharmacist: Emergency Supplies

I've spoken a little bit about the sort of conditions I've come across in the community pharmacy setting. Today I want to talk about one specific issue which affects community pharmacists time and time again: the emergency supply. 

Having worked for many years in community, I have definitely experienced a large amount of anti-pharmacist opinion. I can understand where it comes from: it's a very weird setting for a professional service, in a shop. Patients tend to build up a relationship with their GP, and the very setting of a surgery, with its closed-off rooms and offices free from distractions lends itself more to a professional image. There's a public perception that because pharmacist work in a shop, they're less important, less professional. This is a real shame, and often not the case. I suspect that many members of the public don't even realize that pharmacy is considered a profession: anecdotally I know of occasions where people with no qualifications have applied for pharmacist jobs and have been surprised to learn that you actually need a 4 year masters degree plus one year pre-registration training. It's a great shame that, in the eyes of many members of the public, we are nothing but glorified checkout operators. People are used to a "The Customer Is Always Right" attitude, but unfortunately in pharmacy, which is governed by specific laws that make it different from other retail situations, this isn't always the case.

It seems to me that this often leads to an assumption that where things go wrong with medicines supply, it's always the pharmacist's fault. We are the faces across the counter from you telling you that for whatever reason, you can't have your medicines. We are therefore the obvious target for the complaints, the "well if I die its all your fault!" statements which we hear regularly. But is this fair? 

Let's imagine its a Saturday morning. You go to your local pharmacy to pick up your repeat prescription which the pharmacy picks up from your surgery for you, and its not there. Lets consider what might have gone wrong here: 

1. The pharmacy has picked up the prescription and lost it. Rare, but it does happen. Most pharmacies/ surgeries will have records of what's been picked up though so its usually easy to find out if it is in the pharmacy or not. In this case, its fairly obvious that the pharmacy is at fault. The solution to this is also pretty obvious: you hunt high and low around the pharmacy until you find it.

2. The prescription is still at the surgery. Either it's been put in the wrong box for collection (a really easy mistake to make, used to happen at the surgery local to my pharmacy loads) or it hasn't been issued in time for the weekend. It might be that there is a query on the prescription or similar, so it hasn't been issued for a reason. However, its Saturday morning and the surgery is closed, so there is no way for the pharmacist to know why the prescription hasn't arrived in the pharmacy, only that it isn't there. In this case, it would be the surgery who is at fault as they've failed to ensure the patient's prescription arrives at the pharmacy ready for them to pick up. 

3. The patient hasn't ordered the prescription in time for it to be ready for the Friday evening collection. Most surgeries will take 48 hours or so to process a prescription, and depending on the pharmacy you might have to add another 24 hours on to make sure it's dispensed. If the patient hasn't ordered their prescription on time, there's a good likelihood that it wont be ready at the surgery for the pharmacy to pick up. 

Now don't get me wrong, option 1 definitely does happen, but in my experience the vast majority of cases are because of options 2 or 3. The pharmacy often doesn't know whether to expect a prescription for a particular person, so without telepathy is unable to do anything about it when the surgery is still open, on sometimes a prescription hasn't been issued because a patient is overdue a review, or there's been a change in their therapy, or just because of a genuine mistake. 

With some patients none of this matters. It doesn't matter how much you explain to the patient that it still seems to be at the surgery, or that if they've ordered their prescription on Thursday and it takes 48 working hours for the surgery to process it, in their eyes you're still the one to blame. It's common to have patients shout at you that if they die because they haven't gotten their medicines, it'll still all be your fault. There are a combination of reasons for this: a mistrust of pharmacists, a belief that GPs can do no wrong so it *must* be your fault, distress that a patient will be without their medicines, and most of all the fact that you're there stood in front of them in a retail setting, so they vent. This might sound a bit over the top but it really does happen all the time. I've been shouted at, sworn at, and and had things thrown at me over the counter on an alarmingly regular basis in these kind of situations. And because I'm a professional, and I believe in good customer service, I stand there and respond politely, and do my best to try to resolve the situation, whilst all the time I'm thinking "hang on a second here, this isn't actually my fault, yet I'm the one getting shouted at."

So anyway, back to our Saturday morning situation. You've ran out of  your meds and the prescription isn't there for whatever reason. So what can the pharmacist do about it? Well, there is provision for pharmacists to provide an emergency supply of a prescription only medicine to cover just such scenarios. This involves us essentially selling a prescription only medicine without a prescription. It's legal, provided we are able to justify the sale in accordance with the law. It's worth remembering that the worst case scenario for a pharmacist is that you can be done for manslaughter, so every pharmacist sort of learns to constantly think to ourselves "will this harm the patient?" and "Could I justify this in court?" So there are a couple of things that the pharmacist will be considering in the case described:

It must be an emergency situation: 

It needs to be a situation where harm would be caused if the drugs were missed. The definition of this might vary from pharmacist to pharmacist: some might not supply an emergency supply of the contraceptive pill for example, because there's a perfectly suitable alternative available in the guise of condoms. That's fine, and its at their discretion. I tend not to do emergency supplies for statins, because missing a couple of days of a statin is highly unlikely to cause such an enormous raise in cholesterol levels that the patient has a heart attack. However a patient missing a few days of an anti-epileptic medication can mean that they get rebound seizures, which could go on to have a huge impact on their lives.

The patient can't obtain a prescription within a reasonable time: 

If the surgery is open, then we really shouldn't be doing emergency supplies. It's worth noting that "reasonable" does not always mean convenient to the patient, but we would be unable to justify an emergency supply if a prescription can be obtained in a reasonable timeframe. If a surgery is closed for the weekend, this is exactly the sort of situation an emergency supply is handy for, but do remember that there is always out of hours doctors or hospitals that could potentially supply a prescription.

The pharmacist needs to be pretty sure that it is a patient's regular medication. 

This is fine if you're a regular at that pharmacy, but can be terrifying if you don't know what the patient is on. I've had patients asked for their "epilepsy tablets, you know the ones that are purple" or "the blue blood pressure tablets" or something suitably vague. If I gave the wrong thing, and the patient was harmed, it would be me in the dock and me who would never be able to live with the guilt.

How much should we supply? 

The guidance used to state a maximum of three days supply in most cases. That's usually more than enough to wait until the surgery reopens to sort out an emergency prescription. This has now been changed to a maximum of 30 days, but it is important to realize why this guidance was changed. It was increased pre-emptively a few years ago when we were waiting for the bird flu pandemic to hit. The theory was that surgeries might have been overwhelmed or closed (due to the fact that everyone was dead from the flu!) so this would allow pharmacists to have some more leeway to provide medicines in that very specialized scenario. It's therefore difficult to routinely justify giving out 30 days supply when in most cases a prescription could reasonably (even if not conveniently) be obtained within a few days.

Pharmacists are able to charge for emergency supplies.

 If nothing else, it's a right faff to do, and it can take a while to dispense, so some renumeration would be nice. But from a business perspective, if we didn't charge we're giving  away medicines for free with no guarantee of reimbursement. Think about it: you wouldn't expect that from any other retail situation. You wouldn't expect Tesco to just give you your weekly shop for free if you offer to pay for it later on in the week. Most places will be happy to reimburse the charge on presentation of a prescription, so its usually not too onerous. Again, its at the discretion of the pharmacist whether or not to charge. I remember a particularly aggressive patient who was very upset about how urgently he needed his cream for his skin condition that he hadn't gotten round to ordering. "It'll be YOUR fault when my skin flares up!" he was saying. "YOUR FAULT! I need it URGENTLY!". I explained that I would do an emergency supply for him so he wouldn't be without his cream. For some reason I can't quite fathom, he decided his skin wasn't actually that bad when he found out it would cost him over £65 for the cream. "Oh, it doesn't matter, it ummm, it feels a bit better now" he said, and shambled off.   

There are other laws and considerations that also need to be taken into account. but here's my overall point: The next time something goes wrong with your medicine supply, consider the fact that your pharmacist will and should do everything they can to help you, but they are bound by law and guidance and they need to be able to justify their supply. Sometimes, just sometimes, its not all their fault, and whilst I understand that pharmacists are visible and at the end of the line, so they might seem like the appropriate people to shout at, that isn't always the case. Pharmacies should have robust measures in place to ensure continuity of supply: not feeding back to the surgery if there is a recurring issue with their measures means they don't know to strengthen them. It sounds petty, but having to constantly hear customers who you do your best for assuming that something is your fault is wearing. It chips away at your professional pride and I know there have been times when I think "seriously, why do I bother?".

Pharmacists have feelings too. Some of them, anyway. Something as small as just saying "I know its not your fault but..." can be enough to make your day.  


Update: I am sorry if this post sounds a bit whingey. However I do think that there is a tradition in pharmacy (and probably many other areas of health care) of just sucking it up, and keeping quiet.  I think its useful to explain the kind of thought processes we go through so people can understand the often difficult position we are in. 

And Another Update: Guys, I'm bowled over by you lot. This post has started a bit of a discussion on twitter which shows just how proactive we pharmacists can be once we start talking. There is talk of organising a pilot to see about reporting emergency supplies as systems failures to highlight where the problems lie and attempt to resolve them. This just proves to me that there are some really brilliant pharmacists out there, and that given the time, resources, and opportunities to be proactive, we can really make a difference. Do get in touch if you have any ideas or thoughts tweet me @SparkleWildfire

The General Pharmaceutical Council: Let's hope they do the right thing

Many years ago, just after I qualified, I was working in a new 100 hour pharmacy in a very well known supermarket chain. 

To be honest, the working conditions were pretty terrible in that store. I had brilliant staff, but not enough of them. At the time, the policy of the supermarket for 100 hour pharmacies was to have no support staff there for the first hour and a half of the day, and the last two hours of the day. I argued tooth an nail against this, as we all know that pharmacists should ideally not self-check a prescription, no matter how quiet the pharmacy was between those times. The attitude of the company was that I was in the minority, and that I was complaining unnecessarily. 

At this time I was the only permanent pharmacist working there: the rest of the time we were running on locums. The company policy was to ideally use their locum booking system, but this was notoriously unreliable. I found myself setting my alarm for 6 am every morning, getting up and getting ready to wait for a phone call to tell me I would have to go in because the locum hadn't turned up, even on my days off. I found myself doing 16 hour shifts, occasionally one after the other, and with 3.5 hours of that spent on my own.

Even without the horrendous attitudes from other managers in-store (the daily battles, the snide comments about how much I was getting paid, the total lack of understanding about pharmacy law, and the outright sexism), these conditions were brewing for a dispensing error. 

The day it happened, I was working a 14 hour shift the day after working after a 16 hour shift. I was having to check a prescription whilst also being on the phone, because of the lack of staff. I checked that the drug, strength, directions etc were correct, but I didn't spot that the wrong name was on the label. 

The patient rang up to check that the cream was the right one for them. We apologised profusely, offered to redispense, offered to go through our complaints procedure etc. the patient was happy with the reassurance that it was the right cream and refused the other measures, stating that she was quite happy that the situation was rectified.

Next thing I know, I'm being investigated by the then-regulator, the Royal Pharmaceutical Society of Great Britain. You can't even imagine what this did to me. I was an absolute mess, convinced that I was going to lose the career I had worked so hard for. I co-operated entirely with the investigation, just as I had with the patient. I informed the inspector of the working conditions and my fears that it would lead to something more serious. None of this was taken into account in the final report, which gave me a warning, and the fright of my life. 

All this for a minor dispensing error, which caused no harm to anyone. 

You'd think, then, that the current regulator, the General Pharmaceutical Council, would come down hard on any pharmacist who actually endangered patients willingly. You'd think they would take decisive action, particularly where a pharmacist has had similar previous warnings which they have chosen to ignore. You'd think this would especially be the case where the pharmacist in question had been caught out by a BBC journalist posing as a concerned mother wondering about whether her child should be protected against whooping cough, a disease which can - and does- kill people.

See where I'm going with this? I'm hearing reports that the GPhC are suggesting that the Ainsworth's pharmacy case is nothing to do with them, and that as homeopathy is regulated by the MHRA it isnt their area. If that's the case, why is Mr Pinkus and the premises even registered with them?

I'm really hoping that this isn't the case, and that the GPhC are actually going to take decisive action. After all, what sort of a message does it give out to the public if they aren't being protected from harm? What sort of a message does it give out to the pharmacists that do their bet every day, trying their hardest to be as accurate as possible in working conditions that are ill-designed for such a purpose? 

Come on GPhC, be fair to the majority of your pharmacists who work according to your standards and actually do put patients first, and who do ensure that their recommendations are evidence-based and made with the best interests of the patient at heart. .


The Magazine of Doom

Today, I and several others have sent strongly worded emails to W.H. Smith's.

The reason? A magazine they are stocking which is frankly disgraceful. Encased in a glossy, brightly coloured cover, this is clearly such a blood-pressure-raising piece of crap it's ridiculous


However, to the untrained eye, it's another helpful glossy magazine, packed with useful hints and tips for how to stay healthy. Look at that nice, smiling, benign healthy looking lady. And it is a sad fact of life that patients and the public really do respond to these sorts of publications more than they do to advice from their healthcare practitioners. I can't tell you how many patients have stormed into my pharmacy with a piece of paper cut from a newspaper, demanding to know why they have been given this horrifically dangerous drug. Goodness only knows how many would turn up at their doctors. I would often spend a lot of time with these patients and explain to them what i could about the limitations of these sources, but to be honest I often felt that i had neither the resources or time to be able to do so properly. Some would change their mind, some would be marching off to their GP, usually demanding  more expensive newer drugs whose safety record we know even less about.

To be honest, even the title of this publication upsets me: What Doctors Don't Tell You. As if they are willingly sat in their surgeries or their hospital wards, giggling evilly about all of the suckers that they are going to see who are in pain, or depressed, or generally feel sick and vulnerable, rubbing their hands together, and all the while they are thinking "I could CURE you within a second, but I'm not going to, I'm going to sit here and watch you SUFFER! MWAHAHAHAHAAAA!". Actually, doctors (and any other healthcare professional) are usually people whose primary aim is to help people. They're usually overworked and under-resourced, and I suspect that many (like me, when I worked in community pharmacy) constantly feel guilty that they aren't able to help as much as they would like, because of their lack of time and resources. Yes, there is the odd Shipman character here and there, but I suspect very few people actually go into front line health care purely for money, or for the kicks of withholding various cures and treatments from their patients. Doctors, pharmacists, nurses, and other healthcare professionals may not get everything right every time, they may not be as up to date with evidence as they would like, and they may not make exactly the right decision for every single patient. But my word, I bet they really, really would like to.

The fact of the matter is: What The Doctors Don't Tell You about are usually overly hopeful health claims based on little evidence, and peddled by people who DO have the intention to make money. What they don't usually tell you about is unicorn tears and magic water and rooms made of salt and badges with unicorns drawn on (listen to Skeptics with a K podcast episode 45) because they very probably DON'T WORK, and your doctor wants more than anything to make you better. No doctor is going to advise that you try to avoid a hysterectomy with diet (Front Page of What The Doctors Don't Tell You)  if you are in a lot of pain now and a hysterectomy would improve your quality of life for you quickly, as an example. A nutritional therapist, though, as an example, may advise you to delay surgery and try diet instead, causing you to suffer for longer than is necessary.

I know this has turned into a bit of a rant. It's hardly evidence based, but it is based on genuine emotion from someone who, despite all my cynicism and negativity, just wants to do whats best for patients. I know that most of my health care professional colleagues feel the same, and this sort of sugar coated nonsense is actually rather offensive. I used to lie awake at night worrying about the patients i had seen through the day. I had many episodes of private tears for the ones that i couldn't help, and my whole week would be lifted when I had made someone's life a little bit easier. I wonder how many purveyors of woo could say the same.

Anyway, the general gist of this post is: email W.H. Smith and tell them to get this nonsense off their shelves.