Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Thursday, May 15, 2008

Dear Angry Pharmacist

I really like your blog. In fact, I rarely comment because I almost always agree with you. Unfortunately, this means I can't remember which form of my Username I used to create an account to allow me to comment; either that, or my new computer has cookie issues. In any event, although your recent post about your hellacious Friday was heartrending -- and didn't actually say anything about me at all -- someone was kind enough (no sarcasm; traffic has been through the roof) to link to me in your comments. Many (many!) others have since come here and commented as well, so I'd like to address those folks directly.

I'd just like to point out that obviously many doctors are idiots. Uneducated front office staff calling in prescriptions must be maddening; illegible handwriting, nonexistent dosage forms and ridiculous quantities are certainly infuriating; waiting on hold over and over to clarify these things -- while saving the necks of ungrateful patients -- surely earns you millions of karma points towards your halo. That's why I like your blog; you put those doctors squarely in their place with great anger (obviously) but also with humor and panache.

I'm also certain you agree that patients are morons; many so stupid you wonder how they manage to breathe and blink at the same time. Of course they hear what they want to hear; often the exact opposite of what was actually said, whether by you or me.

It just so happens that there was this one particular patient who really really really needed a cholesterol medicine, and with whom I spent an inordinate amount of time carefully explaining exactly why he really really really needed it. So when this particular patient reported that a pharmacist (actually not one but two) told him he should stop taking it...I did not in fact go ballistic in front of him, but rather spent another extended visit explaining why he didn't have to take it if he didn't mind being at increased risk for another heart attack; and succeeded in persuading him to go back onto a different statin, as it happened. Still, there was exasperation, and the blog provided a fun way to let it out.

So for the record, I'd like to specify some things to those who so graciously commented on my humble rant:
  1. I don't see drug reps, nor do I accept anything -- including food -- from them.
  2. My handwriting is quite legible.
  3. My office phone is answered promptly -- by a person.
  4. I prescribe narcotics and other controlled substances with great caution, but
  5. I try always to be acutely aware of patients in true pain who are not abusing their drugs.
  6. I do not rush patients through my office, and in fact probably see only about half as many patients a day (usually the same day they call) as some other docs; of course I'm only making half as much money, but I believe it's worth it.
  7. Some of my best friends are pharmacists; by which I mean that in person I have wonderful, respectful working relationships with my local pharmacists (which actually means I should call the one (or two) this patient spoke with and get their side of the story.)
Finally, to all those who called me things like "idiot", "tard", "moron", "lazy", "know-it-all" and "spoiled": please, I beg you, go peruse Cranky Epistles for a little while and come up with some original insults. Heaven knows Cranky Professor has elevated the epithet to an art form! The least you can do is exercise some creativity.


At Thu May 15, 10:51:00 AM, Anonymous Anonymous said...

I'm an anon. pharmacist who reads you both. This particular post of yours seems to be a round about way of apologizing for dumping all pharmacists with the same characterization as Angry Pharmacist does with physicians, dentists, office staff, etc.....I get that it was a rant, with all your explanations of how great a physician you are, spending time with patients, not using a Levaquin pen to write your rxs, never approving early CIII refills, didn't acknowledge both of us are fighting the same battle. The pt is getting as much - or more info from that very trustworthy dr on TV who wants his pt to take Crestor, why Cialis will make every man's life better & be able to be in a bathtub on the edge of a cliff with a beautiful woman beside him....oh & don't forget - the ever believable print journals. You know the ones I'm talking about - Reader's Digest, Redbook, Parenting, Prevention Magazine. We are in this boat together. Yep - I've been there when your 70-something has complained about aching knees & hips. He starts out by saying what about this new medicine Dr Dino gave me (simvastatin - I NEVER dispense Zocor) - after all, it says so on the TV & that stupid informational sheet I have to give out with each rx. So, while trying to convice the guy to not buy the 500 count ibuprofen (because you also prescribe lisinopril & his diabetic kidneys aren't so good), I say....welll.....yeah, it is a possibility, altho rare. Why don't you have another discussion with Dr Dino (because I can tell - even though you think you convinced him, he's not convinced!).

You WILL know when I tell a pt to stop taking a drug (ahhhh - did you get my fax about the Digitek recall & I told your pt to stop & I switched it to Lanoxin & you might want a blood draw???).

So - like you, being such a good Dr as you are - there are good pharmacists too - as you pointed out at the end of this post. So, why the anger & rant about us in the previous post? We're in this together. Sure you can "get back" at us by sending rxs to mail order. Thats only going to increase our work when we transfer them back because pts ultimately hate it. I could undermine you & send your pt to a doc-in-the box, but I wouldn't because I don't think thats good medicine.

Think about how much misinformation both of us need to deal with when we talk to patients. Give us some slack. We really do want to help your pt understand why a drug that doesn't make him feel any different & is costing $120-300 a year is worth taking. That's just one rx you've prescribed. Most diabetics I dispense for will run up bills in excess of $1000 per month. They don't pay that - particularly when I discount to match a crazy Walmart price because it doesn't help them to pharmacy jump anymore than it helps them to Dr jump. But - someone is paying for all this. Often, its my company, which passes it along to you when you buy products other than my rxs. But - my information is always free & ALWAYS includes a question - when you spoke with your doctor, what did he/she say about this?

You're both funny posters - its just too bad that you turn on each other then lump everyone in that same profession together.....sad really.

At Thu May 15, 12:48:00 PM, Anonymous Anonymous said...

Even though I read TAP, and haven't (until now) read #1 Dino, I think that the pharmacists here have probably over reacted in response to the initial post that is being referenced. Just like TAP goes on a rant about a particular bad doctor, #1Dino here has gone on a rant about a particularly bad pharmacist.

I have worked with bad Pharmacists when I was a tech, and I have to clean up after their shifts now that I am a pharmacist. Even TAP (and all other pharmacists here) can agree that they know a dipshit pharmacist that could have pulled off what this rant was about. #1Dino can obviously read TAP's blog and not feel the need to comment every time that TAP blasts a doctor, because #1Dino knows that dipshit too, and can laugh with us. Why can we do the same thing with his rant?

The hostility in me is toward all the anon. doctors, or even the blogging doctors, that used this rant as a forum to blast an entire profession. I agree that most doctors don't have a clue how often pharmacists bail them out, or have any idea how difficult retail pharmacy can be. It is inexcusable for a doctor to send a patient to another pharmacy because he was put on hold so the pharmacist could counsel another patient. In fact, shouldn't you as a doctor want your patient to go to that pharmacy where you know that they actually do take the time to make sure the patients understand their medications?

So here is my final thought.
R.PH's... just calm down, look at the idiot that worked the shift before you and say "I can see him doing that jackass of a move" and let it go.
MD's... take a moment and realize that the dumbass R.Ph is an exception and not a rule, and cut the rest of the profession a little slack. We really do our best to look out for your patients best interest.

At Thu May 15, 06:51:00 PM, Anonymous Anonymous said...

The hostility in me is toward all the anon. doctors, or even the blogging doctors, that used this rant as a forum to blast an entire profession.


At Thu May 15, 07:34:00 PM, Blogger Ian Furst said...

Hey -- take a pill.

Just read the back and forth rants. Someone should remind all of the commenters that the first rule of blogging is to stir it up. I'm lovin' the rants and Dino - you're frequent and creative use of the word fuck (my personal favourite was "fucktard")should be enshrined in the blogger hall of fame. Some might call it ebuse, I call it a colourful debate. Thanks for the laughs.

At Thu May 15, 08:26:00 PM, Anonymous Anonymous said...

Can you email me plz:

I couldn't find your email on your site.

At Fri May 16, 12:37:00 AM, Anonymous Anonymous said...

I love you both. And I'm a doc who happens to love pharmacists and rely on you guys a lot, particularly when I suspect someone's a drug-seeker (note I don't mean people with actual pain using narcotics appropriately).

I can see both sides. Dino was ranting, though not maybe as fiery, in a style reminiscent of TAP. TAP, you rag on us docs all the time and we (definitely I) still love you. Ranting is what you do, so your response was completely expected.

Can't we all just get along??

At Fri May 16, 09:11:00 AM, Blogger tk said...

Wow, where have I been . . . I can't believe I missed all of this excitement! ;)

At Sat May 17, 01:55:00 PM, Blogger 30 years from Darling said...

I'm with you tk

At Sun May 18, 02:24:00 PM, Blogger Unknown said...

Isn't this what we call in the nursing world "horizontal violence??" Although we like ours with a little more cattiness if you please:>) I'm new to the blogging world and very new to the "healthcare provider" ones, but has it occurred to anyone that there is one group of "fucktards" that travels around to visit all of us?? Like the circus, or gypsies, or locusts. I think so, cuz I recognize a lot of the folks discussed here. I say if you want to be pissed, be pissed that you do not have the $196 million lottery ticket that the winner somewhere in our area is not coming forward to claim.

At Mon May 19, 12:15:00 AM, Anonymous Anonymous said...

Ah, distracted by shiny objects appears to be from the Cincinnati area as well. Givin' a shout out!

At Mon May 19, 09:43:00 AM, Blogger Unknown said...

Shout out to you also! Hoping you have the winning lottery ticket from Amelia. I just enjoy thinking about it:>)

At Fri May 23, 05:36:00 PM, Anonymous Anonymous said...

Lesson in absolute risk reduction

#1 Dino, you speak as if NOT taking a statin as a diabetic is certain death. Lets look at the numbers.

According to the Heart Protection Study:

"Coronary mortality had occurred in 6.5% of simvastatin-treated diabetics versus 8.0%"

Coronary mortality was only decreased by 1.5% (absolute risk reduction)???. When translated into Relative Risk Reduction (6.5% vs 8.0%) it "magically" becomes nearly 20% reduction. EUREKA!!

Puhlease. Acting like NOT taking a statin in this patient for a 1.5% better chance of not dying from an MI is a bit ridiculous.

Let's not lose sight of the fact that these statistics are manipulated to sound GREAT. The company is trying to sell its product to as many people as possible.

If a 74 year old guy with chronic pain THINKS that his pain is worse when on simvastatin, then by g-d, don't make the guy take the drug.

Why am I so skeptical?

Let's use an analogy. A roof salesman comes to your door. There's nothing necessarily wrong with your current roof, but he explains that you're at risk of a leak eventuatlly. Ok, well, all roofs will eventually leak. He explains that his expensive roof leaks 20% less often. Wow! I'm buying one!!!

Would you still buy this roof knowing the facts?

Percentage of leaks:

Your current roof: 8%

New Expensive roof: 6.4%

Relative Leak Reduction: 20%

Absolute Leak Reduction: 1.6%

I Didn't think so.

At Sun May 25, 08:52:00 PM, Anonymous Anonymous said...

So it does reduce risk, and the doc would get sued for not including it in the drug regimen.

At Tue May 27, 01:54:00 PM, Anonymous Anonymous said...

"So it does reduce risk, and the doc would get sued for not including it in the drug regimen"

Medicine isn't that black and white. Drug therapy poses risks. In the case of statins there is the (remote) risk of elevated LFT's, (even more remote) risk of rhadbomyolysis, and in this case unexplained muscle pain which may or may not be drug related (or related to rhabdo...not likely).

Drug therapy risk versus benefit always has to be outweighed. Doctors aren't getting sued over not using drug therapy despite evidence favoring their efficacy. If that was the case then why isn't EVERY post-MI patient on a beta blocker? EVERY CHF patient with LVF < 40% on an ACE-I? EVERY diabetic on an ACE-I for renal protection. On and on and on...

The answer? Because the public isn't aware of these things. If a diabetic isn't treated properly for 15 years they will develop sequelae (such as renal failure), but the MD will chalk it up to the normal course of their disease.

In the case of the 74 year old gentleman with diabetes, why make him suffer with muscle pains (that may or may not be from zocor) for a 1.5% decrease in mortality? Is that worth it? Quality of life versus drug therapy benefit.

This always has to be taken into consideration.


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