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"Do not be anxious about anything, but in everything, by prayer and petition, with Thanksgiving, present your requests to God." Philippians 4:6
Each issue will include an editorial on a topic that is important for the profession of pharmacy, as well as a review of a new drug that includes a comparison of the new drug with previously marketed drugs that are most similar in activity, and a New Drug Comparison Rating (NDCR) for the new drug. Read on for this month's issue.

March 2023 Issue [Download PDF format]
In this issue:
• There is NOT a National Shortage of Pharmacists Now: But There Soon Will Be!
• From a Former CVS Pharmacist
• Leadership Wisdom and Perspectives: Our Profession's Brand Failure
EDITORIAL:

There is NOT a National Shortage of Pharmacists Now: But There Soon Will Be!

A "national shortage of pharmacists" has been the theme of numerous recent media stories. The support for this concern are the claims of chain pharmacies that there are not enough pharmacists to be hired, with the results that they are understaffing their stores, reducing their hours of operation, and offering signing bonuses to recruit pharmacists. However, these same chain pharmacies are identifying excuses to terminate higher-salaried older pharmacists for the purpose of trying to hire recent graduates, many of whom have huge college debts, and who may be desperate to find employment and are willing to accept lower salaries.

The current reality is that there ARE enough pharmacists to occupy the available positions, but there IS a shortage of pharmacists who are willing to work in the chain stores. The primary reason for this is that most chain stores are severely understaffed and continue to cut hours of staffing, thereby creating very stressful and error-prone working conditions that place the mental and physical health of pharmacists at risk. Many of the pharmacists currently employed in these chains are actively, even desperately, seeking other employment as a pharmacist, or leaving the profession to pursue other opportunities. Many student pharmacists and recent graduates have learned enough from part-time employment, participation in curricular experience rotations, or from what they have otherwise learned, to conclude that they will only work in these chain stores as a last resort. Therefore, the shortage of pharmacists claimed by the largest chains is self-inflicted and they are also sabotaging the reputation of the profession of pharmacy as an attractive career option, as well as the pool of potential applicants for the colleges of pharmacy.

Deja vu

Approximately 25 years ago there was a shortage of pharmacists for which one of the primary factors was the transition in the educational requirements required to pursue licensure as a pharmacist. The increased length of the pharmacy curriculum from the 5-year baccalaureate program to the 6-year (2 years pre-professional and 4 years of professional studies) Doctor of Pharmacy program resulted in a transition year with very few graduates. Some from both within and outside the profession viewed this as an opportunity to establish new colleges of pharmacy and satellite campuses of existing ones. This had already been an emerging initiative but the shortage of pharmacists fueled the rapid momentum that has increased the number of colleges of pharmacy in the U.S. to more than 140. This is approximately twice the number of the 72 that had remained unchanged for several decades prior to 1985. Although the chain pharmacies strongly resisted the increased length of the academic programs, they enthusiastically embraced and financially supported the establishment of new colleges of pharmacy.

Back to the present

Although there is not a nationwide shortage of pharmacists now, it can be anticipated that there soon will be. Multiple factors are approaching a collision that will cause the shortage and serious concerns for the future of our profession. These factors include but are not limited to:
  • The reduced number of high school graduates and others with aspirations to pursue a college education;
  • The increased concerns about the impact of huge college debts on future opportunities and decisions;
  • The reduction in the number of applicants to and enrollments in colleges of pharmacy that is disproportionately greater than the reduced number of high school graduates;
  • The substantial decline in the number of independent pharmacies that have traditionally provided part-time employment and fulfilling experiences that have motivated high school students and other college-bound individuals to pursue study and careers in pharmacy;
  • The dominant position of chain pharmacies and the stressful working conditions that result in errors, and threats to the mental and physical health of pharmacists and other employees, as well as the strongly negative impact on college and career decisions of young part-time employees;
  • The lack of any commitment on the part of the management of chain stores to improve working conditions, practice standards, and professional services;
  • The closure of less profitable stores by the large chains at a faster rate than they are opening new ones;
  • The number of pharmacists who are leaving the profession long before retirement age because of the stress and lack of fulfillment resulting from employment in chain stores;
  • The failure of employers to recognize the important and valuable role of pharmacy technicians as supportive colleagues for its pharmacists and in the operations of the pharmacy, with the resultant high turnover rate because of the stress and abysmal compensation provided;
  • The increasing number of situations (e.g., availability of the abortifacient mifepristone in pharmacies, prescribing of puberty blockers for children) in which those who would exercise conscientious refusal will choose careers other than pharmacy;
  • The governmental and corporate economics-driven policies, programs, and mandates that negatively impact the quality and scope of healthcare services and products for patients.

Do the chains have a hidden agenda/strategy?

Some years ago in a discussion with two pharmacy leaders at a national meeting, I raised a question for which I knew the answer, "If the chains could identify a way to legally dispense prescriptions without the involvement of pharmacists, would they do it?" The immediate response from one leader was "in a heartbeat" and, from the other, "faster than that." Recent events reveal multiple steps in that direction.
  • The increased use of remote central-fill locations and robotics;
  • Promotions and financial incentives for customers to use their unregulated or minimally-regulated mail-order pharmacies;
  • Minimal and continually reduced hours of pharmacist and technician staffing in their local stores;
  • The consequences of understaffing that include pharmacists not having time to use their knowledge and skills, or even personally communicate with customers unless specifically requested;
  • Efforts to increase the responsibilities and utilization of technicians by increasing or eliminating technician : pharmacist ratios;
  • The increased membership and influence of chain employees on state boards of pharmacy.
The authorization of pharmacists to administer vaccines is one of our profession's greatest recent accomplishments. Acquiring this authority required extensive commitment and efforts over many years on the part of our professional organizations and pharmacy leaders. One of the noteworthy experiences of the COVID-19 pandemic was the emergency authorization that permitted pharmacy technicians to administer vaccines. The technicians have assumed this supportive role very capably, with very little supervision and in a manner that has enhanced the role and reputation of the profession of pharmacy in responding to a health crisis. It has been clearly demonstrated that technicians can effectively assume this responsibility, and it can be expected that the chains and the profession of pharmacy, with valid reasons, will strongly oppose the withdrawal of this responsibility for technicians when the emergency authorization concludes.

However, this accomplishment also raises questions as to how the chains will respond to this "opportunity." Will the administration of vaccines become a responsibility almost exclusively fulfilled by technicians receiving much lower salaries? Will chain pharmacists continue to administer vaccines or even be involved beyond providing a minimal level of supervision? Will the initiatives of the chains to include clinics in their stores and/or to acquire or collaborate with physician practices result in the responsibility for immunizations being switched from the pharmacies to the clinics or physician practices?

Other questions regarding the level of education needed by pharmacists employed in chain stores will become increasingly important. With limited exceptions, the understaffing and stressful working conditions in many chain stores, do not provide the time for pharmacists to utilize their professional expertise and skills. The limited exceptions are most likely to be the "slower" stores with lower prescription volumes, that are also the least profitable and most likely to be closed by chain management. Therefore, is it necessary to require chain pharmacists to complete a minimum of 6 years of education? Would 4 years of education be sufficient? Should a two-level model for community practice be actively pursued that would include "mini-service" chain stores and "full-service" professional independent pharmacies?

What is the strategy of our national pharmacy associations?

Our national associations have many excellent leaders and have provided fine programs and services. However, we are now in a period of time in which the challenges are outpacing the accomplishments. Paramount among the challenges is the question, "Who will study pharmacy?" There has already been a substantial decline in the number of independent pharmacies, and colleges of pharmacy will most likely be the next group to experience a decline in numbers because of reductions in enrollment that will threaten financial viability. There are already signs that colleges of pharmacy are becoming more competitive than collegial.

What is our profession's strategy to increase pharmacy practice standards in a manner that will be highly visible and attractive to prospective college students? What is our strategy to identify and successfully recruit the most highly qualified students to study pharmacy? I have not been able to discover such strategies but perhaps I have missed them. If you are aware of them, please share them with me. And if none of us can find them, why can't we and who should be accountable?.


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 EDITORIAL:

From a Former CVS Pharmacist

Editor's Note: As much as I would like to give credit to the pharmacist who provided the following commentary, his identity can't be disclosed because of concerns about possible retaliation against him and his current employer. However, he wishes to be available to share his experience and guidance with those who could benefit, and pharmacists with an interest in communicating with him should contact the editor at DanH@pharmacistactivist.com.

I just read your January 2023 issue about the warning from the CVS pharmacist and as someone who used to work for CVS but now works for an independent I wanted to tell you about my experience as a pharmacist. I want to first say that I appreciated CVS for giving me a chance to work as a pharmacist when no one else would (I couldn't find a job anywhere and they were the only ones hiring at the time), but I knew exactly what I was getting myself into. I knew the horror stories and had witnessed firsthand the awful working environments while in pharmacy school on rotations, but I had to receive a paycheck one way or another so CVS here I came.

I started at a 24-hour store as a staff pharmacist in the biggest volume store in the district at around 3,500 scripts a week. Everyone I did training with warned me that they threw me into the worst store to start my career off with and that I'd quit within six months. They weren't wrong about the store but they were wrong about me quitting. The first four months were absolutely miserable. We were at least 600 scripts behind in the queue every day no matter how much help we had. Customers were always mad, our work environment was atrocious, and no one cared how bad we were doing. The only reason we ended up out of the hole was because a very wealthy and powerful customer with a direct line to our CEO/President at the time called and complained about having to wait for a prescription that had been called in earlier in the day. Within a month we had more techs than I have ever worked with along with more pharmacist hours than we knew what to do with. We were back up and running along at 100%, but it's sad that a high-profile customer having a temper tantrum is the only way we could get our store fixed. I will acknowledge my manager at the time was a great manager who stood up for his employees (the ones that actually showed up to work and did their job) and I appreciate his dedication to actually helping customers and coworkers alike.

A couple of months later I took a manager position at another CVS pharmacy that needed help getting back on its feet. This store wasn't as bad as the previous one and did about half the volume. I found myself again very behind due to incompetence (had a tech who was very lazy and a staff pharmacist with one foot out the door), no tech help, insurance changes that brought more scripts in than we could handle, ridiculous vaccine quotas, and at the start of the year our tech budget was slashed in half. I was told at the time to suck it up and do what I was supposed to with what I had been given and that every other store had the same issues but mine was the only one failing. I would never forget that. I had medicine that expired over a year before I took over on my shelves because I couldn't find time to go through and pull meds, I had multiple customer complaints about how I was lazy at my job because I couldn't get to a phone quick enough while trying to do four other jobs at the time, that I was a jerk because I let my emotions get the best of me at work when I couldn't help a patient in a timely manner, and I was terrified I would lose my job because my job performance was so bad according to company standards. I cried in my mom's arms when she came to see me at work one day because I didn't know if I could handle being a pharmacist with CVS anymore. Anxiety was out the roof, relationships suffered, I was always angry and dreaded work, and worst of all my faith suffered as result of it. After about 9 months from when I took over we finally pulled through and became a store that was reliable and running smoothly. But I never forgot what they told me. Suck it up and do what we tell you to do. I lost count of the incorrect fills and errors that occurred because I was so rushed to fill scripts to meet demand and keep my scripts from entering the dreaded "Red status."

After another 6 months I transferred back closer to home and took over an even smaller store and ran it smoothly for 2 years. Didn't have near the issues I had previously but I still hated it. My first district manager at my last CVS stop was great though. He left me alone and allowed me to do my job my way. The next boss was not great. We didn't like one another from the start. I was on his hit list from the moment he started because I bucked the system and called them out on their crap. The vaccine mandate that came from corporate headquarters was the icing on the cake that pushed me out.

Thankfully I found my dream job. I took a job with an independent pharmacy about a year ago and I couldn't keep the smile off my face my first day at work. If I hadn't been hired to work at my new job I would have left the profession of pharmacy within 3 years. The boss I have now is incredible. He gives me free reign to take care of customers the best way possible and doesn't push a bunch of corporate crap down my throat to make higher-ups happier. I truly believe him when he says we take care of customers first and foremost to the best of our ability. For the first time ever in my career I actually feel like a pharmacist who makes a good impact. I used to fear phone calls from my bosses at CVS, but I don't fear them from my new bosses here. In fact I welcome their calls. To all who are reading this and stuck with a corporate pharmacy they hate working for, I want you all to know there are better places to work and opportunities are available and that my deepest empathy is with you right now. It might not be your desired location and most likely the pay will be less (although I might argue independents pay more because I know for a fact CVS and Walgreens are firing older pharmacists who make $65-70/hour and hiring new pharmacists at $40-45/hour to do the same job), but it's worth it. I promise you the grass is greener on this side and I will do my best to never go back. I've said many times that I will go take over my dad's business before I go back to corporate pharmacy and I mean it. The two best days of my life are 1) my wedding day and 2) the day I turned in my 2-weeks notice to my boss at CVS. I was asked what would it take to keep you here and I said there's no amount of money you can throw at me for my freedom from here. I tell everyone that asks how much better working for an independent is over corporate. Losing my benefits and some of my pay was worth my mental health and happiness. I hope that anyone reading this who has a similar story will share it with others. The only way we can enact change is for everyone to see these stories. May God bless you all the way he has blessed me  and remember that he will give you what you need and desire if we put all of our faith in him.

Mark 11:24 "Therefore I tell you, whatever you ask for in prayer, believe that you have received it, and it will be yours."

Sincerely,
Former CVS Pharmacist

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Leadership Wisdom and Perspectives

Editor's note: As a value-added feature of The Pharmacist Activist, I am pleased to start including commentaries prepared by pharmacist leaders and other experts in this issue and some future issues. The first of these "Leadership Wisdom and Perspectives" commentaries has been written by Lowell Anderson whose numerous responses and comments on previous issues have been of great value for me.

Our Profession's Brand Failure

By Lowell J. Anderson, Pharmacist*

A little background

Nationally college enrollment continues to decline at about 4% per year. Speculations as to the reasons are several: increasing number of jobs no longer require a 4-year degree and many of those jobs pay quite well; the unsustainable and unrecoverable cost of higher education; changing attitudes about work and career, and; irrelevance of many college majors and degrees as preparation for employment.

Application and enrollment numbers for pharmacy are even lower than the national averages for colleges. In the five years ending 2022 there was a 30% decrease in applicants as measured by the Centralized Application Service (PharmCAS). And even with that not all available seats were filled.

Going forward, will the resulting reduction in workforce require rethinking of the respective roles of pharmacists, technicians, and automation? Might we even consider bringing back pharmacist assistants as is the practice in much of Europe?

In contemporary society we like to talk about "root causes." So, what are the root causes specifically for our profession's applicant decrease beyond those that apply to college enrollment in general?

I believe that the single biggest root cause is the image that the pharmacy profession presents to the public and therefore to young people choosing careers.

That was then

When I made the decision to be a pharmacist – and for many years after, the corner drug store and the local pharmacist were the face of pharmacy. There was usually a locally owned pharmacy in nearly every town in America, as well as one in nearly every neighborhood in our cities.

Among the historically unrecognized values of these community pharmacies was that they provided the first job for many young people – a positive experience that benefited them throughout their working life. They witnessed the relationship that the pharmacist had with their community and with other health-care professionals. They observed the pharmacist as a person who was essential to the health and well-being of their community. The pharmacist was a friend and trusted adviser to their families. These positive experiences resulted in many of these young people choosing pharmacy careers.

This is now

What does the young person looking for a career see at the pharmacy today? There are so few locally owned community pharmacies remaining that the big-box pharmacy is for many the only opportunity to see a pharmacist in action. Here they will see a person in a back room trying to stay ahead of the unrelenting demand for quick, cheap and accurate. Nor do they see the institution-based pharmacy clinicians as they practice their profession. They can never talk to a pharmacist should they wish to – and chances are their parents' prescriptions are delivered by the postman anyway.

Tomorrow's Challenge

Reputation and brand are significant determinants of market success – and must be earned. The evolution of the marketplace has caused our brand to suffer because the image we now present to the public is of a faceless someone who puts pills in bottles. I recognize that other health professions are also experiencing brand deterioration. I wonder how they are addressing these changes.

In my opinion our brand's failure contributes significantly to the fact that 5000 fewer young people chose pharmacy for their career in 2022 than did in 2018.

Should we be satisfied with the way our profession's brand has changed over time? If not, what are we going to do about it? Maybe the better question is Are YOU satisfied with YOUR profession's brand? If not, what are YOU going to do about it when YOU go to work tomorrow?

*Lowell J. Anderson, D.Sc., FAPhA, FFIP, practiced in community pharmacy for most of his career. He is a former president of Minnesota Pharmacists Association, Minnesota Board of Pharmacy, and APhA. In addition, he has held positions in the Accreditation Council for Pharmacy Education, National Association of Boards of Pharmacy, the United States Pharmacopeia, and as co-editor of the International Pharmacy Journal. He retired most recently as Co-director of the Center for Leading Healthcare Change, University of Minnesota; Manager MTM Network, UPlan MN. He is a Remington Medalist.

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