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not to harm you, plans to give you hope and a future." Jeremiah 29:11
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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.
February 2024 Issue [Download PDF format]
In this issue:
• Should chain pharmacists unionize? YES!
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EDITORIAL:
Should chain pharmacists unionize?YES!
The number and severity/harm of medication errors for patients continue to increase.
Many chain stores are significantly understaffed, contributing to a toxic culture and stressful workplace that result in mental, physical, and moral injury for pharmacists and other employees.
The large chains are destroying the applicant pool of young people who might consider a career in pharmacy as they hear and observe the stress, negativity, and criticisms of chain pharmacists.
The professional community practice of pharmacy is under siege and disappearing as a consequence of the actions of chain executives, PBMs, and insurance and pharmaceutical companies.
Many associations, boards, and colleges (ABCs) of pharmacy ignore, and/or are inactive in responding to the challenges.
The future of the entire profession of pharmacy and the quality and safety of drug therapy are threatened.
The profession of pharmacy, without powerful allies, can't substantially influence the role and destiny of community pharmacy practice, and large chain stores won't.
Lawsuits and legislative proposals responding to these challenges are necessary and must be supported, but the influence of pharmacists and our ABCs is limited and dependent on courts and legislators in what may be years-long processes with no assurances of favorable outcomes and actions.
Urgent actions are needed!
There is a strategy through which pharmacists can not only influence, but control and move more quickly in attaining favorable outcomes.
Pharmacists in large chains must unionize!
Many recipients of The Pharmacist Activist, as well as my former students, will be surprised by my having become an advocate for the unionization of chain pharmacists. Until now I have not viewed unionization as a course of action that would best address the concerns of the profession of pharmacy, and some background for my change of opinion is appropriate.
One of my responsibilities as a faculty member at the Philadelphia College of Pharmacy was to identify and facilitate discussion of the Ethics topics included in the Pharmacy Law and Ethics course. One of the topics I included was the unionization of pharmacists and, following the discussion of a topic by the students, I would provide my personal views. In recognizing that the ultimate course of action of a union is to call a strike of its members, I voiced my opinion that if I was a member of a union of faculty members, I would not participate in an action to strike, even if there were valid and important reasons to do so. My rationale for not participating in a strike action was my knowledge that it would be my students who would be at the greatest disadvantage and inconvenience by having their education interrupted and possibly delayed. In the pharmacy practice workplace, it would be the patients who would be at the greatest disadvantage because of the delay in obtaining needed medications. My conclusion was that I could not urge pharmacists to participate in a union that might call a strike if I personally would not be willing to do so.
Over a number of years, I have written many editorials and made recommendations such as urging the executives of large chains to implement substantial changes, urging the national pharmacy associations and others in our profession to provide an organizational structure and resources that will facilitate the recruitment and active participation of a large number of chain pharmacists, and the formation of a national association of chain pharmacists. These recommendations have failed to generate any actions or even serious interest among those in our profession who are best positioned to provide leadership which results in successful change.
I have been fortunate in having had recent extended phone discussions with pharmacists and other individuals with expertise, experience, and valuable perspectives in the broader context of health care. I have learned from these individuals and their perspectives and opinions, and their views have expanded my analysis and reaching a conclusion regarding an action that I consider important and urgent for the community practice of pharmacy specifically, and the entire profession of pharmacy in general.
The Kansas City walkout
On September 21 into September 22 a group of CVS pharmacists in Kansas City participated in a "walkout" of numerous CVS stores in that area (please see the October 1, 2023 issue of The Pharmacist Activist and my editorial, "The Courageous Kansas City CVS Pharmacists"). The walkout was brief in duration to minimize the delay and inconvenience for customers who needed prescriptions. However, the walkout quickly received national media attention for the concerns and actions of the pharmacists. CVS management quickly provided a response that included a "semi-apology" that was interpreted in different ways (i.e., "we can't deny what he said but this is what he meant") and an increase in staffing that was very self-serving, localized, probably temporary, and designed to quickly diminish negative publicity, but has not resulted in changes of egregious policies and metrics. The media coverage, however, will be of lasting value.
The Kansas City walkout was followed by an announcement of a planned national 3-day walkout of CVS and Walgreens pharmacists, designated by some as Pharmageddon. As well-intentioned as this plan may have been, it had minimal impact on the operations of CVS and Walgreens, but it has had valuable continuing media commentary. Subsequent plans have included the formation of a guild and a working relationship or affiliation with an established union, and an extension of the initial issues for the pharmacist leaders that began with the occurrence of errors and patient safety, as well as understaffing and resultant mental and physical stress for pharmacists and pharmacy technicians, but now also include increased salaries for pharmacy technicians.
Common perceptions of the roles and actions of unions are that they focus, sometimes exclusively, on salaries and benefits for their members and provide financial and other support for political candidates and issues selected by the union leadership, but with which some individual union members may not agree. Some may view these activities as valid but limited, and only serving the interests of union leaders and members.
The events of the last several months have resulted in an expansion of my understanding of how a union of chain pharmacists developed under certain conditions could well serve patients, pharmacists, and the profession of pharmacy. I consider the following to be particularly important if a union of chain pharmacists is to be credible and effective:
A group of individuals (with a majority of pharmacists) who are committed to improving the quality and safety of medication use and the services of pharmacists, and who are best positioned to provide leadership in the formation and operations of a union, should be identified.
The union must have a prominent identity of representing pharmacists or pharmacists plus other health professionals.
The union should be affiliated or have a working relationship with an existing union that already has an infrastructure that will facilitate recruitment of chain pharmacists and implementation of strategies, communications, and programs. The union of pharmacists must have autonomy in making decisions and implementing programs/actions that is not restricted by the existing union with which an affiliation or other working relationship would be established.
The primary goals should be prevention of errors, protection of patient safety, a professional and appropriately staffed workplace environment, and the avoidance of mental and physical stress for pharmacists and other pharmacy employees. The programs and actions should not include salaries, benefits, or other financial issues that could detract from the recognition of the importance of the primary goals. Although increased salaries for pharmacy technicians are very important and necessary, their addition to the initial concerns identified by the pharmacists participating in the September walkout risks the perception that the primary focus of the group's efforts is on economic issues, as is the case with most other unions.
Actions of a pharmacist's union must be well planned and organized, and provided sufficient support to assure favorable and extensive media coverage. The absence of some of these elements was a primary reason for which the planned nationwide 3-day walkout of pharmacists had little impact on the policies and operations of CVS and Walgreens.
Alliances with patient/consumer advocacy groups should be formed to expand the coverage and understanding of the concerns being identified and for which the support of the public is being requested.
Affiliations with like-minded existing unions or advocacy groups should be established to hasten the implementation of plans and actions. Affiliations with existing unions that do not currently have a strong identity with pharmacists or other health professionals should be avoided.
Walkouts or strikes should only be considered as a last resort. Although I have noted the reasons for which I would not participate in a strike as a pharmacy faculty member, I also recognize that the walkout of the Kansas City pharmacists was intentionally brief in duration so that patients/customers would not be inconvenienced for long periods of time. A concern that I often hear from chain pharmacists is that understaffing results in substantial delays (e.g., a week or more) in completing large numbers of prescriptions that are backed-up in the queue to the point that pharmacists triage the backlog to give priority to the prescriptions for which prompt availability is most important. In this context the impact of a short-term strike would differ little from the situation that already exists that has been caused by chain management.
In a recent discussion with a reader of The Pharmacist Activist, I was made aware of the Doctors Council (doctorscouncil.org) with a membership of physicians and dentists that is identified as "a union of doctors, for doctors, run by doctors." I am very impressed with that description, although I would have added "for the health and safety of our patients." The Doctors Council is a national affiliate of the Service Employees International Union (SEIU). I have also had several recent discussions and have learned from individuals who have expertise and experience that I don't have regarding employee/employer relationships.
I have certainly not hastily reached the conclusion that chain pharmacists should form a union and the recommendations that I am now providing. My one regret is that I did not have the vision to anticipate and be an active participant much sooner in decisions and actions that might have avoided the crises to which we must now respond.
CVS
Moving forward, a high priority should be given to exploring the formation of a Pharmacists Council that would be affiliated or have a working relationship with the established Doctors Council. When the infrastructure for the union of pharmacists is established and appropriate strategies identified, the recruitment should begin with pharmacists at CVS, the largest employer of pharmacists and the company with the most egregious and destructive executive-imposed policies and metrics.
It can be expected that CVS will claim that most of its pharmacists are "managers" or "pharmacists-in-charge" and, therefore not eligible for union membership and representation. This claim is disingenuous and must be rejected because pharmacists in CVS stores are not permitted to have autonomy and authority for the most important decisions that might be considered the responsibility of a manager, such as staffing levels, protecting the safety of customers and employees, and the establishment of a workplace culture that is professional and positive. Therefore, the pharmacists designated as "managers" are employees with added responsibilities but no authority. The designation "manager" does no more than provide a shield that protects higher-level employees/officials from any personal accountability when errors, violations, and lawsuits occur. CVS pharmacists who voice concern about or even question decisions and policies mandated by the actual managers at CVS, are at risk of disciplinary action including termination for some other fabricated reasons used to "justify" the actions. When errors or violations occur, these same pharmacists are at risk of suspension or revocation of their licenses by the state board of pharmacy. The pharmacists incur all the personal risks, but have no authority!
Walgreens
The experiences and risks for Walgreens pharmacists are no better than those for pharmacists at CVS, and they are the second group of pharmacists to be recruited for union membership, UNLESS there would be rapid, substantial, but unexpected reform in Walgreens priorities, policies, and operations. In July 2023, the title for my editorial in The Pharmacist Activist is "Can a Large Chain Change Priorities? If I was the CEO of……." In that commentary I voiced my opinion that Walgreens, which was started in1901 by pharmacist Charles R. Walgreen, Sr., would be the best candidate to "reform." Sadly, if Charles Walgreen, Sr. was alive today, I do not think that he would recognize the company that bears his name and would be shocked by what he saw. In that commentary I identified 5 reasons for my opinion and 10 actions I would take if I was the CEO of Walgreens.
I wish I could say that there was even a flicker of an encouraging response, but there has not been. The individual who was CEO of Walgreens Boots Alliance in July has since resigned or been terminated. The most extensive previous experience of the recently appointed CEO was as an executive at Medco and as CEO of Express Scripts. Therefore, it can't be expected that any priority will be given to patient safety, better staffing in pharmacies, and strong commitment and advocacy for the professional role and services of its pharmacists. Conditions in Walgreens stores could go from "very bad" to "worse." However, if Walgreens leadership would substantially change corporate priorities and commit sufficient resources to implement and sustain the above changes, I would be pleased to commend and publicize those actions. I challenge Walgreens to become the anti-CVS!
There are also other large corporations that operate pharmacies including chains (e.g., what's left of Rite Aid), big-box stores (e.g., Walmart), and grocery stores (e.g., Krogers) in which unionization could be advantageous for pharmacists.
Positive exceptions
There are companies that highly value their pharmacists and other employees, and a positive workplace culture, are committed to the provision of medications, counseling, and services that will assure favorable therapeutic outcomes, and at which there is no need or advantage to consider unionization. Wegmans is a regional grocery company with approximately 100 locations that provides a family-like workplace culture that is valued by its pharmacists and other employees. The turnover rate is very low.
I am not familiar enough with Publix to comment about its pharmacies, but I am very impressed by what I have heard and read. It is the largest employee-owned company in the U.S. and I would like to think that the pharmacies are well-staffed and operated professionally, but I need to learn more.
Positive to negative
Pharmacist positions in Target stores were highly regarded and sought before Target sold its pharmacy operations to CVS. This change created a toxic workplace for its pharmacists and pharmacy technicians, and a higher risk of errors and harm for patients. Now CVS is closing dozens of its pharmacies in Target stores that it doesn't consider profitable enough.
There are also other large groups of employed pharmacists for whom unionization may have advantages.
Mail-order pharmacists
Mail-order pharmacies may provide better and more predictable work schedules, as well as meal and bathroom breaks. However, assembly-line operations and call centers with incentives to have only brief conversations with invisible patients will not provide professionally stimulating and fulfilling employment experiences for pharmacists. For the vast majority, there is no personal communication with patients and this reduces the motivation to maintain and build drug therapy expertise that will not be used.
Hospital/health-system pharmacists
There are pharmacist positions in hospitals that are professionally fulfilling and some require advanced training, experience, and/or specialized expertise. However, many hospital pharmacists have no personal communication with patients with the result that their role and services are invisible and unknown. As the decision-making executive positions in hospitals/health-systems are increasingly occupied by individuals who are not health professionals (e.g., individuals with business/management backgrounds and experience, venture capitalists), hospital pharmacists will more often encounter challenging workplace experiences. The same challenges and moral injury now experienced by chain pharmacists may soon be experienced by hospital pharmacists.
Media coverage
I had intended to review in this commentary the media coverage of the challenges and risks experienced by patients and pharmacists. Within the last several weeks, there has been an avalanche of media attention to these topics, and I will identify and summarize this coverage in an upcoming issue of The Pharmacist Activist. However, I will not wait to identify two exceptional investigate reports:
"CVS pharmacist's death becomes cautionary tale of crushing stress at work" by Emily Le Coz (USA TODAY – online version published February 8 and print version on February 13).
"What's Gone Wrong at Pharmacies? A CVS Store in Virginia Beach Holds the Answer" by Catherine Dunn (Barron's – online version published February 9).
To consider these as news "articles" does not do justice to these commentaries. They are thoroughly-researched investigative reports that are extensive and explosive. They should be required reading for every pharmacist and pharmacy student!
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