EDITORIAL:
As Wake-Up Calls and Crossroads Warnings are Ignored -IS PHARMACY NOW ON LIFE SUPPORT?
"This is a wake-up call for Pharmacy!"
"Pharmacy is at a crossroads!"
Pharmacists have heard these declarations so often in recent years that they have become almost routine and lacking in urgency and actions. These statements made by leaders of our profession, as well as individual pharmacists, are well-intended and communicate important concerns. However, to what extent do they lead to actions that have results that effectively respond to the challenges and opportunities?
Have we slept through the wake-up calls? Are we still standing at the crossroads in a state of indecision about which road to take, or even retreating in a state of confusion? Yes, there have been strongly-worded statements, policies, and resolutions in response to concerns, as well as declarations that the current crisis must never happen again. But "words" have little meaning unless they are accompanied by decisions and strategies that result in needed actions and changes.
I was recently speaking with a pharmacist friend who has extensive experience with national and state pharmacy associations. He caught me off-guard with his statement, "Pharmacy is on life support!" This was not voiced as a question as it is in the title of this editorial, but rather his conclusion regarding the current status of our profession and whether it will survive. Our ensuing discussion confirmed that we have the same concerns, and frustrations that our profession has been too timid, weak, and ineffective in responding to challenges that threaten our survival.
The "words" used to describe the threats that pharmacy faces do not matter but how we respond does. Does our profession have the commitment, ability, and resolve to achieve progressive change? My response to that question is "Yes," BUT those qualities are not impactful or evident now, but must be soon if our profession is to not only survive, but thrive. I do not claim to know the specific strategies and actions that are necessary, but my long-term experience in the profession positions me to provide opinions that I consider essential for success.
The basics
1. Community pharmacy is the foundation on which the profession of pharmacy is constructed and continues to exist. It is our largest and most visible entity, and provides the identity of the profession for the vast majority of the public, legislators, and other decision-makers.
2. No other area of practice/responsibility within pharmacy has the size, strength, and identity to replace community pharmacy as the foundation of the profession. Therefore, all other areas of practice/responsibility are dependent on and have a responsibility, both individually and collectively, to preserve and strengthen the foundation of community pharmacy.
3. We should be encouraged and inspired by knowing that the expertise and skills of pharmacists, individually, collectively, and synergistically, are of unique and important value for the health of the public, and that the discovery, formulation, and dispensing of medications, coupled with counseling and monitoring, are essential for optimizing the quality, effectiveness, and safety of drug therapy for patients. Our patients and the public can be our strongest allies.
4. We must not compromise the quality, safety, and value of our responsibilities and services, or our personal integrity, in response to employer, efficiency, expediency, and other pressures.
5. We must not be silent, passive, or timid in being advocates for our profession, but must be bold and confront the individuals and organizations which ignore, diminish, or undermine the value of our knowledge and services. The destructive actions of PBMs (e.g., CVS Caremark, Express Scripts, Optum) and health insurance companies on the practice of pharmacy and patient care have been extensively publicized, and several pharmacy associations have been highly critical of and have initiated legislative proposals and legal actions against these companies. However, to date, these actions have been fragmented, weak, and of limited success. With the exception of chain pharmacists and a small number of others, our profession and its associations have ignored and refused to confront the large chain and "big-box" corporations with pharmacies regarding their damage to the applicant pool needed for the future of our profession, and their staffing and workplace conditions that jeopardize patient safety, as well as the mental and physical health of their pharmacists and other staff. Executives of these corporations "talk a good game" in claiming to support the expansion of the professional roles of pharmacists, while concurrently operating their stores with inadequate staffing, metrics, and other conditions that preclude adequate practice and safety standards. Their hypocrisy must be recognized and exposed.
Many pharmacists with responsibilities in areas other than community practice, and the associations that represent their "specialty" areas, ignore or are ignorant of the fact that it is the foundation of community pharmacy that enabled the extension, specialization, and diversity of the roles, responsibilities, and sites in which these pharmacists are employed. Some even attempt to separate and distinguish themselves and their "professional" roles from what they consider to be the chaos and minimal standards and services in community pharmacy.
Community pharmacies/pharmacists preceded the establishment of colleges of pharmacy, professional associations, major pharmaceutical companies, and practices of pharmacy in hospitals, specialty pharmacies, and other areas of responsibility. Community pharmacy was and, in spite of current challenges, continues to be the foundation of the profession of pharmacy. If our foundation crumbles, the rest of our profession will also. No other areas of pharmacy employment, individually or together, have the size, distribution/accessibility, visibility, identity, or strength to claim the status of a health profession.
6. Colleges of pharmacy must assume greater responsibility in developing and providing professional practice roles for students and graduates, and instilling within their students the importance of professionalism, organizational membership/participation, and activism.
7. Professional associations must critically self-assess their successes and failures in serving their membership, and the interests and welfare of the entire profession of pharmacy. Hard questions must be asked in a context that inspires action and change. Examples include:
In addition to serving the interests of its members, to what extent is the association supporting the interests and welfare of the profession of pharmacy?
Does the national and state organizational structure of pharmacy associations best serve the interests and advancement of the profession of pharmacy? If not, what alternatives should be actively considered?
What are the three most important accomplishments of the individual associations within the last three years?
Has the number of pharmacist members of the professional associations significantly increased in the last several decades to a degree that corresponds to the increased numbers of colleges of pharmacy and pharmacy graduates?
Why has the number of applicants to colleges of pharmacy significantly declined, and what actions are being taken to reverse that trend?
How do pharmacists view and rate the effectiveness, strength, and influence of the professional associations?
What percentage of pharmacists personally pay membership dues in one or more professional associations?
Why do so many recent pharmacy graduates not join or continue their membership in professional associations?
To what extent are the associations transparent with respect to the sources and amounts of non-dues revenue?
What percentage of pharmacists in full-time practice responsibilities can be considered to be "practicing at the top of their license?"
How do pharmacists rate the profession of pharmacy on a scale ranging from "apathetic and weak" to "active and strong?"
How do pharmacists respond to statements such as: "I made the best decision in studying and pursuing a career in pharmacy" and "I made the best choice in selecting my college of pharmacy and my career pathway?"
Answers to some of these questions will not be encouraging but are of value in determining priorities and a course of action to respond to current challenges and being proactive in responding to new opportunities.
8. Our profession must assume ownership and leadership in preventing medication/dispensing errors and assuring the safest use of medications.
9. Our profession must assume ownership and leadership in assuring the quality and potency of medications dispensed, and optimal therapeutic outcomes for patients.
10. Our profession must not tolerate understaffing and working conditions that increase the risk of errors and cause mental and physical health challenges for pharmacists and other staff. We must support those who have the courage to criticize and take actions (e.g., unionization of chain pharmacists) to respond to these challenges.
Wake-up calls and crossroads warnings have been ignored! I will stop short of characterizing our profession as being on life support because of my continued hope that pharmacy can attain our unfulfilled potential. "Crisis" may be a characterization that encourages rescue. Which pharmacists and associations will provide the necessary leadership?
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EDITORIAL:
Protest at Express Scripts Headquarters – May 17
Loretta Boesing is a patient safety champion and strong advocate for independent pharmacists. Her son is a transplant recipient who was prescribed immunosuppressive medications to reduce the risk of rejection of the transplant. She initially obtained the medications from her trusted local pharmacist but the terms of her family's prescription plan required that she obtain the medications from a mail-order pharmacy. Her son's transplant was rejected and Loretta was aware that his immunosuppressive medications were delivered on a 102-degree day. Upon further investigation, Loretta was shocked to learn that, even though the manufacturers of medications identify safe storage temperature guidelines, mail-order pharmacies are essentially unregulated with respect to the conditions under which they ship and deliver medications. Her recognition that her son's medications were not protected against heat extremes for many hours raises the possibility that the medications deteriorated and lost potency, and their reduced effectiveness may have been an important factor in the rejection of the transplant. After hospitalization and changes to his immunosuppressive medication, Wesley recovered.
Loretta was determined to learn as much as possible about prescription benefit programs that require patients to use mail-order or other selected corporate pharmacies and exclude participation of local pharmacists, as well as the safety protections (or lack thereof) pertaining to the storage and shipping of medications. She was inspired to establish Unite for Safe Medications (uniteforsafemedications.com) to increase public awareness and support actions that would improve safety in the use of medications. Her messages reach thousands of consumers, and also many pharmacists and other professionals. She has met with multiple boards of pharmacy to request the adoption of regulations that protect the quality and potency of medications distributed by mail-order pharmacies. Her website states her commitment to "ensure that medications are properly handled and patients have options and coverage to a pharmacy staff who knows them personally, and that America's trusted pharmacies are allowed to compete and are paid fairly."
Loretta and Unite for Safe Medications have organized a protest on Friday, May 17, 2024 (9 am – 1 pm CT) against Express Scripts on the public sidewalk in front of the PBM's headquarters (1 Express Scripts Way, St. Louis, Missouri). Numerous pharmacists, including representation from the APhA, NCPA, and PUTT (Pharmacists United for Truth and Transparency) will be participating, as well as other health professionals whose responsibilities are restricted/compromised by the PBMs. A high priority is also being given to have a large turnout of patients/consumers, families, the public, and the media. Help spread the word and encourage participation of those who are in a position to do so!
Thank you, Loretta, for your strong advocacy for medication safety measures and the services of independent pharmacists!
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Pharmacy Workplace Challenges – Moral Injury, Trauma, Mental Health
Many of my recent editorials in The Pharmacist Activist have addressed understaffing and highly stressful workplace conditions in many chain pharmacies. In addition to an increased number of errors and the risk of harm to patients, the corporate-imposed workplace experience creates challenges to the mental and physical health of pharmacists and other employees. The workplace challenges may add to other difficulties such as family and other personal relationships and financial concerns. Although the profession of pharmacy must address many important issues, none are as personally threatening to the health and welfare of individual pharmacists as the mental health consequences of workplace moral injury and trauma.
Some pharmacy associations and individual pharmacists have given a high priority to these challenges and have voiced strong concerns and provided self-evaluation tools and strategies for coping with mental health issues. These are important actions that are of value to some. I wish I could say that the workplace problems are less frequent and intense, but I can't because the corporations that are responsible for the workplace problems have essentially done nothing to improve working conditions. If anything the challenges have worsened.
Pharmacist Helen Sairany has the personal and professional experiences and abilities which position her to authoritatively address trauma challenges and propose helpful interventions. As a Kurdish child living in war-torn Iraq, she endured experiences that subsequently resulted in her diagnosis of post-traumatic stress disorder (PTSD). She aspires to live "in a world where the vast majority are trauma-informed, feel psychologically safe and valued for their work they put out, and return home fulfilled." Since the outbreak of the COVID-19 pandemic, she has openly shared her dormant childhood trauma, and given presentations at national and international forums on topics such as trauma-informed care, leadership, and the workforce. I have read and learned from both of her books, "Grenades for Candy; A Kurdish Refugee's American Journey," and "The We You Don't See; Understand the Long Shadows of Trauma."
Most recently, Helen has developed the Trauma-Informed Workforce Certificate Training Program that is designed to gain mastery of everyday stressors, increase self-awareness, boost workplace morale, and elevate overall well-being. Modules include topics such as "Is Workism Making us Sick?" "Your Introduction to Trauma," "Leading in Times of Trauma," "Don't Bring it to Work: Childhood Patterns that Limit Success," "Identifying and Working With Hidden Saboteurs," "Working With ‘Never Good Enough' Imposter Syndrome," "Narcissism Bullying Harrassment, and Spiritual Bankruptcy in the Workplace," "Weapons of Mass Distraction," "How to Cultivate a Culture of Belonging," and "The Addict in All of Us." Additional information can be obtained on her website, drhelensairany.com.
Helen had asked me to review an early draft of the module, "Weapons of Mass Distraction." I found it to be very informative and thought-provoking, and her knowledge of the publications and experiences of others is impressive. She has provided a valuable service in transforming her expertise and experiences for the benefit of others. If you, a family member, friend, or colleague is coping with trauma/stress, access the website to learn more. The consequences of harm to one's mental health can never be overstated, nor can the value of a caring and helpful recommendation.
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