Healthcare 2013. Despite the tremors rattling its foundations amidst major healthcare reform legislation, it is an immensely powerful and productive industry, accounting for 17% of the gross national product, employing countless professionals in a galaxy of stakeholder groups, and spawning countless innovations that save lives and sustain health, particularly when its vast resources are managed properly. The intelligent organization of resources and stakeholder collaboration can provide the very efficiencies sought by legislation and could indeed reduce the need for government intervention to force the right things to happen to curtail costs and to improve outcomes.
Retail pharmacy has long been the quiet giant among stakeholders, yet it has immense power to influence health and affect patients’ awareness of their ability to incorporate health-giving lifestyles. Inside Pharmacy was launched to help galvanize this potential into action. In general, we turn to the seasoned experts for their insights into how to reinvent the profession to remain relevant and to bring value to healthcare as it undergoes its massive paradigm shift. Key opinion leaders (KOLs) understand the science and its practical application, making them an obvious target for our editorial content. We seek their wisdom to advise you, our readers, in establishing the leadership in your field that keeps your eyes on the prize: patient wellness. Pharmacists have considerable untapped potential to “move the dial” in the healthcare system. One tactic is the mantra of Inside Pharmacy: “Come out from behind the counter” and interact with patients, following through on the physician’s initiative and turning a prescription into a passageway for wellness that the patient understands.
Thus, you might expect our interviews to be restricted to KOLs, assuming they have the answers worth hearing. But a “tabula rasa” provided by recent pharmacy school graduates brings a useful counterpart to the seasoned professional, indeed providing us with a starting point for addressing their very inexperience, thus bringing clarity of principles before they are hitched to short-term business pressures—and clarity of purpose is nothing to be taken lightly. These graduates are the recipients of today’s updated curricula (which are generated by KOLs). That offers value in hearing their perceptions, their knowledge base, their expectations for healthcare, and their career ambitions offered by the retail pharmacy field as it undergoes a reinvention to stay viable. Entering the field during this time of disruptive innovation must be a mixture of excitement and concern, and we want to capture that. These individuals belong to the future of retail pharmacy, and they should have a voice in the pages of Inside Pharmacy alongside the experts. This month, we interviewed Margo Demeter, PharmD, a highly motivated class of 2013 graduate of Duquesne University, and present her thoughts, aspirations, and concerns as she embarks on her career as a healthcare provider with such extraordinary ability to influence patient health and bring equilibrium to the healthcare system.
Robert Henry: What led you to pursue becoming a retail pharmacist, what opportunities do you see there, and how progressive can its activities be and remain “cutting edge” without becoming “leading edge”?
Margo Demeter: Well, to begin with, my career path may differ from others, for I had 3 years of experience in retail pharmacy work but had planned on doing a residency, not retail. Then I had a rotation at Johns Hopkins in October of last year before I had to decide whether I wanted to do a residency. While I was there, I realized this wasn’t the setting for me. Having worked in retail, I could see that this was where I wanted to stay, preferring the patient interaction it offers over the clinical aspect. During the entire time I was in the hospital, I didn’t interact with any patients, and I found that this interaction mattered quite a lot to me.
Henry: At what point did you realize that retail would bring you the professional satisfaction you sought?
Demeter: The first week I was there, I realized that this wasn’t what I wanted to do. My preceptor also had a pharmacy resident there, and I was able to see everything the resident was going through. She explained to me the process, the assignments, and the work that she had to do while she was there. She was working very long hours, just as we do in retail, but I felt I wouldn’t be fulfilled by staying in an office and researching patient charts all day. That showed me that this wasn’t the route I wanted to take.
Henry: And what brings you enjoyment now in what you are doing in retail pharmacy?
Demeter: I have been at the same store for about 4 years now, so I know most of our patients that come into the store. I’m able to have conversations with them and know what’s going on in their lives aside from the medication that I’m bringing out to them. I really like being able to make those connections and form those relationships with patients, whereas in the hospital setting I didn’t feel like I could do that, especially because of constant patient turnover. You don’t see the same patients day after day as you do with retail.
Henry: What’s your biggest fear about graduating and starting your pharmacy career? Is there one for you?
Demeter: I think my biggest fear is probably the same as every new pharmacist, and that’s making a mistake. In some classes in school, we discussed that everyone is human and you are going to make a mistake at some point. But that doesn’t eliminate the fear of it, for I fear that this mistake will actually hurt somebody. So I know that it’s going to happen eventually; I just hope it isn’t anytime soon.
Henry: Is there a system in place in retail pharmacy to prevent mistakes?
Demeter: There absolutely is, at least at the pharmacy that I work at. We have a couple of workstations for people who are data entering the prescription into the system. We have barcode scanning to show the correct drug that was entered in is actually the one that’s being filled. Then, with our system, we’re able to look at the actual hard copy in the computer and see if the data entered into the computer match both to the hard copy and to what is in our system. So, there are several layers of validation that happen.
Henry: What do you consider to be the greatest opportunities offered by a career in retail pharmacy?
Demeter: In my view, it comes back to what we discussed before, just having that interaction with the patient. This is my number one priority. In the pharmacy school, one of the first questions they ask is, why did you choose pharmacy? Some people have bad responses like, “Oh, I’m in it for the money,” which is not a good response at all. But I think the main reason why people get into pharmacy is to help people. We’re viewed as drug experts, and we’re probably the most convenient medical healthcare provider for our patients and the most accessible. I think that they value that, and they value the convenience of coming to a pharmacy instead of having to schedule an appointment with their doctor. I think that they really look to us for guidance for a lot of their healthcare needs.
Henry: Do you consider that the compensation retail pharmacists receive is sufficient for the contribution that they bring to healthcare?
Demeter: I absolutely think it’s sufficient for what we’re doing. I recognize that there is some disparity between different healthcare settings for pharmacists’ compensation, but I think in every setting we are a huge benefit to our patients and the team that we end up working with.
Henry: Do you have any apprehensions about the profession as a whole, given the volatile changes occurring in healthcare?
Demeter: No, I really don’t. I do think that our career is changing very quickly, whereas in the past decade or 2 it was pretty stagnant. But with different advances and paths the pharmacist can take, I think that we are in an environment that is changing constantly. Especially with new healthcare laws, we’re going to have to adapt very quickly to those types of changes and be there for our patients who don’t necessarily understand what’s going on. I think we need to be prepared for that. But I don’t think that’s necessarily an apprehension; I just think that’s where the industry is going.
Henry: In terms of progress or stagnation, how would you say innovation in new molecular entities is faring?
Demeter: I think that there have been huge advances, even within the past couple of years, in new medications, such as personalizing medication for specific patients based on their genome. We aren’t there yet, but that’s where things are heading. Some patients with cancer, for example, can have drugs selected that treat the exact kind of cancer based on the patients’ cellular details, what mutation they have, and how their body will respond to that treatment.
Henry: For a number of disease states, the pharmacist has approximately 85% of small-molecule drugs that are off patent. Where does that leave pharma? What is your view of pharma as an innovator of new molecular entities?
Demeter: I think they are going to have to start tackling some of the more complicated disease states now to stay innovative in various types of treatment methods. But whatever they do to remain useful, just relying on extended-release versions of existing drugs is not the answer. That flies in the face of the kind of new drug innovation that existed back in 1975.
Henry: So where is drug innovation most needed and able to grow?
Demeter: I think that the innovations in biologic-
type medications is where innovation is going, and that tackling more complex disease states like the cancers and orphan diseases will be their mainstay for the foreseeable future. I think we’re entering the era of more complex disease states such as rheumatoid arthritis, multiple
sclerosis, and different cancers.
Henry: What advice would you give to students just beginning pharmacy school?
Demeter: For myself personally, I think going into pharmacy school, I didn’t really know what to expect. Our first year of pharmacy school, they attempted to weed out a lot of us, scaring us with all of the course work that we had to do, and that was absolutely our hardest year. My most important advice is that if you can get through that year, you can definitely make it through pharmacy school; it isn’t as scary as it seems. But you also need to be aware of what you’re interested in. If you realize early on that you want to take one path or another, you should get involved and try to mold yourself to becoming the best pharmacist that you can be by getting involved in things that you’re interested in. There are many different pharmacy organizations that can help students along the way. My best advice is to get involved, and try to figure out exactly what you want to do before your last year.
Henry: What does your typical day look like now?
Demeter: In a retail setting, the majority of the time is spent checking prescriptions and getting them out to the patients. The pharmacy where I work is working on medication therapy management (MTM), but we aren’t billed for MTM. We make a lot of phone calls to patients to ensure that they are getting the medications they need on time. If they’re past due, we get an alert saying this medication should have been filled, and we contact the patient to see if they need it refilled. We go out of our way to make sure that our patients are staying adherent to their medications to ensure better health outcomes. I think that a lot of our time, besides filling prescriptions, is spent on trying to contact these patients and making sure that they’re getting all the medications they need.
We also have other programs in place. One is a program for adapting care, so if we have a diabetic patient who is not on an angiotensin-converting enzyme or an angiotensin receptor blocker, we get a flag. We then have to call the prescriber to see if this was an oversight and if they should be on either type of medication. The rest of the day we spend calling doctors for refills, calling them regarding high-dose alerts, and then just talking with our patients when they come in to pick up their medications.
Henry: Does it follow that the pharmacist of tomorrow, or even of today, should be looking for ways to continue the dialogue that’s been initiated by the physician? Is that a valid way of regarding how the role of the pharmacist might be changing over time?
Demeter: I absolutely think so, and I know when I first started in pharmacy school, our professors kept saying, “In retail pharmacy, you won’t be needed as much, and they might just change to technicians to check prescriptions.” I think that retail pharmacists have been moving more toward just being able to talk with their patients about their medications in light of the MTM process. I think that being able to discuss with them all of the issues, concerns, or problems that they have with their medicine will be very valuable to them. I definitely think the future pharmacists are leaning that way.
Henry: Perhaps technology could be very useful in equipping you to reach out to your patients. I can foresee keeping in touch with your patients through smart- phone technology, apps, and the like that just require a little direction from the pharmacist community. Could this, perhaps, be where the future of pharmacist career modification is going to be headed?
Demeter: Yes, I definitely think so. I think that technology is a huge thing that our patients look for and appreciate. I know that, at least with my store, patients love going online and being able to see all the prescriptions they have, what refills they need, when they should get their refill, and being able to call them in. I think that the automation of doing that is something they definitely like, and if a pharmacist is available through technology, through smartphones and things like that, that they would definitely utilize that.
Henry: Aside from obvious areas such as adherence, are there any other areas of knowledge that you would envision being able to help the patient understand that they have a bearing on their health?
Demeter: I think that being knowledgeable about the different legislation that is occurring right now would absolutely benefit our profession, especially the patient-centered medical home. I did a project on that at one of my rotations, and that was the first time that I really delved into the topic and figured out what it was and how it could help patients. Once Medicare starts deciding that they are going to pay for this type of service, I think that the pharmacist, in talking with the physician, is the best relationship that patients can have—one that will ultimately impact their outcomes and definitely optimize their therapy just by having those open lines of communication. I think one of the biggest downfalls of our healthcare system is that it is so hard for a patient to be able to talk to any type of healthcare provider at their doctor’s office, even if they just have a question. I know whenever I’m trying to make doctor calls at the pharmacy, they have those automated prompts and you have to choose a number for whatever you need, but then it turns into a voicemail. If in this patient-centered medical home system, they’re going to be available 24 hours/7 days a week for their patients, I think that is something that definitely needs to be started and implemented, and I think pharmacy will definitely be a huge part of that.
Henry: For the past 50 years or so, adherence had been looked at as a problem that physicians around the globe were trying to resolve, yet nobody seems to have gotten through to patients as to its importance. Is it more a matter of distrust that patients have toward the side effects of medications, or is it just that they are trying to save money? Is it because they think that they’ve actually been healed and are better?
Demeter: You know, I think it’s a combination of all those things, and I think that’s why it’s so hard for us to make sure that all of our patients are adherent. I know that, with the copays and the price of the medications, it is definitely a huge deterrent for keeping these patients adherent, especially ones who have trouble making monthly copays. I also think that with the amount of counseling we have to do, and the amount of information we need to give our patients about these medications that they’re taking, it definitely scares them away sometimes. I’ve had patients who have come in and said, “I just went online and saw that this is the side effect of this medication. I don’t want to take it anymore. I called my doctor to switch me to something else.” So I think especially in this day and age with the technology and the access that patients have to things on the Internet, they can definitely get scared away from things that will actually help them.
As pharmacists, we need to be at the forefront of that and explain to them that this side effect happened in
1 in 1000 patients. It must be put into perspective—not trivialized, but made realistic. Every step you take to be treated or healed will bring an element of risk, but so too is doing nothing, and the patient has to learn how to deal with both types of risk. They have to know that it exists, but that it’s not necessarily going to happen to all or most patients.
Henry: Taking good care of the patient will be good for business, but only if it does not interfere with the processing of prescriptions, too—it must be a balancing act. Are there areas where pharmacists can be penalized for taking the time to talk with patients, and could that be an impediment to the patient getting that interaction that we have been discussing? In short, must the decision to interact with the patient have managerial, even corporate, support before attempting it?
Demeter: I absolutely think so. I don’t know if it’s a blatant penalization of the pharmacist, but I know that, at least at my pharmacy, we have certain metrics that we need to meet, which include our wait times and making sure the prescriptions are out on time. So, if a pharmacist is being graded on that, and your bonus depends on whether you get the prescriptions out or not, I think that will become more of a focus for them throughout the day than necessarily counseling every patient who walks in the door. I think that if that is a focus of the retail companies, then we might need to have 2 pharmacists on duty—1 who can check and 1 who can counsel—just so we offer our patients everything they need.
Henry: And again, never forgetting, always hanging in the background, is technology. How it can help reduce the amount of time that would come out of attending to each individual patient. Hence the need for technology to help take some of the strain off the pharmacists, enabling them to use that technological ally to help them do the special services you’re talking about. So it’s getting interesting, isn’t it?
Demeter: It certainly is.
