I spent one year working full-time as a pharmacy technician at a high-volume community pharmacy prior to entering medical school. Besides learning the intricacies of billing and the dispensing process, I was also granted access to a world few physicians are aware of. At the time, my job was just that — a job. There were perks like counting pills in multiples of five and visualizing colors and sizes of tablets that I had never come across before. Yet it wasn’t until medical school that I began to fully appreciate my pharmacy knowledge.
My school has a free student-run health clinic and I was asked to manage its dispensary of over-the-counter and prescription medications. The dispensary was in disarray when I took it over; medications were arranged by their most common indications, making it difficult for students to efficiently find specific medications requested by their attendings. After a unanimous vote from the student board, I set to work rearranging the shelves alphabetically. Locating and dispensing necessary medications at no cost to our special population of un- and underinsured patients became much easier.
Everything was running smoothly until a group of physicians, who volunteer in the weekly resident-only clinic, saw the shelves. There was a minor revolt, in the form of a collaborative hand-written page of notes from residents and one attending, requesting the dispensary be returned to its original arrangement. They were unable to locate specific medications since the change and stated they didn’t “think like a pharmacist.” Apparently, these physicians had been searching in vain for the trade names of decades-old medications. I arranged the shelves back into their general sections — anti-depressants, antipsychotics, beta-blockers and miscellaneous, even though many medications have dual purposes or off-label uses that span multiple categories. After implementing these desired changes, physicians and students continued to search for brand names of medications that have for years only been found as generics.
Brand versus generic is only one reason why a pharmacy elective should be offered to medical students. In a time when health care systems and patient compliance are thoroughly being studied, we cannot forget the pharmacy as an integral continuing part of patient care after departure from the hospital or clinic. I have seen from personal experience that a provider who talks to a patient solely about Effexor during a visit will cause future confusion, and perhaps distrust, of the venlafaxine prescription that ends up being given to a patient at the pharmacy window.
There are also issues when prescription strengths aren’t accurately prescribed. Our pharmacy had numerous cases of providers writing “Vicodin” and “Norco” prescriptions with the incorrectly written hydrocodone-acetaminophen dosage combination (5/300 mg and 5/325 mg, respectively). While this may seem like splitting hairs, both medications are Schedule II drugs due to their hydrocodone content; therefore, prescribing and dispensing them is carefully monitored and scrutinized by both the pharmacy and the Drug Enforcement Agency (DEA). Patients would often have to wait while we phoned the prescriber for clarification on which medication they intended to prescribe. If the prescriber could not be immediately reached, then the patient would have to leave without getting the pain medication filled.
There also seems to be some confusion among providers on DEA scheduled classes of drugs. Several providers I have spoken with seem unaware of classifications numerically higher than Schedule II drugs, which include the infamous Fentanyl, oxycodone and amphetamines. While this is certainly an important class to be aware of, addiction and abuse still occur with benzodiazepines, modafinil and tramadol — all Schedule IV medications.
Familiarity with physical characteristics of medications is also important; knowing that many types of potassium tablets are available for dispensing, some of tolerable size and others of horse-pill size, could mean the difference between a patient using their medication and not taking it. Medication sizes, smells and textures are all factors involved in patient compliance — and most importantly, so is cost. Understanding how expensive some medications can be for our patients and how much of a burden this puts on them — especially for Medicare Part D patients in the “donut hole” — is essential. Working in the pharmacy introduced me to ways to help patients who cannot afford their medications: drug distributor coupons and prescribing syringes or vials of medication rather than auto-injector pens can all save patients a great deal of money. A 10mg strength tablet of a medication might be on a pharmacy’s discount generic list, whereas the 20mg strength is not. The year I worked in the pharmacy, doxycycline hyclate was hundreds of dollars cheaper than the same dosage in doxycycline monohydrate — nearly interchangeable antibiotics that varied so widely in cost we would often request a prescription change for the benefit of the patient.
When business got slow I used to pass the time in our pharmacy by having our pharmacists identify stray pills. I marveled at their quick identification of names and dosage strengths (not an easy feat with several manufacturers per generic drug, and hundreds of drugs within the pharmacy). I don’t expect providers to be at this level, as we don’t have four years of pharmacy school under our belts. I do, however, see the value in knowing more than just the mechanism of action and common side effects of the medications we prescribe to our patients on a daily basis. As our own schooling is intense and long enough, I like to see pharmacy electives offered during fourth-year of medical school. As medical schools continue to teach us to consider non-physiological aspects and barriers to our patients’ health and well-being, so too should they consider the major impact that specific medications and pharmacy interactions have as well.