Pharmacists dispense pills, counsel patients, screen for illness, give vaccines

By Sandra G. Boodman

Special to The Washington Post
Tuesday, January 12, 2010

When Charley John tells people he's a pharmacist, he knows what many of them think: that he spends his workdays sequestered behind a counter doling out pills, dropping them into little plastic vials and handing them to customers.

That may have been an accurate job description for a retail druggist circa 1978 -- the year John was born -- but it bears little resemblance to the multi-tasking the job requires these days. Pharmacists, particularly those who, like John, work for large national chains, are moving into areas that have long been the exclusive province of doctors and nurses: providing immunizations for diseases including H1N1 influenza, screening for chronic health conditions such as diabetes, counseling patients about the increasing panoply of medications they are prescribed and, in a sour economy with dwindling access to health insurance and primary care, offering basic medical advice. Health-care reform legislation would probably increase pharmacists' involvement in patient care by expanding reimbursement for certain kinds of medication counseling.

"We are the face of neighborhood health care," said Edith Rosato, a senior vice president of the Alexandria-based National Association of Chain Drug Stores. "We see the role of pharmacists as helping the patient improve health outcomes," not merely dispensing drugs.

Pharmacists' training and duties, Rosato said, have undergone a metamorphosis in the past two decades, as health care has become more complicated and the use of medications has exploded. Between 1997 and 2007, the number of prescriptions purchased by Americans increased by 72 percent, from 2.2 billion to 3.8 billion, according to a 2008 report by the Kaiser Family Foundation.

Pharmacists have become "physician extenders" in hospital and community settings, said Lynnae Mahaney, president of the American Society of Health-System Pharmacists. Drug therapy, a cornerstone of treatment for everything from attention-deficit disorder to whooping cough, is "much more complicated, both the number of medications we have and the number of patients" taking medicines, she said. The nation's 100 colleges of pharmacy have overhauled their programs, extending training from a four-year bachelor's degree to a doctorate that requires six years of schooling.

John, who began working for Walgreens while a student at the University of Florida, says he regards talking to patients about their medicines and their health as the best part of his job. "I was always interested in medicine, and I really wanted to be an expert on what is safe [and] on the impact of drugs on the body," said John, who manages to be unflappable, efficient and empathic.

He is the pharmacy manager of Store 10616, open round the clock and located along Alexandria's busy Route 1 corridor, a diverse slice of urbanized suburbia that includes raw-looking new townhouses, high-rise condos, garden apartment complexes and a handful of inexpensive motels.

John oversees a staff of 10, half of them pharmacists, and contends with a steady and occasionally frenzied work flow; his store fills between 100 and 200 prescriptions per day, well below the 500 a really busy pharmacy dispenses.

The job requires physical stamina -- pharmacists stand for hours on end -- as well as the ability to deal with frequent interruptions, little downtime, the arcane rules of dozens of health plans, and customers who can be harried, confused or needy.

Recently a reporter spent several days with John as he brewed liquid Tamiflu for sick children; screened people at a walk-in diabetes clinic; filled dozens of prescriptions, many for painkillers and antibiotics; and provided basic medical advice to a steady stream of customers, some uninsured or visibly ill.
 
Free Screening

The free, six-hour diabetes screening clinic had been advertised for weeks and John, hoping for a big turnout, arrives early to set up tables in the cosmetics aisle at the front of the store. Two drug saleswomen lugging large sample cases arrive to lay out their wares, which include a stack of glossy pamphlets entitled "Diabetes and You" and tiny square pillows that can be used for practice injections. Before leaving, they promise to buy lunch for the pharmacy staff soon.

In addition to a blood test to measure glucose levels, which costs between $15 and $60 in a doctor's office, those who already know they have diabetes will be checked for hemoglobin A1C, which reveals how well blood sugar levels have been controlled during the previous few months. A day earlier at a clinic held at a Walgreens in rural Warrenton, John had found a patient whose blood sugar was so high it was potentially lethal. He advised the man to immediately seek treatment at a nearby emergency room.

A little after noon, a 52-year-old woman rushes in, thrilled to be the first in line. She looks crestfallen when the visiting nurse who will be drawing blood tells her the event doesn't start until 1, when the woman's lunch hour ends. John, who overhears the conversation, agrees to begin early.

"I don't have health insurance," says the woman, who declines to give her name, citing embarrassment over her lack of coverage. She works full time at an IT job and cobbles together free or low-cost health care by searching out free screenings. When she needs prescription drugs, she hopes they are generics available for $4 at Wal-Mart.

To her obvious relief, John tells her her blood sugar is normal, then launches into the practiced spiel about the importance of a healthful diet and exercise that he will repeat 74 more times before the clinic ends at 7 p.m. By then John will have seen a 28-year-old man with bipolar disorder who takes a medication known to increase the risk of diabetes (his blood sugar is fine), a gaunt woman in her 40s complaining of frequent urination, numbness and blurred vision whose blood sugar is normal (John recommends she make an appointment with a physician) and a 63-year-old diabetic with alarmingly high blood sugar readings. John urges him to see his doctor in the next day or two.
 
Flu and Tamiflu

The large name tag pinned to his short white lab coat proclaims John a "certified immunizer." Like virtually all of the 17,000 Walgreens employees authorized to administer shots, on this day he has neither seasonal nor swine flu vaccine, to his -- and his customers' -- frustration.

Walgreens exhausted its supply of seasonal flu vaccine in mid-October, giving 5 million flu shots in a seven-week period in 2009, compared with 1.2 million in 2008. The swine flu vaccine that was quickly supposed to follow arrived months late. John's store didn't get its first batch until Dec. 16, when it received 100 doses of nasal vaccine. As of Monday, Walgreens had administered a million H1N1 immunizations at stores around the country.

The concept of enlisting pharmacists took off during the bird flu scare several years ago, when states adopted regulations allowing them to provide immunizations to cope with a possible pandemic. John said local physicians and urgent-care clinics do not seem to resent the competition and have referred many patients to his store for various shots.

Vaccine isn't the only thing in short supply. To cope with a shortage of liquid Tamiflu, which is taken by children to blunt the severity of H1N1 illness, John and his staff began making their own. The simple compound, made from grains of Tamiflu capsules pulverized using a glass mortar and pestle and mixed with cherry syrup, is stored in the pharmacy's large white refrigerator.


Triage

A phone is pressed to his ear, its long white cord swaying, as John pivots with balletic grace to reach a bottle on the bottom shelf in a far corner of the 900-square-foot pharmacy. He returns to the counter, pours small round pills onto a plastic turquoise tray and, using a spatula to count by fives, flicks 30 pills into an amber plastic vial bound for a waiting customer.

Nearby, one technician is ringing up a sale at the drive-through window, while another is stuck on the phone in an unsuccessful 20-minute attempt to decipher a doctor's name on a prescription. Several customers whom the pharmacy staff refers to as "waiters" are wandering the aisles or lurking near the counter when a woman rushes up clutching a prescription. John, who as the lone pharmacist on duty must check and verify all prescriptions before they are dispensed, stops what he is doing and heads to a bay to confer with her.

"CVS is out of it and they sent me here," she said, referring to the morphine prescribed for her mother by a Northern Virginia oncologist. "Do you have it?" Relief floods her face when John tells her he does. "I'm between conference calls, but I'll be back," she says, racing off to pick up her mother's insurance card.

John spends the next 10 minutes conferring with a 70-year-old regular customer whom he greets by name; the man is having trouble getting his diabetes meter to work, and John tests it. He then fields a call from a woman asking what she should take for gas pains; another caller, who is breast-feeding, wants to know the best time to take a sleeping pill.

A young mother, her sick-looking 9-year-old daughter in tow, approaches the counter to ask John what she should give the little girl, who has had a fever for a week. After talking with the woman for five minutes, he recommends an over-the-counter medicine, then urges her to insist on an appointment with the child's pediatrician. "A week is too long," he tells her.

An elderly man who speaks little English hands John a ripped piece of notebook paper with a long list of medications written in purple ink; he wants help tracking down a medicine. "We'll figure something out," John says, putting the sheet on a growing stack of prescriptions to be filled as he heads back to the drive-through window, where a woman in an idling minivan waits.