Behind the Pharmacy Counters

Introduction

Humans are living in a society where each of us is servicing the others, depending on the circumstances.

• Sadly, there are times or people who forgot to respect the others.

As a practicing outpatient pharmacist, the majority of patients that I have met are friendly and nice.

• However, there are a few patients who are demanding and being unreasonable for not listening to our explanations.

Some Common Complaints

Often, pharmacy is the last station that a patient would end their hospital visit with.

• Undeniably, due to patient crowd and limited specialists available at outpatient clinics, they may have waited from the morning till afternoon (almost half a day). Hence, another waiting of 30-45 minutes at outpatient pharmacy frustrated some of them.
• However, please bear with us, because we have also been busy with the never-ending crowds since the morning.

At government facilities, there exists a policy to supply one month medication at each visit.

• This is to minimise potential medication wastage in patients. Some patients may be hospitalised and have treatment plan change before the next clinic appointments. Some elderly patients may pass away too.
• Plus, if all patients are requesting us to give a full supply of medications as per prescription (6 months or 1 year), we probably need to dispense at distributor warehouse instead.
• We are not looking at individual needs, but to ensure whoever comes can have some medications home.
• Moreover, the cost of some patients' monthly medications can be up to RM1000 or more.

There are few patients who write in complains because they think the pharmacy staff is being impolite.

• At this COVID pandemic, patients still complain that staffs are not smiling, as if they can see through the N95 masks.
• Due to the face shield and face mask that we wear as personal protective equipment and constantly noisy atmosphere, pharmacy staffs are forced to raise their voice to be audible (Yes, we are not intentionally shouting at you!).
• Plus, please be realistic, can you still smile after greeting 500 patients in a morning?

I have also met few patients who take advantage of our current health care system and secretly sell or share the medications that they have received.

• "You, pharmacist, just need to dispense what is already written on the prescription. Just give me the same medication (repeated medication in different prescription)! You don't lose a penny also if you give. Why being stingy?", he shouted.

Worst of all, these demanding patients are being extremely rude and unreasonable when they need your service.

• To illustrate, they are scolding on "why is it not their turn yet and they have waited for XX minutes?", instead of asking to check their prescription processing status.

Sometimes, I wished there is a "rude customer policy" where we can kindly inform the patients to bring along their prescription to pharmacy outside to purchase the needed medications and not allowed to come back collect ever again.

Truth to be told, all these frustrating disturbances slow us down dramatically and greatly influence our emotions. As a health care professional, we would not prioritize your prescription purely because you have made a complain. If not, it will not be fair. There are huge crowds that have waited there for much longer than you.

Yet, with all these fusses that they made at the scene (each time), they are still coming to the outpatient pharmacy to collect their FREE medications monthly.

The Behind Scene

Here comes the golden question of all time: "why does it take so long for pharmacists to prepare a medication supply (including for 2-3 drugs prescription)?"

After a prescription is received by a pharmacist staff,

• A pharmacy staff will transcribe the medication labels manually or by electronic system (e.g. PhIS).
• Another pharmacy staff will fill the medications according to the written prescription. For certain medications, there are also facility's documentation requirements to adhere, such as bin cards and Prescription Registers for psychotropic substances.
• Another pharmacist (usually senior pharmacist) will countercheck the prepared medication (CQDC = Centralised Quality Dispensing Control) before the final pass to dispenser (the pharmacist working at the front counter).

Throughout the process, staff at each stage is checking if there is any intervention needed for the prescription.

• Could there be a dosing error, frequency omission or missing drug?
• If a doubt is identified, we would need to call up doctor to clarify, which will eventually lengthen your waiting time.
• Probably, when we are calling up the clinic, the doctor is busy treating the next patient, and we have to wait to get the response.

NOTE: You probably have noticed that there is a different staff doing each tasks, so please stop asking dispenser on why your medications are not yet ready. We are equally clueless, because we are busy dispensing medications.

At times, we may also encounter unfamiliar drug or dosing. Hence, we may need to spend few minutes checking up drug references.

• Yes, I also used to think that pharmacists can remember all drugs and dosing in their heads, but in reality, they did not.

For some paediatric patients, we may have to prepare extemporaneous preparations.

The reality is that we are not doing this process for one patient, but repetitively for few hundreds of patients, with only one aim: supplying the right medication with the right dose and frequency to the right patient.

• Assuming one prescription will take roughly 10-minute processing time (4 minutes for transcribing, 4 minutes for filling and 2 minutes for CQDC) for a team of 3 staffs, the number of prescriptions that can be completed in an hour by 24 staffs is estimated to be 120 prescriptions (i.e.960 prescriptions in an 8-hour working day).
• On the other hand, our patient load at 12 noon may already reach this figure, since the patient load is often not evenly spread.

The Challenges

The reality at outpatient pharmacy is all the outpatient pharmacy staffs are constantly exhausted by the heavy patient crowd in front.

• Similar to private setting, we do not have the luxury of a backup team to replace us when we are tired.
• We could have been dispensing for few hours straight, with no rest.
• Yet, there could be no signs of reducing crowd.

Outpatient pharmacy, being the most hectic rotation, are often allocated with merely sufficient staffs.

• When there are staffs not on duty (possible reasons include medical leave, child fall sick, maternity leave, annual leave and car accident), other staffs would have to cover their jobs and this stretched us even further.
• Plus, to provide value added services for the ease of patients, it is ideally to have extra staff allocation for each new service, but this often does not happen.
• In short, we are being pushed beyond the limit.

Apart from lack of manpower, low in stock for a particular drug could happen because we are waiting budget allocation from government, nationwide out-of-stock issue, or there is a sudden surge in usage.

• For these cases, we may have to restrict the medication supply to 1-2 weeks and borrow drugs from other health care facilities simultaneously.

Apart from chasing to clear the patients at outpatient pharmacy, we have to maintain high standards in dispensing medications to patients.

• Any medication error could potentially lead to a medico legal case.

The Way Forward

To be honest, even without patients' complaints, the ground floor pharmacists all knew that a long waiting time should not be a norm. However, we have little power in changing the whole healthcare system.

• Yes, I also wished all pharmacists are supermen and superwomen.
• None of us want to stay back to finish the work or completely exhausted by patient load at work.

Given the huge patient load at outpatient pharmacy, practical and impactful measures should be implemented. Main strategies should include

• To create more outpatient pharmacies at a hospital, with each catering for one or few subdisciplines, aiming to dilute the patient crowd.
• To reshuffle sufficient manpower to outpatient and inpatient pharmacy, with careful considerations of staff leave, work commitments and extra portfolios.
• To adopt a flexible yet practical management to maximize the efficiency. For example, when staff shortage happens, the staffs at each station may have to be reduced accordingly, but be mindful of potential for burnout and longer wait times for patients should be expected.
• To make transcribing of electronic prescription starts at prescriber end, instead of pharmacy-based transcribing. This may also enables doctors have a clearer picture of patient medication profile when the patient is following up at multiple specialist clinics or newly discharged from wards.
• To make PhIS system a faster and more user friendly system.

Nonetheless, there are few key reminders that I would like to highlight to my fellow pharmacists.

• Dispensing should not be just about passing all the medications to patients, but we should also look at patient facial expression to seek if there are any unmet needs.
• Do not panic due to patient crowd. On the other hand, dispense carefully to the patients still. We do not wish to create medication errors when rushing.
• Ask for helps if you are unable to cope with the situation.

Summary

Frankly speaking, long waiting time is happening at private medical centres too. I have been there and experienced it also.

I hope that all patients can appreciate us more, or at least respect our profession.

• Pharmacists don't owe you money or sorts, but we are just staffs working to earn a salary.
• Plus, we are supplying you FREE medications.
• Often, it is not the work that exhausted our soul, but patients' unreasonable complaints demotivate us the most.

We are not demanding a gift from the patients, but often, a simple "thank you" or "continue your good work" greeting mean a lot to us. In fact, if you make a request politely, there is probably a higher chance for us to assist you willingly.

Again, please do not take our almost FREE health care (including consultation and medications) for granted. At government health care facilities, we are concerning about your health (not your wealth) and trying to give you the best treatment option.

External Link

• NMC Proposes Refusal of Treatment by Doctors in Cases of Abusive, Unruly, Violent patients or Relatives, 2022