Community Introductory Pharmacy Practice Experience (IPPE) Journal May 9-27, 2011 GoodLife Discount Pharmacy, Albion, NE Introduction:

As I currently work in Drug Policy at the University of Nebraska Medical Center, I have had very limited exposure to community pharmacy and even processing prescriptions. In fact, the first and only time I have filled prescriptions was over spring break during my P1 year when I participated in a service trip to the Winnebago and Omaha reservations. There, I worked in pharmacies in both the clinic and hospital settings. There was a remarkable difference in the facilities in each location, in procedures, and in the role of the pharmacists. Therefore, I was very excited to participate in the summer clerkship program in a community pharmacy setting. I began my first community pharmacy experience in the GoodLife Discount Pharmacy in Albion, NE. I worked for a pharmacist, Dr. Vanessa Gottier, who graduated from the University of Nebraska Medical Center and had been practicing in the community pharmacy setting for about 10 years. Albion is a town of approximately 1700 people, so this pharmacy provided me exposure to a rural pharmacy setting. The GoodLife Pharmacy is one of two pharmacies in Albion and serves the people of Albion and most the surrounding towns. Daily, we saw between 50-100 people as well as filled prescriptions for two nursing homes and assisted living center. Week One: The very first day I got the full experience of retail pharmacy. When I arrived at the site at 9am, there were a group of men outside the door who congregated to socialize before the pharmacy opened and they could get their prescriptions filled. From then on we had a steady stream of patients, phone calls from doctors, and refill orders from patients. Dr. Gottier immediately trained me on the computer operating system. It was a very straightforward program to use. (Having never worked in a retail pharmacy before, I am not sure if this was a standard system found in most pharmacies. ) Refills could be entered by their 8 digit numerical code, anything beginning with a 6 was a non-scheduled drug, anything with 4 was a scheduled drug, and anything with 2 was a C II drug. If there were no refills on the prescriptions, we could immediately fax a refill request to the doctor or clinic. I was very surprised that the fax was an integral part of the pharmacy operation. I expected that most of the communication between the pharmacy and the physicians would have been through email. A little more challenging was entering new prescriptions. You chose a drug from a formulary list for the pharmacy, the correct dose, and then wrote out the sig in laymans terms. Dr. Gottier had many of the sigs preset with a short-hand code to speed up the process. For example, T1T2D was shorthand for Take one tablet by mouth two times daily. Another one I used quite frequently was ZITH which was the sig for a Zpak-Take two tablets now followed by one tablet daily, until gone. These were especially helpful in speeding up the filling process while the patients were waiting. An important lesson I learned this week is that you have to be very cognoscente of patient confidentiality in this type of pharmacy. The pharmacy actually sits behind the cash register and there

are usually multiple customers in the store either waiting on their prescription, photo processing order, or shopping. The pharmacist, Dr. Gottier told me of a learning experience she had when a patient came in with her sister to pick up a prescription. In addition to the prescription, she had also ordered a special prenatal vitamin which had to be ordered. Dr. Gottier was ringing this woman up and mentioned that she had placed the order for the prenatal vitamin and they would arrive the following day. The woman turned to her sister and said, well I guess you know now that she was pregnant. Dr. Gottier used that example to reinforce the importance of patient confidentiality and how innocently it can be breached. I felt that by the end of the week I had made significant progress in the areas of fill prescriptions, taking down prescriptions from doctors (even though this is still very intimidating), using the computer system, and using the register to check patients out. I still feel more comfortable counting by 3s when filling prescriptions, but I am sure I will get faster with practice. I am able to work independently for most cases, however sometimes Medicare coverage becomes a problem when filling someones prescription and I require Dr. Gottiers assistance. I am surprised at how much I am enjoying the retail pharmacy setting. Week Two: This week, Dr. Gottier explained the drug inventory and reordering process. It was done automatically through McKessen and new drug inventory was delivered every morning. She explained that the system was pretty reliable; however, they sometimes ran into situations when they didnt have enough drug on hand due to filling nursing home prescriptions. Nursing home medications were filled every week; however, they are billed at the end of the month. While I was working at this pharmacy, there were only a handful of instances when we ended up owing the patient a partial order. Also convenient was the relationship the GoodLife pharmacy had with the other pharmacy in Albion. When someone came in with a script for a drug we did not have, we could often borrow it from the other pharmacy, and viceversa. I am not sure if this is a common practice in larger cities, but it works well in small communities so that they dont have to stock a large amount of rarely prescribed drugs. One of the more intimidating aspects of this job is taking down a prescription from a prescribing doctor. There were several doctors that made this a very easy process, but there was one doctor, in particular, who seemed to be pressed for time and immediately started communicating his order as soon as the phone was answered. I quickly learned to always answer the phone with a pen in hand! Dr. Gottier provided me with notes so that I could review my Latin abbreviations to aid in transcribing the Sig to patient directions. Dr. Gottier spoke to me about the future of pharmacy. She explained how difficult it is to maintain small retail pharmacies with the availability of mail-order pharmacy. She thought that there were a significant number of people who received their prescriptions by mail and said that some of them would have medication questions or insurance questions and come to her for help. Since she was not their primary pharmacist she was often no help, and she saw this as a drawback to mail order pharmacy. Week Three:

Throughout the three weeks I have worked at the GoodLife pharmacy, we have had several opportunities to counsel patients. One interesting patient was a 9 lb baby who needed to take Ranitidine. The doctor was not sure how to dose the infant, so we had to refer to resources to find this out. Once the father came to pick up the medication, I was able to council him on dosing and pulling up the correct volume of medication in the syringe. I was a little dismayed that he had no interest in listening to my instructions. I am surprised that most patients are not interested in being counseled and dont want to spend the additional time it would take, although it would only take minutes. I see this as a challenge for pharmacists and maintaining quality patient care. Another interesting patient was a woman with a daughter who had a sever ear infection. She tried two different antibiotic eardrops but the infection was so severe that she couldnt get the eardrops into the ear canal. They started her on oral antibiotics, but we did not have the chewable form of the medication she needed. So we gave her capsules which we instructed her to sprinkle in applesauce or pudding. But there were compliance issues, so they called in a different antibiotic that had a chewable form. It was neat to see the full progression of the treatment; I dont believe this would have been possible in a large pharmacy. This week, I had the distinct pleasure of working in the pharmacy during scheduled drug inventory. We counted every scheduled drug that was on the shelves as well as the expired drugs. That day I got a lot of practice counting pills and now feel comfortable enough to advance to counting by 5s!! Also this week I had the opportunity to participate in compounding an analgesic cream. We triturated the pain tablets, levigated them with a base, and to ensure through and even mixing, we used the syringe and leer lock system we learned in our Compounding Lab last semester. Evidently, the GoodLife pharmacy in Or, Nebraska has a compounding lab where most of the compounding takes place, but Dr. Gottier does some of the more standard compounding, such as this, I noticed that we filled a lot of orders for Zpaks and saw an increasing amount of allergy medications (Flonase) being filled. Dr. Gottier said that they will see increased allergy medications this time of year and then cold and cough season from November-February. We had a case where the doctor prescribed a single dose of 2g azithromycin. I thought this was unusual, as up until then I had seen it most often prescribed as a 5 day regimen Zpak. I thought that the prescription might be incorrect, but Dr. Gottier showed me in the MPR reference book that 2g azithromycin was given as a onetime dose for the treatment of gonorrhea. This was a very interesting week and I learned a lot about many of the facets of community pharmacy, from inventory to compounding. Summary I was surprised at how much I enjoyed retail pharmacy. Overall, the experience working for Dr. Gottier at the GoodLife pharmacy was very rewarding and educational. I especially appreciated the location of my clerkship and think that one of the reasons I enjoyed my experience so much was that it was in a rural setting. The services this pharmacy and Dr. Gottier offer are probably unique to this setting. The

technicians delivered medications to local homebound patients free of charge. They had a mail service to send refills out to patients in other rural communities so that they would not have to travel to Albion. They stayed open late or planned a meeting location if someone could not make the store hours and needed to pick up their prescriptions. Dr. Gottier mentioned that she sometimes even received phone calls at home (which is not ideal, but probably a consequence of living in a small town). I was very impressed that Dr. Gottier remembered her patients, their medical circumstances, and their medication histories. For example, when filling prescriptions, during her final check, she would often change lids to safety caps when she knew there were young children at home. This is a personal aspect that I am not sure that you could achieve in a mega-pharmacy in a big city. I saw that the patients really trusted her and relied on her, and she took this relationship very seriously. If there was ever a medication question which required communication with a doctor or insurance, she immediately tried to resolve it in order to serve her customers as quickly as possible. As this was a brand new experience for me, I felt that I got a lot out of this IPPE clerkship. I became acquainted with medications, learned to fill prescriptions, became more efficient on the computer system, became more efficient and comfortable with taking prescriptions from doctors over the phone, worked well with the pharmacist and technicians. Additionally, I learned about inventory, vendors, scheduled drug control, insurance, and Medicare/Medicaid. Working at the GoodLife pharmacy also taught me how to be invested in every patients medical care and to do our very best for the patient no matter the circumstance.