Welcome to your friendly neighborhood drugstore, where you can buy lawn sprinklers, Dove Bars, cat litter, greeting cards and--oh, yes--prescription medicines. Way in the back of the store, on a raised dais surrounded by frosted glass, pharmacists tap into computer files and pack pills into brown bottles.
But practitioners of the job that has been described as an endless round of "count and pour, lick and stick" are pushing to give their customers more than this. And, if they succeed, the health-care consumer stands to benefit from expertise and services that might otherwise remain sequestered behind the frosted glass.
Indeed, the California Board of Pharmacy is planning a regulation change that would require pharmacists to talk with the customer about each new prescription.
And a few California pharmacists--generally at small, independent operations--are offering their knowledge and skills in services that go well beyond passing pill bottles across a counter.
Paul B. Schickling has a special area of his Guardian Pharmacy in Santa Ana where diabetics learn how to use machines to monitor their blood glucose levels, hear about the importance of their drug therapy, and can ask a dietitian questions.
"I think you're going to see more and more specialized pharmacies, whether they just get involved with home IV therapy, or specialized compounding of medicines, or a specific disease like we did," said Schickling, a diabetic himself.
In Marin County, Ross Valley Pharmacy has a sign on the counter offering $30-an-hour, comprehensive drug consultations. Customers can gather up all their pill bottles and ask pharmacist Paul Lofholm about potential problems--such as drugs that cancel out each other's effect, combinations that could be harmful and duplicative drugs.
The pharmacy also offers specialized services such as formulating special medication, including oral narcotics and intravenous drugs for terminally ill people under hospice care at home.
It is this kind of special attention that businessmen fear is too expensive but that pharmacy researchers say consumers should demand as they look to get the best health care. Even large chain stores can and should routinely offer one-on-one advice to their drug customers, these researchers say.
Both Lofholm and Schickling are members of the American College of Apothecaries, a group of 1,000 pharmacy purists who agree to emphasize medical service and minimize retail sidelines in their stores. Members agree, for instance, not to sell tobacco products.
But with only 16 of more than 5,500 pharmacies in the state listed as members of this group and the market dominated by busy chain stores, California consumers are more likely to get their medicines from pharmacists who are too rushed to talk much.
Chains account for 26% of the pharmacies in the state but fill 60% of the prescriptions, says the California Retailers Assn. Nationally, the sales picture is reversed: chains account for only 42% of prescription drug sales, according to the industry publication Drug Store News.
Pharmacist F. James Grogan, author of "The Pharmacist's Prescription" and associate professor at the St. Louis College of Pharmacy, illustrates the potential problem with the chains by recalling his own experience at the store his health insurance requires him to use.
"The pharmacist there doesn't know me," Grogan said. "At least six or eight times I've been in that place, no one has given me one word of advice on how to use the medication. That's not good. That's not what pharmacists should be doing."
Without a strengthening of the pharmacist's role in health care, pharmacists will see their profession disappear, contends Michael B. Nichol, a pharmacy administration researcher at USC.
"I can put together a machine that will do most of the mechanical things that are necessary to fill a prescription," Nichol said. "It's when you get to the more cognitive aspects, such as evaluating that prescription, being able to understand how it relates to other drugs the patient may be taking, that a pharmacist can excel."
Nationwide, only 13 states now require that the pharmacist "consult" with prescription drug customers--that is, actually talk with them about how to take the medication and what the possible side effects are.
The California State Board of Pharmacy in May passed a regulation to add the state to the list. Chain drugstores oppose the rule as unnecessary and are reserving judgment on whether to fight it in court, said Robert M. Shillito, executive vice president of the California Retailers Assn.
The regulation was approved Friday by the Department of Consumer Affairs for review by the Office of Administrative Services, the final step necessary before it takes effect July 1. However, retailers could appeal in court if the rule is approved, and the board could appeal to the governor if it is rejected.
The last time the board tried to mandate patient consultation by pharmacists--in 1978--the board withdrew the regulation after it was challenged in court by three Sacramento pharmacies.
This time around, executive director Lorie Rice is cautiously optimistic.
"This is a real mom, flag and apple pie issue," Rice said. "I don't see how anyone would want to put their name to any kind of suit against the Board of Pharmacy for trying to promote consultation . . . without looking like they had purely economic motivation."
If the regulation does survive opposition, it would codify what already should be standard practice for all pharmacists, everyone agrees.
However, to help make more time for pharmacists to do this, the pharmacy board also passed a rule allowing druggists to train unlicensed technicians for the mechanical functions of dispensing medication, under a pharmacist's direct supervision.
To those who question whether all this is really necessary, pharmacy advocates point out that the U.S. spends $600 billion every year on health care, 8% of it on prescription drugs. Activist pharmacists can assure that that money is well spent, and even save money in the long run, they contend.
David Sclar, assistant professor of pharmacy at USC, says this is especially true for the chronically ill, people who must take medicines regularly for their entire lives. It's known, he noted, that 40% to 50% of the people on medication for chronic illness stop taking their medicine within the first year.
A diabetic or hypertension patient who does this is likely to end up in the hospital at a cost of thousands of dollars, Sclar said, when if the pharmacist had mailed him drug refill reminders that might not have happened.
Similarly, a pharmacist who works closely with doctors could increase patient compliance by, for instance, suggesting that the doctor prescribe pills that need be taken only twice a day instead of more frequently.
Who Will Pay?
Some worry, though, about who will pay for the expanded services. Diane Giaquinta, director of pharmacy services for Blue Cross of California, noted that someone needs to do studies of whether such services really do save insurers money.
"Right now, no one is paying the pharmacist to act in a service function," Sclar acknowledged. "The pharmacy is being reimbursed for a dispensing function only."
Nichol contends that long-term customer loyalty and repeated purchases because of the extra service will make extra pharmacy services pay for themselves. Working with Long's Drug Stores, which has more than 200 stores in California, he has done two separate studies of over-the-counter drug purchases to test that idea.
The first study--a report on the second is still incomplete--placed a pharmacy intern near the over-the-counter drugs to advise customers on their purchases. The study found that 7% of the people would have used the wrong medication, that 55% changed the drug they purchased based on the encounter, and that 25% bought extra drugs they wouldn't have bought without it.
Stephen Roath, executive vice president of Long's, said he is skeptical that a retailer could justify higher prices overall to pay for the pharmacist's time.
"About the only way you could justify the rather large expense of the professional in the over-the-counter aisles is to justify that the added purchases or the loyalty provided because of the service would allow you to pay for that (pharmacist's) time through the product itself," Roath said. "I don't think it's reasonable to ask the consumer to pay for a service for which they can't really understand the benefit."
Nonetheless, Nichol, Sclar and others remain convinced that such services are essential both to the future of pharmacy and good health care for consumers. As the profession moves toward more of a service orientation, they say, finding a good pharmacy doesn't necessarily mean going to a small store rather than a large chain.
"What is most important is the kinds of services you get," Nichol said. "Is the pharmacist available to provide information? Does he take the time to go over use of the drug and potential problems?"
Grogan suggests making several visits to a pharmacy before deciding to use it, just to see how the pharmacist interacts with consumers--and whether he or she is accessible at all. Lofholm suggests going in with questions about a drug one already knows about, just to see what the response is.
Sclar adds that, if required by convenience or an insurance company to frequent a pharmacy that isn't service-oriented, a person still can politely press for information and should be prepared to wait for it.
"Consumers can act as change agents by asking for more and more service from pharmacy . . . ," Sclar said. "They have every reason to ask the pharmacist for information and should expect to receive it."
Choosing Your Pharmacy Pharmacists say the ideal pharmacy is one that can answer "yes" to all the following questions. They also say that the ideal outlet may be hard to find. And it may not be the least expensive one around. Pharmacists suggest that if a pharmacy doesn't offer the services indicated below, one should consider talking with the store manager, and that when a suitable store is found, one should stick with it to ensure continuity of care. Is the pharmacist easily available to answer questions? Does he or she talk to customers directly rather than through a counter clerk? With a new prescription, does the pharmacist ask customers about other drugs they are taking and talk about precautions in taking the new drug? Are questions answered enthusiastically? Does the pharmacy keep records on all medications a patient takes? Does the pharmacy respond to customer's special medication needs? Does the pharmacy send reminder cards when it's time for a refill? Is the pharmacist available to give advice about choosing over-the-counter drugs?