Is Pharmacy Stressful?

The pace. Specifically, the pace combined with the liability. I verify between 300 and 380 prescriptions on a normal shift. That's one every two minutes if I don't eat, don't take a break, don't answer the phone, and don't counsel a single patient at the window. But I do all of those things, which means the actual time per verification is less than two minutes on the ones I don't stop on. Some of them I'm clearing in 30 seconds. And every single one of those 30-second clearances is me saying, with my license, that this prescription is safe.

My district manager, Craig, he came in for a site visit last month. He watched me work for about 20 minutes. He said my verification rate was "strong" and suggested I could improve drive-through wait times. I was standing eight feet from him when he said it and I thought, you are watching me make 300 clinical decisions a day and your feedback is that the drive-through window is slow. The disconnect between how the company sees this job and what this job actually is, that's what stresses me out. They see throughput. I see 300 chances to be the reason somebody's kid gets the wrong dose.

My roommate Bess works in marketing at a tech company. She came home one day stressed about a product launch that got delayed. I am sympathetic, genuinely, but the nature of the stress is so different. If Bess makes a mistake, a deadline moves. If I make a mistake, a patient could end up in the emergency room. That weight is not comparable and I carry it every single shift.

I dose chemotherapy. The margins for error are measured in milligrams per square meter of body surface area. When I verify a chemo order, I'm calculating the dose based on the patient's height, weight, renal function, hepatic function, and protocol. If I calculate wrong, the patient gets too much of a drug that is, by design, toxic. Chemotherapy works by killing fast-growing cells. If the dose is too high, it kills too many of the wrong cells. Neutropenic sepsis. Organ damage. Death, in the worst case.

The stress isn't the math. I can do the math. The stress is that I do this math for 15 to 20 patients a day, every day, and each calculation has to be perfect. My colleague Annette, she covers the solid tumor clinic. She told me once that she keeps a tally of how many individual dose calculations she's done since she started. She's over 40,000. Forty thousand calculations where "close enough" isn't a phrase that exists.

I go home and my wife, Carmen, she asks me how my day was and I say "fine." Because what am I going to say? "I calculated poison doses for 18 people and one of them is a 32-year-old with two kids and I spent 40 minutes making sure his carboplatin AUC was exactly right because the difference between therapeutic and toxic is about a 15% margin?" That's not a dinner conversation. So I say "fine" and I play trucks with my son and I think about patient 12's creatinine clearance while I'm reading him a bedtime story. That's the stress. It lives in your head even when you're not at work.

From 11 PM to 7 AM, I am the only pharmacist in this building. Four hundred beds. One pharmacist. Every medication order that gets entered overnight, every emergency, every code blue, every dose adjustment, every question from a nurse at 3 AM, comes to me. There is no backup. There is no second opinion sitting next to me. If I have a question about a drug interaction, I look it up myself. If I'm unsure about a dose in a pediatric patient, I calculate it, double-check it, triple-check it, and release it, because there's nobody else to run it by.

Last Wednesday, we had a code blue on the cardiac floor at 2:15 AM and simultaneously a rapid response on the neuro step-down. I physically cannot be in two places at once. I went to the code because the code pharmacist role is mandatory. A nurse on the neuro floor paged me during the code asking about a stat dose of labetalol for a patient whose blood pressure was 210 over 120. I'm in the code, pushing epinephrine, and my pager is going off. The code lasted eleven minutes. By the time I got to the neuro floor, the nurse had called the on-call physician and they'd given a dose based on a standing order. The dose was fine. But the eleven minutes where nobody was pharmacist-checking anything on that floor, where a nurse made a medication decision without me, that's the thing I think about.

My boyfriend, Perry, he works construction. He tells me his back hurts at the end of the day. I tell him my brain hurts. It's not a metaphor. The cognitive load of being the sole clinical pharmacist for 400 patients for eight hours, some nights I drive home and I sit in the parking lot of my apartment complex for five minutes because I need the silence before I go inside.

The reimbursement. I'm not stressed about clinical decisions. I've been doing this long enough that the clinical piece is second nature. What keeps me awake is the business. I filled a prescription last week for a generic blood pressure medication. My acquisition cost from my wholesaler was $12.40 for a 90-day supply. The insurance company reimbursed me $11.80. I lost 60 cents dispensing that prescription. That's not a rounding error. That's a system that is designed to push independent pharmacies out of business.

My pharmacy does about 180 prescriptions a day. On maybe 30 of them, I am reimbursed below my acquisition cost. The PBMs, the pharmacy benefit managers, they set the reimbursement rates. They own mail-order pharmacies. They have a financial incentive to drive prescriptions away from my counter and into their mail-order operation. They do this by reimbursing me below cost on enough prescriptions that my margins shrink every year. Six years ago I had an 18% gross margin. Last year it was 11%. My accountant, Barbara, she showed me the trend line and said "Lonnie, you have about four years at this rate."

I have three employees. My lead tech, Hank, has been with me nine years. He makes $19.50 an hour and he deserves more. I can't give him more because my reimbursement doesn't cover it. I had to let go of my fourth employee, a part-time technician, last spring because I couldn't justify the payroll. So now we're running the same prescription volume with one fewer person, and the clinical work doesn't get easier just because I'm paying fewer people. The stress is watching something you built get squeezed by companies that are bigger than you'll ever be and knowing that the quality of care I provide, which is excellent, has no bearing on whether I survive financially.

The patients I can't help. Not clinically. Clinically, I know exactly what to do. I manage chronic disease states under a collaborative practice agreement. I adjust insulin doses, titrate blood pressure medications, manage anticoagulation. The clinical part is the part I trained for and I'm good at it. The stress is the part that has nothing to do with pharmacy school.

I had a patient last month, a 56-year-old man, Type 2 diabetes, his A1C was 11.2, which is dangerously high. I see him every two weeks. His diabetes is uncontrolled not because I don't know how to dose insulin. It's uncontrolled because he can't afford the copay for his continuous glucose monitor and he's estimating his carb intake because he works two jobs and eats whatever's fastest and cheapest. I adjusted his basal insulin. I recommended a sliding scale for meals. He nodded and said "I'll try." And I know, because I know him, that "I'll try" means he'll take his basal insulin when he remembers but the meal-time coverage isn't going to happen because he's eating a gas station hot dog at 2 PM between his warehouse shift and his custodial shift and he's not going to check his blood sugar and calculate a dose in the parking lot of a Sheetz.

My supervisor, Dr. Langston, she's a physician who's been doing community health for 25 years. She told me early on, "You're going to lose patients to poverty before you lose them to pharmacology." She was right. I went into pharmacy because I wanted to help people with medications. The stress is learning that medications are sometimes the least important variable in whether someone gets better.

The debt. Everything else, the pace, the patients, the insurance stuff, I could handle all of that if I didn't owe $203,000 in student loans. I went to a private pharmacy school because I didn't get into the state program and I thought, well, it's a doctorate, pharmacists make $130K, I'll pay it off. I was 22 and I didn't understand compound interest at the level I understand it now.

I make $126,000 a year. After taxes, health insurance, and my retirement contribution, my take-home is about $6,800 a month. My loan payment on the standard 10-year plan would be $2,340 a month. I'm on income-driven repayment at $1,100 a month. The remaining interest capitalizes. My balance has grown by $11,000 since I graduated. I owe more now than I did at commencement. My older sister Bethany is a nurse practitioner. She went to a state school, owes $62,000, and makes $118,000. Our per-dollar-of-debt earnings are not comparable. She's free in four years. I'll be paying this off into my late forties.

The stress isn't just financial, it's existential. I chose this career at 22 based on a salary projection that assumed a specific debt-to-income ratio. That ratio was wrong. I didn't fail pharmacy. The math failed. And I can't un-choose it. I can't give back the degree and get a refund. I'm locked into a profession that I like, I genuinely like the work, but the financial architecture of getting here means I'll spend most of my thirties underwater. My girlfriend, Hannah, she's a physical therapist with her own loan situation. We've done the spreadsheet together, both of us in our kitchen at 10 PM with a laptop, looking at the year we'll both be debt-free. It's 2039. That number is the stress.