Tackling Pharmacy Burnout, Patient Safety Requires Holistic Approach

Aislinn Antrim: Hi, I'm Aislinn Antrim with Pharmacy Times, I'm here with George MacKinnon, founding dean of the Medical College of Wisconsin School of Pharmacy and a professor there, to discuss burnout in the pharmacy and how we can ultimately impact patients. Dealing with this burnout takes time but improving patient safety seems like a very immediate concern that needs to be addressed. What can be done to improve the safety concerns, despite the existing burnout? And I would imagine the long process that it would take to really address this on a widespread scale?

George MacKinnon, PhD, MS, RPh, FASHP, FNAP: Well, certainly when we talk about safety, there's a lot going on there. There are the aspects of medication error reduction during what I would call the prescribing process, right, there's medication error reduction that occurs during the fulfillment and filling process, and there's medication error reduction that can and should occur during the patient consumption process, right? All 3 of those are linked, but they have somewhat separate ways to deal with them.

On the prescribing process for medication error reduction, how simple would it be for a prescriber to tell us what the intended prescription is for? That helps us when we counsel that patient, why it was prescribed, just a simple indication, and even the outcome goal of therapy that they want to get to. That directs my conversation in a much different way as a pharmacist to that patient. Now that I know why they have this medication, there's medications that are used for pain and other medications that are used for depression. And so, there's different ways you're going to handle that conversation with the patient, if you knew going into it. The example I give to students is it's like we're on 2 trains going in opposite directions on the track and this prescription floats in between the 2 trains. We have to grab it and figure out what it was prescribed for and make good sense of it. So that's on the prescribing side.

On the fulfillment side, there's a lot of technologies that are in place in pharmacy. We almost certainly lead health care delivery in embracing technologies from way back when we did adjudication of prescriptions, even e-prescribing was part of the system. But on the fulfillment side, we need to be making sure we utilize technologies to the fullest potential.

And then lastly, on the patient side and health care provider side, is making sure that we give them the tools that are necessary for medication adherence. And part of that is their own health literacy as patients. Are they well informed, is the caregiver well informed, because as we know, not everybody who consumes pharmaceuticals is ultimately knowledgeable about them. It might be a caregiver, or it could be a child, it could be somebody who's incapacitated, and are they informed of how to take the medications properly? So, there is certainly the health literacy of the patient that we need to be aware of. We need to make medication labels simpler and easier to read for patients, we need to use pictograms that identify, you know, the morning, the afternoon sun in the evening, so people know when to take their medications. There's also technology, believe it or not, with RFID technology that smartphones can actually be put up to a prescription and it'll talk back to them and tell them the directions. Again, that's great if you have the smartphone technology, but if you're a patient who doesn't [have a smartphone] that's not useful. And likewise, if your literacy is low and you're illiterate, you can't read, so proper directions don't help you either. So, it's a multi factor system.

Aislinn Antrim: In addition to the increasing issue of burnout, I think we're also starting to see some more widespread discussion and pushback about the issue. How do you think this aspect of the COVID-19 pandemic could impact the future of pharmacy?

George MacKinnon, PhD, MS, RPh, FASHP, FNAP: Well, I think what the COVID impact was from a workflow standpoint was, you think about what you know, describing you know, pharmacists, whose shift begins with hopping on a call, because there's a refill call, there's a prior authorization call, there's a doc office call, there's somebody in the drive thru, there's somebody who's over in an OTC aisle, and now somebody wants a COVID-19 test and somebody is waiting for their follow up. Okay, that's your first 10 minutes of the day. There is no work environment really, other than probably the ER, where you've got a lot of other personnel triage and what's going on in a system that looks like that. So that's the challenge of the work environment.

I think we've got to take a step back and say, who really needs to do what? And do the Boards of Pharmacy allow us to do that and make that definition determination of who should be doing what? And again, each state is different. But again, the State Boards of Pharmacy are there to protect the public health interests, and if we can demonstrate that that is part of that workflow, that if I have 10 people behind the counter, that are all doing very specific functions, that they contribute to the overall success of the product fulfillment, and ultimately, the counseling that goes on and making sure we have no errors, that should be acceptable. As opposed to saying, “Well, you can only have 2 people behind the counter for pharmacists.” Okay. The second part to that is, again, as I alluded to, is the requisite number of pharmacists. There are times where a health care provider, in this case, a pharmacist has to take time in think through what is actually going on with the situation in front of them. And you can't have other things in front of you, distracting from that.

So, I think we really do have to get back to some metrics that do put appropriate numbers of pharmacists back, frankly, behind the counter or in other health systems. The other part of that is on our pharmacy technicians in terms of burnout, we have to be able to pay them a living wage, we have to have a career ladder for them, that they can escalate and come in as an entry point. And once they have proven their capabilities, and they enjoy the pharmacy work environment, that there's a career trajectory for them, that they can make a living wage throughout their career with us. And some systems have done a great job of that. Others certainly struggle with that. So, I think we need to make sure that that occurs, because that will reduce the burnout of our pharmacy technician, which is certainly a paramount workforce that makes things occur well behind the counter, or wherever we might be.

Aislinn Antrim: Absolutely. Is there anything you want to add or something I didn't think to ask about?

George MacKinnon, PhD, MS, RPh, FASHP, FNAP: Well, you know, there's a lot of things. As we said at the beginning, this is not something that just emerged because of the pandemic. It's kind of been simmering for a while. And what's been simmering is what I've said before, is going back to the issues of what's driving this. And what's driving it, frankly, unfortunately, is the almighty reimbursements. And that's what we get paid for prescriptions.

I'll give an example. I had a contact from a pharmacist the other day with a COVID-positive patient that was symptomatic, prescribed Paxlovid. When they finally spent 1 hour working with that patient, they were reimbursed one cent. Now, that's not a sustainable business model. If they were reimbursed $10, that's not a sustainable business model. We have to pay commensurate fees for the service that's being done in our pharmacies. We have to get the PBMs, frankly, in a model by which they really are paying for the services and not rendering the profits themselves. They really are becoming a distraction. We're starting to understand, again, unraveling that what value provides to the pharmacy clients that go to the pharmacies, when they have choices, and where they can direct them where they want to go for better care. Consumers know that. Consumers know that when you go to a restaurant, right, and there's a line waiting to get in, there's a lot of people want to be there, right? And so, we want to create not those lines of pharmacy in the sense of you have to wait, but a demand.

And I would also say, back to the educational point, I think the one thing that the pandemic has helped us think about is when you go in for a COVID test, you had to schedule that. When you went in for a COVID vaccine, you had to schedule that. So, we've begun to rethink what that community pharmacy is. And I'd like to say community pharmacy is the access point to health care. We're the front door to health care. We've got to get people to recognize it, we’ve got to get insurance to pay for it. And so, reimagining what that front door looks like for patients willing to make a scheduled visit, willing to take on med synchronization because they have multiple medications for their chronic conditions. And they have one appointment with a pharmacist maybe every 6 months just like they have a prophylactic dental visit to go over their meds. That's where we need to go.

And certainly this is a little bit off topic of burnout. But it all comes together because it creates a workflow environment that makes sense at the community pharmacy and protects the public health. And so, you know, the short answer is yes, burnout, workforce environment impacts, does impact patient safety. Therefore, we know we reduce burnout, we are likely to reduce issues of public safety and medication errors. So, they're so well in front of us. It's just now putting in place the measures to make these changes.

Aislinn Antrim: Absolutely. Thank you so much for talking with me about this.

George MacKinnon, PhD, MS, RPh, FASHP, FNAP: Absolutely was a pleasure.