Neuroscientist Warns Of The Common Habit That Destroys The Success And Thinking Ability Of Even The Most Brilliant People
Dr. John Kruse reflects on what he believes has led to decreased performance and productivity.
Linkedin Sales Solutions | Unsplash Three out of 10 pharmacies in business in 2010 had closed within the decade, according to a recent summary that indicated that many neighborhoods across the US have lost their local pharmacy.
Some of this churn is due to corporate decision-making that values profit over the medical and emotional needs of patients. The rise of mail-order pharmacies has also contributed to the decline of retail stores. While these factors are part of the story, as a prescribing physician for more than 30 years, I’ve also seen a deterioration in the ability of pharmacists to think and communicate — keys to helping any business thrive.
More than ever, pharmacists create or escalate problems, rather than helping solve them. I’ve seen it. My patients see it. This behavior of pharmacists is a neglected factor contributing to failing pharmacies.
Perplexingly, this decline in pharmacist performance has occurred simultaneously with an increase in the rigor of pharmacist training. Pharmacists spend more years in the educational system, with greater emphasis on patient interactions, than ever before.
Most pharmacists are hardworking, caring individuals who conduct their jobs adequately much of the time. Rising rates of poorer performance by pharmacists derive from broader social trends.
We’re all flooded with too much information and pressure to respond quickly. Our lives are more hectic. Looking at what is occurring in pharmacies gives us a glimpse at how we are changing our whole world, and not necessarily for the better.
Years of scrolling on our phones have shortened our attention spans, made us less patient, and increased our propensity to respond quickly but without adequate consideration of context, nuance, and consequences.
Yuri A / Shutterstock
My practice isn’t perfect, either
I’m aware that I may sound like the codger lamenting how things were in the old days. Much of my evidence about pharmacist behavior is anecdotal.
I haven’t increased the number of patients I treat or prescriptions I write, but the amount of time I waste each month sorting out problems with pharmacies has increased substantially in the last decade. More problems arise, and they take longer to resolve.
The challenges are not all the fault of pharmacists. I occasionally make errors in entering prescriptions into my electronic system. Perhaps I’ve become less intelligent, less articulate, or less patient over the years. But feedback from other realms of my life doesn’t support those conjectures.
I am friends and neighbors with several smart, conscientious, and empathetic pharmacists. I’m not claiming that all pharmacists are failing all of the time. But in an era where the field proclaims that we are moving towards “precision” medicine and “individualized” medicine, pharmacists are failing too often with mainstream, everyday dispensing requests.
I understand that pharmacists are overworked. I get it that in addition to corporate pressures, they face increasingly intrusive government regulations. These are major contributors to any pharmacist’s workplace stress. I don’t want to blame the victims. However, an increasing tendency for pharmacists to respond before thinking has compounded the problem.
An anecdote, not an antidote
My patient Sara’s ADHD was well controlled with three 18 mg pills of an extended-release form of Ritalin each morning. She takes two upon waking and the third pill about three hours later, before noon.
If she takes all 54 mg first thing in the morning she feels unmedicated and less functional by the end of her day. The three 18 mg pill regimen has been much easier for her to manage than two separate prescriptions.
When she tried to juggle taking a 36 mg pill first, and an 18 mg pill later, she had too many days with either unfilled prescriptions or misplaced pill bottles. Simple things like that trip up many individuals with ADHD.
Her life was on track…. until her most recent attempt at filling her prescription. I entered the instructions into the electronic prescribing software. For clarity, and to prevent the insurance company from forcing Sara to take a single 54 mg pill, I amended these directions so they read:
“Take 3 pills every morning. Two pills early a.m., and one pill late a.m..” In addition, the system required that I check boxes that denote that for a 30-day supply, Sarah will receive 90 pills.
After months of this prescription working smoothly, the pharmacy abruptly objected. Their fax demanded: “Six pills a day?”
I faxed back that nothing in those two separate sentences, or the box marked “three pills a day,” indicated six pills a day. I received faxes back about “inconsistent instructions.” The pharmacy sent me more than six faxes before they were willing to fill the prescription.
This was not a case of deciphering illegible handwriting. Or translating obscure Latin abbreviations. When I shared the story, some people suspected that the pharmacy response was so inane that it must have been written by AI, not a real human. Perhaps.
But the system is broken if it took six back-and-forths before fixing a non-existent problem. Maybe it was generated by a bot, but the pharmacy’s reaction aligned so closely with many other incidents.
These are cases in which a pharmacist responded quickly, and without thinking, to a prescription that seemed slightly out of the ordinary, and then had trouble comprehending and reframing their initial impulsive reaction.
Numerous times pharmacists have claimed that there were “discrepancies” between what my electronic prescribing system printed in different sections of a prescription when all of the entries conveyed the same information.
Electronic prescribing to the rescue
Most states now mandate that prescriptions be sent in electronically, rather than as hand-written hard copies. Illegible handwriting no longer leads to filling a prescription with the wrong medication, or wrong dose. Upwards of 10% of hand-written prescriptions were not decipherable, and pharmacists tended to make more mistakes than doctors or nurses in reading them.
Ironically, I had at least two instances, years ago, of pharmacists calling to verify whether I had prescribed because my handwriting was so neat and legible. In this era of electronic prescriptions, I don’t have to worry about such calls anymore.
Electronic prescribing was supposed to eliminate problems with poor handwriting and decrease errors in filling prescriptions. However, some studies found that the type of errors only shifted, rather than decreased, with the switch to electronic prescriptions. It was too easy for prescribers to click the wrong button, or select the wrong item when clicking on a list.
Many electronic prescribing systems are poorly designed, with cluttered and conflicting screens, and redundancies that don’t ensure quality control. Potential error warnings are delivered so frequently, and for such trivial and nonsensical reasons, that they are customarily ignored by many prescribers.
I’ve read automated warnings that were incorrect about:
- drug-drug interactions
- the mechanism of action
- the duration of action
- how long a patient should take a medication
- effective doses
One recent, unnecessary alert informed me:
“This is above the accepted daily dose range for this drug (400.0 mg/day) but near or below the accepted maximum daily dose of 450.0 mg/day. Please evaluate this dose for appropriateness.”
Pharmacists who are exposed to such nonsense all day long incorporate misinformation into their understanding of medications.
And why are we still using faxes in the medical world? Having loose paper fluttering about the office is both an environmental waste and an opportunity for privacy violations.
Many fax systems convert the faxes to emails anyway, so what is being saved or protected? Medicine needs to move beyond the Dragnet days of Sgt. Joe Friday asking for “Just the fax, ma’am.”
One more computer problem
For almost a decade, Walgreens pill bottle labels incorrectly stated “no refills” about 20% of the time when there were actual refills on the original prescription. But their computers contained accurate records of those potential refills.
The erroneous information on the labels created untold anxiety and inefficiency, as worried patients contacted their pharmacy to find out whether they had refills or not, doctors had to field calls to rewrite prescriptions that were still in the system, and pharmacists had to deal with aggravated patients.
This problem was pervasive enough that it was not a simple data entry problem, it was a software problem. I understand that a coding bug that causes an intermittent problem is harder to detect and correct than an error that completely shuts down the system. But this error cost pharmacies time and goodwill and should have been solved much more quickly.
This failure to fix a problem reinforces the public’s perception that the corporate forces running modern medicine simply don’t care about people. They don’t care about the people they are serving or those they employ.
Another example of this is that many big chain pharmacies appear as if they are intergalactic pharmacist training centers. As soon as a pharmacist grows comfortable with their computer system and familiar with the customers, they get transferred away to another location. The pharmacists are treated as indistinguishable cogs in a machine, rather than as a part of a human community.
More than half of pharmacists currently endorse that they are experiencing burnout. Excessive workload and paperwork top the list of contributors to this burnout.
Kite_rin / Shutterstock
Pharmacists are leaving the field in record numbers. There were more than 60,000 job postings for pharmacists in 2023, and many remained unfilled, despite signing bonuses of tens of thousands of dollars.
Understaffed pharmacies leave more work for those who remain on the job, and longer waits for customers. The prevalence of frustration with corporate control over our current medical system was recently demonstrated by the outpouring of sympathy extended towards the assassin of the CEO of a major managed care conglomerate.
Government makes it worse
In addition to corporate pressure, pharmacists face increasing government regulation. The thousands of needless deaths from the opioid crisis provoked federal agencies to more tightly regulate the dispensing of controlled substances. As a result, prescriptions for opioid pain medications have decreased as have deaths from opioid overdoses.
However, some individuals who were using prescription opioids responsibly have been cut off from the medications that enabled them to function and reduce intense suffering. Other downsides of the new regulations are that pharmacies and doctors have been burdened with new paperwork and threats of legal liability.
Magnifying the problem, some pharmacies have employed draconian measures extending far beyond the federal regulations. They seem more concerned about the potential for reprimands than about providing a service to their patients. They’re practicing cover-themselves pharmacy rather than patient care.
A patient stuck in the morass
For seven years before I first started working with Ferris, and for the 11 years he has been my patient, he has been using the same medications to deal with symptoms from his lupus, degenerated spinal column, ADHD, and occasional panic attacks. He never refilled his controlled substance prescriptions early, had shown no signs of medication misuse, and had no problematic or dangerous side effects.
Recently, a panic attack sent Ferris to the ER. Hours later, the pharmacist refused to refill his prescription for the anti-anxiety medication he takes for emergencies.
I called and spoke with the pharmacist, and then the chief pharmacist managing the store. I reviewed with her Ferris’ diagnoses, symptomatic responses, stability of his dosing regimen, and his awareness of the potential for side effects and drug interactions.
She said that she wasn’t comfortable filling his prescriptions. She said it was because of the DEA scrutiny regarding individuals taking multiple controlled medications. I reminded her that I had just explained the medical justification for each agent and that her notes about our conversation would satisfy all DEA requirements.
She insisted that the DEA required that she have all of Ferris’ office notes and that she wouldn’t fill the prescription without them. She didn’t question, or cite as problematic, any aspect of his care.
She claimed that even a signed and written note from me summarizing what we had just discussed would not suffice. No chart, no prescription refill.
After more than two decades of using this pharmacy, Ferris, with back pain and limited mobility, trudged three-quarters of a mile down the street to a Walgreens pharmacy. He had never filled prescriptions there, and the pharmacist was completely unfamiliar with him. Yet after a simple check of the state database of his history of filling controlled substance prescriptions, the pharmacist filled all of Ferris’ prescriptions.
No DEA rule precluded him from doing so.
I don’t know what motivated the first pharmacist’s reluctance. I’m pretty sure she wasn’t a bot. However, she was unwilling to engage with the facts of the situation, either regarding the patient’s health or what government regulations stipulated. It appeared that she made an impulsive decision and was unable to stop and think about her position.
Our brains on computers
In 2011, author Nicholas Carr’s book The Shallows: What the Internet Is Doing to Our Brains summarized the neuroscience showing that internet immersion results in shorter attention spans. But more importantly, he explored how computers rewire our brains so that we respond more quickly, crave emotionally laden information, and reduce our ability to think deeply about topics. Our ability to understand context and nuance diminishes.
As we think less deeply, we also diminish our ability to empathize. Multiple factors are at play in shaping all of our behaviors. The busy workdays and excessive paperwork facing pharmacists interfere with their very ability to do their jobs. But I think I am detecting larger, more pervasive trends in local drugstores that reflect greater social patterns.
The influence of the internet may provide us with more facts, more entertainment, and more stuff, but it is also contributing to us being less patient, more superficial, less informed, and less considerate. It makes us more easily manipulated by corporations, the media, and political parties.
How do we remedy this? Pharmacists should strive to
- Remove inaccurate and redundant warnings from their systems.
- Pay attention to patient responses. Dosages are simply screening tools. What matters is the impact a drug has on that person’s body.
- Foster connections to customers and their communities, as well as with prescribers.
Whether or not you’re a pharmacist, you’ll probably benefit from the following:
Unplug from the internet for an hour or more. Go for a hike. Read a book. Practice taking life at your own pace, not the rate that the world is trying to impose. Immerse yourself in nature. Interact in real life with people or animals.
Pause to think before firing off that fax or text. Your first impulse probably is NOT your best one.
Remember that you’re interacting with people, not “users.” Regardless of the current price of precious metals, the Golden Rule is still a good one.
John Kruse MD, PhD is a psychiatrist, neuroscientist, and author. He writes regularly about mental health on Medium.com, as well as talking weekly on YouTube channels about adult ADHD and related issues.