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Immigration and Pharmacy – Success Stories

Pharmacy practice is filled with amazing individuals.  We all know Pharmacists that stand out for various reasons. Lately there has been a climate of intolerance towards those that come to Canada or the U.S. from another country. This confuses me given the history of successful immigration not only in Canada but other countries as well. Pharmacy practice is no stranger to this and I have found it necessary to share the brief stories of just a few of the many immigrants to Canada that have and continue to contribute to the profession of Pharmacy.  My regrets are that I couldn’t include more people here and that their stories are so abbreviated in the interest of space.  These are the stories of just 3 such individuals to spotlight their paths of immigration and contribution to Pharmacy and to Canada.

KYRO

My first call was with Kyro Maseh, a Pharmacist from the Toronto area.  He came to Canada in August 1996 with his family from Egypt.  The main reason for their move was the growing religious discrimination they were seeing and decided it was time to leave.  He was 8 years old when they arrived.  His mom was a Pharmacist, which helped their acceptance into Canada.  At the time Canada was looking for Pharmacists from Egypt and his parents read that it was a good place to raise a family. His dad was a well-known and respected vetrinarian of livestock in their area but gave up that profession when they came here.  Kyro had very little English language and no alphabet skills when he came here but you would never know that now.  He now speaks French, English and Arabic.  His early days in Canada were modest by his standards today and back in Egypt.  Their furniture came from what they could scrounge up from the garbage and housing was not luxurious to say the least.  To add to the family’s stress, his mother was diagnosed with cancer after their arrival.

Kyro eventually returned to Cairo for his Pharmacy education.  At a metropolitan centre he wouldn’t experience the same discrimination as his family did in Asyute where he was born.  One day a mother came into the pharmacy and told Kyro that her son didn’t wake up that morning, he had overdosed.  She said to him that she wished someone had warned him. It was in The Beaches area of Toronto where there is a small community feel.  He began to feel at this moment that it was his calling to help educate others, particularly young people about addiction and prevention of addiction.  Mental health and addiction became an area of focus for Kyro from then on.  He feels that as pharmacists we are good at talking to people and we are knowledgeable in science.  Teaching then becomes an important and natural part of our job. His #EndTheCrisis campaign tries to focus on kids on awareness of addiction.  His warning in hesitancy of immigration points to the case of Raymond Schinazi, who was forced from Egypt, only to become instrumental in the development of antiviral medications we use in pharmacy today.  He says there is strength in diversity, something he is living proof of.

Christina

Tina Privado Azzopardi (Christina) grew up in a relatively poor setting with both of her parents, 3 brothers and 1 sister on the beautiful island of Cuyo in the Philippines.  It’s an area that is quite isolated transportation-wise from the urban areas of the Philippines and very much more laid back.  To see this tiny spit of land on a map verifies the isolation they lived in. She moved to the more metropolitan centre of Manila to pursue a degree in Pharmacy and graduated in 1997.   This would not have been possible without the scholarships she received and monetary help from an Aunt she moved in with during that time in Manila.  Her Aunt was a business owner and fairly well to do.  In return, Christina would help out with the bookstore business as was needed. Upon graduation, she was employed as a lab instructor at the private University she had attended and worked there for 5 years.  The pay was not high in this position.  

Pharmacy practice and overall healthcare in the Philippines is quite different than here in Canada.  She recalls the system as very sad and medications can be difficult to obtain with little structure to any healthcare system, little private insurance, and expensive prescriptions.  The Physician is rarely challenged on a prescription when it comes to switching to a generic or dealing with an interaction.  Physicians are held in high regard like they are here, but it is more of an authoritative role.  Collaborative care with a Pharmacist’s input is not common.  Brand name reps often visit the physicians and leave samples. This leads the physician to often write for the brand name of medications and there is no switching to generics unless it is written for.  Christina tells me it is still this way today back home.  It is not uncommon for antibiotic prescriptions to be filled for part of the total days supply due to the cost.  Being on a chronic medication can financially ruin a family that tries to pay for them.  

Christina eventually saw a benefit in working in Canada.  With the help of a broker that spearheaded the move for Zellers who was looking for pharmacists, she prepared herself for the transition, which included 3 qualifying exams.  She recalls this as an unsure time as scams were often present with such brokers.  At the time, the internet wasn’t as widely used as today and verification of such scams was more difficult.  Eventually, through friends of hers that knew the friends of the broker she was fairly satisfied this was above board and made the move with a group of 5 others; all academia and non-retail in background.  This particular group came from Centor Escolar University and from the University of the Philippines.  Unfortunately for Christina and her family her father passed away of cancer before her time to leave came.

She recalls her arrival in the GTA after 24 hours of travel when the 3 girls in the group opened the door to their new apartment and realized it was completely devoid of furniture.  It was a feeling of emptiness she recalls.  She recounted having the bed sheets she travelled with that night and they eventually got some furniture that was donated by other Philippino families living in the building.  It was in a building that had many other immigrants from the Philippines.  She lived in Barrie for three years where she worked and paid off her commitment to Zellers.  Making the switch from academia to retail in a corporate environment was tough but she was mentored during that time and felt comfortable becoming a store-owner after that.  She embraced the chance to become involved in the independent Pharmacy world.  She now owns a store on her own and partly owns three others.  She purchased a home, got married and has a 6 year old son in Tottenham, Ontario, about 70 km from Toronto.  Her mom stays with her for ¾ of the year and goes back to the Philippines for the remainder. Her commitment to the pharmacy profession is obvious but her 6-day weeks with 4 stores will hopefully become 4 day weeks to give her more family time eventually.

Johnny

Johnny Marya has no direct recollection of his birth country of Greece.  His parents were Christians living in Syria, a minority group in that country.  His father started work when he was 13 with Johnny’s grandfather in the jewelry business in Syria.  It was a family of 6 children and a life of productive work looked more favorable than school.  Early on they knew that North America offered more potential than they saw in Syria, including education for Johnny.  Before Johnny was born they moved to Greece where they lived for a short time around his birth.  His Father became a jeweler – making a fairly good living there.  They decided to begin the work to start the path to Canada and his father moved his wife and Johnny back to Syria while he went to the U.S. to begin the paperwork to have the family moved over here.  The year was 1989.   This is a process that lasted nearly three years.  During this time he didn’t see his father, who supported the family from the U.S., undoubtedly a long period for Johnny.  Finally, in 1992, when he was 2 ½ he moved to Montreal with his mom to be reunited with his dad.

Growing up in Canada offered Johnny and his family (which also now includes a sister) opportunities and education they would not have had back in Syria.  Johnny saw the value of education.  As an immigrant it was instilled in him to get an education first in order to be successful and to work hard to get what you need.  He went to work at small jobs at the same age his father did as a young boy.  His first job was at a grocery store, receiving orders and preparing fruits and vegetables for sale.  His next jobs included a Subway, a Theatre, a paper route, a duty free shop at the airport, snow removal, a forklift driver at a warehouse, a truck driver for a delivery company, and a clothing salesman for H&M. With his family they also started a tourist agency and a popcorn company, both of which they ended up selling.

As Johnny started his 4 year Bachelor’s degree in finance, he approached his father to rekindle the jewelry business that he had started to wind down.  Johnny developed a business plan and incorporated a proposal that included updated technology and smaller batch custom-made jewelry production with little to no overhead in inventory.  This was a busy time for him, working 40 hours per week while in university.  During this time he interned for a live broadcasting company that expanded and offered him a great job that he couldn’t refuse so he took that job and still offered to help his dad with the jewelry business.  He was 22 years old at this point.  He worked there for a year and turned to a recruiting agency to find a job in finance.  He was immediately offered a job with the recruiting company and within 2 years he was one of the top producers, mainly with pharmaceutical companies.  This is how he started to learn about drug companies, including McKesson.  His sister also became a Pharmacist.  After some extra legwork he convinced his future employers at McKesson that the recipe to a successful hire of a salesman isn’t in the salesman’s background in what they sold in the past (like automation), it’s in the ability of the individual to sell.  After all, Johnny spent a long time with the recruiting company coaching others in how to nail an interview.  Johnny has become Regional Sales Manager for Atlantic Canada and been doing that job for 3 years.  

Johnny’s extended family has also immigrated.  An uncle who was a physiotherapist back home, now works in Canada as a masseuse, another uncle is a successful physician in New York, and a cousin is with the Canadian Army.   Johnny’s story underscores the belief that immigrants often have a strong work ethic, come to Canada because they recognize the simple formula of education and hard work leading to success, and can be hired by companies that recognize this value and potential in this country.  While he not a Pharmacist, Johnny represents one of the many immigrants that have come to this country and contribute immensely to healthcare through their special expertise, not to mention the contribution of his family that also came to North America.  He has contributed to the success of many Pharmacies in this country.

The stories from immigrants were all equally interesting for differing reasons as I interviewed them for this blog.  I soon realized it was going to be difficult to tell their stories fully to and keep the blog’s length appropriate.  Immigration has proven to contribute to the success of Pharmacy in Canada.  Its benefits are seen both directly through immigrants who began here with a Pharmacy career and flourished, but also through the children of descendants that have come here from abroad.  Something I have learned through this exercise is how Pharmacy operates in other parts of the world.  From the examples I have heard, Canada is actually an excellent country to practice this profession, given the complaints we may have here in this country.  The respect given to Pharmacists and the value of pharmacy as a profession is strikingly higher here comparatively.  Thanks to all for their contributions in helping to promote the value of immigration through our profession.

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Why the Pharmacy OTC Section Will Be a Growing Target for Evidence Based Medicine Trolls
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The front store of the pharmacy has traditionally been where the pharmacist and patient relationship grows to a level beyond where it would be with just prescription counseling alone. It affords to pharmacists a selection of products that empowers the lay public to take some sort control of their health in almost any way they choose. With certain selective issues (or perhaps a wider selection in their minds), they can bypass the waiting room of the physician, the poking and prodding, the embarrassing questions, the waiting at the pharmacy counter – all gone with just a wave of the hand from the OTC aisle to the pharmacist peering down to you from his or her stoop in the dispensary.

The general public questions this type of medical treatment very little, partially because of the level of trust that is consistently demonstrated towards pharmacists, or perhaps because most of what is available to choose from in this realm has been virtually unchanged in its ingredient list for decades. In fact I am willing to bet that if I were to walk through the aisles of my neighborhood pharmacy on the day I was born nearly 50 years ago, aside from a few struggles with brand names and a few recognized products that have been discontinued, the ingredient list on most items in the entire store would be much the same as my store today. This brings with it a level of trust in these products by the public, sometimes a false sense.

Back then many of these products were put there in the front store without a whole lot of randomized placebo controlled double blinded/crossover trials (RCT’s) that brought most of the prescription medications to market and back 50 years ago there was little debate as to their effectiveness. The pharmacist recommended it and you took it and it worked. That was that. The path that each product took to land on the shelves of your pharmacy each has a story and history of their own.

There is a growing concern that pharmacists are now selecting items for patients that have little backing scientifically. For example, one of these families of products, known as homeopathic, is one of them. Back 50 years ago you may have even spotted one of these in your neighborhood pharmacy. Now before I go any further I’ll end your guessing of my views of homeopathy: I don’t think it really does much of anything for anybody. For those of you still reading, because you’re in agreement of that last statement, just hold on a second. If we are slamming this mode of treatment because we feel the studies don’t back it or because there is nothing in the actual dosage form, that is fair enough. The supplement aisle is another category that brings about much criticism, and for the record, I have a different belief in this category (just not fanatical in like everyone should have all of them). But as “evidence based” practitioners, in all fairness we need to apply this to the entire store.

Applying our strong standard of evidence to everything else, we look with our magnifying glass at all other products: cough medicines, constipation relief, lice remedies, pain relief selections, antacids and reflux relief meds, skin creams, acne relief, teeth whitening (ok maybe not available in the 60’s), hemorrhoid relief, bug spray, lozenges, lip balm, and lots more. Can you quote or summarize the randomized controlled history for these categories? Perhaps can you find evidence against what you are recommending that product for? Acetaminophen for lower back pain? Cough syrup for someone with a common cold. You can check out a fuller explanation of these categories here .

So getting back to our original claim slammed against us: Why do we sell these items that obviously have some doubt as to their effectiveness? As a pharmacist I am always striving to supply what people want to use for their health as long as it does not harm their health in taking it. Secondly it should be effective. The order of these two is important. My community wanted organic food so that’s what I got in to sell at the pharmacy. Removed 12 feet of magazines and replaced it with organic, gluten free, non gmo. Does it harm them? No. Is it effective for what they are taking it for? Maybe. Maybe not. But it does not harm them.

When Cold FX was going through it’s court case on the claims it was making I voluntarily removed it from my shelves. When the case ruled in their favor I brought it back – much to the delight of my customers who had been asking for it for weeks and months. Is it safe – yes, and is it effective – who the hec knows. I push vaccines, but I also sell Muco Coccinum and stress that you cannot rely on that to prevent the flu or much of anything else. I sell probiotics but screen those with suppressed immune system who cannot safely take them. I ensure that it is used safely first and if it is effective for their gut health, immune health, skin health or mental health then so be it. I try to guide them with the studies I have available to me but first and foremost it must be used safely. That means the product won’t interact with their medication or medical condition or result in them omitting proper established treatment for their condition especially should it be serious or life threatening. No one should be curing cancer or treating their heart disease in this part of the store, but if they have a drug induced lowering of vitamin B12 then I’m their guy. If they are looking to prevent a cold they feel might be coming on with Zinc tablets then great (something I take).

The point of all this is most if not all of new drug research is targeted towards bringing new prescription medication to market, not OTC drugs. While it’s true that some prescription medication may trickle down to OTC status (and thankfully this should have RCT’s to back them up, which is great) not much groundbreaking in the OTC field happens for the most part. Recently I have seen a new product come out for varicose veins and one for vaginal dryness, but for the most part we are stuck with what we have out there, and it’s not an area where we test existing products on new indications, nor do we really go testing a lot of the current indications for existing products that they are sold for (perhaps with a few exceptions). Unfortunately the vitamin/supplement and herbal market is always pushing the boundaries of what science thinks will happen if you take pill A and what an RCT says. What this means is going forward we will be left with an aging pool of products, a number of which have questionable efficacy for the indication they are being sold for and a growing list of products that have the same backup. This pool may have some new additions here and there but the old standards stay around.

Complaining about a select group of these items such as homeopathy is noble, but is kind of two faced when we don’t slam other pharmacists that sell all the other products that have similar lack of actual evidence to back them up. Particularly when the pharmacist is following the law. Being a pharmacist is not being a doctor. We can now prescribe for minor ailments in my area, but the pharmacists today didn’t invent this front store they have available to them. A pharmacist’s recommendation may not always be the same as a doctor’s recommendation, or the same as another’s recommendation, but it should be as safe.

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What’s the real reason for not counselling and missing interactions?

Lately we have heard stories of Pharmacists not doing their job correctly.  To be exact, in a survey of a sample of pharmacies, it was discovered that medications that are kept in the pharmacy but did not need a prescription, there was insufficient or completely absent counselling on behalf of the pharmacist.  These medications are in a special class in that they can only be sold in a pharmacy, behind the counter of the dispensary, and the customer must ask for the medication in order to be screened for interactions with existing medications and medical conditions, as well as proper use of the medication so that it is safely used and gives the best results.

Although there were arguments that the sample size used in this observation was too small to make an overall conclusion, just 50 pharmacies, and that the study was not scientific, showing even one pharmacy not counselling this type of medication is not good.  As pharmacists we don’t shoot for a certain percentage of jobs done correctly across the country in the run of a day.  We more importantly look at any incidence of improper counselling and try to better ourselves by looking at why we didn’t do our job correctly.  Undoubtedly spurred on by a few recent reports of dispensing errors across the country, this survey began in BC and spread across the country based on the results in that one province.  Trust me, when a pharmacist makes a mistake, it hits them like a ton of bricks, regardless of the outcome.

This nationally broadcast report was fuelled by a week long buildup that caught the eyes of pharmacists and general public alike.  Word began to spread in the New Year about the story and certainly when it finally came to air, there was a huge reaction from those who watched it.  Many pharmacists chimed in.  Initially claiming unfair reporting in that it made pharmacists look completely inept.  Others claimed that the story completely avoided the good that pharmacists do that is totally ignored for the most part.  This was followed by examples of what we do as pharmacists every day.  The reporter afterwards quickly claimed that the show was more about quotas imposed on pharmacists to increase script count than exposing pharmacists not doing their job correctly.  It was certainly a perception of mine leading up to the program and certainly after watching the program that the latter was the case.

As someone that works for an independent in a small community, the concept of pressure imposed by quotas for increased prescription count is definitely foreign to me and one I must admit I had never heard of before.  Pharmacists interviewed for the program claimed that this pressure to increase script count was responsible for other parts of their job slipping, including counselling these behind the counter medications and focussing properly on the filling and checking process.  Let’s suppose this were true, and maybe it is.  Then obviously it is something eroding pharmacy that needs to be addressed.  These pharmacists interviewed pointed to the problem of non pharmacists  now able to own pharmacies – something new over the last couple of decades.  The profession of pharmacy is certainly not against change, but the change we have seen over the last 20 years has absolutely lead to great things, but in some cases has also lead to the erosion of the profession.

Before I graduated from the College of Pharmacy in 1993, things were strict.  You kept things professional by not being able to advertise “free prescription delivery”, you couldn’t connect any incentive to a prescription like “points” for your prescription purchase or bonuses for transferring your prescription file to a pharmacy, you couldn’t say “accurate prescription filling” because it was unprofessional and implied someone else had inaccurate prescription filling, among other strict rules.  Gradually, we saw big box stores start to include incentives to their employees when they had their prescription filled at their banner, then drug plans that are affiliated with the pharmacy with restrictions that you are covered when you get your prescription filled only at that pharmacy chain and no other.  While on the subject of third party plans, in my opinion the most dramatic effect overall in the pharmacy business today, we have seen a very gradual undermining of the pharmacy business because dispensing fees and reimbursement to pharmacy from the third party plan has not grown with what is reality in dispensing.  Dispensing has become a volume business in order to show a real profit.  In fact we are starting to see decreases in dispensing fees from third party plans.  In a lot of ways I feel these plans are a part owner in my business.

A sweeping move initiated by provincial governments across the country was a huge hit to the bottom line of pharmacies, like Nova Scotia’s Fair Drug Price Act.  A move that seemingly made sense to the general population in that it aimed at lowering prescription prices by coming up with an imaginary dollar value for various popular generic medications, regardless of what the pharmacy paid for it.  This move came about from the practice of generic companies giving rebates for purchases, a common practice in many types of business.  The government saw this as their money.  These were the main dollars we used to run the programs of our pharmacy and the dollars we used for donations and community programs that came to us for help.  Very quickly this money was gone.  In effect, this attempt by the government to lower prescription drug prices was accomplished on the backs of the pharmacies in the provinces.  Our communities are now realizing the effect of lack of income in their community pharmacies.  Before too long, we saw other third party plans jump on this bandwagon, and gone were more dollars we used to run health programs we conceived on our own for the health our community.

Enter the expanded scope of practice.  We as pharmacists were allowed now to write prescriptions in certain cases of minor ailments, extend existing prescriptions, do med reviews, injections, adaptation of prescription, and order and interpret lab tests.  The reason was we can charge for these services to make up for what we were losing on the other end with rebates.  Definitely this is an honourable theory: make money for actually doing something that helps with the health of our patients.  The problem being that there was now no money to run these new services anymore and most plans weren’t on board with paying for them .

One might argue, “then why not just drop your affiliation with third party plans?”  Then we could set our own prices bases on our own pharmacy needs and staff levels .  Small town low volume stores could have better control over their income and not allow third party plans to control what they earn on a prescription.  Instead of getting paid 12 dollars for a prescription that costs 15 dollars to fill, you could charge what you paid for the drug and a fee that allows the dispensary to make money on its own regardless of the front shop.  Well we do this because it allows our patients to afford their medications and they probably fill more prescriptions for their health when they have coverage, not to mention that all pharmacies not dropping plans means patients shop for pharmacies that take these plans.

This brings us back to the original issue of why are we dropping essential counselling and why are we too busy to catch interactions?  Well perhaps the pressure we should be looking at isn’t the pressure to fill more prescriptions, it’s the pressure imposed by third party plans on the pharmacy whereby they don’t make enough on each prescription to pay for itself in the first place.  Maybe this is the reason for the “quota” being imposed on pharmacies to fill more.  The lack of reimbursement forces any pharmacy to scratch for more prescriptions since they cannot afford to hire the staff to run these extra programs and give time to the pharmacist to do their work of not only bettering health, but preventing harm from meds.

To top off the issue of missed interactions because of lack of time, consider the thought process involved with each and every prescription when the possibility of the patient dying from the medication exists each time a prescription is filled.  The side effect of any  medication is death and there are so many side effects and potential warnings on any given medication it would take an hour to explain them all to each patient.  On top of that, the sheer volume of prescription interactions with other meds or disease states makes the evaluation of these interactions an art that is not just based on book smarts, but also on clinical experience.  If there is a 0.00001 chance of a dangerous interaction occurring do you call the doctor, alert the patient and change the drug?  Is the evaluation of these interactions a black and white science or is it based on followup with the patient on their overall health and history.  Recently I wrote a blog on a type of interaction called prolonged QT interval ( https://stonespharmasave.com/blog/?p=694 ) that describes the complex evaluation involved with just one interaction.  There are thousands of such interactions to evaluate for each fill and you reset your brain when you fill the next prescription.  If I give you a prescription there is a very slight chance you might leave the pharmacy, take the medication, have an adverse reaction or interaction with another medication and die.  Perhaps I will be on the evening news for not telling the patient this.  Do I tell you this?  Not necessarily.  But if I evaluate the probability of this reaction occurring then I am in a better position to act on it.  When we take off in an airplane do we sign off on the fact that it might crash?  There is inherent risk in taking any medication.  It’s our job to make sure you have the best possible medication and outcome from that medication.

Getting back to the lack of counselling in these behind the counter medications – guilty.  We accept that.  The more pharmacy and pharmacies are left to be run by corporations (big box stores and third party plans) and not pharmacists, the more and more this profession will erode and show up on more undercover specials.

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