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Controlled substance ethical question

Discussion in 'Pharmacy' started by plv731, 08.12.11.

  1. plv731

    plv731

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    Hi guys,

    I am actually a technician but I need to ask pharmacists about this.

    I just got hired at a pharmacy (and I won't give names out for my own protection, I'm based on the West Coast but I won't say any more). I have worked there for two weeks and I am concerned about the liberal dispensation of controlled drugs.

    Here are my concerns:

    1. People come from 50 miles away for narcotics and narcotics seem to be about 75-85% of the total prescriptions we fill. I did not fill an antibiotic prescription until my third day there and I have yet to fill any for birth control (and we do stock it). I fill an average of one blood pressure prescription and one diabetes prescription per day. I have no problem with dispensing controlled drugs for legitimate medical purposes I am concerned that we are too liberal in dispensing controlled drugs and we are more drug dealer than pharmacy.

    2. The setup at the pharmacy is chaotic. There are usually at least four technicians in the pharmacy and we are frequently pulled from our stations while counting and dealing with controlled medication. There is no way to ensure a clear chain of custody of the medication while getting it to the pharmacist.

    3. The pharmacy is located behind a cage but the C-II medications are not kept in a secure room or safe. They are kept in an unmarked drawer. There are two locked doors that someone would need to get in to (with one having an electronic lock and the other requiring either a key or being buzzed in).

    4. They do tech check tech on C-II prescriptions and the places I trained at did not even let technicians deal with C-II prescriptions (But I did my training in another state so the regulations might be different). The pharmacist does not even usually do a final approval of C-II medications going to the customers.

    5. There is not a live inventory of controlled drugs. The used bottles of controlled medication go on a shelf where they are restocked at the end of the day with the C-II drugs going to a special area near the pharmacist's station. I'd assume that the pharmacist does an inventory of the C-II medication at the end of each day but I have no idea if he does.

    6. The offer to counsel patients is not made clear to patients when they check out. At the chains, they have a box to check to request it. At this place, they do not even ask patients if they wish to speak to the pharmacist about their medication. The best that we do is a sign on the wall in a fairly out of the way place saying that the pharmacist will answer any questions that you have. I believe (and correct me if I'm wrong) that OBRA 90 states that all patients must be directly asked if they have questions for the pharmacist.

    7. When we have patients pick up controlled prescriptions, we take their ID number and we write down race and gender. I'm concerned that this might be discriminatory profiling (although we have security cameras that can do the same thing).

    8. The area where we check customers out is too packed with people for there to be adequate privacy protection by HIPAA standards (or at least the way I read them which is to be as strict as possible). We call to people over the intercom by saying their first name and that their prescription is ready when I was trained to say that they should be asked back to the pharmacy. There is a window for counseling but it is hardly private.



    I'm ethically torn as to whether I should continue there. There are two main problems. The first is that the job market where I live is not particularly great and money is tight for me. If I run out, I will have to move back in with my parents in Tennessee (and I worked damn hard to get to the West Coast). The other problem is that I genuinely like the people that I am working with.

    But do I have an ethical obligation to resign in the face of systemically bad pharmacy practice? Or should I speak to the manager about my concerns first?
  2. Sparda29

    Sparda29 En Taro Adun Gold Donor

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    I don't see anything wrong with the operation of that pharmacy. Narcotics need to be less policed and less regulated in this country.
  3. owlegrad

    owlegrad Uncontrollable Sarcasm Machine Staff Member Administrator SDN Senior Moderator

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    #4 strikes me as being unbelievable.
  4. All4MyDaughter

    All4MyDaughter SDN Mommystrator Staff Member Administrator SDN Senior Moderator Lifetime Donor Partner Organization

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    Me too. Tech check tech is not legal outside of hospital settings in most states. I wonder if the OP means that one tech counts the meds and the other does the second count? That would be fine. The pharmacist doesn't have to count them but should have to do the final verification.
  5. plv731

    plv731

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    Yes. That is what happens.

    But he rarely does a final verification. The verification is all done before the prescriptions are counted.
  6. Unchained

    Unchained

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    If people are coming from 50 miles away and 75% of the business is narcotics then this is a shady operation. They are driving past many pharmacies for a reason. If you have a high percentage of cash customers this is also a red flag. Do the customers look like drug dealers or legit pain patients? They are just recording Id for show. They probably don't actually follow up on verifying anything. The amount of information you have presented would give me a moral justification for leaving.
  7. All4MyDaughter

    All4MyDaughter SDN Mommystrator Staff Member Administrator SDN Senior Moderator Lifetime Donor Partner Organization

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    I'm not sure I understand this work flow. What do you mean verification is done before counting? Can you elaborate?
  8. plv731

    plv731

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    A lot of cash customers and Medicaid. Some with insurance.

    I have no idea what a legit pain patient looks like as opposed to a drug dealer. As far as I know, they could all be legit or they could all be drug dealers. I'm pretty trusting of people.
  9. plv731

    plv731

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    The pharmacist pulls the medication and checks that it is the correct one and then the technicians count it. We initial it and then bag it so it goes out to the customer. Another technician checks the controlled drugs so they are counted twice. But the pharmacist does not do a final spot check to make sure it is the right medication or amount before it goes in the bag to the customer.
  10. Quiksilver

    Quiksilver Secundum Artem PharmD

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    #6 is a direct violation of OBRA '90, all new scripts need to be counseled. You can still dispense it if they refuse to counsel but it has to be documented.

    Where CIIs can be located is dependent on the state but in a community pharmacy in my state they can be located on the shelves actually and don't need to be locked up.

    Rules about inventories is also state specific. Daily logs are not required in my state either.

    Perhaps telling us at least a state may get better answers from those who practice there.
  11. Praziquantel86

    Praziquantel86 Moderator Emeritus

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    Counseling law is state dependent. OBRA '90 mandates counseling for all Medicare/Medicaid patients, the rest are at the discretion of state law. That being said, a good pharmacist should counsel on every new prescription, every time. The law is the minimum standards of practice, not the pinnacle.
  12. 1ive2die

    1ive2die

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    Seems legit to me. Why do pharmacy employees love playing armchair detective?
  13. Sparda29

    Sparda29 En Taro Adun Gold Donor

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    I hate this about a lot of pharmacists, techs, and interns. After I had a knee surgery I was given a Rx for Percocet and Oxycontin. We had to run around to like 3 different pharmacies post surgery in a bumpy ass car. Thank god for the nerve block and the anesthesia still holding for the 1st day because the Percocet and Oxycontin had no effect on me. So I call the MD to let him know and to get me stronger painkillers. My mom goes to pick up the scripts from the doctor. He prescribes long acting morphine and dilaudid. So my mom goes back to the same pharmacy to fill it. Pharmacist is being a dick because we just picked up the Percocet and Oxycontin the day before and doesn't wanna dispense it even tho we told em that it wasn't working and the doctor called to tell him. After that, had to run around trying to find pharmacies that carried the stuff and were independent so they wouldn't have an Rx history.

    Oh, and the fact that I don't have Rx insurance didn't help my cause at all.
  14. Old Timer

    Old Timer SDN Advisor SDN Advisor

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    Here is my advice:

    [​IMG]
    as fast as you can. before you become the guy in the jacket::

    [​IMG]

    Any store that:

    Goes three days without filling an rx for antibiotic
    Fills 75% of their scripts for narcs
    Patients come from 50 miles away
    Patients pay cash for narcs

    This is a pill mill and you will end being:

    [​IMG]

    Run, do not pass go, do not collect $200.00. Thank them for their time, give them two weeks notice and then get the hell out of there.
  15. Unchained

    Unchained

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    Sparda29 you have to be kidding me? You after reading her post see no problem with this pharmacy? Do you actually have any experience working in a pharmacy? There are red flags all over the place. There is a war going on out here over prescription drug abuse. I advise you to get on board. I believe they are opening too many pharmacy schools. I think your professors would be embarrassed at your position on this.
  16. Sparda29

    Sparda29 En Taro Adun Gold Donor

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    I didn't read the whole post, only commenting on the comments about liberal narcotic dispensing. I've worked for quite a while in a pharmacy. Why should we join this stupid war that the DEA is concocting against drugs? Have you noticed how every single time people come up with a new way to get high (DXM, synthetic weed such as K2 and spice, salvia), the DEA and the government move fast to ban the stuff? It's bull****. I honestly don't give a **** about people using prescription drugs to get high. They go to a doctor, muster up some fake pain, and get a script for it. I don't care. Just fill it and send them on their way and let em do what they want.
    Last edited: 08.14.11
  17. Unchained

    Unchained

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    I understand that this comment comes from a pharmacy student at Tuoro school of pharmacy in Harlem but you will as a pharmacist have a moral and legal obligation at the very least to refuse to fill these prescriptions. The DEA does visit high volume narcotic pharmacies and will fine or close the establishment if they find they are not making an effort to reduce diversion. It is not up to you to rate the futility of the war on drugs. Addiction is destroying 1000's of lives and communities per year and it is imperative that we make a difference no matter how small it may be.
  18. Sparda29

    Sparda29 En Taro Adun Gold Donor

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    I'm not gonna be a crusader for a worthless cause.

    If I legitimately think it's a forged prescription or if the doctor's pad was stolen, then I'm gonna turn them away. If the doctor is just being apathetic, then whatever just fill the prescription. There is also a difference between addiction and dependence. This foolish war on drugs is making it harder for patients who have to take narcotics for life and are dependent on them to get their medications.
    Last edited: 08.14.11
  19. Old Timer

    Old Timer SDN Advisor SDN Advisor

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    It will be a sad day when you get your license. You have no understanding of the real world. Do you know how many people die each year from these drugs. You should know that people who take narcotics on a regular basis die earlier. Are you going to give your diabetic patients Hershey Bars because they taste good and they like them? Free fries with your Lipitor rx. You are a disgrace. You should not be allowed to practice. There is the faint hope that at some point in time you might grow up, though that is highly doubtful.
  20. rph3664

    rph3664

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    You're kidding, right? I sure hope so.

    The OP is describing a pharmacy that's in cahoots with a pill mill.
  21. Sparda29

    Sparda29 En Taro Adun Gold Donor

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    I'm not denying that there is a problem in the function of that pharmacy. Comments 2-8 all show that there is something off. I'm only talking about the OP's first comment. What if narcotics is this pharmacy's niche? What if the owner reached out to pain management docs in the radius and asked them to refer patients to his/her pharmacy while promising that he wouldn't hassle and scrutinize their legit narcotic prescriptions? I know a lot of people who get like 540 oxycodone tablets every month, and there is a legit reason.

    Every time they have to go somewhere for a while and aren't able to return home to get the script filled at their regular pharmacy, they get major problems with every pharmacy they go to fill their Rxs. Some of these pharmacists won't even call the docs if they have a suspicion, and most of them won't even answer a simple question if they have it all in stock over the phone.
  22. rph3664

    rph3664

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    You don't have to work as a pharmacist, or even a tech, for very long before you know the difference between a legitimate pain patient, or pain specialist, and scammers on any level.
  23. Kansas Pharmer

    Kansas Pharmer

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    All I have to say is WOW!!! Granted, I am only applying to pharm school this year but again WOW!!! The lack of ethics in the newer generations of people in this country is appalling.

    Do you want to see how a pharmacy turns out like the one depicted by the OP? Just use your favorite search engine and look for Schneider, pill mill, Wichita KS or any combination thereof. This was a doctor/nurse husband/wife team that that did mainly "pain control prescriptions" and they are implicated in close to 70 deaths. I am sure some of the local pharmacies actually stopped this number of deaths from being higher.
  24. Carboxide

    Carboxide

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    I could not agree more. I truly hope he does not get a residency to prevent him from having even more access to patients.
  25. rph3664

    rph3664

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    Or that s/he actually gets a pharmacy job and learns about laws and ethics.

    When I was fairly early in P-school, one of the profs told about someone who got in trouble for refilling IIRC Maxzide for 7 years without authorization, and one classmate, a woman who was notorious for asking questions that couldn't be answered, said, "It's not okay to do that as a favor for one of your friends?" :confused: Those of us with actual pharmacy experience let her know that no, it wasn't.

    This woman showed up at a Bible study I was at too, and sure enough, she played "stump the pastor"! :laugh: I'm sure she's an excellent pharmacist now.
  26. Sparda29

    Sparda29 En Taro Adun Gold Donor

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    Have a pharmacy job but I work at an in-house pharmacy for a long term care place. Don't have to deal with this issue anymore.
  27. plv731

    plv731

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    I actually put out applications for CVS and Walgreens already (I had them before I got the interview for that job). I'm PTCB certified and state licensed (and I would rather work at a chain pharmacy anyway).

    Oldtimer, what kind of liability do you think techs would have if a place like that were busted?
  28. plv731

    plv731

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    The employees often ask patients but they do not ask every time (I'd say about 40-50% so far). I'm of the school of thought that every patient getting drugs should be asked if they have questions for the pharmacist and be offered to speak to them if they wish and that this should be done in a direct and unambiguous manner. I always say something along the lines of "make sure you read all of the directions that come with the medication and contact the pharmacist if you have any questions" as I was told that was within what a technician can say (since we can not counsel). Walgreens, Rite Aid, and CVS have a box in the checkout to ask patients if they want counseling.
  29. plv731

    plv731

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    On Friday, two people come in at the same address. They see the same doctor (who is about 30-35 miles from where they live depending on the route taken) and come to our pharmacy (with at least three closer pharmacies on the way from the main road and maybe three more total closer in terms of distance). They bring prescriptions in for the same amount of the same controlled medication. The pharmacist tells me that we will learn that certain doctors have different office hours and write prescriptions on different days so we should expect to see a lot from Dr. Smith (I honestly don't remember the name) on Fridays.

    Anything a little dicey about that?
  30. rph3664

    rph3664

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    There's nothing about it that ISN'T dicey.
  31. rph3664

    rph3664

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    None of this is anything new, Kansas Pharmer. It's always gone on.
  32. Kansas Pharmer

    Kansas Pharmer

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    I understand it is nothing new. I just guess I am showing my age (37) when it comes to ethical questions. I was raised that you always did things right now matter how many people you pissed off.

    And to quote my mentor when I was learning quality assurance, "If you dont make at least one person mad every day, then you are not following all the rules".
  33. type b pharmD

    type b pharmD

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    From my limited retail experience, this sounds mildly shady but not completely outrageous , not "DEA + handcuffs" outrageous. Inefficient and risky for the practitioners who are violating board of pharmacy laws, and possibly risky for the business itself (audit red flags, losing track of inventory, being sued by a patient), but I have a hard time seeing the DEA busting down your doors and arresting everyone for the things you specifically mentioned.

    The key deciding factor (which you did not mention) which could override everything you said would be if you suspected fake prescriptions, criminal activity involved in forged scripts or 'corrupt' doctors who are writing with no medical diagnosis or without patient face time. In that case, GTFO.

    I think you need to decide whether these things on your list would put your own license in jeopardy, or if they are just a sign of a poorly run business and pharmacy. Certainly pharmacists who are not counseling and not verifying are putting their own licenses on the line, but that would not automatically get you in trouble.

    #1 Would be true in the case of a scam pill mill but just because it's true doesnt mean the pharmacy is one. Maybe you guys just keep a lot of controlleds in stock, are fast, and dont hassle your patients.

    #2 Mildly Shoddy workflow and organization structure. From what i've seen this kind of thing happens in if not a majority then a sizeable % of busy retail pharmacies.

    #3. Completely legal and standard practice in several pharmacies i've seen. Risky for audits and diversion , probably, but is fine unless DEA orders/sues you to do otherwise.

    #4. Pharmacist should do final approval, seems like that individual's license would be on the line from the board for this, not necessarily some kind of DEA thing. Techs doing controlled counts is legal in many states, as long as pharmacist is doing a check on the drug/dose/patient/correct pill.

    #5 Live inventory and daily inventory is not required by law in many places. I worked at a place that only did monthly counts, and at another place that only did end of day counts (but was later required to switch to 'live' counting due to a problem they had with the DEA)

    #6 Obra '90 only requires this counseling for govt patients. The ethical and legal question relates only to the pharmacist who is skipping counseling.

    #7. Doesnt seem unethical on its face, and seems like a good idea to help the staff. Is there preferential treatment going on either overtly or subtly involving patients of a specific race or gender?

    #8. It is what it is. Again seems like another situation where its *possible* management could get hassled about it but this seems like the case in many retail pharmacies across america. Are you going to be hassled by the board for not having a properly designed pharmacy ?

    If it were me, i'd make sure to dot my I's and cross my T's legally with regard to counseling, final checks, and record keeping, and stay on the lookout for a new job. Someday, some patient is going to sue their ass for either miscounting, failure to follow hippa, or negligence for failure to counsel. Also, someday, there will be some diversion from some of your 'large' staff. In this situation it seems inevitable. I would worry about being blamed for allowing diversion to happen or being scapegoated as the new guy. The other things, probably wouldnt mean your own ass, but would certainly be bad if you had to look for a new job after the pharmacy got shut down. Also, the longer you stay there, if you intend to stay in the same area, other hiring pharmacists may look at your resume poorly, if they have an idea in their head that you guys are a corrupt 'pill mill'.

    Personally I dont think youre at imminent risk of being handcuffed by the DEA (if there's indeed no foul play script wise) or sanctioned by the BOP (until you make a serious error), but on the other hand there's about 10 reasons why its a risky long term work environment

    HTH
  34. plv731

    plv731

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    Type b, I have no suspicion that any of the prescriptions are faked but I don't do the prescription processing really. They have another tech that does most of those. I just happened to see two people in a row from the same doctor with the same controlled rx who lived at the same address (and were nowhere near the doctor's office).

    I'm suspicious that people are getting rxs filed from questionable pain clinics but I don't know if anything illegal is done, just lots of unethical things and things that are a bit beyond what i am comfortable with.
  35. xtsukiyox

    xtsukiyox Moderator Emeritus

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    Did you just answer your own question there OP?
  36. Kansas Pharmer

    Kansas Pharmer

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    Thought I would add this to this thread:

    http://news.yahoo.com/apnewsbreak-doc-charged-prescription-drug-case-204625557.html

    And some people think that narcotics should be less regulated? Or maybe a bunch of scripts from the same doc for controlled meds isnt a problem? Just a reminder of how serious our current jobs/potential jobs can be. Imagine if you were an innocent pharmacist filling some of these and the DEA showed up with handcuffs and warrants?
  37. oh no dont stop

    oh no dont stop

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    This thread has become a little silly regarding legal responsibilities of technicians. The duty of dispensing rests solely with the pharmacist. Since when do technicians have any clinical responsibility or judgement? None in my state. (No offense)

    If you are not comfortable with what is going on there (definitely some suspicious activity going on there), call your local DEA office and have them investigate. 75% control volume is quite high. I'm sure your local DEA field officer would like to know what may (or may not) be going on there.
  38. plv731

    plv731

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    So update time:

    First of all, I largely agree with Sparda29. The drug laws in the US are hopelessly ineffective. They have done nothing over decades to reduce supply or demand for illegal drugs and they have only shredded civil rights laws and cost billions to fill prisons with minor nonviolent offenders. That being said, there isn't much that one pharmacist or technician can do.

    So the Rite Aid interview went well but they had a better candidate so I didn't get the job. I got the normal "we'll keep you in mind for the future" line so I might as well not have applied there.

    I do have a position at Walgreens lined up but I am waiting for the background check to come back (and then a drug test so it should be like 2-3 weeks but it might be tomorrow for all I know) and the location is a bit far in terms of distance (and I can't break my lease for 25 miles that easily without some negative credit impact). I have an interview with a closer CVS next Friday but it is a 24 hour location and I may have to do some crazy erratic hours. I'd assume CVS has some similar paperwork. I'm not sure what I should do here, should I take the job I get offered first or the one with better pay (assuming there is a big difference here) or the closer one?

    The thing that has me the most worried is that we apparently have an inspection coming up from the state board. So I want to get all of the paperwork done at the other job before that so I don't get caught up.

    The system at this place is so chaotic. An average of five people (pharmacists, certified techs and non certified techs) touch any given prescription from the time it gets handed to us to when it gets bagged and put in the basket for customers to pick up. Technicians get pulled away in the middle of counting pills all the time and there is rarely enough room on the counter to keep any prescriptions together. There are times where the counter has five or six prescriptions for multiple people right next to each other and there is no real barrier between them.
  39. kvl1027

    kvl1027 Member

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    I think you are so suprised because you have not become accustomed to Sparda's posts as most of us have. Most are grossly innapropriate, it is not a blanket judgment of the guy, he is probably a nice kid with a character flaw.
  40. Unchained

    Unchained

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    Plv731 if you find yourself agreeing with Sparda on anything you might consider rethinking your position. I hope he is not representative of the student body at a fairly new pharmacy school in Harlem that has low applicant numbers, doesn't look at the PCAT and extends their admission period.
  41. Sparda29

    Sparda29 En Taro Adun Gold Donor

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    Why do you keep mentioning Harlem? Are you just specifying the location of the school or do you have something against a pharmacy school being opened in Harlem?
  42. Kansas Pharmer

    Kansas Pharmer

    Joined:
    06.20.11
    Messages:
    490
    Location:
    Oz
    Status:
    Pharmacy Student
    While you may indeed be correct, it is not just Sparda that surprises me. The other students that I share my classes with also surprise me. Since I am in Organic, Biochem, etc, these "kids" are all on track to be RpH, MD, DDS, etc. and a bunch of them lack the prerequisite morality required of these positions.

    Of course, I cannot say that I was that much better when I was 18/19 but I never broadcast anything like this generation. :rolleyes:
  43. Unchained

    Unchained

    Joined:
    07.29.11
    Messages:
    394
    Status:
    Pharmacist
    SDN 2+ Year Member
    Sparda I'm not going to subject forum members to a discussion which I'm sure has been had many times before. Kansas, I believe with the opening of more pharmacy schools the quality of the applicant pool has been diminished. I think pharmacy schools place a high premium on a students ability to finance their education and decide to deal with character flaws over their 4 yrs. I believe that we will have a surplus of pharmacists but a shortage of quality which is great for some of us.

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