A Clinical Pharmacist on Why Your Prescription Takes So Long and What Big Pharma Hides

Vance Crowe [00:00:00] You probably don't realize that your pharmacist is working a 12 hour shift, doesn't get a lunch break and gets UTIs because they can only pee twice during the shift because they can't leave the pharmacy.

Kelly Erdos [00:00:10] Really?

Vance Crowe [00:00:11] Yeah. This is the Vance Crowe podcast.

Kelly Erdos [00:00:18] Welcome back to the podcast. I'm glad you're here. When I think of a pharmacist, I typically think of a white lab coat and a person stuck all the way in the back of a CVS or a Walgreens, doomed to a professional life of counting out little tablets, one at a time, and always interacting with sick or injured people that are probably not very pleasant. And so that's why this week's interview with a clinical pharmacist named Kelly Erdos was so interesting. Kelly and I go back a long ways as you'll hear in the beginning of the interview, but we had a chance to have a really candid conversation where I was able to ask those kind of blunt questions that you might be a little bit hesitant to ask if you were talking to a person you didn't know very well. I asked her, why can't we just turn all pharmacists into robots if all they're doing is counting out medication and why is it that it takes more than 10 minutes to fill my prescription? Then we go into other topics like, what should a parent know about their child and being exposed to germs and medication. We talked about things like essential oils and we even got into the benefits of CBD oil and cannabis in general. Kelly is a longtime friend and you will tell very quickly that she has a gregarious and bubbly personality with a big laugh and an even bigger heart. I was really grateful that she was willing to sit down when they were here on a, on a vacation getaway with our family and we had a chance to talk about all the things that we did today.

Kelly Erdos [00:01:50] I really hope that you stay through the whole interview. It's an enjoyable one and one that opens up the world of pharmacists in a way that I had never thought of before. So enjoy

Vance Crowe [00:02:02] Rolling. Alright.

Kelly Erdos [00:02:07] Kelly Erdos.

Vance Crowe [00:02:08] Yes. Welcome

Kelly Erdos [00:02:08] To the studio. I'm, thank you.

Vance Crowe [00:02:10] Very glad to

Kelly Erdos [00:02:10] Have you. So just so the listeners know, you and I are good friends. Yes. You were best friends with my wife Annie in high school. Yes. And you came in from Arizona to visit?

Vance Crowe [00:02:21] Yes, I did.

Kelly Erdos [00:02:22] And so last night we were sitting out having some drinks and you mentioned that you gave the commencement speech

Vance Crowe [00:02:29] Oh,

Kelly Erdos [00:02:30] At the end of your pharmaceutical

Vance Crowe [00:02:33] Yes.

Kelly Erdos [00:02:33] School, yes. So let me ask this straight outta the gate. Is pharmacy school difficult and what in the world do you say to a, to a room of pharmacy students as they've just graduated?

Vance Crowe [00:02:45] So definitely pharmacy school, school is extremely difficult. One of my best qualities is I go through something really terrible and then at the end I say, that wasn't that bad when it was real bad. So asking me almost now, 10 years out of pharmacy school, I probably would say it wasn't that bad. But in the library for hours and hours and hours, it was, it was tough. But I think what I would say to them is, what you will learn and be able to achieve with the knowledge from the education that you receive is such an amazing gift. And healthcare in general, I think is all what you make it. So one of the reasons I went into pharmacy school originally was a couple of things. So Anna and I, we were in all our science math classes together. A lot of the people in those classes went off to do things like engineering and I wanted to be with people. I didn't like blood, so I definitely didn't wanna be a physician or a nurse. But pharmacy spoke to me because it was rooted in that, that science. And at the time I thought there were answers. If you're sick, you get this medication. And I still got the people the, the aspect of being able to communicate with them impact them directly. And so that's why I went into it. And I think that that's also something I would say to new graduates is always remember why you started. Hopefully those were good intentions. Not, well, I wanted to make a good amount of money, which you do, but the patient should always be per put first and don't forget that.

Kelly Erdos [00:04:21] So what are you studying in school when you say it's really difficult, you're studying biochemistry, what? What?

Vance Crowe [00:04:27] So you're studying everything starting at the ground level with these medications. So you are learning the actual Yes. Chemistry behind molecular structures and how that relates to things like if you have a patient with a sulfur allergy, well, if you're looking at the sulfur group off of a medication, how that might be different for other medications. So that's how we can say, if you're allergic to this antibiotic, we shouldn't do this antibiotic. Then also taking that chemistry and understanding things like drug interactions. So when there's new drugs on the market, they haven't been researched as much. And so with certain things like warfarin, warfarin is a blood thinner used for people who have had stroke or blood clots in their body, A DVT or a PE pulmonary embolism. And that medication has thousands of drug interactions. So you can go in your database and you can look, okay, the person's getting started on fluconazole, they're on warfarin. We know we're gonna have to cut their dose of warfarin in half and recheck them in a couple days. But if there's a new drug that comes on the market, there might not be all that information available. So that's when I don't necessarily look for, if there's a listed drug interaction, I go back and I see how is that new medication metabolized in the body? And based off of that knowledge, you can make an educated decision on if it is likely to interact. So you have to know the very structure to understand everything that comes from that point forward.

Vance Crowe [00:05:59] Also, when you're looking at how drugs are metabolized or go through the body, a lot of times it's through the liver, through the kidneys. And so if someone doesn't have a great functioning liver or doesn't have great kidneys or what we would call renal function, that's definitely gonna change their course of therapy as well.

Kelly Erdos [00:06:16] So how long is is it's just called pharmacy school,

Vance Crowe [00:06:20] So you can go into pharmacy school without your undergrad degree completed. So technically you could probably get all your prereqs done in two years. I did it in three and then most are four year program and you get your doctor of pharmacy.

Kelly Erdos [00:06:34] Okay. And so, and that's a total education of how much time spent studying medicine. So

Vance Crowe [00:06:40] Six to eight years. And then what most people do now, it wasn't as common when I graduated, but I'd say over half of people that graduate now do, what's a pharmacy residency? So you get paid, you get paid about half a third to half of what a regular pharmacist would make. And it's a year of specialized training. So where I work and in my residency is Banner Baywood out in me, excuse me, Arizona. And we are associated with a outpatient clinic and with a heart hospital. So during that year, I spent a month over at the heart hospital. I spent a month down in the outpatient clinic. I spent a month on the floor for surgery floor. I spent a month in the emergency room in the ICU. And so you get all these different experiences with these highly trained pharmacists that let you first get a big picture about all the different areas of pharmacy, but then also decide what you want to do as well. After a PGY one residency, you can do a specialized second year residency. So the shortest, shortest it could be is six years, you know, from start to finish or you could be at eight to 10 years.

Kelly Erdos [00:07:52] Okay, so this is a little bit blowing my mind. You have six years of studying medicine. Doctors take six years to become a doctor, but they're learning how to set a bone and how the heart works. So how much do doctors know about the medicines they're prescribing and relative to a pharmacist?

Vance Crowe [00:08:09] It depends on the physician. Obviously some of them are really great. A lot of times they have pharmacists incorporated into their practice now. So you will have a, the rounding team, which is gonna be the nurses, the physician, and the pharmacist is right there. And so they'll say, this is what's going on with the patient, what do you think that we should do? And they can collaborate. I'd say that in my setting, the physicians that are in that area have overall a very, very good understanding of the medications, but some places don't as well. So is

Kelly Erdos [00:08:42] That because they're doing medication in one domain? So like the, the cardiologist is, is has kind of a, a realm of medicines that they're using? They can get to know those?

Vance Crowe [00:08:52] I would say that's probably definitely plays into it. There's sometimes where we'll get a call from a physician and you know, we'll say, is there any other alternative that you can use because of X, Y, Z? Again, pharmacy and the area that I work in is very well respected. And so a lot of times they'll take those recommendations, but you definitely have then on the flip side, friends who will have the same exact situation and the physician's ego says, no, that's what I want because that's what I want. Not because maybe that's what's best for the patient at the end of the day.

Kelly Erdos [00:09:23] So the only pharmacist that most people know, in fact before I knew you, is the pharmacist at CVS or Yes, Walgreens. So to me pharmacy has always been like, like a prison guard in reverse, right. Where they are guarding the the the drugs and they have the special yeah. License to be able to say, yes, you can have this and this many and they count out the pills and it seems like a job their robot could do. Yeah. So what's going on there? Why?

Vance Crowe [00:09:49] So a robot definitely could do the counting for sure. What they couldn't do is looking at all of those other things to make sure that it's the right medication for that patient. So again, looking at things like medication reconciliation or a med rec, because you need to make sure there's not duplicates in therapy, there's not the drug interactions, the dose is the right dose for that person. We've had several times too where a patient will bring in their bottle and say, okay, this is what I picked up from the pharmacy and I look at it and it's not necessarily what the physician meant to prescribe. So it was misfilled, it was probably four years ago. I had a patient and he was on warfarin. He came to our clinic and at our clinic we usually will call in or electronically send over the prescription for the warfarin because we're doing all of the management of that drug.

Kelly Erdos [00:10:46] So you're not you in your job, you're not sitting there doing the little counting that you always

Vance Crowe [00:10:50] See the, so

Kelly Erdos [00:10:51] There's on the B roll these

Vance Crowe [00:10:52] I see no pills in my job. I don't touch a medication. Everything that I do is a one-on-one consultation looking at things like if the patient comes in with uncontrolled diabetes, where are they in terms of checking their blood sugar, adjusting their doses of insulin. And we're able to do that in the clinic ourselves. So before I came out and visited you, I had a new patient who had diabetes and she was actually coming in for a couple different things. But for anyone listening out there who has D diabetes, her A1C was 12.4, your A1C is probably in the four to five range. It's a measure of how high your blood sugar is over a three month period. And so she's got very, very, very high blood sugars and so on, two different types of insulin. So we sat down and we went through and made adjustments with her insulin regimen that she's taking and then I'll see her again on Monday and she'll bring in those blood sugars and we'll look at it and make it another adjustment at that point.

Kelly Erdos [00:11:53] So this is interesting, this is like actually doing what I would've put in the parameters of what a doctor does. It's saying you can look at the test results and as long as they're within the print, we know this person needs to be on insulin. But in your pharmaceutical judgment, this is how much you should have or which specific type of insulin or

Vance Crowe [00:12:11] Yes. And the pharmacist is also gonna be looking at things like perfect world versus real world. This is something that I always tell our residents that come in, in the perfect world, I might want this insulin, this dosing, this testing. It doesn't matter what we want, it matters what's gonna get done. And so there are, when

Kelly Erdos [00:12:31] You say what's gonna get done, you mean like is the patient gonna take the pills they're supposed to take?

Vance Crowe [00:12:35] Is the patient gonna take it? Is the insurance gonna cover it? And those are I the big two things. Can they afford it? Is it covered by the insurance and are they actually gonna do it? So if I want someone to be taking insulin three times a day, but I know that it's gonna be a struggle to do it one time a day, well then let's do it one time a day. The best that we can build that relationship and trust and then throw in a second dose during the day.

Kelly Erdos [00:13:02] No kidding. This is mind blowing to me that that, so you take into consideration whether or not they'll do it.

Vance Crowe [00:13:10] Oh yeah, a hundred percent.

Kelly Erdos [00:13:12] That's that. That's a flexibility or an aliveness to medicine that I didn't, that I didn't think of because

Vance Crowe [00:13:17] Yeah,

Kelly Erdos [00:13:17] Anytime I've ever been prescribed a me medication, I had an antibiotic the other day and it was take two pills, 12 hours apart. And that's just what I did. And there was not, there was not a, the doctor didn't ask whether or not I thought I could do it

Vance Crowe [00:13:31] And antibiotics are gonna fall in a little bit of a different category. But let's say you went and filled that prescription and for some reason it was gonna be $400 to take, that's where the pharmacist should come in and say, okay, well these are maybe some other cheaper options that if it's gonna be nothing or this, what is that this that we can get get to?

Kelly Erdos [00:13:54] And so how much flexibility, so if I'm the going back to the Walgreens CVS pharmacist, I come there with the prescription that says I need this particular medicine. What's their flexibility or do they just fill that bottle?

Vance Crowe [00:14:07] They a lot of times will probably just fill that bottle because they are understaffed and overworked. So when people come in and say, you know, why does it take 10 minutes to slap a label on that? That's

Kelly Erdos [00:14:18] Exactly what I think. Fax, that's right. 25 minutes.

Vance Crowe [00:14:22] So it's not a fast food restaurant. What you don't see is the hundred orders of medications they've got in the queues, the doctors, they're calling about these potential problems or suggesting an alternative. And retail pharmacists from when I started to now have become come. So just so overworked. You probably don't realize that your pharmacist is working a 12 hour shift, doesn't get a lunch break and gets UTIs because they can only pee twice during the shift because they can't leave the pharmacy.

Kelly Erdos [00:14:54] Really?

Vance Crowe [00:14:55] Yeah. So their managers at those stores a lot of time is the manager of that CVS or Walgreens store and all they care about is the money and the numbers. Whereas in pharmacy, the pharmacist is hopefully their number one concern, the patient. So if a pharmacist wants to go slower to be able to make these interventions, they'll probably get fired because they're not gonna fill enough prescriptions and not make enough money for the pharmacy.

Kelly Erdos [00:15:22] But medicine is so expensive, it's surprising to me that they have understaffing issues at a thing like Walgreens.

Vance Crowe [00:15:30] Yeah.

Kelly Erdos [00:15:31] And is that what, what would you say that's a function of

Vance Crowe [00:15:33] Money?

Kelly Erdos [00:15:34] Too many, too many Walgreens, like

Vance Crowe [00:15:36] Too many. They want their bottom line to, to look as good as it can. And so pharmacists have historically been great at getting things done and so they'll get it done. Being understaffed, does that mean there's higher burnout? Does that mean there's higher medication errors? Does that mean it's not the best thing for the patient? Yes, but that manager of that store wants to look good. And if the pharmacy's the money making point, when you have a pharmacist that makes six figures, even adding half a pharmacist extra is a lot of money that's gonna take away from that bottom line. And they don't like to do it.

Kelly Erdos [00:16:12] And so if a person comes into a Walgreens CVS and they say, I want this medication, they, they find out how much it's gonna cost, they go crazy.

Vance Crowe [00:16:22] The

Kelly Erdos [00:16:22] Pharmacist has the power to change that or the power? No. Okay. So so what happens then?

Vance Crowe [00:16:26] So in that situation, the pharmacist would have to reach out to the doctor to make a change. In the situation that I am at, we have collaborative practice agreements with the physicians. So that patient that I saw on Wednesday, it says diabetes management and that includes being able to change their insulin, which actual insulin they're on and the dosing of that as well. So I have a lot of flexibility with what I do. Retail, their hands are tied in terms of they can't make any of those changes without having a touch touchpoint with the physician. And again, that's time, you know, so that person's ahead of you getting your antibiotic, their antibiotic's not covered, the pharmacist is taking 10 minutes to try to get that resolved. You're even more upset that you're having to wait longer 'cause you don't see anyone in line. You know, the pharmacist is just back there and you say what's going on here?

Kelly Erdos [00:17:22] So the retail pharmacists, it sounds like it is just as bad of a job as I imagined it to be sitting in the back. It's worse. Okay. What, what else makes it worse?

Vance Crowe [00:17:33] I think that a lot of, and there's definitely friends that I have that that love their job, that enjoy their job, that have good, good employers. So I don't wanna say that all of those are negative, but next time you go and get your prescription filled asked, do you feel that your pharmacy is appropriately staffed? And I would definitely feel comfortable saying at least probably 75% or more of retail pharmacists would say, no, we need more technician hours, we need another pharmacist. They don't feel significantly staffed.

Kelly Erdos [00:18:05] And, and there are other people in the back there that are not pharmacists, they're pharmacy tech, pharmacy tech. So what's the different, what's, what's going on there?

Vance Crowe [00:18:12] So a pharmacy technician is someone who just goes, and I haven't worked in retail in so long, I don't know the minimum requirements. If it's like a high school graduation and then they have to, within a three year period take a test and become certified. I think that's what it is, but I'm not a hundred percent sure. So they're the ones who are maybe getting those things ready for the pharmacist or you know, counting by fives the medication that then the pharmacist double checks. So they're trying to take everything off the pharmacist plate that they can so that the pharmacist can in theory do those higher level type things. Which is also what my job entails as well is looking at practicing at the top of our license. So a physician is typically the person you would go to for your insulin making these adjustments. For example, they make 'em, they see you in three months. I see you, I can see you in three days if I want. Because my structure is so much different. We're able to call patients and do phone follow up throughout the day, which is a great thing as well. So it depends, it depends on where you are and what type of practice that you have also.

Kelly Erdos [00:19:20] Okay, so there are retail pharmacists and there's you, why don't you talk a little bit about what you do Sure. And how that's different than retail pharmacists.

Vance Crowe [00:19:28] Yeah, so I work from where I did that residency at Banner Baywood out in Mesa. We had the heart hospital, the medical center, and then the outpatient clinic. And during that time I realized I loved the clinic, we got to sit down and have one-on-one conversations with these patients and we were able to make such big and positive impacts in them. So currently I see patients who have diabetes, who have high blood pressure. Soon we'll be seeing patients that have COPD or asthma. And then the bulk of what I do is still patients who are in the blood thinner Warfarin,

Kelly Erdos [00:20:00] COPD.

Vance Crowe [00:20:01] So that's a breathing disorder.

Kelly Erdos [00:20:04] Okay. And so they all are coming to a specialized practice for these issues. And then you are a part of the, the, the larger medical practice. So

Vance Crowe [00:20:13] In our clinic it's just pharmacist run. So all the pharmacists that you'll see in our clinic have their doctor of pharmacy and are also board certified in ambulatory care, which is the hardest test test as a pharmacist that you'll ever take. And it's the one time where if you don't pass it, no one's like ugh. They're like yeah it's bad. And so they have specialized training in those different areas. So if you come in to see us, you'll just check in with the secretary and then you'll see one of the clinical pharmacists in our clinic.

Kelly Erdos [00:20:44] Okay. And so somebody comes in to see you for the first time they've got a pile of medicine jars. Yeah. And they're just being like, here you go. Or

Vance Crowe [00:20:52] Sometimes they are, if they're coming there for general medication review or what we would call like a comprehensive medication review, yeah they will come in with bottles that might fill half the stable and say help me. And so we will go through all the prescription ones, all the non prescription, you know, over the counter supplements, things like that and say okay, what do you need? Where can we get rid of medications? I'd say that's also a think people find surprising is that pharmacists hate having people on too many medications. We will always try to get you off of medications that you don't need because we see all the potential side effects and things that can go along with that. So anytime we can suggest to the physician to get rid of a medication, we will. And

Kelly Erdos [00:21:41] So in what circumstance would that happen that they would be prescribed a medicine that the pharmacist would say, are you sure?

Vance Crowe [00:21:47] Shockingly a lot of situations. So you might have the cardiologist that P puts a patient on one blood pressure medication and then the primary care already had them on one in a similar drug class and they're not talking to each other and the names of the medications are different. So the patient might not realize it, maybe they even filled them at two different pharmacies so the pharmacist might not know when they're filling it that they've got this other one already at home and then the patient starts taking both of them and so their blood pressure is then the opposite, you know, it's going down way too low. Things like that. You would think that that wouldn't happen.

Kelly Erdos [00:22:24] Yes, that's exactly right. I'm thinking that precisely

Vance Crowe [00:22:27] You would think. How does that happen? It happens because you're at that cardiology's office, they're in a different practice. The patient, when they're filling out their paperwork doesn't put all their medications on there because a lot of times patients will miss one or they just will say, oh I don't know, I'll get back to you with that. They'll fill it at one pharmacy and then fill at another pharmacy. So those pharmacies are in different systems and they're not talking to each other. So you have all these silos instead of one cohesive group and it can fall through the cracks really easily. So those patients, they come in, they put down all those bottles and then that's where I'm able to say, okay, you definitely need only this or that. And then we will call the doctor and say, which one do you want? A lot of times with patients kind of self-medicating over the counters, herbal supplements, we'll see that as well. You know, maybe they're taking a multivitamin, a B vitamin 10, other vitamins that they don't realize that have all the same second ingredients so they think they're doing good by, you know, getting all these supplements where really they're just bombarding their body with things that they don't need and too much of it as well. That's one thing that patients think if it's not a prescription then it has to be safe and that's a hundred percent not true.

Kelly Erdos [00:23:44] Oh, we will definitely come back to that. But I, I want, I'm, I wanna stick with the, with the part of people coming in and, and so is when they come to you, are they scared? Is this something that somebody told them they needed to do? Like how what's going on there? It

Vance Crowe [00:23:59] Has to be a referral either from a community provider or from the hospital itself. And to be honest, usually it's like clockwork. They come in and they have all their medications and say, I don't really understand what I am here for. And then by the end they say, I am so glad that I kept this appointment even though I didn't know what we were gonna be going on. So most of the time I'd say people are just very open when they come. We do have patients who, if it's that they just got out of the hospital, we do a lot of heart failure education as well. So if it's someone who just had a new diagnosis of heart failure or is coming to us right after a stroke, those patients are the ones that are scared. But overall, if they've made it to the appointment, they want to be there. Even if they're not a hundred percent sure what's gonna be going on.

Kelly Erdos [00:24:45] So they go through this, this process with you and they're saying these are all the medications, you get them done and then they're outta there or they come back multiple times or

Vance Crowe [00:24:53] It depends. With those ones in particular, most of the time then they're done. I give them my card and usually I have kinda my standard phrase of think of me as your personal pharmacist. If you have any questions, feel free to call. We can make an appointment for you to come back if you feel like you need to. But if I feel that everything's kinda wrapped up with a bow at that visit, then those ones won't come back. That diabetes patients, the heart failure, all those ones that we're dealing more instead of with just general medication review, we're looking at chronic disease states, those are the ones that we'll follow follow up with.

Kelly Erdos [00:25:27] When I see these things sold at the pharmacy where they've got like Monday, Tuesday, Wednesday, you know, I guess I'm a young person that doesn't need medications but I see that they're getting bigger and that people need more and more medications. Yeah. What do you think of the volume of medications that people are on these days? Is it actually going up? It feels like it's going up.

Vance Crowe [00:25:48] I, I would say I would agree with that. I think part of that is inherent in that people are living longer. So sometimes a patient will come in with a new diagnosis of diabetes and you know, they're 75 and they don't have any family history, anything like that. But no one above them made it to 75. You know, something else got them first. So as we live longer, we have the opportunity to let these diseases have more of a chance of popping up as well. Obviously a sedentary population where obesity is very prevalent at a younger age. So now we're living longer, we're getting sick sooner, there's definitely gonna be a rise in medications because of the diseases that are, are more prevalent.

Kelly Erdos [00:26:37] And are, are most of your patients older or younger?

Vance Crowe [00:26:40] They are, yeah,

Kelly Erdos [00:26:40] They are older.

Vance Crowe [00:26:41] So where I live in Mesa, we definitely have a very large geriatric population. I'd say the average age is probably like late seventies, eighties.

Kelly Erdos [00:26:50] Okay. Yeah.

Vance Crowe [00:26:51] And

Kelly Erdos [00:26:51] Then do you have to worry about people with dementia making sure they take their pills?

Vance Crowe [00:26:55] Yes. For example, this past week I had someone that came in and he's manic depressive and he said, I've had a really bad week, I'm in my depressed state. I haven't been taking my medications because it's been hard to get outta bed. And so I said, okay, in the last seven days, how many days do you think you did take your medication? And he said two. So you have people with different diseases like dementia or mental health issues that are also going to affect them taking their medications as well. The pill box I think are the best for people who just don't remember, you know, they take their medication in the morning, they do everything else that they were doing that day and then it's, wait, did I take it? Or was that yesterday? Did I take it? I, I don't remember. And then they can look in the pill box and then they say okay, I took it. It's one of those things where if your routine is the same every day, you can almost get those false memories you know of Yeah, I shut the garage door, didn't I shut it? So you go back and you look and make sure it's down. Same thing with the pill box. You go back and you look and say, okay, yeah good, I did take it.

Kelly Erdos [00:27:59] So you were talking about medical, like going through the different medicines and checking maybe people have double up on blood pressure.

Vance Crowe [00:28:05] Do

Kelly Erdos [00:28:06] You also see patients that you're like, what are you doing on this medication?

Vance Crowe [00:28:10] Sometimes. Usually it's not as, you know, kind of, oh wow, what the heck is going on here? A lot of times it's more the subtle things or you'll have a patient who comes in and they're describing certain symptoms of how they're feeling and it's maybe possibly due to a medication, not a new disease or a new problem that's popping up. So always looking at that as well, if patients aren't responding well to a medication or if they are having the side effects sometimes then you get another one to cover that up, you know, so that's the cycle that we don't want is okay, I need something that's gonna make me feel good during the day, but then I can't fall asleep so I have to have someone to help me fall asleep. And then now I'm jogging in the morning. So those vicious cycles, we don't want to to see those as well.

Kelly Erdos [00:29:02] When one time my brother was going on a trip and right before he went on the trip for some reason he got some medication and it said in big letters, you know, do not take with alcohol. Yeah. And he was like, well I'm going on a cruise. Yeah

Vance Crowe [00:29:13] I'm

Kelly Erdos [00:29:14] Gonna be drinking. How serious should people take those, those warnings on there?

Vance Crowe [00:29:18] You know, in the setting of an interview like this, I would say always follow those instructions, you know, as a pharmacist, do what the label says. If we were having a beer tonight and you said, you know, I'm on the last day of my antibiotics, like is it okay if I drink this beer? I'd be like, yeah, have the beer. But as a professional I would say no. Follow the instructions and abstain from it. But it's all everything in perspective too. I mean depending on what you're on, there's,

Kelly Erdos [00:29:46] I mean those directions can be crazy. Yeah, they're re So do you have stories of people not understanding the directions that they're reading? Oh

Vance Crowe [00:29:53] Yes, very much so. Just to touch on that point really quick though, there are definitely certain antibiotics that if you do drink you can become violently ill on. But the one that you're getting probably for a sinus infection, those are not the ones. So that's a caveat as well. You can't say, oh it's bogus all the time 'cause they're there for a reason, you know? So definitely take that with a grain of salt, but oh my gosh, directions. And retail pharmacists would have so many of these stories where you think, why do I have to put like inserts and blah blah blah directly, you know? And then a patient comes back and they put their suppository in their nose or something. Or we had a patient in our clinic where we have a medication that's an injectable called Lovenox. And so if people are off of their blood thinner for a procedure, but they're really high risk of a stroke or a blood clot, we don't want them to be unprotected for even a few days. So they switch over to what this injection is, is Lovenox. And so you do it where you pinch an inch, put it in, you know, inject the entire syringe and then you put it in a little red sharps container. And so I had a colleague that came in and the patient had done one of these Lovenox, what we call Lovenox bridge 'cause it's bridging you while you're off your other blood thinner. And he said, I have another procedure coming up so I guess I'm gonna have to do that Lovenox stuff again. And my colleague said, okay, you know, and starts going through all the things and he's like, ah, but that stuff just tasted so gross.

Kelly Erdos [00:31:27] Oh no. And

Vance Crowe [00:31:28] He is like, it what? He's like, yeah, it was disgusting. He's like, why did you taste it? He's like, well I took the syringe and he injected it into the red sharps container 'cause he thought that was a cup and then he drank.

Kelly Erdos [00:31:42] Oh no. And these kinds of things happen all the time. Yeah.

Vance Crowe [00:31:47] Like, yes. So obviously that was a good point for that pharmacist that even more instructions on how to do the injection were necessary for that, that patient in particular. So route of administration is definitely one of the number one things that people get wrong, I would say with their meds.

Kelly Erdos [00:32:09] The other thing that comes with complex prescriptions is not just the how to take it, but the warning labels and particularly the ones where you see them advertised on tv. Yeah. So somebody says, you know, take this for your depression, however it may cause symptoms of of suicidal right thoughts and da da what is going on there? Because a lot of times it seems like the, the the warning label is more scary than the whatever disease you're

Vance Crowe [00:32:35] Fighting. Yes, yes. That's where you definitely have to look at what's the risk versus the benefit. And those warning packages list everything in the kitchen sink again. And that's a liability issue. But it also comes from what patients report as well. But something like, let's say upset stomach. If you're at dinner with a group of 10, 15 people and you say, did anyone have an upset stomach today? Probably at least one of 'em is gonna raise their hand. If that was a clinical trial, then that one person would count towards a percentage that upset stomach is a side effect of that medication. Because

Kelly Erdos [00:33:12] If they found out later that it really was causing it, then nobody reported it, then you get sued. But as long as you disclose it, then people would be like, okay, well that's a part

Vance Crowe [00:33:19] Of the side effect. Right. It could be that. So that's where when I originally went into pharmacy, I thought it was so much more black and white. One of the things that I loved in high school and even undergrad was when you would do something like calculus or organic chemistry, you got an answer and you put a box around it and that was the answer. And then I went into practice and instead of things being black and white, I have learned that there are just a whole lot of shades of gray. And that was shocking to me. I thought, you know, this is the problem, these are the solutions and you pick one, but it's, it's not like that. And looking back, of course it's not. If it was that easy, the field would be very different. So looking at all those different shades of gray is where you have to see. So if you're taking a medication that is going to benefit you in terms of improving the quality and the length of your life with minimal side effects, it's an easy decision if it's going to extend your life, but reduce the quality of that life. That depends on the person. I am more of the belief of I would want something that is going to improve quality of my life over the length of it. Other people aren't. Other people want to have as long of a life as they can. Even if that is gonna involve more suffering from something like extended chemotherapy treatments or things like that.

Vance Crowe [00:34:51] So that's where the other factor comes in. And I always tell my patients that it is your choice. They say, how much longer do I have to take this medication? I say, you don't have to take it at all. You could stop taking it today. That is your choice and you need to be part of the team that makes that choice. But your risk of stroke is gonna go up by 35%. And is that a risk that you're willing to take?

Kelly Erdos [00:35:11] That's interesting. 'cause I mean you grow up when you're taking medicine as a child

Vance Crowe [00:35:15] And

Kelly Erdos [00:35:15] There isn't a choice. Yeah.

Vance Crowe [00:35:16] And

Kelly Erdos [00:35:16] So now I do have that strong sense of a doctor prescribed something for me. Not only do I have to take it, I have to take all of them. And if I didn't then I'm bad and I'm contributing to antibiotic resistance. Yes. And I'm a terrible person, which

Vance Crowe [00:35:27] That statement is true. So finish your antibiotics.

Kelly Erdos [00:35:30] And so do you have those conversations with people about Yes, all the time. This is the side effect. So if you're feeling this nausea,

Vance Crowe [00:35:38] The

Kelly Erdos [00:35:38] Reason you're taking this medicine is because of X, you can get rid of this nausea feeling, but it may expose you to to earlier death.

Vance Crowe [00:35:47] Yeah, pretty much. So it's all looking at those things and putting 'em into perspective. Nausea for one person might not be that bad or it might be debilitating for another person. So whatever that original medication is treating, you know, that you're ending up with that side effect that's up to the patient. If that's, if it's worth it.

Kelly Erdos [00:36:08] What is it like spending so much time with the geriatric population where they, where you are watching people extend their life, not necessarily quality. What have you learned about the, the way you wanna live that you wouldn't have if you hadn't been in the field?

Vance Crowe [00:36:24] That's a really good question. I'd say that overall my patients give me so much perspective of what's to come in terms of they share their life experiences, they share how it is, you know, to watch your child get older. They have all these really great insights that help me put things into perspective sometimes I'm very much one that believes whatever is is good for you might not be good for me. And so even if I have a patient that might make a different decision than what I would, as long as they have all the information to make that decision, that's my job. If that decision's different with the given information than I would make, that's their choice.

Kelly Erdos [00:37:06] How much do they ask you? What would you do in this situation?

Vance Crowe [00:37:09] A lot. Yeah. And

Kelly Erdos [00:37:10] How does that feel?

Vance Crowe [00:37:11] It feels good. I have a lot of patients that I've had for several years that have known me before. I, you know, had my 4-year-old child. And so they got to, you know, see me through that whole process. And I would say that we have developed very good relationships and it definitely feels good to not only be helping people, but have them tell you that I also have a really great patient population who does tell me that, you know, who says, the doctor gave me this new medication, but I knew I was seeing you tomorrow. So I didn't wanna start it until we discussed it. So I feel like that is a very big honor to have. But it's something that I've also worked very hard for, you know, that that just didn't come with the job. That comes with what you put into it as well.

Kelly Erdos [00:37:56] You know, I had a cardiologist on a few weeks ago and he, he and I talked a little bit about the distance that you have with your patients and he deeply cares for his patients, but you're describing really very, something very different than what he had. Do you ever find yourself getting in the position where you're like, dammit, just take your pills. Just take your pills?

Vance Crowe [00:38:15] The thing that I tell to myself and the residents is you can't care more about the, than the patient does about their own medications. So yes, it's very frustrating and it's very difficult to see people who have access to healthcare have access to medication and just don't want to do it. Whereas there's other people who would love to have this decision to make, but they don't have those resources. And so for someone to willingly not take those things that would help them, that it's a very easy decision can be frustrating, but you just can't care more than the person cares about themselves.

Kelly Erdos [00:38:52] Do you also then see patients that it's actually their child that you're helping manage but they're not old enough?

Vance Crowe [00:38:59] No. So with all of our protocols, it's 18 or older and I'd say that my youngest patient is still probably late twenties.

Kelly Erdos [00:39:09] Okay. Yeah.

Vance Crowe [00:39:10] Which is very, very purposeful. That's something that I could not emotionally deal with a younger and pediatric population. It would be too hard emotionally for me.

Kelly Erdos [00:39:20] Really? Why?

Vance Crowe [00:39:22] It's a lot easier to see an old person die.

Kelly Erdos [00:39:24] Whoa. Okay. That was, that was, that was bold. Yeah. So

Vance Crowe [00:39:28] Because

Kelly Erdos [00:39:28] It, because it's just seems like the more natural part of life and the other one is more tragic.

Vance Crowe [00:39:32] Yeah.

Kelly Erdos [00:39:34] Interesting. And is that something you knew going in or is it something you had to learn the hard way?

Vance Crowe [00:39:38] No, I, I knew that going in, so I also like, I just like old people too. I mean that's, that's definitely was the initial draw probably. And then as you know, you lose patience. It, it's so difficult and it's hard because you also become hardened. You know, you can't let that consume you. You just have to focus on, on the good. One of the things that's very difficult and what we see is we see when the things go wrong. We don't see the thousands of time that we prevented a problem. We see the, the times that it didn't get prevented. And that can be hard. So you don't see the stroke that you prevented, you don't see, you know, the, the progression of diabetes not leading to worsening neuropathy. You see them continuing to do well. But a lot of what I do is preventative. You're not gonna be necessarily turning someone around. You're preventing those things. And so you always have to remind yourself of that as well because then when someone does pass away from from their disease, that's what you focus on. You know, it's like when you're in the room and everyone's clapping and one person booze, you stay up at night thinking about the one boo. Right. You know, the same thing. You don't see all the people who are clapping all the time for you or, or their health. And then you see the, the negative outcomes, which is going to happen. You know, you can't have everything always go perfectly

Kelly Erdos [00:41:07] Well. So you're also dealing with medicine that people need to stay alive tomorrow. So what is the high pressure part of your job? Is it always having, you know, being able to pay attention and stay alert? What's going on there?

Vance Crowe [00:41:21] I would say one of the things fortunately in the ambulatory setting is time is always on our side. So when I was during my residency and we would be upstairs, you know, know everything there is acute, you know, you have to figure it out right. Then downstairs it is to a certain point. But if it was an emergency, they wouldn't be in the outpatient setting also, which is also a decision I made because I like that structure more. I think that not being too comfortable would be the biggest thing that I, I focus on in terms of even if you're doing something and maybe it's an easy, easy task not to get into that mindset of that it's easy and you don't pay as much attention. So just always trying to stay as sharp as you can.

Kelly Erdos [00:42:13] So speaking of staying as sharp as you

Vance Crowe [00:42:16] Can.

Kelly Erdos [00:42:16] Yes. And my sister-in-law just had a child a little over a year ago and, and so you see her heightened alertness and awareness Yeah. At all times.

Vance Crowe [00:42:25] Yeah. And

Kelly Erdos [00:42:25] I'm sure you being a pharmacist, people probably have a lot of questions for you about like, what medication should I give my kids? Yeah.

Vance Crowe [00:42:32] What should

Kelly Erdos [00:42:33] I be careful of? What is the thing that parents, you see stressing a lot about that? You'd be like, you know what, that you can just put that down. You don't need to be worried about that.

Vance Crowe [00:42:41] Yeah, it's, it's hard because I've have not in the pharmacy itself setting, but you know, it's the friends that call and say, my daughter has a fever, how much, you know, Tylenol or ibuprofen am I supposed to give her? There's definitely situations that you don't mess around with in terms of a child being ill, you know, infections that actually need antibiotics would be one of them. High fevers would be another one of them. But small things, you know, I mean,

Kelly Erdos [00:43:10] What's a high fever when, when you say a high fever, what's a high fever? You,

Vance Crowe [00:43:13] I'd have to double check, but I like, I mean for me I'd be like, it's a hundred, but not like that. I mean like a hundred, 203, that's where you're, you're starting to get concerned with a child. But again, geriatric pharmacist, so Right. Put that little caveat in there. Certain things though that I would say just chill out is it's okay to be sick. It's okay to be a cold, have a cold, have a runny nose. Actually your wife and I this morning were talking about it and I said, you want your immune system to do something because if it doesn't, it can get bored and goes and causes trouble. That's what you don't want. An immune system that is not challenged has a greater risk of turning into an autoimmune disease. So let them eat a little dirt, let them, you know, go in that really dirty mall play center and don't freak out if they lick the slide. Like, yeah, it's disgusting, but germs are not bad.

Kelly Erdos [00:44:08] Oh, very interesting. And so you, you feel like you were pretty open with your daughter on, on letting her get into dirt and

Vance Crowe [00:44:13] Get into trouble? Yeah, like I have a very strange personality and I'm very organized. I'm, you know, very orderly, clean, but with certain things I'm like, that's fine. Like I'm, I'm more relaxed with certain things with her than I thought I would be, but stricter in other areas. But yeah, germs are okay, let 'em, let 'em go and do that. You know, if you have a play date, and I mean, again, this is kids, this isn't a four day old, you know, newborn that we're talking about. But if there's a play date between two four year olds and one of 'em has a little bit of a cough, I don't know, don't cancel the play date. It's okay to be exposed to those types of things. I think. Now that being said, if your friend says, I think that they've got pink eye, well okay, cancel that one hand, foot and mouth, cancel that one. But just loosen up about some of those things. As a parent,

Kelly Erdos [00:45:02] What do you, you know, there are a lot of parents now that are doing their own kind of pharmaceutical work Okay. For things like with things like essential oils. So as a pharmacist, what should people know about phar essential oils and what do you, what do you think of them?

Vance Crowe [00:45:19] So I would say remove that the parents are doing their own pharmaceutical work because those are not pharmaceuticals, right? The essential oils. Those are essential oils for certain things. I think that they are great. Having a diffuser or that you use when you're doing something like meditation can enhance that.

Kelly Erdos [00:45:38] Enhance it in the sense that it gives you a, a physical sensation that you like, a smell that you like, something like that.

Vance Crowe [00:45:44] You know, I'm a firm believer in if it works, go for it. You know, before they had all the clinical regulations, they would literally, in medicine have studies where they would do knee surgery, half the group got knee surgery for real, and the other half didn't. And they told the patients, you know, you might have or you might not have. Now that's would be considered unethical, but at that time they saw similar rates of improvement in certain subgroups. And so that person got better because either they were going to naturally or because they thought the surgery fixed what they had. So I think that essential, the mind is very, very powerful and your mind does have a, plays a part in your health. And so if those essential oils can help you in a way mentally, I think that you yourself mentally might have some better outcomes. Like the GI system is a perfect example. Think about if you're nervous, if you're anxious, you're upset. A lot of people will feel sick to their stomach. You know, part of that's fight and flight. Part of it is that's how certain people internalize their stress is they can make themselves physically ill from it. So if you want to do that in those types of things, I say go for it. If you think that an essential oil is going to cure your child of a disease that needs antibiotics or is in place of a vaccination, I think that you are not only uneducated on the topic that you are being dangerous.

Vance Crowe [00:47:24] And that's a really, really concerning situation where people think that, you know, essential oils are gonna be able to help all of those, those different problems in that setting. So I'm probably a little bit more in the middle with adults in terms of, I think people would think, you know, that pharmacists are completely against them. Where I, I'm not, I mean,

Kelly Erdos [00:47:47] I mean I think you're, I think you're definitely what it sounds like to me what you're saying is if it's gonna give you some psychosomatic benefit and it like, makes your head feel better about the whole thing, fine. But if you're talking about your child's health, yes, go get medicine. Right? So I think you sound like you're trying to be on the middle ground, but really what you're saying is you're

Vance Crowe [00:48:06] Right. It's

Kelly Erdos [00:48:07] Not, it's not magic.

Vance Crowe [00:48:07] This is your skill. That is, that is what I'm saying.

Kelly Erdos [00:48:11] So what do you think about the giant rise in it? I mean, are are, have you seen bad or heard bad cases of I'm, I'm, I'm being very leading because I think that essential oils and I'm, I'm willing to be pushed back on this, are more powerful than people realize, but not for what they think. So meaning that you are taking, you can take lemons and, and concentrate it so much that it becomes an acid, right? Like it really is. And so you're literally applying acid to your child's skin. Yeah.

Vance Crowe [00:48:42] And

Kelly Erdos [00:48:42] You can watch third degree burns.

Vance Crowe [00:48:44] Go on. Yeah.

Kelly Erdos [00:48:45] I I think this stuff is stupid. Yeah. And I think it's ridiculous that people aren't calling it out. What do you think?

Vance Crowe [00:48:52] So I think that it goes under the, the kind of category of just because it's not a prescription, it doesn't mean that it's safe. There are a lot of dangerous things that are out there naturally. I always say, well, cocaine's natural, you know, I mean right. Marijuana's natural. And on that subject, I think there's a lot of great medicinal benefits for CBD, marijuana and everything like that. But just because it's natural doesn't mean it's safe, the burns. I haven't personally seen any of those, but I think that that's definitely one of the, the big concern, even something like if I saw an article a patient was diffusing and it got on their face and then later they were doing like cooking and they still had that residue and they got a severe burn on the face from that ingesting them when a lot of times they say on the bottle they're not to be ingested, you know, can be potential issues. So I definitely think that they do have an area for potential good if they're used responsibly. But that's the problem, you know, I mean, if you're rubbing it on your child thinking that it's gonna cure them of everything, I think that's, that's a naive perspective as well.

Kelly Erdos [00:50:05] What do you think is driving the essential oil craze in the world right now?

Vance Crowe [00:50:09] Money.

Kelly Erdos [00:50:09] Money.

Vance Crowe [00:50:10] But

Kelly Erdos [00:50:10] I mean, it's gotta be more than that because there's people selling 'em for sure, but there's yeah.

Vance Crowe [00:50:14] There's

Kelly Erdos [00:50:14] People buying them Yeah.

Vance Crowe [00:50:15] That

Kelly Erdos [00:50:15] Would rather buy, they're spending $10,000 on an essential oil set and whereas they could have spent that on medicine to cure something or,

Vance Crowe [00:50:24] Yeah, I think that the, the thing is that anything that is a chemical is bad. Anything that's unnatural is bad. And so that if you use an essential oil, you're being more natural and more natural has to mean good, which I don't necessarily agree with. I mean, that's why we've as a society come so far as we've been able to have these great developments in health, in science and all those different areas, but there's that pushback of, well we don't, we don't want to put too much of that in our body. But then you have someone who, let's say, is doing the essential oil for an illness that actually does need antibiotics and that poor child is gonna suffer, but not only suffer, have to end up with a lot more medical intervention than if they just went to the doctor and got their course of antibiotics like they should have as well. So I think that the repercussions of that can be a lot, lot larger that people don't think about, you know, you think you're trying to prevent these things and then you cause even more trouble and then you're gonna get more chemicals in your body to fix the thing that you caused.

Kelly Erdos [00:51:30] Yeah. I think the, one of the bigger challenges is the, the storytelling aspect. And this really happens with anything that becomes industrialized. Yeah.

Vance Crowe [00:51:38] Right.

Kelly Erdos [00:51:38] Because as a pharmacist, if you say, Hey, the reason you should take this Cialis is because there was a man walking down the street and he had this problem and, and we gave him Cialis and it was solved.

Vance Crowe [00:51:49] Yeah.

Kelly Erdos [00:51:49] Right. That you're not allowed to do that. Yeah. You have to say, right,

Vance Crowe [00:51:52] This

Kelly Erdos [00:51:52] Is what the tests were, this is what that's true. But the, all the others is stories. And my belief is that human beings see the world almost entirely through stories.

Vance Crowe [00:52:00] Yeah.

Kelly Erdos [00:52:00] And the, the pharmacy school that you're going through is the opposite of storytelling. It's like pounding

Vance Crowe [00:52:06] Through

Kelly Erdos [00:52:07] Yeah. Data so you can get rid of all the, the anecdotal evidence.

Vance Crowe [00:52:11] Yeah.

Kelly Erdos [00:52:11] But that doesn't translate right.

Vance Crowe [00:52:13] And it, they don't have to, you know, I mean those types of businesses and categories aren't held to the same standards as pharmaceutical industry. One of my favorite things is I did a rotation at Arizona Poison Control when I was a student and it was amazing. But they gave the same example of Snake Bites because there were, at the time, all these like contraptions, you know, like, do you suck out the venom? Like do you throw an egg on it? Do you put steak on your head? And I think that was the one actually. And so it was, you know, a guy goes into the desert and he gets bit by a rattlesnake and he goes home and he puts a stake on his head and he is fine. Nothing happens. So he tells all his friends and he says, if you ever get bit by a rattlesnake, you put a stake on your head and you'll be fine. So the next day his buddy gets a, a snake bite and it puts the stake on his head. He has a mild reaction. The first guy didn't know, but there was no venom injected. They have dry bites sometimes. So the first guy had a dry bite. No matter what he would've done, he wouldn't have had any problems. The second guy had a mild amount of the poison, you know, injected. And so he did the steak thing and it it, he thought maybe it kind of helped, you know, he was in between. The third guy does it and he gets the full dose of the venom and dies, you know, because he is in bed with a steak on his head. So those are the things, you know, if you only hear those stories of the first and the second person with an essential oil with different things that you're doing without looking at a large group of people, you can make a whole lot of claims. What

Kelly Erdos [00:53:40] Else did you see at Poison Control that you thought was interesting?

Vance Crowe [00:53:43] I loved poison Control. Be

Kelly Erdos [00:53:45] You're sicko.

Vance Crowe [00:53:46] Very interesting. Mean love poison control. Oh I loved it. It was,

Kelly Erdos [00:53:49] That had to be people in the most terrified moments of their lives. Nobody calls poison control for fun.

Vance Crowe [00:53:54] Yeah, I guess

Kelly Erdos [00:53:56] So what did they, what did you, what did you get calls about?

Vance Crowe [00:53:57] Oh, we got a lot of calls about children and ingesting things. So like those silica beads that come in everything. Oh

Kelly Erdos [00:54:03] Yeah. That

Vance Crowe [00:54:03] Say do not ingest,

Kelly Erdos [00:54:04] Like call poison in control, eat freak out when those things are around. So is that legit? Don't, don't eat those.

Vance Crowe [00:54:08] Well don't eat 'em. But not because they're toxic because they're a choking hazard.

Kelly Erdos [00:54:13] Oh.

Vance Crowe [00:54:15] So it's not, you know, if you touch it, it's not bad if the kid swallows it, it's not bad if the kid can't swallow it and start choking on it, that's bad. We got those, we got calls about a lot of herbal supplements and products like that. Homeopathic things that if a child, you know would find the whole bottle or you know, the gummies, things like that. What,

Kelly Erdos [00:54:38] What happens? What do you mean

Vance Crowe [00:54:40] It depends. So you know, mom's got her bottle of vitamins that are the chewy ones and Billy comes by and eats them all 'cause they're gummy bears, you know, so they call and they freak out. So with that thing, a lot of times it's, you're looking at the iron content and like a multivitamin that would be toxic to the child. So

Kelly Erdos [00:55:00] A good buddy of mine has a YouTube channel where he made a video about a kid eating something like a hundred of those gummy vitamins.

Vance Crowe [00:55:08] Yeah. And

Kelly Erdos [00:55:08] It goes horribly wrong.

Vance Crowe [00:55:09] Yeah, I mean, so I guess I didn't like the poison control because of the bad things. I liked being able to, not a sociopath. I liked being able to bring comfort to people in that panic state because a lot of things that you do over ingest aren't necessarily as bad as you might think. So being able to, to reassure people out In Arizona, we also have scorpion stings that they call in quite a bit and people get kind of disproportionately freaked out about those certain patients and populations are definitely at a higher risk of having problems. But I just, I thought the toxicology aspect was very interesting. So

Kelly Erdos [00:55:48] Are there full-time pharmacists that are like you, professional career people that are in poison control?

Vance Crowe [00:55:52] Yeah, so it depends.

Kelly Erdos [00:55:53] What are those crazy people like?

Vance Crowe [00:55:55] They were amazing and I think that's probably why I liked spending time in that setting as well. And so I thought that I wouldn't like it because pretty much it's a call bank for the most part. So you're sitting around in a circle and depending on the time of day, you know, there's a couple pharmacists, probably a couple students, maybe some interns and you're just taking the calls, you know, you're just taking the calls. You never know what it's gonna be, who you're gonna get to talk to. But they were a really, really great group of people. So in Arizona, in Tucson it's run by pharmacist, but then in the Phoenix area I believe it's run by nurses.

Kelly Erdos [00:56:32] Interesting. And you're just waiting for people to call? Yeah, for like my child drank a bunch of Windex. Yeah. Which did I do now? Yeah. Interesting.

Vance Crowe [00:56:40] So another area you didn't know that pharmacy was involved in, right?

Kelly Erdos [00:56:43] No. Uhuh, I had no idea who was staffing those banks.

Vance Crowe [00:56:46] Yeah.

Kelly Erdos [00:56:46] Alright, so poison control is when you made a mistake or your child came

Vance Crowe [00:56:50] In

Kelly Erdos [00:56:51] And drank something. But in the pharmacy world, is it possible that that either the pharmacy or the doctor makes a mistake in prescribing the incorrect or

Vance Crowe [00:57:00] It is. One of the things is it's usually the Swiss cheese effect. I don't know if you've heard this before. No Uhuh. But if you, let's say pile five Swiss cheeses, you know, slices of Swiss cheese on top of each other, a lot of times the holes aren't gonna line up right. They're someone's gonna cover the other hole in the Swiss cheese effect. All those line, those holes line up perfectly, no one caught it. So for example, I had a patient, this was probably four or five years ago that he came to us for his warfarin management. He had a history of blood clots

Kelly Erdos [00:57:32] And warfarin is a, the blood thinner that you're talking about earlier.

Vance Crowe [00:57:34] Yeah. He real smart guy engineer and very on top of his health and his medication. So at the time he was on a dose of four milligrams a day of the warfarin. Something happened where usually they call us and we call in a prescription for them, but his pharmacy contacted his primary care doctor and they sent over a prescription. It was a prescription for two milligrams instead of the four milligrams that he was taking. So half the dose, the patient goes, picks up the prescription and on the label it says this color, this medication may look different, it might be a different shape or size. We've changed manufacturers. So the patient gets the medication home, he says, well it looks different. Oh but they told me it was gonna look different, it's fine. He takes that for two or three weeks and he ends up with a massive blood clot because he's on half the dose of what he should be. So that's all those little holes lining up. Good

Kelly Erdos [00:58:30] Lord.

Vance Crowe [00:58:30] And those things happen again a lot more often than you would would think or hope. Thankfully we've gone towards electronic prescribing for most things, but I'm in a Facebook group of pharmacist and sometimes without patient information they'll post the, the writing of the prescription and it's like you're playing detective, that's the other thing. And you know, why has it been so, so long?

Kelly Erdos [00:58:54] What is going on with that? Why are, I mean like those things actually look like they are fake,

Vance Crowe [00:59:00] Right? There's no reason that you shouldn't be completely electronic. But there's still quite a few physicians who do the handwriting which opens up so much potential for, for medication errors.

Kelly Erdos [00:59:11] And And was that like a, like a sweet trick that doctors were playing writing those things to be illegible or was it just that they are,

Vance Crowe [00:59:19] Because

Kelly Erdos [00:59:19] I remember it doesn't happen so much, much now as an adult, but I remember as a child it wasn't even cursive. Yeah.

Vance Crowe [00:59:25] It was

Kelly Erdos [00:59:25] Like something in and you would wonder how does anybody read

Vance Crowe [00:59:28] This? Yeah, I mean and some of it's shorthand too, you know, using Latin in terms of like before or after with me the route, you know like instead of oral they'll put PO for by mouth. So some of it's that, so some of it is not English and the other part is the the terrible handwriting. And again you think in this year in electronic age, how is that even still something that happens? And it happens quite a bit. So,

Kelly Erdos [00:59:59] So speaking of prescription pads, why are some drugs regulated by the government and behind that wall at the pharmacy and other things? Not over the counter or Yeah, when they are over the counter. Yeah,

Vance Crowe [01:00:11] So it's all about looking at the safety profile of them with what you need is a prescription versus a non-prescription. So you know over the last several years, allergy medications for example that used to be need a prescription to get now or over the counter because they're very effective but they're also very safe. You know, the side effect profile is low and so taking out kind of that middle man or or middle step for it. So that all just goes to the FDA. In terms of regulations,

Kelly Erdos [01:00:41] Are there things that you think are not regulated that should be

Vance Crowe [01:00:44] Hmm, probably the reverse like that there's probably a lot of things that don't need to be regulated then do I'd have to think about that one.

Kelly Erdos [01:00:54] Yeah like so I'm hyperallergic to poison ivy and I've had to get prednisone. I know, I mean that one actually you have to be a little bit careful 'cause you have to

Vance Crowe [01:01:01] Step

Kelly Erdos [01:01:01] Off of it. Yeah. So maybe that's not

Vance Crowe [01:01:03] A great example. I would not never suggest that to be one that was over the counter. But along that thought process with certain medications there are are ones that potentially could be, or even things like birth control, you know, making birth control more available. They've even talked in, this isn't necessarily kind of where I spend my time so I might not be speaking completely to what's the most current but almost like a middle class of medications. So it would be something that you would have to discuss with the pharmacist before getting it, but that you wouldn't need an actual prescription for. Definitely again, looking at having these professionals practice at the top of their license, letting the pharmacist do that. Or what I do in my clinic is letting the physician focus on not the low hanging fruit that someone else can take care of. You know, really focusing on other things and trying to give them more time to dive deeper as well.

Kelly Erdos [01:02:02] When I was preparing for this interview, I went to Reddit and I actually, there's a whole subreddit called the pharmacy. So

Vance Crowe [01:02:08] I dunno

Kelly Erdos [01:02:08] If you know about this. And I posted that I was gonna do this interview and I said, are there any good questions?

Vance Crowe [01:02:13] Yeah.

Kelly Erdos [01:02:14] And they, one of the ones that got upvoted was, are there any, do you have any reconciliation, medicine reconciliation stories that are funny?

Vance Crowe [01:02:23] Oh, a lot of times.

Kelly Erdos [01:02:24] So first of all, what is a medicine reconciliation?

Vance Crowe [01:02:26] So med rec is where you are looking at all the medications that the patient's on and reconciling them. So in the electronic medical chart or history, you have an accurate up to date list that you're working off of, which again is something that sounds extremely easy but it's not, why isn't it extremely easy? Patients don't know what medications they're taking. So for patients they need to know why they're taking medications and not only the name of it but the dose and how much they're taking it. So certain patients are awesome, they'll have a list and they'll have all that information when it was started, who prescribed it, which is amazing. Other times patients say I think, I don't know, it's for blood pressure, it starts with an L, it's kind of like this size and I'm like okay. And you can go through the dose, you know you're like losartan, lisinopril what? But they just don't know. And so that's the number one barrier. The number two is if patients go to multiple pharmacies, so let's say you have that patient and you say, okay, I'm just gonna call your pharmacy and see where, what your medications are. So you call the Walgreens down the street that they tell you to go to but they forgot that they use CVS sometimes or it's January and they just switched because their insurance is dictating where they have to go now. And so half their prescriptions are at CVS and half of them are at Walgreens. That's another issue also, just the time barrier, you know, if these patients are coming in through like our emergency room, it's tricky because if it is a true emergency, you know they're gonna want to get them to wherever they're going.

Vance Crowe [01:03:59] You might not have the time to extract that information for them. But I would say that no matter what area of pharmacy you in that you are in that med rec is a problem and it's definitely time consuming and a pain. And that's probably why if it was pharmacists who put that on there is that no one likes doing or I would think no one likes doing med rec. But yeah, it's something that we have to deal with.

Kelly Erdos [01:04:22] And And do patients like raise their hand and say, Hey, I'm on a bunch of meds. Can I have this checked out? Is that what happens?

Vance Crowe [01:04:30] You know, in certain areas probably. Definitely in my area because that's what we're there to be able to help them with.

Kelly Erdos [01:04:38] Who helps people with medicine if they don't have somebody like you or a clinic like you to, to access a

Vance Crowe [01:04:42] Lot of times no one, which is extremely sad, you know, to see patients are their own advocates and you know, I'll have people that come in and say, this per office hasn't called me back. I'm not sure if I'm supposed to be doing this. I don't know when my surgery is gonna be. And I'm like, you shouldn't have to be the one that's coordinating all these things. But again, real world versus perfect world, we live in the real world. In the real world you wouldn't have to be the one who calls your doctor to remind them about setting up an exam, getting your lab results, getting your refills in. But you have to, and if you're not your own advocate, you're gonna get, you're gonna fall through the cracks at some point. And in my area, a lot of times family members help out as well. There are lots of really amazing community pharmacists, but again, it all goes back to the time. So a lot of times they will not be able to dedicate the 15 minutes to that because there's that guy yelling about his antibiotics and why they're not ready.

Kelly Erdos [01:05:41] Yeah, that's So what, you know, you talked several times about the perfect world and not perfect

Vance Crowe [01:05:47] World. Yes. What

Kelly Erdos [01:05:48] Happens when somebody gets to the point where they can't afford the medicine that they, they have been told they need?

Vance Crowe [01:05:55] So that's where we look at what, what's the most necessary. And I'd rather have someone, let's say we're diabetes for example, with diabetes, there's a lot of comorbidities or different diseases that we get concerned about as well, like blood pressure, cholesterol, stroke prevention, things like that. And so instead of then in that patient, you know, having perfectly controlled blood pressure, if that's all they could afford were those three medications saying, you know, I mean I don't like to, but if we can have you keep on just the cheapest blood pressure medication, maybe increase the dose of that, then that'll free up the money to allow you to buy insulin. So Walmart actually has their own brand of insulin at a cheaper price. Really something that's interesting about insulins is they, not all of them need a prescription to be purchased either. And I don't know if that's different in the states as well. And then Colorado recently, just a couple months ago passed a law capping the maximum amount of copay that a patient can will have to use for insulin so that they won't have to spend $500. That it gets capped at a certain amount and I think that's a hundred dollars, but I'm not sure.

Kelly Erdos [01:07:12] So speaking of Colorado, and you mentioned marijuana earlier, THD and and CBD as somebody that understands the biochemistry of the human body, I see signs everywhere that are talking about how great CBD is, what is going on with CBD?

Vance Crowe [01:07:28] I think that there is definitely a really great place for it in, in certain things. One of them, the first form being approved for a rare seizure disorder in, in children for helping with that. That's had great results. Helping stimulate appetite in cancer patients or patients you know, who aren't being able to have that appetite to eat, helping with other things like anxiety, controlling those. So I definitely think there's a role for it, but it's, it's kind of like not the same as the essential oils, but you can't just like sprinkle C, b, D all over your body and then you're cured of everything like that. It just logically doesn't even sound like it could be, right. 'cause it can't, you know. But I think there's a good role in certain areas.

Kelly Erdos [01:08:14] And now with the legalization of marijuana in lots of places, both medical and then recreation, what should, what do you think people should consider before they go to experiment with marijuana for the first

Vance Crowe [01:08:26] Place? That's a really good question. That it's still a medication so it can interact with your medications that you're taking. Just because it's legal doesn't mean really it's a hundred percent safe, you think.

Kelly Erdos [01:08:34] Do you safe think that's gonna, you think that's gonna be something people will have to test for in the future? How it interacts with t hg?

Vance Crowe [01:08:39] It's something they're already doing. So with certain medications there's, there's known drug interactions with it as well already.

Kelly Erdos [01:08:47] Interesting. And that would probably be particularly true with the geriatric population. If you're saying, oh I have glaucoma, but I also have low blood pressure. Well you tell me, I'm just guessing here.

Vance Crowe [01:08:56] You know, there's just so many different medications that are out there. So you're looking at in terms of drug interactions, how, what is the interaction gonna be? Could it be something additive? You know, so let's say someone's on a mood medication and then with medical marijuana that can be mood altering as well. So is it on that level? Is it on a structural drug interaction level? Could it make a certain medication not be as effective or on the flip side be more potent. So those are all things that there's definitely gonna be more research as time goes on, but it's already being done.

Kelly Erdos [01:09:36] Interesting.

Vance Crowe [01:09:36] So,

Kelly Erdos [01:09:37] And, and do you have any thoughts or warnings or, or thumbs up about THC that you would give as a,

Vance Crowe [01:09:43] I think that I always go back to, especially when something's relatively new, is everything in moderation and then you've kinda got your bases covered, right? So if it comes out in 20 years that it's the worst thing in the entire world for long-term side effects for this, well if it was used in moderation, you're probably okay. But again, using the least amount of any type of medication possible is what I would say with that. Also with use recreational or medicinal, either way.

Kelly Erdos [01:10:14] It's interesting as a pharmacist you don't actually make more money based on how much drugs people buy. No.

Vance Crowe [01:10:21] What

Kelly Erdos [01:10:22] Do you think of as the impact of the pharmaceutical industry? The, the people that are like, hey we need to sell more of these pills to make more money. What do you think there, is it as bad as, as what sometimes you'll hear on podcasts that big pharma is destroying everything.

Vance Crowe [01:10:37] Yeah.

Kelly Erdos [01:10:37] Is it, do you think they really are influencing doctors' decisions? What do you think? I

Vance Crowe [01:10:41] Think they definitely are. I mean, and that's really with the opioid epidemic that you can clearly see in the nineties these drug companies said your patients aren't gonna get addicted. You can use them safely and come off at any point. You're not gonna be potentially causing any problems. Is

Kelly Erdos [01:10:56] That really what they were saying?

Vance Crowe [01:10:58] And that's why there are people going to jail at this point now for driving that, because that drove sales. There's also, and I forget what it was, but I was starting to read or watch a video about even like collusion between different drug companies. So they would say we're rising raising the price on this drug, you know, next week. And then the other two companies would do the same so that everyone raise at the same time, which is the exact opposite of know.

Kelly Erdos [01:11:29] Yeah. It's collusion instead of a free market.

Vance Crowe [01:11:31] Yeah. So that's something that is mind boggling to me. And especially when your mind doesn't process that way, you know, you go into medicine to help people and obviously there's the financial aspect with anything, but I think it's absolutely ridiculous. The EpiPen is a good example, again, a few years back where they gouge the price of that so much. I mean that is a lifesaving medication that is not something to mess around with. So you can have another cruise on your yacht.

Kelly Erdos [01:12:02] And do you think the prices of drugs will come down over time? Or you think that, because that was another thing that I got asked when I put it on Facebook and I was gonna do this interview, people were asking about the price of drugs. Yeah.

Vance Crowe [01:12:13] With

Kelly Erdos [01:12:13] The, it seemed to me to be the implication that they're getting more expensive, are they getting more expensive? And do you think they will continue to be that way?

Vance Crowe [01:12:19] I, I'm not sure. And in my setting, I don't always see all the different medications, you know, to speak to price. I wouldn't be as well informed with that. You know, on the flip side is it costs so much money to get these drugs developed as well. And so I think that there's, there's both sides of that coin of how much money and time goes into making it that they do need to recoup to be able to keep going and finding new medications. And also when you look at, you can start with however many new drugs, you know, again, I'm not exactly sure numbers, but 20 new drugs, only one of 'em is gonna make it to market. But you still have to spend all the money along the way seeing why the other 19 didn't. With that, I do think though in general there's been a lot more attention brought to this subject and understanding that the price increases is not just because of that research and development, it's because of the people at the top wanting more money and people really looking into that more. And I think that that is definitely something that is gonna be more regulated as we go forward looking at

Kelly Erdos [01:13:28] Cost. Yeah, it's tough because you don't wanna knock the price incentive out for people to take it, you know, chances and to,

Vance Crowe [01:13:34] To

Kelly Erdos [01:13:34] Discover new things. Right. But at the same time it feels as though you're

Vance Crowe [01:13:38] Holding

Kelly Erdos [01:13:38] Something above people and saying, you can't have this unless you pay. Which is, which is a tough one. It's, it is.

Vance Crowe [01:13:44] It's very difficult.

Kelly Erdos [01:13:44] It's the darker side of the capital

Vance Crowe [01:13:46] Markets.

Kelly Erdos [01:13:47] So this has been great. You, and actually we would stay for a very long time and talk, but we have lunch plans.

Vance Crowe [01:13:52] Yes.

Kelly Erdos [01:13:52] But before we go to lunch plans, one of the other questions that somebody asked on Reddit was, what should somebody know about their pharmacist? Oh, before trusting whether or not their advice is good or bad or, you know,

Vance Crowe [01:14:05] That is a really, really great question. I would think that the pharmacist is really one of the healthcare professionals you have the potential to spend the most time with. And so I would observe them, see, you know, how they're interacting with other patients. I would in the area, not necessarily just go to the pharmacy closest to you, you know, go around, ask something about an over the counter medication and see how that pharmacist responds. You know, you can say, my allergies are really acting up right now. Can you recommend something And see how they handle that type of question. You know, do they say, oh, just take gras down that aisle, or do they ask you, you know, how long has it been going on? Is it get better or worse with anything? Have you taken anything in the past? Those are the types of questions that a good pharmacist should be asking. I would also wanna know how long they were a pharmacist for. I always think with my own healthcare providers, I try to balance that they're enough outta school. So they're experienced, but they're not too far outta school, that they're not keeping up with the current literature. So I think that that is a great question to to know as well. And you can probably just see from their pharmacy license in the back of the pharmacy also. And then also someone that you feel comfortable with. You want to be able to have an open conversation with your pharmacist. So you do want to find someone that you enjoy and that you find is reliable as well. And again, back to the thing of, and pick one pharmacy and stick to it, you need to stay in one spot so that pharmacist really can own that medication list and know what's going on with you altogether.

Vance Crowe [01:15:40] And

Kelly Erdos [01:15:40] If you decide, well, you know, you move or they're, what should you do to make sure that the pharmacy that you're going to now is fully aware?

Vance Crowe [01:15:48] Yeah, so there's a couple things. They can just transfer all of your prescriptions over to that pharmacy or you know, when you, depending on if you're moving outta state or something like that, you're gonna probably find another healthcare provider who might just call in your new prescriptions to the pharmacy as well. So that's probably a little bit easier. It's, you just don't wanna have active prescriptions at multiple pharmacies.

Kelly Erdos [01:16:12] Well thank you so much for stopping by. Know you're

Vance Crowe [01:16:15] Welcome. We're getting welcome.

Kelly Erdos [01:16:15] I'm getting text messages about going to lunch.

Vance Crowe [01:16:17] Yes. I'm getting hungry. But wait, I have a present for you.

Kelly Erdos [01:16:19] Oh gosh. You had mentioned this book,

Vance Crowe [01:16:22] So we can add it to your bookshelf for a pro. Oh, I, I like, this

Kelly Erdos [01:16:26] Is very good. Yeah, we can place that right up here.

Vance Crowe [01:16:28] It technically might be a Raven, my husband said, but the intent

Kelly Erdos [01:16:32] Your husband is, is a, a man that knows details, very detail oriented guy.

Vance Crowe [01:16:37] But I, I thought it was a nice little, little thing to bring to you for having me on your awesome podcast.

Kelly Erdos [01:16:42] I love it. Love it. Thank you. Well, it will remain there. Awesome. Thank you very

Vance Crowe [01:16:44] Much. Thanks for coming. Awesome. Thanks fans.

Kelly Erdos [01:16:47] That's it for this week's interview. Thank you so much for sticking around all the way to the end. I hope you'll consider subscribing, giving me a five star review or just even hitting that thumbs up button. It really helps it get out to a wider audience. And I have been absolutely staggered by how many people are now listening to the podcast every week. It grows and grows and that's getting a little intimidating. And to respond to that level of fear that I get as the audience grows, I'm trying to make this podcast better and better. I'm trying to improve at the discipline of having better conversations. So if you can see any way that I can improve the audio quality, do the video a little bit better, or even ask questions that help my guests open up in ways that I am not thinking of on my own, please let me know that I am very open to feedback. I want to improve on this discipline that is podcast interviewing and I can do it best with your help. So thank you for sticking all the way around. We'll be back next Wednesday and I'll see you then.