Current state of pharmacy in ontario

These are my thoughts in response to the recent series of events in the news about the Canadian pharmacy landscape. 

Background: the general public and pharmacists are unhappy about the cold calls coming from mostly shoppers employees, and CBC news has picked up the story, spreading the issue widely for awareness. As a pharmacist, this has been difficult to respond to in my practice setting.

This has been a long time coming. Even before COVID, SDM had quotas. Still, I imagine executives in the Ministry of Health, SDM head office, and Loblaws running into a meeting room together in desperation, saying "shit shit shit this is bad" then throwing together a pizza lunch disguised as an informal town hall. (And then pointing fingers afterward.) Obviously I don't have a very rosy impression of working in a corporate setting.

Quotas are not a problem at the front line staff pharmacist level, but a problem with the overall lack of funding to pharmacies at the government level. Since COVID restrictions were lessened, the need for in-store symptomatic testing for patients and prescription extensions (occasionally netting the store a $15 fee per prescription) disappeared, resulting in reduced billing of professional services to the government and thus less profit entering the pharmacy owner’s pockets. SDM corporate wanted to minimize this profit drop after the pandemic, so started  emphasizing the billing of Medscheck services at this point in time due to their profitability. This all happens because the government only reimburses the cost of the drug at the cost the pharmacy buys it at and returning a marginal profit back into the store owner’s pocket (*). Drug pricing in canada is another can of worms currently open to debate as well (look up PMPRB drug pricing reforms). 

(*) this actually depends on the class of drug (high-cost biologics vs. non-biologics) and is subject to changes in drug pricing and changes to the government formulary. 

(*) ALSO, this doesn't take into account the NEW updates to the Executive Officer Notice: Change in markup effective April 1, 2024: https://www.ontario.ca/files/2024-03/moh-executive-officer-notice-change-mark-ups-en-2024-03-28.pdf

TLDR: A Volume-based funding model is not profitable enough for corporate since the pandemic occurred, so they supplement it with additional services enforced with quotas. So you can see it is a chain reaction or a series of events that has led to the current state of pharmacy. The quotas issue does not exist in a vaccum. The ON government and OCP were doing nothing to address this issue, and unfortunately our voice is not heard.

General Timeline

July 2013
Loblaws acquires Shoppers.
Maple health gets funding from Loblaws and Jeff Leger used to be on their board of members (this is public knowledge). Loblaw also owns Medeo. And a lot of different grocery stores (another complaint).

The big question is, how close are Loblaw and the Ontario government? 

From 2019 to 2022
Proof #1 - Loblaws literally lobbies the Ford govt re: selling recreational weed at groceries/retail stores 

March 2020
Proof #2 - SDM lobbies the Ford govt during pandemic times 
Proof #3 - ON Govt makes deal with SDM re: free menstrual products in schools 
Additional proof? I got tired of looking for evidence and fear that this post is veering off into conspiracy land. But there is proof (an easy google search) that a) Loblaws is lobbying the government and making contact and b) these lobbying efforts are seen as changes to policy in real-time.

2024

Feb 5 

Manulife reversed the deal to cover specialty care drugs at select Loblaw-owned pharmacies (PPNs). CPhA (our national pharmacy advocate group) issues a statement on legislation concerning PPNs. 

Feb 28

CBC publishes an article about noise from current + past pharmacists of SDM on pressure to conduct medschecks. Jeff Leger (CEO of SDM) denies the truth about corporate targets for professional services.

March 1
- Associates make cringy linkedin posts stating the value medschecks and pharmacists have on patient care. No one buys it. 

- Jack Hauen, The Trillium reporter, posts on reddit asking for proof and information from pharmacists.

March 5
OCP, our regulatory body, conducts an anonymous survey about medscheck targets and plans to host a town hall for this issue. Ongoing negative sentiments about Jeff Leger and SDM online.

March 11
OCP opens registration for town halls from March 11-18. 

Notes after the recent town hall: OCP oversees malpractice, and the patient-related side of pharmacy practice, and should not care about the financial wellbeing of pharmacists and their corporations. But they have a direct role in pharmacy accreditation and regulating scope of practice, such as the ability of pharmacists to conduct virtual medschecks. It feels like a gray area, well summarized in the article, "Jurisdictions across North America are struggling to address the tension between profit and patient protection."

March 14
New article about how SDM continues to deny targets, as well as additional proof of targets from internal emails and associate testimonials. In one week, SDM stores in Ontario billed ~$1,400,000 worth of medschecks; each store conducting an average of 30 to 35 medscheck interviews during that week. To date, OCP has apparently received 4,000 responses to their anonymous practice survey and expects more than 500 attendees for the series of virtual town halls.

March 19
CBC reports on Telus and its new PPN policy. Employers that purchase Telus health insurance now must make their employees abide by its new policy of filling prescriptions at virtual pharmacies. I learned that ODB (healthcare branch of ON government) also uses Telus as its adjudicator. 

Mar 25 - OCP Board meeting focused on these 2 major issues 
package 

re: PPNs 
Recommendations: the board will be directing college management to move forward with a phased, multi-modal approach to addressing PPNs including short, medium and long-term regulatory initiatives: 

short-term action: position statement → PPN policy be integrated with broader business regulations (placeholder recommendation) → long term action: meet PPN regulatory goals; nothing we can do today to prevent pharmacies from entering into existing PPN contracts, but OCP's focus is the longer term for bigger impact

"PPN models were last discussed by the OCP Board in 2018. At the time, despite its concerns, OCP did not have the authority to intervene in the negotiation of PPN agreements by pharmacy owners and benefits providers. OCP raised the issue with the Minister of Health. No changes were made to the regulatory environment that would have increased OCP’s jurisdiction. Following an initial announcement earlier this year about a PPN between Manulife and Loblaw, and as indications suggest such models appear to be having an impact on more patients, this topic will be discussed at the March OCP Board meeting. In its most recent strategic plan, OCP committed to doing what it can to protect patients from the impact of any business model that increases risks to patient safety or gets in the way of a pharmacy professional’s ability to provide care in accordance with standards and their ethical responsibilities. OCP will re-examine its jurisdiction and the impact it can have within its mandate and will work with government and other partners to explore how to achieve this goal."

re: Corporate Quotas on patient/provider safety
How did we get here? College aware that this is a long term issue
esp. since 2017-2018 ESA call for change (pharmacist lunch breaks) were not changed

- OCP wanted to ensure autonomy of pharmacists to allow flexibility in practice

- the ongoing noise and concern about business decisions impacting pharmacy practice became Strategic Goal #1 for OCP's 2024 operational plan; OCP not ready to implement actions yet but needed jurisdictional environmental scan - will start this year

- OCP aware of the media and questions about why OCP wasn't doing anything. 

- Scope of OCP may be limited in this regard; OCP has jurisdiction over pharmacists and pharmacy accreditations; OCP can also propose legislation to government around scope of practice quality assurance, and registration.

The survey results were accurately summarized at the board meeting, and OCP is brainstorming session outcomes.

March 25

OCP issues a zero-tolerance statement on business practices that interrupt pharmacy/patient care, as part of the short-term 

March 27

CBC article on the outcomes of OCP's board meeting. 

******

And now it is April 2nd! In the hopes of publishing this timely blog post soon I have stopped doing research. Although the journey of reading through all these news articles and reddit posts was fun, it also brought me an underlying anxiety about the future of the profession. The future is uncertain, for now.

Extra reddit posts:

https://www.reddit.com/r/ShoppersDrugMart/comments/1anjst5/professional_services_in_pharmacy_has_gotten_out/

https://www.reddit.com/r/ontario/comments/1aznclx/how_can_ordinary_people_refuse_the_spam/

Snakes and Ladders

Small kindnesses are found every day. I am both a target and a victim of kindness. Sometimes I am the provider of kindness. But because I work in healthcare that cup tends to run empty most of the time, or so it feels recently. Today a stranger asked me how to get to Yonge and Wellesley, and I told her, "you have to walk in this direction" while pointing north. She didn't seem crazy, so I helped her. Kindness is withheld in stores. In clinics. Pharmacies. In any high-volume customer service setting really. Our cups do not fill for just anyone. 

Last week a stranger dropped all her change on the curb as she was about to cross the street. M and I along with some other strangers who were about to cross helped her pick up the change. She said gratefully, “you guys are AWESOME.” Also last week my Uber driver helped me load and unload my furniture into his car, even though I said I could handle it. Another kindness is being welcomed when visiting M’s mom’s place. As a kid, visiting friends’ places meant coming and going with politeness and hushed movements, not disturbing the tranquility and forced perfection of the asian household. There’s none of that now. Maybe it means I am growing up and slowly realizing that it is okay to accept the kindness of others. K helped me realize this, whether he knew it or not. 

The Toronto winds howl, and the people wander the street wear winter coats, light spring jackets, sweatpants and hoodies, the outfits as confusing as the weather itself.

We came across a vintage print of a snakes and ladders game in a bookstore during a 50% off sale day. Upon closer inspection, we found something interesting. Sympathy (bottom of the ladder) leads to Love (top of the ladder). Makes sense. Indulgence leads to illness. Indifference leads to Poverty.

In retail [pharmacy], if you hate what you’re doing, you’re going to need a new SSRI for yourself.

The title is a reference to a "Guide to Industry" document from a Reddit user. This document is eerily accurate, which you will see once you read through this post. 
My motivation for doing this: recently I've been thinking about writing from my perspective as a pharmacist: my journey,  finances, thoughts, experience, and where it's all led me. Here it is.

It all started after I graduated last year. I was finishing up the remainder of my student loans by paying rent while living in downtown toronto - a dangerous decision. I didn't want to give up this newly found nice quality of life living in a condo at the waterfront with only 2 other roommates (my previous residence was in a 7-bedroom house I shared with some pharmacy upper years). I had some trouble getting licensed due to the pandemic and due to a disclosure on my application leading to a full blown investigation, but that's a story for another day. While dealing with the headache of administration, I had to make money somehow, so I started working part time as an intern at Shoppers Drug Mart while applying to jobs. Fortunately, a couple months later I got a job at a pharma company, a 1-year contract starting 3 months after graduation. My friend referred me. Going into the job, I thought "we'll see, I might not want to stay for longer than a year anyways," mainly because I didn't want to limit my growth to one place. I was right. 

The day I got my offer, I was moving into a new condo closer to the green TTC line. I felt it was a good move at the time. In September, I started working from home, learning the ropes of this hidden industry. There were frustrating moments and rewarding moments. I became more motivated to work for self-development and to add projects to my repertoire. The corporate environment was really daunting to navigate at first, but I think people are used to being disingenuous. During one of our year-end work meetings, the company invited a high-profile manager of a basketball team (guess which) to speak to us about creating high-performance teams and passion. A lot of the things he talked about didn't apply to us. Basketball and drug manufacturing, really? He felt so passionate about his work it made me depressed. Sports is a very different industry to be in, mostly because of the public entertainment factor. I didn't think this needs to be spelled out. When he spoke about throwing his very being into basketball, the passion was there, and it felt really inspiring to be a part of his journey. When I looked around the event hall, I didn't see the same level of passion. A sad reality, but I'd rather be on the realistic side of things than tell myself lies. Ironically, if people were listening to him they'd be throwing away their corporate jobs in pursuit of their true passions. I did not attend the rest of the work meeting. The impostor syndrome felt too strong and I didn't feel like I belonged with this group of people anymore, a feeling that would sit with me through the rest of this contract. 

I spent the raw winter months in Hamilton cat sitting. Unfortunately a couple of my friend's plants died under my care. Again, I felt very fortunate that the company closed for 2 weeks in the winter, instead of having to work holiday shifts at the pharmacy.  The winter break was very needed.

~The New Year~

Somehow, everything became too much for me to deal with. Not just the stress from work, but I was also dealing with a very stressful roommate situation that led me to move out in early 2023. I hastily moved into a new basement apartment and continued working. My support network contributed to my strength and allowed me to keep going. I debated with myself back and forth, and started taking antidepressants. They helped. I wonder how many pharmacists are in the same boat as me. 

Even though I received my license in the new year, I didn't work until the summer. I didn't feel ready to start signing off on prescriptions, and even tried a training shift at one store. Prescribing for Minor Ailments had just been authorized. At first, I felt disgusted at the lack of training I received, but I wasn't surprised. There was no training for new pharmacists. I have been very anti-Shoppers as a result of some horrible placements. Some of my classmates told me they have been only taking clinical shifts, not feeling ready to prescribe yet either. When I felt ready to wield my new pharmacist title, I found a relief pharmacist job at a small Shoppers store in downtown Toronto. I managed to do a couple of evening and weekend shifts each month. The transition from calling myself a student/intern to calling myself a pharmacist felt very strange. I don't think I felt comfortable with this new identity for a while. After all, you have direct responsibility if a dispensing task goes awry and harms a patient. I kept with this schedule for a few months, becoming more and more disillusioned with the necessity of working. 

Since I moved to a different area of the city, I needed to work at a pharmacy closer to me, again, to maintain my license. I guess a blessing in disguise is that as a pharmacist, you don't need to worry about finding a community pharmacy job due to the mass pharmacist shortages that plagued Toronto since the beginning of the COVID pandemic. Shoppers recruiters send out mass email notifications about which stores are looking for part-time and full-time pharmacists, and the list for southern GTA was endless. I found another part-time dispensing position at a pharmacy nearby with a roster of homeless people that needed OAT. It definitely made for some interesting conversations. 

Slowly, without realizing, I became an anti-work believer. Having the full-time pharma job meant I needed to balance my patient care hours needed to keep my new license with the 9-5 hybrid work that came with the corporate culture. At this point, I was ready to transition into full time remote work no matter how frustrating, because of the awfulness of the alternative reality waiting for me. 

We are now in summer of 2023. I switched to a different antidepressant, because it was making me too sleepy in the daytime, despite taking them at night. The withdrawal made it hard to work for a week. Fortunately the company wasn't keeping tabs on who was online at what time of the day. My hybrid job became a game of how long I could keep my Teams status online for while struggling to concentrate to track and complete the tasks I was given. I gave up on trying to go to office 2-3 times a week, because some people on my team didn't go that often. I was still feeling this impostor syndrome, but now there was a new feeling: I didn't care about producing excellent work anymore, I just wanted to leave this position and find a team that actually valued my input. Why didn't I apply to internal jobs at this point? Probably because I felt burdened with all the things I needed to adjust, and income came first. An excerpt from my diary: "it feels like I've been running a marathon with no time to catch my breath these days. There's always things that need to be done at all times."

I decided to use the 10 vacation days I was allotted on a vacation. Upon my return, I gave 2 months notice to my landlord and signed a new lease for an apartment. I spent most of the fall months packing and finishing up my contract. They made the decision to hire another candidate to replace me instead of extending my contract, which was communicated to me in the summer. I saw it as a win-win. Clearly I wasn’t a good fit for the team because they didn't know how to use my talents and I didn’t show enough “initiative” to do a manager’s job. It felt good to leave the job and the basement.

Reading my previous journal entries, I realize I wasn't happy at this job for two reasons: the corporate environment (everyone says you should pursue extracurricular projects, but somehow all of the projects I’d asked to be on didn’t lead to anything) and the seemingly futile work I was doing, all the while trying to get the team to reply to my e-mails. As a recent graduate, I should consider myself lucky to get this highly coveted position, but I came to realize I disagreed with the way the team operated, the imbalance of resources compared to the amount of work that needed to be done, and the limitation to my development if I had stayed longer in this role. I am now happily settled in another apartment and am slowly reprocessing the year that went by. Quietly finishing my contract job without extension, moved 3 times, lost 2 friends in this process of self-development, transitioning between 3 part-time pharmacist jobs. At least I still have the energy to keep taking shifts at a new Shoppers near me. I am now motivated by the prospect of leaving Shoppers to transition into an independent pharmacy. At this point, I would still like to work in pharma because of the perks. I still feel lethargic when thinking about returning to full-time work, but at least I have more experience and more of a say in where I am working. 

My experience transitioning from school to work was not a smooth progression and definitely not the mainstream experience. In writing about this I realize that I've been at odds with myself the entire time. A sort of "identity conflict." After working my butt off in school, I wanted to relax but instead dived straight into full-time work. I definitely complained about burnout more than once that year. But what did I expect? My identity as a pharmacist took time to develop, and it took many months for me to feel comfortable practicing as a pharmacist, time that I could have spent working and not caring about "the bigger picture of patient care." Money is important at this time, and I felt I was putting myself at risk, moving right after leaving my full-time job. But I am proud that I was able to make it this far. Am I proud of being a pharmacist? I guess we will see as I grow more into the role. Ever since those American pharmacy walkouts happened, change is not too far away.

Topics for next time:

A pharmacist's status in society?

The path to being an MSL is a mainstream one

Job hunting: faking it, impostor syndrome, seeing where you are truly at

Applying for EI

The 4-day workweek, universal income, and other financial things of interest

The stalk market

 https://turnipprophet.io/?prices=106.135.111.97.65.56.105.104.70.64.60.145.125

I am in the process of creating my own rules and telling myself that little things like this, like facetiming my sister, like yoga, matter. 

Volume

Currently listening to: Kiss of Life - Sade
When I was led to you
I knew you were the one for me
I swear the whole world could feel my heartbeat 

At the new shoppers i work at the volume seems endless. Prescriptions, patients to call, endless lists of medication and related things. Sorting through the mess i did see an interesting patient on Tezspire, though. And a lot of people on Symbicort, which isn’t surprising. 

What surprised me the most was that the pharmacy beside me had such friendly people. And they use kroll, not fillware! Some things are just better once you move. 

The lifestyle here feels like a very luxurious and paced one. Although I don’t think I’m done with the travel and living under pressure yet. The feeling of having a lot to do can be pleasurable at times when I am able to strike a balance. 

The TPL has been under cyberattack since end of October. I miss its services.

The haunted month

It’s funny, you pull one pen out of a jar at a stationary store and it has that rubber ballpoint protector on the end, and then you pull another pen out and it doesn’t have that tip and you’re able to test it on the paper  strip that they provide. It feels like coincidence. That somehow you know the second pen doesn’t have a tip on it. Perhaps a simple example of the universe's "quantum physics." 

This time of year, there’s a lot of dead leaves on the ground. Recently I walked by a house on Clinton Street that had a huge sunflower growing on the front lawn one summer. That sunflower is gone now, but a patch of matted leaves remains where it used to stand. I wonder if the sunflower is still underground.

- End of October

It feels like I am aimlessly wandering and spending money between my frequent visits to Mark's, escapades to Wonder Pens, and travels to Eaton centre. I've started to think more about my creative pursuits, such as how to plan out my Hobonichi weeks, A5 planner, and NaNoWriMo. In between these musings, the ongoing pressure of applying to jobs is haunting me. I told myself I needed a break, because I just spent the middle of October moving and setting up a new job and my new space, etc. But somehow, the feeling keeps returning. 

Here are some news headlines on my birthday. Perhaps I should do this every year to capture the state of the world where I spend my (n+1)th birthday.