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Enjoying ‘Small Town’ Pharmacy Practice
Enjoying 6S ma ll Tovvn' Pharmacy Practice Practicing pharmacy in a small town) on an Indian reservation) and in a migrant clinic has brought job fulfillment to three pharmacists. by Walt Albro
W
hy would a pharmacist choose to leave behind the opportunity to make more money and have a more exciting lifestyle in an urban setting and practice) instead) in a rural one? Interviews with three practitioners found some common answers: the ability to have closer relations with patients) the satiifaction of being considered part of the health care team) and the opportunity to take on new responsibilities. Below are the stories of three such pharmacists.
Richard Zarek Small-TolNn Community Pharmacist
Richard Zarek, 41, knew what it was like to grow up in a small town. He was raised in western Nebraska in a town with 1,500 people. So in the late 1970s when Zarek was looking for a pharmacy to buy, he focused on rural areas. He ended up moving to Gothenburg in central Nebraska, population 3,500. The owner of a Jack & Jill supermarket was interested in opening a pharmacy in his building, and the two got together. Zarek's business, Gothenburg Discount Pharmacy, competes with the town's two other pharmacies, but Zarek's has the largest prescription volume. In a small-town practice, the pharmacist gets to know almost everyone in town. Having this close relationship has its advantages, but it also has its down side. Patients, for example, expect the pharmacist to remember all their medical needs. "They'll come in and say, 'I need my red pills, ' and they'll Vol. NS32, No.4 April1992/313
Richard Zarek, who owns Gothenburg Discount Pharmacy in rural Nebraska,jinds that patients ask him for advice on a range of medical problems.
expect you to know what they want right away," says Zarek. Zarek and the town's three physicians work together as a team. Zarek monitors medication and ensures patient compliance. He is the one who maintains contact with the patients in between doctor visits. The physicians tell Zarek how often they want patients to return for tests, such as blood sugar tests for diabetes, and Zarek reminds patients AMERICAN PHARMACY
The disadvantage is that when the time approaches. Zarek has difficulty finding He often provides a varipharmacists to fill in for ety of additional services, ~This is pharmacy the way it is him when he needs time particularly in the area of off. This is particularly hard home medical care. "To be supposed to be practiced I have lots when trying to get away for a pharmacist in a rural area, of contact with patients and doctors.' an unplanned event, such you have to have a little bit as a funeral. He mostly of expertise in all aspects of depends on retired pharhealth care," he says. macists. Some live at inconWhen patients approach venient distances-ll0 him with a problem, he will miles away, in one case. do everything he can to Zarek has to schedule vacasolve it. For example, tions between six and 10 patients ask his advice months ahead to ensure about recovery from surgery that someone will be availor their need for surgical able to replace him. braces. "If I can't solve it, I'll find someone else who can," On those rare occasions when Zarek is away from the Zarek says. His day starts when he opens the store at 8 a.m. For the pharmacy, some townspeople prefer to wait until he returns rather than have a substitute handle their prescription first hour or so, traffic is light, so he works on the books, orders. His relationship with his patients is so personal that handles correspondence, and makes telephone calls. By noon, traffic is heavy enough that sometimes he cansome patients do not feel comfortable having their prescripnot be interrupted for hours at a time. "I eat a large breaktion medications dispensed by someone else. "The last time I was away, I had three or four people fast and a large supper, and I try not to worry about eating waiting for me so they could get their pills," he says. "That's lunch," he explains. He closes at 6:30 p.m. These hours are the same every the type of trust you build in a small town." day of the week except Sunday and holidays, when the business is closed. Zarek works an average of 65-70 hours a week, down from about 75-80 hours when he started the Jim Carder practice 18 years ago. Indian Health Service Hospital Despite his long store hours, his job doesn't end just because he goes home. "People don't hesitate to call you at home," he says. On a typical Sunday, he will average four or five telephone calls. Working in a small, isolated rural hospital in Montana Most of these emergency calls will come from elderly might seem unattractive to some. The opposite is true, however, for Jim Carder, head pharshut-ins who are having problems with medication or equipment, such as a blood glucose monitor. Zarek makes macist at the 34-bed Crow Indian Reservation Hospital, 60 house calls to handle these problems. In other cases, peomiles southeast of Billings, Montana. His job is both fun and professionally challenging, he says. ple who have been released from the hospital's emergency room need painkillers or antibiotics and either do not want "This is pharmacy the way it is supposed to be practo or cannot wait for the pharmacy's regular hours. ticed," he explains. "I have lots of contact with patients and Zarek delivers medications to patients who cannot reach doctors. Plus, there are opportunities to grow and take on new responsibilities outside of pharmacy." the store themselves. If the patient is nearby, Zarek enlists his two sons to make delivery by bicycle. For longer trips, While many small, rural hospitals have only a part-time Zarek makes the deliveries by automobile. pharmacist, the Crow hospital has five full-time pharmacists. Zarek says he loves his job. "I wouldn't want to work The staff is needed because the outpatient clinic is so anywhere else." The small-town environment is a wonderactive. Also, the hospital operates two off-site clinics; two ful place to raise a family, and he enjoys the opportunity to pharmacists spend part of their time at these outlying sites. have his sons help him in the business. Working in a rural area is not new to Carder. He grew up Partly because of his visibility as the town's most active in a small farming community in Texas. After graduating from pharmacist, Zarek is a respected member of the community. pharmacy school in 1972, Carder joined the Indian Health Service (IHS). He has been with the service ever since. He was invited to serve on his church council and the local airport authority. He ran for a seat on the school board and Both Carder and his wife grew up in rural Texas, and beat out six other candidates. Carder likes the outdoors, doing a lot of hunting and fishAMERICAN PHARMACY
April1992/314 Vol. NS32, No.4
questions. Does the patient know how to take the medication? Does he know the expected outcome of using the medication? If the patient does not know the answers, the pharmacist counsels him. "The technique is used to help the patients feel that they are in the driver's seat with respect to their medical care," Carder says. A similar procedure is followed when the patient returns for a refill. The pharmacist reviews the medical record, reading the physician's notes to see if there have been any bad reactions to the drug. Again, there is contact between the pharmacist and the patient. The pharmacist reminds the patient of follow-up appointments. Also, the pharmacist questions the patient about problems, such as skipped doses. Jim Carder, head pharmacist at the 34-bed Crow Indian Reservation in Montana, also runs an outpatient clinic that serves 125-145 patients a day. Because he has been at the hospital for 12 years and because he has so much patient contact, Carder knows many of the patients by first name. As the hospital 's head pharmacist, ing. But not everyone is well suited to the rural life, he conCarder's title is director of clinical support services. Since cedes. Although the job can be satisfying, some pharmathe hospital is involved in comprehensive medical care for cists-or their wives-are unhappy with the social the Crow community, Carder has plenty of opportunities to disadvantages of a rural setting, and usually choose to leave get involved in health care programs outside of pharmacy. For example, he supervises the dental clinic, the laboratoafter a short time. Carder's early assignments were in Arizona and Nevada. ry, the X-ray department, and one of the outlying clinics. In addition, Carder is certified to teach advanced cardiac life The station in Nevada was so isolated that Carder had to support and gives classes twice a year to the hospital's docdrive his pregnant wife 130 miles to reach the closest hospitors and nurses. tal delivery room. IHS transferred him to Montana in 1979. That ability to grow and wear multiple hats is one of the Because the hospital is part of the IHS, it operates more pleasures of the job, he says. For at least an hour each day, like a health maintenance organization than a community he does health care work that has nothing to do with pharhospital. The outpatient clinic handles an average of macy. "When there are that many new things to keep you 125-145 patients daily, Monday through Friday. The facility busy, it's hard to stagnate." draws patients from a community of approximately 20,000 Crow Indians. In addition to its medical clinic with nine physicians the hospital also has a dental clinic with three dentists. David Webster When clinic physicians are finished seeing a patient, they Migrant Worker Clinic send the patient's medical chart to the pharmacy. With this record, the pharmacist can review the patient's medical history, confirming whether the doctor's findings support the Pharmacist David Webster feared that his first day on the use of the prescribed drug. The pharmacist can also check job in a migrant-worker clinic in North Carolina would be to see if the patient is using any other drugs that may react his last. with the new medication. His initial patient was a Spanish-speaking woman. This After the prescription medication is dispensed, the phardid not seem like a problem since Webster knew enough macist meets with each patient in a consultation room. The basic Spanish to do simple patient counseling. The difficulty pharmacist questions the patient using a verification techwas her medication-vaginal cream. nique developed by the IHS. "I realized that my high-school Spanish was not going to The procedure consists of asking the patient a series of Vol. NS32, No.4 April1992/315
AMERICAN PHARMACY
David Webster, a pharmacist at the federaUy funded health center in Newton Grove, N.e, works closely with the center's medical staff to provide year-round care for migrant farm workers.
be adequate," he says. He had to ask a bi-lingual nurse for help. The incident made him doubt whether he made the right decision to w ork at the clinic. He decided to stick it out, however. Now, he is glad that he did. He learned that he could do the job-and that he enjoyed it. Migrant-worker clinics have an undeserved bad image in the public mind, probably because their patients are poor and many are either illiterate or do not speak English. Webster says that in reality, such clinics provide a rewarding, highly professional environment for pharmacists. "If you want to be involved with patients and work closely with the medical staff, this is a good setting to practice in," he says. Webster, who is 40, earned a PharmD degree from the University of the Pacific, Stockton, Calif, in 1978. His wife, who graduated from the same university, went on to do postgraduate work. While his wife was in school-first in Minnesota and later in upstate New York-Webster worked as a hospital pharmacist. Three years ago his wife got a job in rural eastern North Carolina and the couple moved there with their four children. After they had settled in, Webster tried to find work as a hospital pharmacist. This was difficult since there were only two hospitals in the area, and neither had a job opening. One day Webster learned about a job at the Tri-County Community Health Center in Newton Grove, N.C. The facility is one of about a half-dozen in the state that are designed to provide health care for migrant farm workAMERICAN PfJARMACY
ers. They are funded through the federal Public Health Service. At Tri-County, the patients pay for their care on a sliding scale, based on their income. The clinic is open year-round. The patients vary according to the seasons. In the spring and summer, the facility serves Hispanics who come to plant and harvest such crops as tobacco and sweet potatoes. In the winter, it treats mostly rural black farm workers. Webster was unimpressed when he first saw the clinic. "It looked small. It was far out in the country, and part of it was in trailers," he says. "I was put off" He changed his mind when he saw the inside. He was impressed by the wide variety of primary care. In addition to a pharmacy, the clinic has an X-ray department, a laboratory, a medical clinic, a dental clinic, a nutritionist, and social workers. He accepted the job, and-despite his awkward starthas no regrets. He speaks highly of the commitment of the medical staff "The people are not here to make a lot of money. They are here to help people who need help. The staff is genuinely concerned. Everyone makes an extra effort. " The clinic is busy. The pharmacy serves between 110 and 160 patients each day, dispensing prescription as well as nonprescription medicines. There are three doctors and a nurse. The doctors do not hesitate to ask him for advice concerning possible side effects from certain medications. That attitude has helped to make Webster feel like a partner in the clinic's health care team. One of the pharmacy's priorities is to ensure that every patient understands the medication and its proper use. To do this, Webster counsels each patient who receives a prescription medication. He likes the high level of contact. "I'm the type of pharmacist who enjoys being close to the patient, " he says. Webster says there is only one drawback. The pharmacy staff is so small-only him and a technician-that it is hard to find a replacement when he goes on vacation. "It's difficult enough to find pharmacists in this area, but it has also got to be someone who speaks Spanish and knows how to use a computer." As a result, most of Webster's vacations are short~no more than a week. Although neither he nor his wife planned on moving to a rural area, they prefer the rural lifestyle, especially for raising children. Webster originally saw the clinic job as temporary until he found the type of hospital pharmacy that he "really" liked. Now he has been there for three years and has no plans to leave. "I'm involved and that makes it interesting." Walt Albro is a freelance writer from Rockville, Md.
ASpril1992/316 Vol. NS32, No.4
W
hy would a pharmacist choose to leave behind the opportunity to make more money and have a more exciting lifestyle in an urban setting and practice) instead) in a rural one? Interviews with three practitioners found some common answers: the ability to have closer relations with patients) the satiifaction of being considered part of the health care team) and the opportunity to take on new responsibilities. Below are the stories of three such pharmacists.
Richard Zarek Small-TolNn Community Pharmacist
Richard Zarek, 41, knew what it was like to grow up in a small town. He was raised in western Nebraska in a town with 1,500 people. So in the late 1970s when Zarek was looking for a pharmacy to buy, he focused on rural areas. He ended up moving to Gothenburg in central Nebraska, population 3,500. The owner of a Jack & Jill supermarket was interested in opening a pharmacy in his building, and the two got together. Zarek's business, Gothenburg Discount Pharmacy, competes with the town's two other pharmacies, but Zarek's has the largest prescription volume. In a small-town practice, the pharmacist gets to know almost everyone in town. Having this close relationship has its advantages, but it also has its down side. Patients, for example, expect the pharmacist to remember all their medical needs. "They'll come in and say, 'I need my red pills, ' and they'll Vol. NS32, No.4 April1992/313
Richard Zarek, who owns Gothenburg Discount Pharmacy in rural Nebraska,jinds that patients ask him for advice on a range of medical problems.
expect you to know what they want right away," says Zarek. Zarek and the town's three physicians work together as a team. Zarek monitors medication and ensures patient compliance. He is the one who maintains contact with the patients in between doctor visits. The physicians tell Zarek how often they want patients to return for tests, such as blood sugar tests for diabetes, and Zarek reminds patients AMERICAN PHARMACY
The disadvantage is that when the time approaches. Zarek has difficulty finding He often provides a varipharmacists to fill in for ety of additional services, ~This is pharmacy the way it is him when he needs time particularly in the area of off. This is particularly hard home medical care. "To be supposed to be practiced I have lots when trying to get away for a pharmacist in a rural area, of contact with patients and doctors.' an unplanned event, such you have to have a little bit as a funeral. He mostly of expertise in all aspects of depends on retired pharhealth care," he says. macists. Some live at inconWhen patients approach venient distances-ll0 him with a problem, he will miles away, in one case. do everything he can to Zarek has to schedule vacasolve it. For example, tions between six and 10 patients ask his advice months ahead to ensure about recovery from surgery that someone will be availor their need for surgical able to replace him. braces. "If I can't solve it, I'll find someone else who can," On those rare occasions when Zarek is away from the Zarek says. His day starts when he opens the store at 8 a.m. For the pharmacy, some townspeople prefer to wait until he returns rather than have a substitute handle their prescription first hour or so, traffic is light, so he works on the books, orders. His relationship with his patients is so personal that handles correspondence, and makes telephone calls. By noon, traffic is heavy enough that sometimes he cansome patients do not feel comfortable having their prescripnot be interrupted for hours at a time. "I eat a large breaktion medications dispensed by someone else. "The last time I was away, I had three or four people fast and a large supper, and I try not to worry about eating waiting for me so they could get their pills," he says. "That's lunch," he explains. He closes at 6:30 p.m. These hours are the same every the type of trust you build in a small town." day of the week except Sunday and holidays, when the business is closed. Zarek works an average of 65-70 hours a week, down from about 75-80 hours when he started the Jim Carder practice 18 years ago. Indian Health Service Hospital Despite his long store hours, his job doesn't end just because he goes home. "People don't hesitate to call you at home," he says. On a typical Sunday, he will average four or five telephone calls. Working in a small, isolated rural hospital in Montana Most of these emergency calls will come from elderly might seem unattractive to some. The opposite is true, however, for Jim Carder, head pharshut-ins who are having problems with medication or equipment, such as a blood glucose monitor. Zarek makes macist at the 34-bed Crow Indian Reservation Hospital, 60 house calls to handle these problems. In other cases, peomiles southeast of Billings, Montana. His job is both fun and professionally challenging, he says. ple who have been released from the hospital's emergency room need painkillers or antibiotics and either do not want "This is pharmacy the way it is supposed to be practo or cannot wait for the pharmacy's regular hours. ticed," he explains. "I have lots of contact with patients and Zarek delivers medications to patients who cannot reach doctors. Plus, there are opportunities to grow and take on new responsibilities outside of pharmacy." the store themselves. If the patient is nearby, Zarek enlists his two sons to make delivery by bicycle. For longer trips, While many small, rural hospitals have only a part-time Zarek makes the deliveries by automobile. pharmacist, the Crow hospital has five full-time pharmacists. Zarek says he loves his job. "I wouldn't want to work The staff is needed because the outpatient clinic is so anywhere else." The small-town environment is a wonderactive. Also, the hospital operates two off-site clinics; two ful place to raise a family, and he enjoys the opportunity to pharmacists spend part of their time at these outlying sites. have his sons help him in the business. Working in a rural area is not new to Carder. He grew up Partly because of his visibility as the town's most active in a small farming community in Texas. After graduating from pharmacist, Zarek is a respected member of the community. pharmacy school in 1972, Carder joined the Indian Health Service (IHS). He has been with the service ever since. He was invited to serve on his church council and the local airport authority. He ran for a seat on the school board and Both Carder and his wife grew up in rural Texas, and beat out six other candidates. Carder likes the outdoors, doing a lot of hunting and fishAMERICAN PHARMACY
April1992/314 Vol. NS32, No.4
questions. Does the patient know how to take the medication? Does he know the expected outcome of using the medication? If the patient does not know the answers, the pharmacist counsels him. "The technique is used to help the patients feel that they are in the driver's seat with respect to their medical care," Carder says. A similar procedure is followed when the patient returns for a refill. The pharmacist reviews the medical record, reading the physician's notes to see if there have been any bad reactions to the drug. Again, there is contact between the pharmacist and the patient. The pharmacist reminds the patient of follow-up appointments. Also, the pharmacist questions the patient about problems, such as skipped doses. Jim Carder, head pharmacist at the 34-bed Crow Indian Reservation in Montana, also runs an outpatient clinic that serves 125-145 patients a day. Because he has been at the hospital for 12 years and because he has so much patient contact, Carder knows many of the patients by first name. As the hospital 's head pharmacist, ing. But not everyone is well suited to the rural life, he conCarder's title is director of clinical support services. Since cedes. Although the job can be satisfying, some pharmathe hospital is involved in comprehensive medical care for cists-or their wives-are unhappy with the social the Crow community, Carder has plenty of opportunities to disadvantages of a rural setting, and usually choose to leave get involved in health care programs outside of pharmacy. For example, he supervises the dental clinic, the laboratoafter a short time. Carder's early assignments were in Arizona and Nevada. ry, the X-ray department, and one of the outlying clinics. In addition, Carder is certified to teach advanced cardiac life The station in Nevada was so isolated that Carder had to support and gives classes twice a year to the hospital's docdrive his pregnant wife 130 miles to reach the closest hospitors and nurses. tal delivery room. IHS transferred him to Montana in 1979. That ability to grow and wear multiple hats is one of the Because the hospital is part of the IHS, it operates more pleasures of the job, he says. For at least an hour each day, like a health maintenance organization than a community he does health care work that has nothing to do with pharhospital. The outpatient clinic handles an average of macy. "When there are that many new things to keep you 125-145 patients daily, Monday through Friday. The facility busy, it's hard to stagnate." draws patients from a community of approximately 20,000 Crow Indians. In addition to its medical clinic with nine physicians the hospital also has a dental clinic with three dentists. David Webster When clinic physicians are finished seeing a patient, they Migrant Worker Clinic send the patient's medical chart to the pharmacy. With this record, the pharmacist can review the patient's medical history, confirming whether the doctor's findings support the Pharmacist David Webster feared that his first day on the use of the prescribed drug. The pharmacist can also check job in a migrant-worker clinic in North Carolina would be to see if the patient is using any other drugs that may react his last. with the new medication. His initial patient was a Spanish-speaking woman. This After the prescription medication is dispensed, the phardid not seem like a problem since Webster knew enough macist meets with each patient in a consultation room. The basic Spanish to do simple patient counseling. The difficulty pharmacist questions the patient using a verification techwas her medication-vaginal cream. nique developed by the IHS. "I realized that my high-school Spanish was not going to The procedure consists of asking the patient a series of Vol. NS32, No.4 April1992/315
AMERICAN PHARMACY
David Webster, a pharmacist at the federaUy funded health center in Newton Grove, N.e, works closely with the center's medical staff to provide year-round care for migrant farm workers.
be adequate," he says. He had to ask a bi-lingual nurse for help. The incident made him doubt whether he made the right decision to w ork at the clinic. He decided to stick it out, however. Now, he is glad that he did. He learned that he could do the job-and that he enjoyed it. Migrant-worker clinics have an undeserved bad image in the public mind, probably because their patients are poor and many are either illiterate or do not speak English. Webster says that in reality, such clinics provide a rewarding, highly professional environment for pharmacists. "If you want to be involved with patients and work closely with the medical staff, this is a good setting to practice in," he says. Webster, who is 40, earned a PharmD degree from the University of the Pacific, Stockton, Calif, in 1978. His wife, who graduated from the same university, went on to do postgraduate work. While his wife was in school-first in Minnesota and later in upstate New York-Webster worked as a hospital pharmacist. Three years ago his wife got a job in rural eastern North Carolina and the couple moved there with their four children. After they had settled in, Webster tried to find work as a hospital pharmacist. This was difficult since there were only two hospitals in the area, and neither had a job opening. One day Webster learned about a job at the Tri-County Community Health Center in Newton Grove, N.C. The facility is one of about a half-dozen in the state that are designed to provide health care for migrant farm workAMERICAN PfJARMACY
ers. They are funded through the federal Public Health Service. At Tri-County, the patients pay for their care on a sliding scale, based on their income. The clinic is open year-round. The patients vary according to the seasons. In the spring and summer, the facility serves Hispanics who come to plant and harvest such crops as tobacco and sweet potatoes. In the winter, it treats mostly rural black farm workers. Webster was unimpressed when he first saw the clinic. "It looked small. It was far out in the country, and part of it was in trailers," he says. "I was put off" He changed his mind when he saw the inside. He was impressed by the wide variety of primary care. In addition to a pharmacy, the clinic has an X-ray department, a laboratory, a medical clinic, a dental clinic, a nutritionist, and social workers. He accepted the job, and-despite his awkward starthas no regrets. He speaks highly of the commitment of the medical staff "The people are not here to make a lot of money. They are here to help people who need help. The staff is genuinely concerned. Everyone makes an extra effort. " The clinic is busy. The pharmacy serves between 110 and 160 patients each day, dispensing prescription as well as nonprescription medicines. There are three doctors and a nurse. The doctors do not hesitate to ask him for advice concerning possible side effects from certain medications. That attitude has helped to make Webster feel like a partner in the clinic's health care team. One of the pharmacy's priorities is to ensure that every patient understands the medication and its proper use. To do this, Webster counsels each patient who receives a prescription medication. He likes the high level of contact. "I'm the type of pharmacist who enjoys being close to the patient, " he says. Webster says there is only one drawback. The pharmacy staff is so small-only him and a technician-that it is hard to find a replacement when he goes on vacation. "It's difficult enough to find pharmacists in this area, but it has also got to be someone who speaks Spanish and knows how to use a computer." As a result, most of Webster's vacations are short~no more than a week. Although neither he nor his wife planned on moving to a rural area, they prefer the rural lifestyle, especially for raising children. Webster originally saw the clinic job as temporary until he found the type of hospital pharmacy that he "really" liked. Now he has been there for three years and has no plans to leave. "I'm involved and that makes it interesting." Walt Albro is a freelance writer from Rockville, Md.
ASpril1992/316 Vol. NS32, No.4