Let me clearly state the obvious: Many drugs are absolutely critical and even life-saving. If you have type 1 diabetes, insulin is critical for your survival. If you have hypothyroidism, thyroid hormone supplementation is critically important. If you have chronic pain from a fall, a car accident, a workplace accident, etc., pain pills can be critically important in making your life livable. If you have a tooth extracted, an anesthetic can make the procedure tolerable. If you develop pneumonia, an antibiotic can be lifesaving.
This article is not about essential and life-saving drugs. This article is about many of the drugs that are heavily advertised in what I view as a three-ring circus.
According to Andrew Weil, MD (Mind Over Meds, New York: Little, Brown and Company, 2017, p. 12):
“I often ask doctors and medical students to compile a list of the medications they would take with them if they were to live on a desert island. My list would include aspirin, penicillin, morphine, prednisone, and a few other drugs whose effectiveness in our collective experience is great enough to make a favorable risk/benefit ratio. I would include none of the pharmaceutical products now so vigorously advertised on television, radio, and in print. My general opinion of those is that manufacturers consistently exaggerate their benefits and consistently downplay the harm they can cause.”
Why Are Pharmacists So Positive About Pills?
Most people probably think that science is what drives pharmacy today. In fact, marketing is in the driver’s seat. The thing that is most disappointing to me about pharmacists is that most of them don’t seem to realize that Pharma is engaged in a highly sophisticated marketing game which plays Americans for suckers. Pharmacists largely accept Pharma’s pill-for-every-ill narrative at face value, in large part because it is financially lucrative to do so. Pharmacists clearly realize that there’s not much money in prevention. It is pills that pays our salary, not recommendations about dietary and lifestyle changes.
Marcia Angell, M.D., former editor-in-chief of The New England Journal of Medicine, writes in her highly acclaimed book The Truth About the Drug Companies (New York: Random House, 2004, pp. xvii-xviii):
“[The pharmaceutical industry] over the past two decades has moved very far from its original high purpose of discovering and producing useful new drugs. Now primarily a marketing machine to sell drugs of dubious benefit, this industry uses its wealth and power to co-opt every institution that might stand in its way, including the U.S. Congress, the FDA, academic medical centers, and the medical profession itself.”
This article is not about pharmacists’ attitudes toward essential and lifesaving drugs. This article is about the reasons that pharmacists feel pressured to be positive about all the drugs we dispense regardless of the safety and effectiveness of those drugs.
Pressure on pharmacists to be positive about pills comes from their pharmacy education, from their employer, from their professional associations, from doctors, from other pharmacists (peer pressure), from fear of being sued, and maybe even indirectly from state boards of pharmacy. Last but not least is the concept of cognitive dissonance wherein pharmacists battle their own psyche to try to reconcile their worries about the risks versus benefits of drugs.
[1] Employers don’t want pharmacists to be critical of the drugs we dispense
I am now retired but I worked for the big chain drug stores for my entire career. I believe that the strongest pressure on pharmacists to be positive about drugs comes from our employer. Clearly pharmacists are paid to move pills, not to get involved in long discussions with our customers about the risks and benefits of pharmaceuticals.
If a customer asked me whether a particular drug was safe and my district supervisor happened to be standing nearby, it was highly unlikely that I would criticize that drug. I would almost certainly sugar coat my answer under those circumstances. If a customer were to ask me to recommend something for a cold or cough or diarrhea or constipation or sore throat or lack of energy or insomnia, etc., it is highly unlikely that I would recommend a non-drug solution if my district supervisor were standing nearby. If a customer asked me to recommend a vitamin, there was zero chance that I would recommend a dietary or lifestyle change (rather than a vitamin) if my district supervisor were standing nearby. District supervisors’ unstated attitude toward pharmacists seems to be: Your job is to move pills. Your job is not to promote your personal views about the risks and benefits of pharmaceuticals and the value of prevention.
[2] Understaffng means there is inadequate time for in-depth discussions with customers about the risks and benefits of drugs
Understaffing increases profitability by forcing all employees to work at maximum output for their entire shift. With severe understaffing at chain drug stores, there are simply not enough warm bodies present that would allow pharmacists to engage in such thoughtful conversations with customers about the risks vs the benefits of drugs.
Production metrics are what drive chain drug stores. When pharmacists express some doubt about a drug, our customers rightly expect us to explain our reasons in adequate detail. There is simply not enough staffing in too many drug stores to allow such detailed conversations. Giving positive answers to customers’ questions about the safety and effectiveness of drugs simply makes the production line move faster. The big chains don’t want to employ pharmacists who spend too much time speaking with customers in general, and in discussing the importance of prevention through dietary and lifestyle changes.
[3] Doctors become angry when pharmacists criticize a drug the doctor has prescribed
Doctors certainly don’t want pharmacists to criticize the drugs those doctors prescribe. One of the things that pharmacists dread the most is being called by a physician and being excoriated for something negative we said about a drug he/she prescribed.
[4] Patients want pharmacists to reinforce their (patients’) preconceived notions about a pill for every ill
Patients want quick-fix solutions for every health problem. Customers have unrealistic expectations or irrational exuberance for pharmaceuticals as a result of lavish spending by Big Pharma on drug advertisements. Patients expect quick-fix pill solutions and are often disappointed when a pharmacist attempts to direct the patient toward non-drug solutions such as dietary/nutritional and lifestyle changes. Too many pharmacy customers seem to want pharmacists who reinforce their (the customers’) view that there is a pill for every ill. These customers come into the store looking for a pill and seem to be disappointed when they get verbal advice rather than a recommendation for a specific miracle pill.
[5] Pharmacy school curricula seems to have been designed to please Pharma
I am quite serious in stating that pharmacy school has an eerie resemblance to a seminary. In my opinion, pharmacy school is like a seminary where being positive about pills is akin to being in a church where congregants are expected to be positive about religion and not question whether there is a god. In pharmacy school, it is taboo and almost sacrilegious to believe or to proselytize that prevention of disease may be superior to pills.
Pharmacy school has a powerful effect in causing students to have a positive attitude toward the drugs they dispense. If I were to stand up in pharmacy school and say that I’m more interested in prevention than pills, I would be viewed as an outcast or enemy, much like an atheist during a church service. Pharmacists earn their living by selling pills, not by advising people how to prevent disease with dietary and lifestyle changes.
Pharmacy professors’ definition of acceptable science is comparing Drug A vs Drug B or Drug A vs placebo rather than comparing Drug A vs dietary change, or Drug A vs exercise, or Drug A vs lifestyle change, or Drug A vs weight loss, or Drug A vs getting more sleep, or Drug A vs getting a divorce, or Drug A vs a change in jobs, or Drug A versus a whole foods diet, or Drug A vs a firmer mattress, etc. Pharmacy professors seem to have a very narrow view of what constitutes acceptable science: science in the service of pharmacy as a business. Pharmacy schools promote a view of drugs that basically aligns with Pharma’s view.
I view most retail pharmacists (as opposed to hospital pharmacists) as having an attitude similar to a small town grocer. The pharmacist’s job is to sell pills, not to educate the public about how to prevent disease.
[6] Pharmacy associations resembles churches where congregants have a soothingly self-congratulatory tone
Local, state, and national pharmacy association meetings are much like meetings at a church where attendees have a very soothing and self-congratulatory attitude toward the activity they’re engaged in. A pharmacist who announces at a pharmacy association meeting that he is more interested in prevention and not positive about pills is likely to be received as coldly as an atheist at a church service.
[7] Pharmacists seem to ostracize their peers who criticize pharmaceuticals
Pharmacists feel tremendous peer pressure to be positive about pills. I have written over a dozen articles for The People’s Pharmacy since my retirement. The views I have expressed in my People’s Pharmacy articles would have been met with tremendous disdain from other pharmacists if I were still in the workplace. Indeed, among the hundreds of pharmacists I’ve met during my career, I never encountered one with whom I felt completely comfortable discussing my preference for prevention over pills. I was always afraid that one of my supervisors would hear about my doubts about the pill for every ill approach and then concoct some pretext to ease me out of my job.
[8] Pharmacists have a tremendous fear of being sued if our comments about the risks vs. benefits of drugs cause a customer to unilaterally discontinue a drug and something bad happens to the customer’s health
It is extremely risky for pharmacists to be critical of any pharmaceuticals because, for example, one or more of our customers might decide to discontinue the pill we criticized, and then if something bad happened as a result of discontinuing that pill, we could be sued and our future livelihood would be in jeopardy.
It is so much easier to be positive about pills we are dispensing. That keeps our employer happy, it keeps doctors happy, it reinforces our customers’ expectations that there is a pill for every ill, it makes the production line run faster and smoother, and it means that we are not risking being sued because someone discontinues a drug as a result of our criticism of that drug.
[9] State boards of pharmacy could conceivably be vindictive toward a pharmacist who develops a reputation for being critical of pharmaceuticals
The first duty of state boards of pharmacy is to protect the public safety. Pharmacists live in fear of their state board of pharmacy. The state boards of pharmacy have the power to discipline pharmacists, to fine them, and to revoke their license.
Pharmacists serve on many state boards of pharmacy, as do public representatives. A pharmacist who develops a reputation for promoting prevention over pills could conceivably find himself in the crosshairs of the state board of pharmacy under the pretext that that pharmacist is somehow a threat to the public safety by criticizing too many of Pharma’s wonderfully safe and effective products.
I’ve never heard of such a scenario actually occurring, but I think it is conceivable or at least it is something that I would worry about as a pharmacist. Pharmacists want to keep their noses clean so they don’t upset the state board of pharmacy and risk discipline from that board. The pharmacists who serve on state boards of pharmacy might consider such a non-conforming pharmacist to be an enemy to the profession and in need of being weeded out. A pharmacist who views pharmaceuticals critically is potentially placing his license at risk.
State boards of pharmacy seem to accept Big Pharma’s view (“better living through chemistry”) as the only valid view. This is regardless of the fact that most of these drugs come with long lists of potentially dangerous side effects. The establishment view seems to believe that potentially risky drugs have more to do with health than fruits, vegetables, exercise, lifestyle changes, weight loss, avoiding alcohol, etc.
[10] Cognitive dissonance: It is simply too painful for pharmacists to worry excessively about potential harm from pharmaceuticals
It would exact a heavy toll on the psyche of health professionals to maintain serious doubts about many of the pills they prescribe/dispense, and to have doubts about whether the quick-fix pill for every ill approach is the best one, and yet engage in that activity every hour of every workday. Thus it is easier to sublimate those unsettling views and fully embrace the pill juggernaut in America.
How Cognitive Dissonance Discomfort Keeps Pharmacists Enthusiastic About Pills:
In psychology, cognitive dissonance is the mental stress or discomfort experienced by an individual who holds two or more contradictory beliefs at the same time. According to Wikipedia, cognitive dissonance theory is founded on the assumption that individuals seek consistency between their expectations and their reality. An individual who experiences inconsistency (dissonance) tends to become psychologically uncomfortable. Since it is impossible for a thinking person to hold two mutually exclusive beliefs simultaneously, anxiety is usually the result.
Cognitive dissonance is inevitable in every pharmacist’s life when faced with these contradictions:
—The contradictions between the glowing picture of drugs painted by direct-to-consumer advertising and the reality of a long list of potential side effects
—The contradiction between the FDA’s seal of approval and the reality that many side effects don’t appear until after a drug is on the market
—The contradiction between the fact that our health care system is based on drugs and the reality that prevention is safer and more effective than pills
Cognitive dissonance often arises when there is conflict between a pharmacist’s positive concept of himself/herself (The drugs that I dispense are safe and effective), and the reality (Some drugs do more harm than good).
Here is an e-mail I received from a pharmacist in response to my Drug Topics commentary titled “Pharmacists and Cognitive Dissonance” (https://www.drugtopics.com/view/pharmacists-and-cognitive-dissonance):
“I can’t believe you can read my mind so perfectly! The cognitive dissonance you speak of is as familiar to me as getting out of bed in the morning, and much less palatable. How DO you reconcile what you know to be true with what you must tolerate to survive? For many years, I have felt “two-faced” or phony in my practice of pharmacy. What I really want to do is tell my customers to flush the medication and start taking care of their bodies. What I have to tell them is how the medication will “help” them, and how they should take it faithfully. I’ve played the part as long as I can. I’m getting out. I can’t in good conscience keep shoveling this stuff out. Keep up the good work!”—Tired Pharmacist
In conclusion, taken together, these ten reasons illustrate why pharmacists feel tremendous pressure to be positive about pills.
Note: Never discontinue a drug or take it differently from how your doctor recommended without first discussing it carefully with your doctor. Making any changes in the drugs you take can have disastrous consequences if not first discussed with your doctor. Some drugs are essential and even life-saving even though there are potential side effects.
