Spruce Mountain Pharmacy owner Steve Maki fills a prescription at his store in Jay on last week. That fundamental task has quickly become one of many responsibilities pharmacists are being required to take on. Russ Dillingham/Sun Journal Buy this Photo

JAY — For 14 to 16 hours a day, pharmacist Steve Maki ricochets from one task to another.

Calling doctors. Calling insurance companies. Giving shots. Cleaning and sanitizing. Answering customers’ questions about their medications, health problems or, these days, COVID-19. Then there’s catching drug interactions and prescription mistakes. Compounding medications. Managing pharmacy technicians. Counseling people about their Medicare Part D options.

Oh, and filling prescriptions.

“We juggle a lot of different things,” said Maki, owner of Spruce Mountain Pharmacy in Jay. “We usually have two pharmacists here for a chunk of the day so that way one pharmacist doesn’t have to carry the entire load.”

That load used to be a lot lighter.

Soon it may be even heavier.

Pharmacists are unique on the front lines of health care in Maine — they help without appointment, their consultations are free, they’re available on weekends and outside regular business hours. They stayed open during the early days of the pandemic when so many other medical providers shut down or went to telemedicine or limited which patients they would see.

For many Mainers, pharmacists offer the lowest barriers to care.

But asked to provide more and more of that care — vaccinations, medication management, patient consultations, clinical testing — they’ve seen their workloads expand. As the flu season ramps up and COVID-19 continues to rage, that workload now ranges from stressful to unendurable.

With a highly in-demand COVID-19 vaccine on the horizon, that workload could become impossible.

And many pharmacists worry that while they’re paying attention to one thing, they’re missing something else important. Like the wrong medication.

Said Brunswick pharmacist Gary Manzo, “Lives are on the line with everything we do, with each ball in the air.”

‘I’M TERRIFIED’

A generation ago, pharmacists focused primarily on filling prescriptions and talking with customers. Then, in 2009, Maine began allowing pharmacists to give immunizations. That’s about when, some pharmacists say, the job began to expand.

They weren’t necessarily unhappy with the change. It helped people, and they wanted to help people.

“I never saw myself giving vaccinations when I was in college, but things have tremendously, tremendously changed. … We’re basically evaluating the whole patient,” said Abdullah Al-Fdeilat, a pharmacist for 30 years, who now works in Bangor. “I feel very happy that the pharmacist actually is capable of doing these things.”

But the occasional shot turned into a daily stream of shots for flu, shingles, chicken pox, pneumonia and tetanus, among other illness. Vaccinations proved popular with customers and became money makers for pharmacies. Chain store pharmacists, in particular, started getting pressed by their bosses to do more of them.

Gary Manzo, 66, has been a pharmacist for 42 years and currently works in Brunswick. “Lives are on the line with everything we do.” Submitted photo

“It’s put on us, this tremendous sales push. They want us to give overhead announcements every 30 minutes: ‘Come get your vaccine,'” said pharmacist Tracy Street. “They want us to screen every patient that we have: ‘Have you had your pneumonia shot? Have you had your shingles shot?’ Trying to talk them into it. They don’t know what they have (had), so it’s ‘Well, let me contact your doctor and get a prescription for it.'”

Street, like other pharmacists, doesn’t have a problem giving shots or even encouraging her customers to get them, but vaccination paperwork takes time. Doing overhead announcements and calling doctors take time. Giving the shot takes time.

Some Maine pharmacists estimate it can take them 5 to 15 minutes per shot when everything goes well. It takes longer when the customer is nervous about needles and needs some reassurance or when there’s a problem with insurance, both common situations.

During peak flu shot season, pharmacists can do dozens of shots a day.

“I don’t have time to do that,” Street said. “I have a primary job to fill prescriptions, and that itself has become a monster where it didn’t used to be.”

That’s because pharmacists also have to deal with insurance companies. That takes time as well — often 20 minutes or more on hold, then more time talking to a representative to find out why a drug wasn’t covered or to get authorization to fill a prescription. That can happen multiple times a day.

And then there are the calls to doctor’s offices — requiring more time on hold — to double check a prescription, to get an alternate medication the insurance company will cover, or to discuss a potential drug interaction. That can occur multiple times a day, too.

In between, pharmacists have to order drugs and supplies, oversee inventory and answer customers’ medical questions. In some pharmacies, it’s the pharmacist who takes out the trash, responds to voicemails left overnight and answers the phone.

“Some days you just want to turn the phone off,” Al-Fdeilat said.

In recent years, prescriptions — filling them, double checking for accuracy, talking with customers about their new medications — have had to compete to be a priority.

“You get pushed to a level that is absurd,” said Sean Nutter, an Augusta pharmacist who began his career three years ago. “You would like to be able to counsel everybody on their safety and everything, but doing so puts you in a position where you’re just so stressed out because of the pace.”

Things only got worse last spring, when the pandemic began. Suddenly, pharmacists were fielding anxious questions about COVID-19 and handling more general medical questions because people couldn’t or didn’t want to venture into their doctor’s office. Some pharmacists found themselves running prescriptions outside several times a day for curbside pickup or packaging medications to be mailed. Most had to stop what they were doing to clean and disinfect their areas throughout the day, sometimes as frequently as every 15 minutes.

“That’s what the company says to do,” said Nutter, who works for a pharmacy chain. “We do it, but I know other pharmacies do not because they don’t offer anymore help.”

This flu season, too, made pharmacists busier. Concerned about contracting that virus on top of COVID-19, Mainers have shown up in droves for flu shots. At Spruce Mountain Pharmacy in Jay, for example, pharmacists usually give out 150 to 200 flu shots a year; they did nearly that many at the beginning of fall. Larger pharmacies saw even greater demand.

Abdullah Al-Fdeilat, a pharmacist for 30 years, now works in Bangor. “Things have tremendously, tremendously changed,” he said. Submitted photo

“Flu season is always crazy in a regular year — back and forth, back and forth, back and forth. It’s so stressful and exhausting,” Street said. “I’d say most, if not all of us, you’re like at your wit’s end when you work 7 (a.m.) to 10 (p.m.) and give 40 flu shots.”

Now a COVID-19 vaccine is on the horizon and pharmacists have already been tapped to help give 130,000 shots per week in Maine.

“I’m terrified,” Street said.

STRESS

Behind much of the stress: Pharmacists’ concern with the critical mistakes they could make. In between flu shots and paperwork, did they catch every drug interaction? Did they hand over the right pills?

“It takes one second to miss something that causes harm,” Street said. “That’s a stress that we carry every day. That’s a chain that we carry around that you can’t see, but it’s huge.”

Nutter said his employer — a chain pharmacy he didn’t want to name — tracks every task a pharmacist performs and runs productivity reports. Go too slow, get written up. Get written up enough, lose the job.

“You see that you’re behind and you try to make it up and you push the prescriptions out as fast as you can,” he said.

He worries that pace will cause him to make an error, and that error will hurt someone.

“Nobody wants to make mistakes,” he said. “Nobody wants to cause harm.”

It doesn’t help that pharmacy jobs are hard to find in Maine. Two pharmacy schools opened here in recent years to address what was then a shortage of pharmacists. But they now graduate more than 100 new pharmacists a year, sending them into a job market that, according to the Maine Department of Labor, only has 46 openings a year. So if a pharmacist complains that their workload isn’t safe or if they don’t keep up the pace, they could find it hard to get a new job in a career that, on average, pays $64.75 an hour in Maine but often requires more than $200,000 in student loans.

Pharmacy technicians can take over some of the more time-consuming tasks, like waiting on hold for the insurance company or putting a new customer’s information into the computer system. Pharmacists that have enough techs, like Maki in Jay, say they are invaluable.

But many pharmacists, particularly those in chain stores, said they have asked for additional help and haven’t gotten it. They believe their bosses don’t want to spend the money on techs, who earn an average $15.84 an hour, according to the Maine Department of Labor.

Manzo, the Brunswick pharmacist, called the increasing workload and lack of support a “perfect storm for increasing prescription errors.”

NO SINGLE SOLUTION

The University of New England in Portland is home to one of Maine’s two pharmacy schools. Husson University in Bangor has the other.

Kenneth McCall, a professor at UNE’s School of Pharmacy and past president of the Maine Pharmacy Association, said he talks frequently with pharmacists in the field and stress is a common issue, not only because of the workload but also because of ongoing medication shortages, the effects of the pandemic and the risk of catching COVID-19 doing a job on the front line.

“There’s real anxiety. Even for some people, depression, frustration,” he said. “Like other health care professionals, right now we’re just trying to make it through this. But it seems like every week, every month there’s a little bit of a different challenge.”

He said UNE tries to prepare its students for the stresses of the job and also encourages them to intern in the field for a sense of what they’ll be getting into.

Kenneth McCall, professor at the University of New England’s School of Pharmacy. He calls today’s pharmacists and new graduates “health care heroes.” Photo courtesy the University of New England

“They’re graduating not only into their profession and the responsibility of patient care but in the middle of a pandemic,” McCall said. “I would say that our students and new graduates are health care heroes in every sense of the word because never before has this much been asked of (them).”

All of that stress has some students rejecting even the idea of working at a local pharmacy once they graduate. Macknzey Buczek, a 21-year-old second-year UNE pharmacy student, hopes to work at a compounding pharmacy or a university where he can pursue research and teach. He’s even reconsidered whether he wants to be a pharmacist at all.

“I have, due to the stress and lack of control in the pharmacy,” he said. “This is why I have decided to stay away from community pharmacy (jobs) if I can, so that I can reduce stress in my life.”

Pharmacists say there is no single solution to the overwhelming pressure they feel every day. They need more help. They need fewer tasks. They need better job security so they feel more comfortable raising issues. They need customers to know they’re working as fast and as safely as they can.

“After 30 years of experience, when I get overwhelmed with the things I need to do, my practice is actually to slow down. People tell me so-and-so is waiting and I say, ‘Would they rather have it right or fast?'” Al-Fdeilat said. “I’ve always said to people, ‘If you give me a couple of more minutes, it’s for your own safety.’ I have not come across a single person who would say, ‘No, just give me whatever you were going to give me.'”

Back in Jay, Maki fees like he faces a new challenges every day. But he also sees how appreciative people are, and that helps him get through.

“When I’m at the coffee shop getting a cup of coffee in the morning and I see one of my customers and she smiles and she elbows the person next to her drinking coffee with her and she’s like, ‘That’s Steve, that’s my pharmacist,’ it’s a cool thing,” said Maki, “It’s something that just says we’re doing something and we’re doing it well.”