Frieda Wiley, PharmD- Freelance Medical and Science Writer

Ida was a spunky woman whose eyes gleamed with a childlike vigor, seemingly in ironic contrast to the date listed on her birth certificate. With a kyphotic spine and slow gait, she ambulated hunched over a rollator walker with both intent and a careful pace. But from the moment we locked eyes, her physical disabilities instantly melted away. We connected immediately.

I had first met Ida during a comprehensive medication review — an integral part of the medication therapy management program where I traveled to different pharmacies to provide individual medication reviews for patients who were qualifying Medicare Part D members. Sometimes described as a “medication brown bag,” I equated the service to digging for the prize in the bottom of the Cracker Jack Box in more ways than one. I never knew what sorts of medication-related problems I would encounter, but I also didn’t know what kind of patient I would get — or how they would respond.

But Ida was different. She had this infectious, larger-than-life energy where you could feel her presence before she entered the room. As esoteric as it sounds, I “sensed” her aura before she shuffled into my office behind her husband, who dutifully held the door for her, along with her paperwork (and her purse).

Looking back, I guess I must have made an impression on her during our initial consultation, so much so that I became like her personal pharmacist. She sought me out personally for drug information when she would come by the pharmacy where we had initially met. When I’d come back to that same pharmacy after spending days (or sometimes weeks) working at other locations, the staff would give me messages to return her phone calls.

As a recent graduate, the idea of someone trusting me at that level was gratifying and a motivational tool. Ida’s confidence in me made me want to work harder to provide her and other patients a higher level of care — as well as making sure I had the most current knowledge and skill set to back it up. The last thing I wanted to do was disappoint my patients.

I also wanted my patients to perceive me as being approachable and personable. After the intimate relationship I had developed with Ida, I quickly honed a formula to help me gain other patient’s confidence and approval quickly. But in the process, I made one major mistake: I allowed myself to get a little too close to my patient. I had become attached. Yes, I knew it probably wasn’t the best idea, but I also failed to see the potential harm in making an exception for one patient, one person.

Not only that, but I chose to ignore the obvious: Ida was in her mid-80s. Like many people in advanced age, she had some chronic health issues. During our consultation, I would learn that an adverse drug reaction to statins transformed her into a crippled woman who would require assistance to walk for the rest of her life. While I knew she was not immortal, I had made a subconscious (and conscious) decision to overlook the fact that the hourglass of her life had drained down to the final grains of sand.

Then the worst happened. After having spent a few weeks working at other pharmacies, I was excited to return to my home store where I had originally met Ida. When I saw her husband standing in a line too long for me to say hello, I asked the pharmacy co-manager how she was doing.

He paused for a moment before responding carefully. “She died.”

With those two words, all the kerfuffle around me screeched to a halt. Everything went silent — the incessant phone ringing, the fluttery chatter among the pharmacy technicians, the overlapping conversations of patients waiting, and passersby.

I froze, paralyzed with shock and confusion before an overwhelming wave of grief washed over me. I was sad. I wanted to cry. But I had an audience — and I was in a professional setting. Even worse, I was a pharmacist. Was I even allowed to grieve? Was it appropriate? I wasn’t sure and was too ashamed of my feelings to ask or acknowledge them aloud.

Doctors and nurses immediately come to the mind of many when thinking about experiencing and grieving over patient deaths. Yet, the impact on pharmacists continues to remain frequently overlooked and under-acknowledged, despite our frequent and recurring interactions with patients. Perhaps the omission of the pharmacist’s experience in the patient care realm and how its emotional toll on the pharmacist gives rise to the taboo — the taboo which prevents pharmacists from feeling comfortable in openly acknowledging and expressing our feelings (at least not without having to provide some level of validation).

The stigma of societal expectations made me question whether I had a valid right to feel what I was feeling. Because of my shame and insecurities at the time, I chose to suffer in silence. I swallowed my grief, pushed it deep down into the dark abyss of my secret vault of sadness and unresolved issues, hoping the unresolved feelings would never resurface. Nearly a decade would pass before I would learn that my feelings were valid and normal, as well as common. Ironically, my journalistic pursuits put me on the path to healing. Recently, a trade journal asked to write an article about pharmacists coping with patient death. The project opened my eyes and helped me realize that I was not alone. The process of interviewing my colleagues altered my perspective. Over time, I came to understand that grieving a fallen patient is common as well as normal. In the end, writing that piece became both cathartic and empowering. For the first time since Ida had died, I was able to confront awkward feelings I had pushed deep down inside. When I did that, I began to heal.

In the years since Ida’s passing, I have come to learn that it is totally okay to embrace my own humanity when caring for other humans. I know I made the costly mistake of allowing myself to get too close, but I also refuse to let the pain of losing one of my first patients to undermine my natural empathetic tendencies. Allowing my feelings to resurface gives me the power to address my emotions and heal. Today, I share my story in hopes that my colleagues — and other health care professionals — who have mourned the losses of patients will not feel alone or afraid to acknowledge their humanity.

At the end of the day, my story is not about a pharmacist grieving over a patient but rather the story of a human mourning another human who had reached the end of her days.

If you had been Ida’s pharmacist, what would you have done? I also encourage doctors, nurses, and other health care professionals to respond.

In addition to being a licensed pharmacist, Frieda Wiley, PharmD is a contract medical writer and consultant who has written for WebMD, CostCo Connection, and the National Institutes of Health. Before launching a full-time writing and consulting career, she practiced in managed care and community pharmacy. She consulted for Pfizer earlier this year. Frieda Wiley is a 2019-2020 Doximity Fellow.

Frieda Wiley, PharmD was a 2019-2020 Doximity Fellow. This article originally appeared on Doximity.com and was written as part of Dr. Wiley’s Op-Med Fellowship commitment.

All names and identifying information have been modified to protect patient privacy.

With no viable cure or concrete treatment for the coronavirus in sight, the promise of a vaccine — or two, or three — undoubtedly offers the most plausible solution. And the pharmaceutical industry has taken note. As of August 19, 2020, there were more than 150 vaccines for the coronavirus in the pipeline. Perhaps medical professionals are a bit more familiar with the intricate process of vaccine development and how that can delay a vaccine’s market debut. However, one critical-but-lesser-known challenge hindering vaccine development is supply chain management. So important is this area, in fact, that any mishap can hinder a pharmaceutical company from bringing a vaccine to market or reduce the availability of a vaccine for public use.

As Nitin Goel, MBA, senior manager of early portfolio commercial strategy (global vaccines) at GSK in Washington, DC explained in an interview about the perils of vaccine development for a different publication, the predictability and reliability of vaccine products are the greatest pain points in vaccine development.

For example, vaccine batch manufacturers are often plagued by challenges regarding the predictability and stability of vaccine batches. Not only do vaccines often take a long time to manufacture, but batches often have short shelf lives, high batch failure rates, and can expire quickly. These challenges make vaccine manufacture a sizable investment for a corporation when, after dedicating a significant amount of time to develop, they decide to bring a product to market.

To help manufacturers stay on track, supply chain management has six “rights” of vaccine development. These six principles for best practices in this field might equate to the five rights of medication administration in Western medication. These rights of vaccine development are:

The right product: This statement goes without saying. Manufacturers of vaccines must work to ensure that they cultivate a product that is carefully and accurately tailored towards the target pathogen. It’s like trying to find the right skin care product for sensitive skin. Sometimes, you have to hunt to make sure you’re getting the lotion that is just right for you.

The right condition: There are several basic steps involved in vaccine development — each of which is intricate and very involved. Moreover, this also includes the preparation, storage, and transport of the product throughout all stages, as well as once it makes its way to a hospital or clinic. That said, each step presents an opportunity for error or something to go wrong. Equate this to all the effort and countless photos a photographer may take to get “the money shot.” The lighting, angle, and weather all have to be absolutely perfect for the magic to happen.

The right quantity: One way manufacturers ensure they can meet public demand for vaccines is by anticipating need. Imagine trying to squeeze a size 8 foot into a size 5 shoe. The entire foot just can’t fit because there’s not enough material. Vaccine manufacturers have to prepare for a size 8 demand. When it comes to vaccines, tracking infectious disease trends can prove helpful in some cases. For example, the influenza virus famously thrives during fall, winter, and summer months.

Vaccine manufacturers can thank agencies such as the WHO and the CDC for their constant surveillance of infectious diseases in helping with market projection.

However, perpetual screening for disease outbreaks due to viruses, bacteria, and other pathogens can only do so much. The other arm is that manufacturers must have the available resources to respond to demands, as well as the ability to produce ample amounts of the needed products for the populations and demographics affected by the condition, or whose health might be threatened.

While trying to forecast disease trends makes plenty of business sense, manufacturing vaccines in advance or in anticipation of a health care condition crisis can be a costly venture for manufacturers — especially with no crystal ball to answer questions such as whether the vaccine batches will thrive or how much product will move if successfully produced.

Manufacturers use this well-established epidemiological trend to start developing vaccines in anticipation of the strains expected to be most active during the impending flu season. However, even if manufacturers are able to get ahead of the curve, there are certain challenges they will face, regardless of how well they plan.

A prudent manufacturer might also account for product loss after its vaccine reaches the health care system. According to the WHO, at least 50% of vaccines are wasted either before or after opening the vial. Among the culprits are loss, theft, accidental freezing, leakage, and expired product.

The right place and the right time: The vaccines require transport to the right locations in a timely manner. Sounds a lot like finding that dream job: sometimes, it boils down to being in the right place at the right time to make things come together.

The right cost: Designer clothes are a great luxury, but most people cannot afford to shop at Neiman Marcus for a special occasion, let alone on a regular basis. The same thing applies to vaccines (and health care) in general. Regardless of how good a product may be, it cannot be useful if the majority of the population cannot afford it. Despite the efforts of such government initiatives as the Affordable Care Act to expand coverage to millions of uninsured Americans and help make medications more affordable and therefore accessible, recent years have seen an unprecedented increase in high-dollar drugs.

Zolgensma, the drug for the fatal genetic condition, spinal muscular atrophy, famously leads the pack with its $2.3 million price tag. However, numerous drugs, such as newer therapies for hepatitis C and sickle cell anemia, harbor in the $100,000 range in annual costs. These days, insurance companies have begun implementing new strategies, such as stop-loss policies, to help contain costs. On that same note, even if a vaccine is proven to be effective in preventing a disease, it is useless if the average patient cannot afford it — regardless of his or her insurance status and coverage.

Given the global need for a vaccine, it’s highly unlikely a single manufacturer will be able to address the public’s needs. Perhaps the introduction of several coronavirus vaccines will not only help prevent more people from getting sick but also reduce the vaccine costs through competition. Meanwhile, with numerous vaccines in the pipeline, health care workers and the public alike must remain hopeful and vigilant.

Frieda Wiley, PharmD was a 2019-2020 Doximity Fellow. This article originally appeared on Doximity.com and was written as part of Dr. Wiley’s Op-Med Fellowship commitment. 

Over the last several months, I have seen a drastic change in humanity — some for the better, some for the worst. A few weeks into first a self-imposed, and later, a mandatory lockdown, I often feel like the woman in the poem, “The Lady of Shalot,” by Lord Alfred Tennyson; only, I am not a masterful weaver sitting atop a hill while drawing inspiration for my tapestry by watching the city life below. Instead, I am watching life — or the stagnation of life — from the confines of my window.

Most of the bustle even remotely reminiscent of once-normal human activity has come to a sharp halt like still images permanently frozen in time. Aside from the occasional dog walker or random vehicle, the visual mirrors a scene from “Village of the Damned”: a defunct, immobile community. Lately, the only real sign that any life form exists has been witnessing spring foliage coming into full bloom.

At the beginning of March, a neighborhood stroll meant encountering strangers and striking up lighthearted conversations in passing. Then things changed overnight. The stark contrast literally feels like the juxtaposition of night and day. Perhaps better said, the monstrosity of fear reared its ugly head. The hideous creature’s tentacles extend in a near-ubiquitous reach — much like those days when San Francisco’s advection fog eerily drifts in from the ocean. At its worst, the nebulous haze grows so thick that it buries the red towers of the Golden Gate Bridge in their entirety. The fog of fear is so heavy these days that at times, it seems blinding.

As a highly sensitive person, I find fear an all-too-familiar fiend. Though age and wisdom have helped me respond more skillfully to fear’s harmful effects, I now struggle daily, having to constantly remind myself to stay sane, positive, and hopeful. Until recently, I thought I had gotten better at managing the aftershocks of trepidation. Then, after interviewing a pharmacist colleague in a journalistic capacity for a story I was writing about COVID-19, I hit rock bottom.

“If I get COVID-19, I’m prepared to enroll in clinical trials in my area,” she told me in a matter-of-fact tone.

With that one, cryptic statement, my heart cracked open with fear and empathy. Those words flowed from her lips a little too easily, her inflection a bit too casual. It was as if she had already given up — accepting a dark fate that she somehow knew was sure to come.

It took me a moment to collect myself. We are roughly the same age. She is a wife, a mother, a daughter. Despite having a full, meaningful life waiting outside of her career, this intelligent, amazing woman seemed to accept a self-determined death sentence.

I felt tremendous sorrow; at the same time, I found her tenacity and forethought admirable. Somehow, she had the strength to continue fighting this biological warfare from the precarious arena of the front lines. When many would ponder calling in sick or walking away, this woman — like so many pharmacists and other essential workers — is an altruist in the purest sense. Yet, this amazing woman remains dedicated to continuing to serve a patient population that needs and depends on her. Even more incredible is that, after working 10-hour shifts where demands and stressors run at constant all-time highs, she carved out time to talk to me on a weekend night after tending to her young children.

Her story is thought-provoking and touching; but her testimony is one of thousands of essential workers — most of whose names will never make headlines and whose faces will never grace our television sets. The pharmacist made the decision to remain anonymous. For many, anonymity is not an option but rather guaranteed whether it be in the media or on a local level, because most people who perform essential work not tied to health care are never interviewed or acknowledged.

An encounter with a grocery store worker illustrated this issue very well. After nearly a week of staying inside, I made what I had hoped to be a quick dash to the grocery store. In my haste, I inadvertently held up the self-checkout line by setting off the alarm enough times that I should have been permanently suspended from the line. When the cashier came over to assist me for what surely must have been her fifth trip, I did two things: First, I thanked her for her service. Second, I told her that the benefit of assisting incompetent shoppers such as myself guaranteed her job security when layoffs were at an all-time high.

She laughed and said, “Of all these years I’ve been working here, this is the first time someone actually told me I was ‘essential.’”

As we talked, a gently used N95 mask dangled around her neck; her hands were bare.

Only a few days earlier, I had watched a postal worker make Sunday deliveries from the safety and comfort of my window. At that moment, I had an epiphany. Not only did this man sacrifice valuable family time on a weekend, but he did so during a pandemic. He was essentially putting his life at risk to deliver packages and other mail so that people like me had both the choice and luxury of staying at home.

Watching him that day inspired me to make a list of all the people who work hard to keep the rest of us safe. It is not just the doctors, pharmacists, nurses, physician assistants, and other health care workers. It is the office staff, janitors, mail carriers, insurance workers, bankers, call center employees, truck drivers, convenience store and gas station workers, cashiers, stockers, hotel staff assisting with quarantines, etc. The list goes on and on.

Pharmacy aside, as a journalist, I am compelled to tell stories that deserve but may not otherwise be heard. It is not always easy or glamourous, and not every story I pitch gets written. Sometimes, I am limited in terms of how much of the story I can tell. In other cases, getting someone to go on record is the hardest part. Some may choose to speak out, but only under the shield of anonymity — like my pharmacist colleague. For that reason, I will respectfully carry her identity to the grave. But it doesn’t make the state of affairs any easier — or her story any less valid.

In the same way that trepidation and physical or social distancing have caused many of us to withdraw from each other, the fear of consequences for speaking up silences many of us. Speaking out can be hard, but sometimes, verbal acknowledgment is the first step to finding a solution to tough problems and healing.

After nearly a decade of telecommuting, I, too, struggle with the psychological effects of being on lockdown. Isolation can be scary and depressing indeed. But on those days when I feel the dark tentacles of fear or depression creeping in like the San Franciscan fog, I remind myself that I still have much for which to be grateful. And it starts with looking outside the window, observing life from afar that has forever changed.

Frieda Wiley, PharmD was a 2019-2020 Doximity Fellow. This article originally appeared on Doximity.com and was written as part of Dr. Wiley’s Op-Med Fellowship commitment.