All In The Game
Behind The Counter | 03 | A Lesson From The Wire
Welcome to another edition of Behind The Counter. My ongoing series where I share short stories from my patient interactions, offering a glimpse into my world behind the pharmacy counter as I attempt to help my patients navigate the complex sick-care healthcare system — not by pushing pills, but by dispensing a dose of humor, hope, and insight.
“We do worse, and we get paid more.”
— Russell “Stringer” Bell. The Wire. S01E03.
I would say I have high TV standards. On my Mount Rushmore, I’d rank Breaking Bad, The Sopranos, Mad Men and The Wire as my favorite series of all time.
If I had to pick just one, it would be The Wire. Not just for its depth, character development and realism, but the practical, and very cynical, insights it provides into the institutions within our cities and municipalities: law enforcement, education, politics, media and unions. The one key institution missing? Healthcare.
There are flashes and moments here and there, scenes of characters in hospital settings, etc. There is one scene from the first season that provides a unique insight into the realities of the drug trade. Now, I’m not comparing illegal drug trafficking to community pharmacy, but, if you examine closely, there are some interesting parallels.
Let’s examine:
D'Angelo Barksdale : We'll be doing even better when we get that new package.
Russell 'Stringer' Bell : [laughs] New package same as old, man.
D'Angelo Barksdale : Say what?
Russell 'Stringer' Bell : Ain't no new package. Just gonna put that same shit out in a different colored gel-cap is all. Might spike that shit with some procaine or some caffeine, but otherwise it's the same.
D'Angelo Barksdale : String, man, people already coming back on us tellin' us that shit is weak.
Russell 'Stringer' Bell : I know; shit is weak, but, y'know, shit is weak all over. The thing is, no matter what we call heroin, it's gonna get sold. Shit is strong, we gonna sell it; shit is weak, we gonna sell twice as much. You know why? 'Cause a fiend, he gonna chase that shit no matter what. It's crazy, you know. We do worse, and we get paid more. The government do better, and it don't mean no nevermind.
[pointing to the money]
Russell 'Stringer' Bell : This shit right here, D, is forever.
— The Wire | The Buys | S01E03
We Do Worse, We Make More.
In my community practice, I’ve witnessed this sad reality during a banal conversation with a patient, who also happened to be a family doctor. For the sake of his post, we’ll refer to him as “Dr. X.” He was attending the pediatric clinic with his sick child. While I was preparing the Amoxicillin for his kid, he informed me he’s a doctor, and we began chit-chatting about the daily grind.
He seemed like a cool dude. Up until that point, we were having a good time, laughing while shooting the breeze and sharing stories about our struggles on the frontlines. Things changed when I asked him about his experience as a family doctor and the trends he’s seeing in mental health. His response was unexpected and nauseating:
“Mental health is my bread and butter. A patient comes to me and asks for dopamine. I let them have it. I tell them to play lotto 649. They ask for Zoloft, Lorazepam, Quetiapine, I let them have it.”
— Dr. X, who will remain nameless, but should probably be investigated by the CPSO for some form of professional misconduct.
Dr. X provided a textbook example of Stringer Bell’s theory in action. Now, perhaps some of his patients are really benefiting from the benzos and lotto tickets. But putting people on hedonic treadmills and never-ending prescriptions, without proper guidance or any intention to actually help them develop the tools and strategies to improve their health, is shady as fuck.
The bravado he delivered his sentiment is what still sticks with me. It’s like he was expecting me to give him a high-five for prescribing psychiatric drugs like skittles. After all, some pharmacists probably would have. The business of community pharmacy is ruthless; the competition is fierce and in order to survive in a market with soaring expenses and shrinking margins, many cut deals and make tradeoffs.
“Yeah, but the game ain't gotta be played like that, yo”
— D’Angelo Barskdale. The Wire. SE1E03
We’ve all been forced to make the tough decision between what is right and what is easy. It’s easy to reach for the prescription pad, or refill scripts and keep patients dependent on medicines that barely work better than placebo. Doing the right thing is hard; it pays less and requires more time and effort. Charlie Munger was right when he said show me the incentives and I’ll show you the outcome.
After all, healthcare is overflowing with surging demand, and healthcare providers can only do so much. It’s easier to follow algorithms and treatment guidelines, rather than hold patients hands and coach them along the difficult path towards physical or mental health rejuvenation. The prescription pad promises a viable and billable solution to many peoples problems, and medicines will always be an integral part of our toolkit against chronic disease and mental health.
Who can argue against this system? After all, doctors do “their job” and bill OHIP. Pharmacists “do their job” and rightfully earn their share. Patients? They come into the system with their hands out, and walk out with a quick fix. Win, win, win, baby!
I ended the conversation after Dr. X made his remarks on mental health, handing him the amoxicillin while secretly hoping I run into him in the back-alley of a pharmacy or clinic. I should have challenged him to a duel and debate on appropriate prescribing and the importance of deprescribing, but, it would have likely fallen on deaf ears.
I got the shotgun, you got the briefcase. It’s all in the game though, right?
— Omar Little.
Thanks for reading.
SG.
Build. Understand. Discipline. Stillness. “B.U.D.S” is written by me, Dr. Shawn Gill - I’m a pharmacist and Father of two boys. During the day, I work as a deprescribing pharmacist, helping patients get off drugs, safely and effectively. At night, I write this newsletter. B.U.D.S is a community that's focused on inspiring individuals to take account of their health and wellness, as well as reverse mental health and chronic disease. If you’d like to support this mission, please subscribe below. Much love. SG