Rural Wisconsin Health Cooperative

A Day in the Life of Rural Pharmacist Mitch

by Carol J. Hermansen

The following essay is a fictional short story about an independent pharmacy owner in rural America. The illustration is intended to draw the reader into the life of this pharmacist-protagonist and the legacy of his pharmacist father--provoking thoughts about the potential one dedicated pharmacist may have on a community. I attempt to illustrate the depth and breadth of relationships that may develop in rural communities, the innovations in service, and the opportunities that rural community pharmacists have to work in conjunction with physicians, other health care providers, and patients themselves to provide needed care to community members.

The number of independently owned community pharmacies in the United States declined 35% between the years of 1990 and 1998 (NACDS, 1999). A recent analysis of the availability of community pharmacies reveals a trend of fewer community pharmacies in rural areas (Doucette, Brooks, Sorofman & Wong, 1999). This suggests potential problems with access to pharmacy services among those people living in rural areas, and in particular, those who earn less than the poverty level. With these trends in mind, it is my hope that the reader may gain a greater understanding of the plight of, and the important contribution of, the rural community pharmacy owner. Thus, additional intent of the essay is to heighten the awareness of the impact of pharmacy practice on rural communities, on the lives of the individual people and on the life of the community at-large. The references included at the end were used to inform the substance of the essay. Original ideas about developing a statewide initiative to identify and nurture innovative pharmacy students, and a seminar-generated idea of developing a rural community-owned pharmacy cooperative also are incorporated into the text for additional rumination.

Mitch Anderson walks to his pharmacy this morning, as he usually does, weather permitting, to get some exercise. Today he walks in after having breakfast with a local internist-turned-geriatrician at the corner diner down the street. Mitch is opening the store a bit early today knowing that Mrs. Atkins, owner of the nearby hair salon, needs to stop by early for her new blood pressure medication before her first appointment. Her physician is trying to get her started on something that she's willing to take. She has been apprehensive about taking anything after the diuretic that she absolutely hated. As he unlocks the door and turns off the alarm system, Mitch recalls the intense conversations he and Dr. Holman have had with her, trying together, to convince her of her need to bring her blood pressure down. Changing her diet didn't help, and her risk of stroke is high with her family history. She'd be devastated if she were to have a stroke.

The sun is just beginning to shine through the blinds of the front windows as Mitch carefully pulls them open, as not to disturb the careful placement of the 4-H Club's "Healthy Pet" display set up the evening before. He muses as he notices the picture of Pluto, Marissa's big retriever-lab mix. What a journey that family has been on these last few months with Pluto's epileptic seizures, the new veterinarian in the town nearby, and Marissa's onset of asthma.

Following the normal routine, Mitch gets the cash register drawer out and ready, adding enough extra quarters and single dollar bills to last the day. He listens to his answering machine, finding a new prescription called in for his neighbor's little girl. Wanting to know a bit more about the choice of antibiotic and dosing, he places a call to the regional medical center to confirm its appropriateness, using the speaker phone as he cleans up the counter for the new day.

Mitch is 45 years old. A graduate of the state university, he first practiced pharmacy in the still-surviving rural hospital 30 miles away. In 1993, he decreased his work at the hospital to part-time and started working longer hours with his dad at the pharmacy. After gradually picking up more and more hours, he eventually bought in as a partner in 1995, the year his dad's brother, who started the pharmacy, died. That year, Mitch finished his M.B.A., commuting to school two days a week for three years. He began fully running and managing the pharmacy three years ago. Just last year, his father retired at the age of 68, after a mild stroke, leaving quite a legacy for his son to continue.

Mitch's experience as a hospital pharmacist and a holder of an M.B.A. is a unique combination. Many of his colleagues see him as an enigma–clearly wanting to practice sound pharmacy, but pursuing a business degree. The older pharmacy owners in the region nearing retirement appreciate his insight which is always given with humility and admiration for their wisdom and years of experience. Those pharmacists freshly out of school can't understand why Mitch would focus so much on the business aspect and not pursue further education to be able to practice what the profession calls "Pharmaceutical Care" (See Note #1 at end of article.) . Mitch carries his gentle, but solid responses with him to his monthly tri-county pharmacy association meetings and continuing education programs--statements about being "well-rounded" and "ready for anything" and suggestions that they look into the opportunities in rural pharmacy to practice the way they want to. He values the ideas behind Pharmaceutical Care. In fact, he is grateful for the time he spent working in the hospital where he was able to work closely with physicians to impact on the medication-related care patients received. He still keeps in contact with some of the doctors–including Dr. Marian Jannus, the geriatrician with whom he had breakfast this morning.

Mitch knows he has a greater understanding about how to run a business with his second degree. He's glad he put the time in to pursue it. He hopes to strike a reasonable balance between providing the kind of care his customers need and managing the pharmacy in a way that will keep it and maybe even the community alive. Mitch is constantly reminded of the countless independently-owned pharmacies that folded during the last two decades due to the squeeze of reduced reimbursements for dispensed prescriptions. Every morning when he opens up the store he is grateful for another day. He accepts his modest income. To his colleagues working in the larger cities around the state, he looks foolish to be trying to keep the pharmacy going. As Mitch looks around the pharmacy today, he is reminded of his dad, who though retired, is still wanting to be active in the profession "from behind the scenes". His dad managed to respond to the changing marketplace during the last 40 plus years, keeping the pharmacy open and its services available to the community. Mitch can't give up now.

Since Mitch's uncle, his dad's oldest brother, opened the store in 1950, the pharmacy has undergone a lot of changes. The building structure was expanded in the 1970s, when the small retail space next door became available. The goods and services sold in the pharmacy have gone through a metamorphosis due to the imaginative minds' eye and energetic work of Mitch's father who took over the store in 1958, only three years after he graduated from pharmacy school. "Optimism and hard work will get you going, but only good friends and the Good Lord will get you through" he has always said. With the help of his wife and children, some local physicians, and even members of the County Board, he has managed to rethink and re-engineer the pharmacy to keep it afloat during some of the hardest times to ever hit the community.

After Mitch's dad took over the pharmacy, he adapted to the needs of the community in a way that only he could do. In the front of the store, he broke the mold by starting to carry some "unique goods" and providing new services that the community needed. A bike trail opened in 1985, replacing the old, unused set of railroad tracks that parallels Main Street a few blocks over. Bicycling tourists are somewhat common during the summer. As a creative response, the pharmacy began carrying bicycling equipment--spare tubes and bike pumps especially. And the longtime clerk at the pharmacy, Rita, has a son who likes the extra cash he gets from servicing bicycles out of the back of the pharmacy. When interviewed by the local newspaper reporter, about "the bike stuff", Mitch's dad smiled genuinely and replied, "We're promoting a health lifestyle." It's true. More of the townspeople now ride their bikes, instead of driving their cars.

The pharmacy attracts customers from up to 25 miles away because of the veterinary pharmacy accounts Mitch's father developed through his relationship with the veterinarian and the farmers in the region. He has relied mostly on word of mouth for his animal accounts. Mitch has recently seen a decline in the accounts due to some area farms being sold. He's considering running Sunday ads to try to expand the pharmacy's clientele to include the pets of the people in the outlying communities. His recent volunteer work with the 4-H club is one attempt to not only support the community, but to keep his veterinary pharmacy practice alive.

As Mitch thinks about the order he placed last night through the state's independent pharmacy buying cooperative, he remembers how instrumental his dad was in getting the buying cooperative established. Mitch shakes his head in amazement as he considers all that his dad has done for pharmacy in that community and the rest of the state. "Dad has never stopped thinking outside of the box. He always had new ideas to share with us at the dinner table. It's remarkable he had the energy to carry out the ideas...but he's always had a way of sort of selling those ideas to others and enlisting their help as partners. He certainly is one for the record books." Mitch muses to himself, "He managed to maintain excellent ties with Representative Meyer and Senator Foxworthy over of the years. They really were wrapped around his little finger--but they appreciated him so much because he was so willing to go out of his way to serve them and their families."

Mitch's father also has been a notable change agent for the community at-large. About 10 years ago, he pushed the redevelopment initiative to rejuvenate the downtown area, offering up some of his own "sweat equity". He paid his oldest niece's boy and one of his buddies, to work two afternoons a week as "free" labor to assist the carpenters the town hired to renovate some of the buildings. As a result of those efforts and others', a few businesses moved into the downtown and all but one seem to be surviving still.

Amid lots of change, the pharmacy has survived due to Mitch's father's ingenuity and his commitment to and from the community. Mitch has wondered on several occasions whether he'll be able to keep it going well into his 60's with all of the difficulties he and other independent owners have been having with shrinking profit margins and the steep, but healthy competition from corporate America expanding outlets in nearby cities. There are days the pharmacy's loyal bookkeeper wonders too, but Mitch has been able to stay somewhat optimistic as he holds onto the established services that seem to still fill some needs of the community of which he is a valuable part.

How grateful he feels to those customers the pharmacy has retained despite the opening three years ago of a corporate-owned discount pharmacy less than 20 miles away. Those who have stayed appreciate the extra services he's been able to develop and maintain, serving the older clientele with home visits and special packaging to assist them in maintaining self-reliance at home. The problem is the financial concerns. He can't keep charging the older, cash-paying customers more, but if he doesn't, he'll be saying goodbye to what little profit he has left. He accepts the contracts of the insurers in order to serve those in the community who do have insurance that covers prescription drugs. But he can't charge them any additional money beyond what the contract says, even though the insured are probably more able to afford it than the older customers without insurance. What a dilemma.

When it comes to paying the bills, the veterinary compounding that his father started helps. Mitch's wife Ann, a pharmacist herself, has graciously stepped up to the task to keep that going as Mitch busy's himself with the day-to-day operations of the pharmacy. She enjoys the hands-on aspect of creating the prescriptions by hand with a mortar and pestle, using more of the raw ingredients. Peter, a recent graduate, began working last year for a relatively low salary, but has proven to be a hard worker and one who really wants to become a part of the community. He and his fiancee want to buy the large Victorian house that's for sale on 6th and Oak and fix it up. His parents who live across the county have always wanted to run a bed and breakfast and they seem pretty serious about it with their retirement coming up next year.

A significant portion of Mitch's clientele seem to require more attention in order to manage all of their medications. Peter is hoping to spend about a fourth of his time working with the older adults in the community who need the extra help. Mitch has begun to identify some of them and is hoping to work with their physicians to develop a medication management program for them. His meeting with Dr. Jannus this morning may have clinched it. Pete, with the help of Mitch at first, will begin meeting with her, and a few of her patients, during office visits to discuss problems and possible solutions revolving around multiple medication use. Some of the details were discussed this morning, but Mitch foresees the three of them needing to meet when she has time next week.

Mitch's colleagues in the next county over are skeptical about this interdisciplinary approach–because of the amount of time it's going to take–and asked him last month out of real concern, "How are you going to pay for this, Mitch?" Mitch talked to Dr. Jannus about this to some degree. She appears receptive and sympathetic. Her brother is a pharmacist, and her own parents who live in Florida could use the special attention she believes qualified pharmacists can provide. Mitch spoke quite frankly about the tight financial situation the pharmacy has been in with the new, but necessary, hire. He imagines handling financial arrangements on a case-by-case basis, and Ann, his wife, is willing to "take a stab at it"–but she is a bit leery about the time commitment on her part. Mitch is hoping the adult children of his patients may be willing to offset some of the expenses. "It actually could work out that Pete would be hired as a part-time consultant for Dr. Jannus, managing some of her and our patients who are struggling with multiple medications and difficult disease states. If that happens, a portion of his salary would be paid by her office. What a long shot, but I can't just sit and watch these people struggle with this stuff," Mitch explained to Ann last night at dinner.

A recent movement in the state has been to offer immunizations. Some colleagues of Mitch's have received training to give immunizations, offering flu shots in autumn to customers as a public health service. Mitch's father asked Mitch about this opportunity last year, but they decided it's not a feasible service or a good investment of the pharmacy's resources. If they decide it's a public health issue for the community where they can have an impact, Mitch imagines they will try to arrange for a local nurse to come in and provide immunizations some week in October.

It seems like there is always more work to be done--administrative as well as patient-related. Without hiring yet another pharmacist, Mitch is destined to work the long hours to which he's become accustomed. It's been difficult to attract pharmacists to this rural community. Many experienced pharmacists have grown accustomed to bigger paychecks and have become victims of, what Mitch once heard coined "the Golden Cadillac Phenomenon"–enslavement to the huge house mortgages and steep car payments of the affluent lifestyle furthered by today's healthy pharmacist salaries. Others are unwilling to leave the bigger cities for fear of boredom and "lack of culture" and even fear of not finding a spouse. Recent graduates receive little counseling about and have limited exposure to the opportunities that do exist. Peter was a God-send.

As Mitch readies the bank deposit from Saturday, he adds in his first check from the state university, a small amount of financial support from the university for his new role as preceptor for a rural clerkship program. He's one of the first sites in the state and is pretty proud of it. His new clerkship student as of last week should be walking in any moment.

Just then the phone rings. It's Dave and Eileen, another pharmacy couple from a neighboring county. They're also involved in the new rural clerkship program. The two of them have been talking with Mitch and Ann about ideas they have to keep rural pharmacy alive in the state. One is a new initiative to increase pharmacy students' awareness of rural pharmacy practice opportunities. Together with Dave, Eileen, Ann, and now Peter, Mitch has been readying a draft of the proposal to share with some key people at the state level, including the state pharmacy association president, the dean of the school of pharmacy and some buying cooperative members. The draft outlines their idea to have a funded program within the state, administered jointly by the state and the cooperative, to identify pharmacy students with innovative tendencies–those with an entrepreneurial spirit. For rural pharmacy to stay alive and provide the needed access to care, it's obvious to Mitch that a great deal of innovation is needed as well as a willingness to take a chance.

Mitch and his colleagues hope to not only attract attention to rural pharmacy as a legitimate practice setting, but to find and nurture those pharmacists-to-be who are the future leaders of the profession. The program would foster collaboration among rural community pharmacists and would provide greater opportunity for pharmacists in different locales to work together and build off of each other's strengths.

The intent is to introduce the proposal as a public health issue, for it really is. Mitch and his colleagues have seen patient access problems in the northern most part of the state and they believe it could only be a matter of time before they begin losing some of their primary care providers as well. Mitch knows of communities that could really use a pharmacist again–rural areas that have lost their pharmacy, people who have to drive 45 minutes to get a prescription filled. He imagines the initiative providing students and then new practitioners with additional training and connections and clerkship opportunities, nontraditional and interdisciplinary, that consider rural communities and their unique access problems and other challenges. Mitch recently spoke with two pharmacy professors from the state university who appear interested in his idea. They have expressed a willingness to work with him in developing the idea and in supporting him with his upcoming presentation. Another project, more late hours, but the pay off could be well worth it.

To those who know and love Mitch, he seems consumed with this innovative pharmacy student initiative idea. But few know he and his father have been talking even more seriously about the possibility of transforming their pharmacy into a community-owned pharmacy cooperative. "If this community values what we have here, I truly believe they will step up and buy into this great old place, investing their time and money, Mitch," his father stated simply last week while having coffee. "People like what we do. They're a part of our lives and we're a part of theirs. They come to us and know us. They want to continue the tradition almost as much as we do. You know that, Mitch. This week, now that I'm feeling better, I'll talk to Bill and some of the docs in the area. Maybe we can call a town meeting or something. We could talk to the press, you know."

Mitch, somewhat tired on this Monday morning, is energized as he remembers those words of his father, and by the honest and clear intent behind them. His dad is not only persistent, but his intuitiveness about the people in this town and what they are capable of doing has been proven time after time. "Dad is going to talk to Bill about it..." Mitch considers that and realizes its importance. Bill is the mayor. He is a loyal customer of the pharmacy, and a good, trusted friend of Mitch's dad. Bill's arthritis has been worsening--he's having pretty bad flare-ups lately. Mitch spent time with him last week, talking about his pain medication use and the difficulties he's had sleeping at night.

"Keeping the pharmacy around is pretty salient for Bill right now, that's for sure," Mitch thinks to himself as he jots down another idea regarding the cooperative as the quiet store front pharmacy comes to life. It's just after 8 a.m. Mrs. Atkins rushes in, late for her first hair appointment of the day, reaching out her hand to greet Mitch as he walks out from behind the counter, first grabbing her new prescription. "Mitch, I'm forever indebted to you, you know that don't you?" she asks with her characteristically dramatic flare. Realizing the mutual business they give to one another, her to his pharmacy and he and his family to her hair salon, he responds, "Yes, you know, I've got those debts piling up, er, receding right up here, Mrs. Atkins." Mitch jokes comfortably as he looks up, drawing attention to his receding hairline.

Looking back at Mrs. Atkins, he becomes more professional, showing concern. He's glad to see her apparent willingness to try the newer medication. "You know, Dr. Holman and I are optimistic that this new one will be better for you." "Yes, we talked about it, and I think I'm finally ready to give in," she says with a sigh. "Seeing your father has made me realize the reality of it all, I think, Mitch. I hear he's making progress and regaining strength. That physical therapist is terrific. She's done wonders for me since that spill I had last fall. No more bicycling for me...anyway, I know how your father likes to be out and about–always doing something. I'm glad things are looking brighter." "Yeah, me too–it's been hard for him and Mom, but ah, selfishly, it's been kind of tough on us here too." He looks around at the familiar pharmacy. Seeing the door, Mitch realizes the time. "You know, I don't want to keep you, but I do want to be sure you're set with this."

He looks down at the little orange bottle and opens it easily to reveal its contents. Mitch engages Mrs. Atkins in a short discussion about how the medication works, how she should take it, what to expect from it, and how to handle any possible problems she may encounter. She asks him for more information about the possible side effects, and satisfied, thanks him again for all of his help. As she turns to leave, Mitch remembers one more thing, "Don't forget to check in tomorrow afternoon. We should have that blood pressure cuff you ordered by then." She acknowledges his reminder and leaves in the direction of her salon.

Mitch steps back into the prescription area and logs onto the pharmacy computer, starting the daily computer diagnostics. While waiting, he opens up an Email from the weekend. He decides to first read a note from Jack, an old friend whom he met over 30 years ago in 4-H, and with whom he later became reacquainted in pharmacy school. If anyone ever asked Jack why he went into pharmacy, he would undoubtedly respond in a carousing way by reaching his arm behind his back as if having his arm twisted, saying, "Mitch and his dad coaxed me into it..." Seeing Jack's familiar, but playful, complaints about the daily grind of work, Mitch begins to think back to those days as a young boy, when he learned what it meant to be responsible, and hard working. He worked in the pharmacy. He lived and breathed the pharmacy. How could he not have chosen it as a profession?

Mitch grew up always believing his father worked the longest hours of any other father he knew. He always respected his dad for his integrity and honesty, and his hard work and attention to detail, though there were times during adolescence when Mitch resented the work and Dad's high expectations. On occasion, Mitch would try to squirm out of his own work responsibilities at the pharmacy–but it was always something he came back to. He doesn't regret those responsibilities--working side by side with his father. He not only learned the ropes of owning a business and what pharmacy was like, he learned how to treat people well and the value of building and nurturing good relationships.

Mitch really did grow up in the pharmacy. When he was old enough, he swept the floor, washed windows and stocked shelves. He also ran errands and made deliveries. He recalls Mrs. Atkins from back then as a young woman opening her own beauty salon and her Aunt Rose who helped to finance the loan. Rose was a widow at age 70, and lived way out on County Road M. Mitch delivered her prescriptions every month, riding out on his bicycle to her farmhouse, while his father called her on the telephone to talk. Mitch's dad became a real advocate for Rose as her health declined, sometimes acting as a go-between with her physicians. Mitch knows how much she depended on his dad, and how grateful she was. She always sent him riding back to the pharmacy with tokens of her appreciation, usually freshly baked breads.

Whether in town or outside of town, the roads Mitch used to ride on as a little boy are still there. A lot has changed along those roads, however many of the people are still the same. They are getting older, though. There have been some younger families moving in for various reasons. Some are drawn back to the town either because of their roots or because of the "quieter way of living" so they say. Some nearby farms have had trouble making payments. Some of the land still lies untilled despite the time of year.

The economic base of the community has changed substantially. Mitch and his wife Ann have been trying for years to talk some of their classmates into moving there from the major metropolitan area where they currently reside. One couple in particular has been feeling disillusioned with the anonymity of suburban life. Mitch and Ann have been coaxing them to move their web-based business out to "the boonies" where they can get more rest and have a slower-paced and more community-filled life. As Ann noted, just last month, one of their friends' newsy Email messages seemed to show some promise. Although Mitch and Ann would love to see their friends more, they know the move of the small company would mean several much needed jobs for the community.

As Mitch finishes reading his Email, Carrie Groen, Mitch's new clerkship student as of last week, saunters in cheerfully, lunch in one hand, coffee in the other. "Good morning Mitch. I'm not late, am I? I just drove in from my parents'–went home for the weekend to see my brother who flew in from Boston. I keep telling him he has to move back closer to home, but I guess he likes it out there."

"--Oh no, I opened early today. You're right on time. Glad you got to see him. It must be hard to see him only on special occasions–your mom's birthday, right?" Carrie nods. Mitch pauses, yet continues, "I think we're going to have an interesting week, Carrie. The 4-H club set up their display yesterday, as you can see, it'll be quite the talk of the town!" Smiling, Mitch points toward the creative display of educational material and photos filling most of the big picture window on the right side of the storefront. "And I got a letter yesterday from the veterinarian who took over Dr. Hull's practice. He's interested in meeting us and seeing our 'operation' as he calls it. My wife has met him already, but he wants to stop in–this week. I'm glad you're interested in learning more about veterinary pharmacy. Ann is still learning, herself, but the two of you together will make a great impression on him, I'm sure."

Rita, Mitch's full-time clerk, enters the pharmacy from the back door, greets them both with a smile and her nearly patented promise of a "golden day" and settles down behind the cash register in the front of the store. As the pharmacy opens for business, the phone makes its presence known, as usual. Sometimes it's new business, sometimes just distractions that pull Mitch away from the in-store conversation with patients, but Carrie's willingness and ability to field some of the calls helps immensely. This time it rings and it's Mrs. Atkins. "Something about the blood pressure medication tasting funny?" Carrie proclaims with a curious look on her young face. Mitch looks up from the computer as he submits an on-line insurance claim for a prescription just filled.

Mitch thinks about Mrs. Atkins' question, worried about her possibly refusing to take this medication now. He has never heard of change in taste with this medication, and she just took it probably an hour ago! He asks Carrie to investigate that for Mrs. Atkins and to call her later. As his gaze returns to the computer, the flashing cursor sparks Mitch's memory–and he thinks back to the antiquated computer they used at the hospital. He remembers a now-retired hospital pharmacist who mentored him and taught him a lot about patience and delegating, and about trusting new pharmacists (and students) with work they are capable of doing. Mitch realizes he really needs to call this mentor of his about the innovative pharmacy student initiative, and scribbles down a note to himself on a nearby pad of paper.

As Mitch turns his attention back to the computer, a familiar customer walks in asking about a special prescription for her dog that Ann had worked on Saturday afternoon. On the doctor's line, a cardiac nurse calls in several new prescriptions for a friend of Mitch's dad who is being discharged from the regional medical center after his heart attack. Turning his attention back to the woman standing before him, Mitch realizes he needs to also dispense an inhaler for her daughter, Marissa. Now off of the phone, after having verified her response to Mrs. Atkins' question with Mitch, Carrie jumps to the task of providing the necessary information about the two new prescriptions.

"Nice window display, Mitch," Marissa's mom smiles with appreciation, "Marissa is admiring it from the car. She's pretty tired today–and not excited about this inhaler business." Carrie, an experienced asthmatic herself, jumps at the opportunity to talk to Marissa and explain how to use the inhaler and share her own experience with asthma. Aware of Carrie's ability, Mitch feels comfortable with her handling this. He gives her the now familiar "go ahead" look, and she, together with the mom, heads out to talk face-to-face with Marissa. Watching them both leave, Mitch notices a writer for the town's weekly newspaper, stepping out of his car, and Mitch remembers the call he got last week pertaining to a write-up about the 4-H display. He sighs. Now is not the best time.

It's about 10:30 a.m. Mitch takes a deep breath and tries not to feel the doubt that creeps out from under his optimism when things get busy and he realizes how tired he is getting. As the reporter approaches the entrance to the pharmacy, he sees Mitch's dad and holds the door for him who, walking more easily than before, cane in hand, winks at Mitch with a big smile on his face. With the door still held open, Bill, the mayor and a prominent physician in town walk in closely behind.

Notes

#1. Pharmaceutical Care is an evolving pharmacy practice philosophy. It highlights the pharmacist’s role in providing close monitoring of patients’ medication use and in assuming greater responsibility for medication-related outcomes (Strand, Cipolle & Morley, 1992). References

References

Billow, J.A., Van Riper, G.C., Baer, L.L., & Stover, R.G. (1991). The crisis in rural pharmacy practice. American Pharmacy. NS31(12):51-53.

Cordes, S., Doeksen, G.A., & Shaffer, R. (1994). Rural economic development and health services. In Rural Health Services: A Management Perspective, (J.E. Beaulieu, D.E. Berry, Eds.) Ann Arbor, MI: AUPHA Press/Health Administration Press, pp. 27-56.

Doucette, W.R., Brooks, J.M., Sorofman, B.A., & Wong, H. (1999). Market factors and the availability of community pharmacies. Clinical Therapeutics. 21(7):1267-1279.

Gangeness, D.E. (1997). Pharmaceutical care for rural patients: Ominous trends. Journal of the American Pharmaceutical Association. NS37(1):62-65,84.

Kleppin, S. (1999). Targeting vaccine preventable disease: Pharmacists can increase flu & pneumonia vaccinations and lower death rates. Journal of the Pharmacy Society of Wisconsin. (March/April):4-6.

NACDS (National Association of Chain Drug Stores) (1999). Industry profile: The chain pharmacy, p. 10.

Ranelli, P.L., & Coward, R.T. (1996). Residential differences in the use of pharmacies by older adults and their communication experiences with pharmacists. The Journal of Rural Health. 12(1):19-32.

Slack, M.K., & McEwen, M.M. (1993). Pharmacy student participation in interdisciplinary community-based training. American Journal of Pharmaceutical Education. 57(Fall):251-257.

Strand, L., Cipolle, R.J., & Morley, P.C. (1992). Pharmaceutical care: An introduction. Kalamazoo, MI: The Upjohn Company.

Venkataraman, K., Madhavan, S., & Bone, P. (1997). Barriers and facilitators to pharmaceutical care in rural community practice. Journal of Social and Administrative Pharmacy. 14(4):208-219.

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