Which Pharmacy Should You Use?

My patients are increasingly expressing unhappiness with their pharmacy. I’m not surprised. A recent study by JD Power  showed a 10-point drop in customer satisfaction with brick and mortar pharmacies in 2024 alone. This is attributed to problems with systemic pressures, health human resources challenges, burnout amongst pharmacists, increasing drug shortages, and competition from online pharmacies. (N.B. I know this was a US survey but I believe the results would be similar in Canada as many of the pressures are the same).

In the past, I would tell patients to choose whichever pharmacy they want. The College of Physicians and Surgeons (CPSO) has some pretty strict rules around who/what I can recommend to patients. They are particularly stringent if there is even a perception of a conflict of interest. This would be why I never insist patients use the pharmacy in the medical centre I work at. Most doctors are very reluctant to run afoul of their licensing body (and I’m no exception).

However, the actual CPSO rules around prescribing drugs states:

“Respecting Patient Choice When Choosing a Pharmacy

13) Physicians must respect the patient’s choice of pharmacy.

14) Physicians must not attempt to influence the patient’s choice of pharmacy unless doing so is in the patient’s best interest and does not create a conflict of interest for the physician“

It seems like I can give some advice to patients. The short version: Stay away from “Big Box” pharmacies.

To understand why I give this advice, it’s important to know what I think of the role of pharmacists. This will surprise those who have been critical of my position on expansion of pharmacists scope of practice, but I actually truly believe that pharmacists are an essential part of a patients health care team. In my area, the smaller, independent pharmacists and their staff all know the patients well. They feel very comfortable messaging me with issues. I often get updates from them about changes to medications a specialist has made (often before I hear from the specialist!). And I’ve always gotten great advice on what alternatives are out there for medications that aren’t unavailable (an increasing problem these days).

The smaller pharmacies always flag drug interactions well (for me and the patient), know which patients react to which medications (even the over the counter ones), have provided great individualized advice on how to take medications. If for some reason, I’m doing something “off label” – they have been very supportive of that.

I (and more importantly, my patients) get that level of support, because the small pharmacies have consistent staff, who have, over time, built up great professional relationships with our mutual patients.

In contrast, dealing with some of the big box pharmacies is getting worse all the time. Some issues are just plain annoying. For example, I generally give a one year supply of medications for patients of mine who have stable medical conditions (three months for diabetic patients). I cannot tell you how many times I’ll get a message from one of the big box pharmacies (the red ones in our area are particularly bad) asking for a renewal three months later, even though we clearly have an electronic record that shows those pharmacies got, and downloaded, a one year prescription. Essentially, the pharmacy refuses to give needed medications to my patients, because of their error inputting my prescription.

It’s gotten so bad that my replies to the pharmacies have, over the past couple of years, gone from informing them of their error, to asking them to fix their internal process, to being rude. I haven’t quite hit unprofessional yet – though the pharmacists may beg to differ.

The big problem with big box pharmacies is that their staff are under pressure to first and foremost, generate profits for their chain. Patient care is actually secondary.

It’s been reported (by pharmacists and staff) that corporate pressure from Shoppers Drug Mart (SDM) head offices led to their pharmacists doing unnecessary MedCheck reviews (and billing the taxpayer $75 per review). Shoppers head office of course denied the accusation and stated all MedChecks were necessary. Yet just one month later the CBC wrote “Shoppers Drug Mart says it doesn’t have medication review targets, but records show it does.“

The Toronto Star had an excellent report in November 2024 outlining just how much pressure corporate pharmacy staff were under. The report showed that:

• pharmacists were asked to rush through minor assessments for their new expanded scope of practice in under 5 minutes (Kathleen Leach, a Hamilton pharmacist recognized that this would degrade care)
• 85% of pharmacists felt compelled to meet service quotas
• there was strong concern about how the big chains had stripped back support staff from pharmacists, affecting care
• It also outlined how patients were encouraged to have health assessments, even when not necessary, to try and increase revenue

This appears to be a Canada wide problem. The Ontario College of Pharmacists is exploring legal options to address allegations of corporate pressure. The BC College of Pharmacist 2024 report on Workplace Practice clearly showed that pharmacists in corporate and franchise settings experience more time pressure than independent pharmacists. The Toronto Start article above also indicated the Saskatchewan Pharmacy College recognized that focusing on business targets leads to errors and increased patient risks. In New Brunswick a pilot program for expanding pharmacy care fell apart, in large part because a virtual care company that SDM had heavily invested in (Maple), overwhelmed pharmacies with referrals.

Kristen Watt, who’s the current Vice-Chair of the Ontario Association of Pharmacists, wrote a blog in the Medical Post strongly supporting expanded scope of practice for pharmacists. While I have, and will continue to, fundamentally disagree on that, I was struck by her comment in that blog:

“Granted, the government roll-out video, shot in a noticeable big box pharmacy, didn’t help us. There are lots of cries of foul about billings going to shareholders of large corporations.”

It’s the kind of statement that clearly suggests some awareness of issues, without getting oneself into hot water. And certainly left me wanting to know more.

As I mentioned previously, a good pharmacist, and their staff, are integral parts of your health care team. They need to know you as a patient. They need to know some of your medical history. Over time they need to develop a professional relationship with you to provide you with the best advice. At the Big Box pharmacies, you are often getting different pharmacists and different staff every time you visit. Due to some of the corporate pressures above, there is a lot of turnover in those pharmacies.

At a small local pharmacy, you’ll get someone who knows you and says “Dr. Gandhi always gives a one year supply of medications, so I’m sure you’ve got refills.” Whereas at a big box, you’ll get some new staff who mindlessly will tell you “Ok, I’ll message him, you’ll have to come back in 48 hours” because the previous person didn’t enter data properly. Or you’ll get advice from different people at different times, which is NOT the same as having a consistent relationship with one pharmacist.

So my advice, to you dear reader. Find yourself a nice small pharmacy. Make sure they are independently owned. Ensure they have a consistent staff. Build a professional relationship with them. Your overall health deserves it.

Bonus: Red Flags When Searching for a Pharmacy:

1. Pharmacies that sell groceries.
2. Pharmacies in department stores or grocery stores.
3. Don’t fall for “points” schemes – not worth sacrificing good health advice for
4. They have different pharmacy staff every time you go