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Background

All US states have adopted generic substitution laws to reduce medication costs. However, physicians may override these regulations by prescribing branded drugs and requesting that they are dispensed as written. Patients also can make these requests. Little is known about the frequency and correlates of dispense as written requests or their association with medication filling.

Methods
We identified beneficiaries of a large pharmacy benefits manager who submitted a prescription claim from any pharmacy in January 2009. We categorized claims as a physician-assigned dispense as written, patient-assigned dispense as written, or no dispense as written. We described rates of these requests and used generalized estimating equations to evaluate physician, patient, treatment, and pharmacy characteristics associated with dispense as written requests. We also used generalized estimating equations to assess the relationship between dispense as written designation and rates prescriptions are not filled by patients.

Results
Our sample included 5.6 million prescriptions for more than 2 million patients. More than 2.7% were designated as dispense as written by physicians, and 2.0% were designated as dispense as written by patients. Substantial variation in dispense as written requests were seen by medication class, patient and physician age, and geographic region. The odds of requesting dispense as written was 78.5% greater for specialists than generalists (P<;.001). When chronic prescriptions were initiated, physician dispense as written (odds ratio 1.50, P<;.001) and patient dispense as written (odds ratio 1.60, P<;.001) were associated with greater odds that patients did not fill the prescription. Conclusion
Dispense as written requests were common and associated with decreased rates of prescription filling. Options to reduce rates of dispense as written requests may reduce costs and improve medication adherence.

With the recent expansion of health insurance coverage to millions of Americans, there is increasing pressure to control health care costs. Greater use of generic medications has been identified as one approach to reduce medication costs without compromising quality. Studies do not suggest meaningful differences in clinical efficacy between brand-name and generic products. Yet generic medications remain underused when appropriate, and efforts to encourage their use can reduce both patient and health system costs.
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Every state has enacted generic substitution laws to promote generic drug use. However, both physicians and patients express concern about the safety and efficacy of generics. Physicians can ensure that a brand-name medication is delivered, even when a generic equivalent is available, by indicating “dispense as written” on their prescription. Similarly, patients can request that a brand be delivered rather than the generic equivalent at the point of purchase.

This pilot project examined the value of health promotion activities in clinical practice and the personal lives of 28 master’s entry Clinical Nurse Leader (CNL) students in their last semester of education. Data collection involved an open-ended questionnaire and focus group discussion. Students expressed concern about finding time for health promotion and noted that patients were often too sick to be appropriate for health promotion. Participants believed that health promotion was better situated in community-based care. Of great concern to students was the lack of role models for health promotion among faculty and staff. Students also noted a decreased ability to attend to their own health while enrolled in the nursing program.

Nursing is a complex profession that has undergone tremendous change, from the provision of mere kindness and support to work that is based in science but focuses on care and nurturing. To reflect this change and allow for future change, contemporary definitions of nursing broadly define nursing practice as the promotion of health, prevention of illness, and the care of ill, disabled and dying people (ICN, 2003).

Contemporary ad campaigns to attract men and women into nursing depict action scenes of nurses racing through hospital halls with patients on gurneys or stationed at the bedside amidst an array of technology (Wilkinson & Van Leuven, 2007). These images reflect the increasing role of technology in nursing care. In addition, nursing faculty face ever-growing lists of “must cover” topics in nursing curricula. These topics are often driven by the growing knowledge base, and commonly centered on skills and technology. This high-tech fast-paced image cannot be dismissed as it does reflect what is commonly seen in today’s hospitals; but these images largely reflect care of the ill, disabled, and dying rather than health promotion and disease prevention activities. If technology and sick care are advertised and emphasized in nursing programs, what role does health promotion play in clinical practice and in the lives of members of the nursing profession?

This pilot project seeks to address these questions. It is part of a program of research examining attitudes, beliefs, and clinical practice surrounding health promotion among nursing students, practicing nurses, and advance practice nurses. In this phase, data were collected from students enrolled in their final semester of a master’s entry Clinical Nurse Leader (CNL) program.

Methods
Students were approached for participation via announcement during a regularly scheduled class. Students were invited to participate in a pilot study on health promotion by reporting to school one hour prior to a required course the following week. Participation was voluntary and unrelated to any curriculum requirements. One hundred percent of the class returned for participation in this project.

It will be easier than you think because you’ve probably already done it a few times but just didn’t know it. The fact is, we reinvent ourselves every day sometimes many times in a single day. One minute you are providing sensitive guidance, coaching, and feedback to staff members; the next you are righteously, relentlessly, resolutely, and often rabidly arguing for increased government funding for a threatened public health project. It’s not a question of can you reinvent yourself you, every day. The question is, can we do it in terms of our work life and when should we?

Every reinvention is not going to be a great success, but it certainly will teach you something, if you’re paying attention. I used to consider needing to move on as failure, but I’ve learned to see these experiences as positive lessons in what doesn’t work for me or what doesn’t contribute to my growth, development, and personal fulfillment.

Don’t reinvent yourself in anyone’s images but your own. Looking for a work change role model is fine. Look for similarities in motives and trajectories rather than work setting or magnitude of change. However, remember: people have different motivations, different degrees of clarity about where they want to go and the self or selves they want to be. Be your selves. (yes, that’s the right way to write what I mean.)

Read more about reinvention ― This is a fascinating idea and much as been written. Start with the references here and see where that leads.

And finally, no matter when, where, why, and how and into what you reinvent yourself, enjoy the exciting dimensions of who you are that are revealed in each reincarnation!

I have learned these the hard way because career development was not a major professional preparation topic earlier in my careers. I hope this and future articles on career development will help make your paths, however crooked, somewhat smoother.

In terms of work, each of us has our own definition of success, our own standards by which we evaluate how well we’re doing. Our measures of work success might be: the salary we make; the title we hold, the “perk package” that comes with the job; the status of the organization that employs us; the power we wield; the visibility and recognition we have; the sense of belonging or accomplishment or of being valued we experience on the job, or of making a difference in the world. When we’re not achieving our definition of success, we begin to think about why, and what, if anything, we want to do about it. If we decide to take action, we usually end up, in one way or another, reinventing ourselves.

So, in closing, let me leave you with a few hard-earned and learned tips for successful reinvention:

Understand why you are reinventing yourself, because the reasons why people reinvent themselves are good predictors of how successful they will be in their new incarnations (Ibarra, 2005).

Transform a negative work-loss experience into a positive personal and professional growth opportunity. As Eleanor Roosevelt said, “No one can make me feel inferior without my permission.” Being fired isn’t the end of the world ― and believe me, I know. Use or reframe the forced “down time” as an opportunity to take a long-overdue sabbatical and to develop a “slash” career.

Successful reinvention depends on how you see yourself. We can see ourselves as “victims” or “owners” (Chandler, 2005). This also means being able to see yourself clearly and candidly ― no holds barred. So if you need to ask others to give you feedback, don’t be shy. It’s one of the greatest gifts you can give yourself.

Think of yourself as having multiple dynamic personalities and identities. As Chandler says and others have confirmed through research, “We don’t have permanent personalities, we have shifting patterns of thought.” (Chandler, 2005; Harkness, 1997; Ibarra, 2003). If you see yourself as one particular personality type (e.g., shy) or as one kind of practitioner or job title, you associate specific attitudes and behaviors with that label, and that either paralyzes you or seriously restricts the range of reactions you can have in response to different situations. If, however, you are open to the idea that people have multiple personalities and can have multiple work identities, you have many more reaction choices.

How many of us don’t dare take that training job, or do a workshop on evaluation, or draft a proposal, or draw up a program budget because we know we won’t do it perfectly and don’t want anyone to see us performing at less than a perfect level? Or is it just me? Remember the saying, “Use what talents you possess: the woods would be very silent if no birds sang there except those that sang best” by Henry Van Dyke?

As well, anxiety, stress, and/or depression are immobilizing and the cycling is relentless: you have done nothing so you feel depressed, stressed or anxious, which makes you more depressed, stressed, or anxious, which freezes you completely.

Two other quick points that might explain people’s reluctance to reinvent themselves. First, reinvention requires calculated risk taking and making trade-offs (Griffiths, 2001): giving up one desired value for another. Second, successful reinvention requires self-awareness or self-knowledge (Helfand, 1995). Some typical trade-offs made during reinvention are nonmonetary, such as identity issues, others’ expectations/disappointments, and self-esteem. Others are clearly financial, such as salary, insurance, and other benefits. Having created and studied the tradeoff list, try working through this “To Do” list (Helfand, 1995) before making a reinvention decision:

1. Identify your significant life experiences
2. Create a list of transferable/functional skills
3. Categorize transferable/function skills into clusters
4. Identify your specific content/special knowledge
5. Prioritize them according to what you’d like to see involved in your next career
6. Identify issues about which you are passionate
7. List products/program/services/causes you might like to work with or help create
8. Identify your life values
9. Identify your work values
10. Assess your adaptive/self-management skills – personal traits and qualities reflecting how you adapt to and survive in your environment as well as the style in which you use your other skills to accomplish what you set out to do
11. Bring together 3, 5, and 10
12. Decide what new skills you need/want to learn
13. Convert perceived negatives into positives
14. Plan for dealing with personal and professional limitations

As Harvard professor Herminia Ibarra’s studies (2003) have shown, reinvention unfolds through phases. Understanding and anticipating these phases can help pave the rough path though there will always be bumps before you get on your way, along the way, and after you think you’ve “arrived.” The four steps, as shown in Appendix B below are: exploring who you are and who you have the potential to be; testing your possible selves the older ones and the new ones; finding and building congruence between who we think we are and what we do; revising our priorities, assumptions, and self-conceptions as we learn from our experiences.

Conclusion: Tips for Successful Reinvention
This article on reinvention has not been about how to win friends and influence people at work by reinventing yourself so that you “belong” or fit in to every situation in which you find yourself or so that you can accommodate every single person you meet at the cost of your own identity ― not to mention your mental, emotional, spiritual, intellectual, social, and physical health. We are not talking about day to day interactions and group dynamics ― though someone probably has and we could all benefit from reading about it!
What we have discussed here is the benefit of assuming a “poised to plunge” stance (Goldman, 2007; Harkness, 1997; Ibarra, 2003) in which you are constantly on the alert and ready to anticipate or react resourcefully. Being able to reinvent yourself is key to realizing your full potential, which I hope is at least part of the reason why we work.

Sometimes our lack of courage is evidenced by a tendency to procrastinate constantly putting off the reinvention process. Or, as NCAA coach Lou Holtz once observed, “When all is said and done, usually more is said than done.” Why? Maybe because we don’t know what we really want (unclear/unknown goals), or we have so many interests and abilities that we can’t seem to commit to any one of them for fear of losing the chance to work in the other areas, or find fault with our alternatives, or because, quite simply, we’re insecure and unsure of ourselves.

Reinvention also can be stymied by a fear of change and its consequences known and unknown. We’re afraid to take risks (Kanchier, 2000). Though it’s change we seek, disruptions of familiar patterns and routines stop some of us dead in our tracks. And what about the consequences of making a change or, my goodness, changes? Certainly there are those among us whose fear of the unknown and/or unpredictable effects of change holds us hostage to our present situation. And what about what we’ll be giving up? Sure, you really are miserable in your job, but it’s your job, you have paid your dues in every sense and have earned the reward of a certain level of job security are you sure you want to give that up? Won’t others think you’re crazy to, of your own free will, risk job security which is so hard to come by? And what about the financial risk? And loss of status? Are you willing to sacrifice your happiness for the title on the door or your seniority on the floor? Are there too many unknowns? Too many sacrifices?

What about your faith in yourself? Do you trust your own judgment? Do you know your own strengths in terms of your talents, assets, resources, etc.? Do you think you can stand being “new” or at the “beginning” again, even in a higher position? What about having to learn to get along with new supervisors and co-workers? Come to think of it, it’s amazing anyone ever moves on, isn’t it?

Fear is a huge factor (Helfand, 1995). In fact, the biggest barriers to reinvention include three of our biggest fears: fear of change; fear of failure; and fear of success. Add to that perfectionism; and anxiety, stress, or depression, and it’s amazing anyone reinvents themselves at all.

What a successful the topic “fear of failure” has become. There are hundreds of books published on failure! I recommend anything that helps you see failure as a lesson learned about what doesn’t work and a chance to make lemonade out of lemons. Remember, 3M post-its were the result of a failed Research and Development glue project!

And what if we do succeed? Oh, my, then what will we do? What else have we missed? Can we stand the guilt? Can we live happily ever after in our new situation? Will our colleagues who we left behind make our lives miserable? Can we stand the fact that we did well?

At a “higher” level, there are positive and negative job-related experiences that can trigger a desire or need for reinvention. Your job might be eliminated, the work becomes boring, your skills aren’t being used or salaries get cut. On the positive side, sometimes you get to reinvent yourself ― see, not just have to, but get to ― you’re your job is expanded ― you get to do more ― or enriched ― you get to go deeper into a responsibility.

Higher still are the positive and negative organizational, industry and societal-level triggers. Again, we’re probably more familiar with the negative reasons for reinvention, but should take time to tune into the positive ones.

Transitions as triggers are usually obvious, but some are less so. We recognize transitions or milestones such as graduation, marriage, birth, death, divorce, promotion, and being let go. Other transitions include career stage transitions as mentioned above.

Finally, please note that reasons for reinvention, whatever they are, are relative. Some reasons are internal ― related to developmental issues in your life ― and some are external ― trends in society and other things we have no real control over (Helfand, 1995). The triggers listed may be either positive or negative depending on the people involved on the situation. For example, a change in supervisor may be a reason for reinvention for one person and a positive trigger for another.

Reinvention Pre-requisites
While there are plenty of reasons to reinvent yourself, doing it is not easy. Many times you know you need to act and yet you just can’t. What gets in the way of successful reinvention?

The 12 closed doors to successful reinvention described by Pollan and Levine (2004) are: thinking you’re too old; thinking reinvention is too great a financial risk; thinking a successful transition will take too long; waiting for permission from others to change; believing that you’re not living in the right place or that you’re not physically fit enough to make the change, or that you don’t have enough or sufficient education and training, or that you haven’t got what it takes to pull off the reinvention, or that you might fail, or that you might succeed. And some of us are simply too pessimistic or fatalistic to take the next step. Mostly, we need the courage of our convictions (Helfand, 1995). The “wrong” motivator or drive can become a quagmire, pulling you down, down, down, rather helping you up, up, and out! Envying someone else and feeling unappreciated or undervalued and bitter is not the stuff of which substantive reinventions are made. So, make sure you have a personally compelling, meaningful, and relevant reason to reinvent yourself.

If you are a person of many interests or passions, with an entrepreneurial streak, becoming a “slash person” is an important reinvention option. I certainly wish someone had told me about it a long time ago! If you’re interested, Marci Alboher’s book is a great place to start!

When Should We Reinvent Ourselves?

Most of us assume that we only need to reinvent ourselves when we get fired or when our current self isn’t working. Just like Lewis Carroll’s immortal Mad Hatter who moved down the table every time he made a mess at his seat at the tea party, we think, “Ok, we’ve made a mess at this job here. Let’s dump this persona and move onto the next one” as if the reinvented you is a completely new you with no real connection to the past (failed?) you.

Others of us assume that reinvention is the privileged prerogative of the chosen few: college students, newcomers/initial starters, those in the official “reappraisal age” (about 28-35 years old), the downsized and outsourced, mid-career restructurists (about 40-45 years old), workers taking an early corporate parachute or public service retirees (in their 50’s), and/or traditional retirement age workers (65). Certainly there are expected periods of life and career transitions (Kanchier, 2000) and anticipating and preparing for transitions is important and helpful.

However, as the previous personal communications and Appendix A show, there are dozens of reasons to think about reinventing yourself (Ballback & Slater, 1996; Harkness, 1997; Helfand, 1995; Solovic, 2003). The reasons can be personal, job-related, organization-related, industry-related, or world-related! Sometimes one at a time ― sometimes all at a time.

You probably know the personal and negative triggers (feelings of pessimism, frustrations, dissatisfaction, boredom, feeling unfulfilled, recovering from an illness or disability). These, I suspect, are the most common reasons you’ll hear why people reinvent themselves.

The personal and positive may not comes as easily to mind, such as when you come back to work after a hiatus, you have a creative spurt, you recognize that you have some skills or talents you weren’t aware of previously, your self-awareness grows through therapy, you want or need more money, you become free(r) in some way, you finish a training program, or you simply feel you need a break/to do something different. These come out of a positive place and are usually overlooked.

At a “higher” level, there are positive and negative job-related experiences that can trigger a desire or need for reinvention. Your job might be eliminated, the work becomes boring, your skills aren’t being used or salaries get cut. On the positive side, sometimes you get to reinvent yourself ― see, not just have to, but get to ― you’re your job is expanded ― you get to do more ― or enriched ― you get to go deeper into a responsibility.

And sometimes, we reinvent ourselves personally in order to survive professionally. As S.G., a health educator with more than 30 years of experience (S.G., personal communication, May 4, 2007) wrote: “My career as a health educator has been varied ― so I guess I reinvented [myself] several times. I went from a volunteer with the Red Cross teaching first aid courses to a part-time staff person with the Red Cross directing the Health and Safety programs at a local chapter to teaching at a high school, to college level teaching, to a full time curriculum developer with a science education organization (writing the health component of the curriculum) to a project officer at CDC to a consultant, to an Executive Director of a professional association. Is that what you had in mind? I also reinvented myself as I was coping with an adolescent child who was having serious problems. The reinvention was to redirect my thinking from “Why me? What did I do to deserve this?” and a focus on her and her problems to, “What am I supposed to learn out of all this?” It was a huge change and made a big difference in my ability to cope ([though] it did not change her acting out).”

A final story, anonymous because of its sensitivity, (personal communication, May 11, 2007) underscores the importance of doing due diligence before reinventing yourself. This health education graduate student decided to reinvent herself when advised that her current health education professional preparation program would prepare her for great success and great future marketability in another field. She therefore studied for her Certification in Alcohol/Substance Abuse Counseling (CASAC) in addition to health education, only to discover she had reinvented herself into a product that was no more marketable than either profession e separately given who decision makers were hiring (clinicians) for counseling positions.

Serial vs. Sequential Reinvention
A final word, if you will, on the concept of reinvention: reinvention need not be sequential ― in fact you can and sometimes have to juggle two or more work experiences at a time. Let me explain.

Most of us think of reinventing ourselves as a chronologic process: First, I was “x”and then (for whatever reason) I became “y.” Certainly that’s one way of looking at it, but many people are not x’s or y’s. They’re “slashes”: x/y…two, or even x/y/z three things at once (Alboher, 2007). It’s a great way to try out a new career or work challenge when you already have a job but want to consider changing or expanding what you do for financial or personal fulfillment reasons. It’s easiest when you have a “safe” “cushy” job as your “main” or “anchor” job to then add on additional “orbiters” or secondary or separate jobs. At one point I was Karen Denard, program manager/adjunct/graduate student, and later I became Karen Denard Goldman, professor/ author/ speaker/ Broadway musical parody lyricist. My very favorite “slash” person is a health educator I met this past year who, after attending my career development workshop, told me she is a school health educator/ dominatrix. You can’t make this stuff up.

In the 1990s, involvement in public policy setting became a significant health education skill as chronic and communicable disease management issues were joined by environmental hazard issues. Health education efforts and programs became geared to the home and to pre-school settings. In the past decade, new skills have been integrated into the health educator’s repertoire: social marketing; computer technology; distance learning; grant writing; evaluation; translating research into practice; and diffusing best practices. Issues such crisis management and terrorism, particularly bioterrorism and emergency preparedness have driven most government funding programs.

In 1998 the Competency Update Project began and in 2006 the second edition of the Competency-Based Framework for Health Educators was released by the National Commission for Health Education Credentialing, Inc.. The framework was reinvented to include 82 sub-competencies with three levels: Entry, Advanced I, and Advanced II. The certification examination was reinvented/revised accordingly in time for the October 2007 test (NCHEC, 2006).

Therefore, if “reinvention” is “in our blood”, is it not wise for us to learn more about and perhaps consider preparing for our own professional reinvention transfusions?

What Does It Mean to “Reinvent Yourself”?
“Reinvention is any type of change, from the material to the spiritual, in which you become a whole person or a different person, hopefully a better person, but certainly a changed person” (Davidson, 2001). Reinvention is about taking charge of who you are and where you’re going and what you’re doing, and it usually involves a willingness to take calculated risks, to start all over again, and to weather some setbacks.

Reinvention is a proactive, not a reactive activity. People who choose to reinvent themselves, for whatever reason, are, by and large, assertive people, with a sense of personal responsibility and accountability for their lives (Chandler, 2004). They reject the role of “victim of circumstance” and assume ownership, if not total control, of situations and set about seeing what they can do about them. They refuse to be part of the problem; they insist, instead, of being part of and often the driving force behind the solution (Chandler, 2004).

Personal reinvention can involve changes in one or more aspects of your life. Reinvention is about shifting, reframing, reformatting, restructuring your perspective, attitude, and actions to whatever degree is necessary in response to a particular trigger. It doesn’t have to imply or involve a wholesale upheaval in who you are and how you do things ― though for some of us at some time, it might actually come to that. It can mean adjusting your attitude toward life; your body and the shape it’s in or out of; your relationships or lack thereof with people, your community, your money, any higher power you might believe in; how and with whom you spend your discretionary time; and, the focus of this article, your work life.