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We evaluated approximately 5.6 million prescriptions that were delivered to retail or mail-order pharmacies and adjudicated through Caremark during the 1-month period. These prescriptions were written for 2,047,124 patients by 315,379 specialist physicians, 126,430 generalists, and 39,128 non-physician prescribers (eg, nurse practitioners). Patients and their insurance plans, respectively, paid an average of $17.90 and $26.67 for generic medications, $49.50 and $158.25 for single-source brands, and $44.50 and $135.26 for multi-source brands.

Of the prescriptions we evaluated, 151,670 (2.7%) were designated as dispense as written by physicians and 112,243 (2.0%) were designated as dispense as written by patients. A majority of prescriptions designated as dispense as written by physicians were single-source brand products for which no generic alternatives were available. Most patient-assigned dispense as written prescriptions were for multi-source brands, which could have otherwise been substituted at the pharmacy without contacting the physician. Patient requests for dispense as written took place almost exclusively at retail pharmacies, whereas approximately one third of physician requests were filled at mail-order pharmacies.

Among multi-source brands used to treat chronic conditions (maintenance medications), patients failed to fill prescriptions more frequently when either patients or physicians requested dispense as written, compared with prescriptions with no dispense as written designation.

In multivariate analyses, older physicians were more likely to request dispense as written than younger ones, and patients age 55 to 74 years were most likely to receive physician dispense as written prescriptions. The odds of requesting dispense as written was 78.5% greater for specialists than generalists (P<;.001). Compared with rates of dispense as written request for oral antidiabetics (the referent class), a dispense as written was more likely to be written for anticonvulsants (odds ratio [OR] 2.2), estrogens (OR 2.2), migraine treatments (OR 2.4), thyroid medications (OR 9.8), and anticoagulants (OR 3.9). Physician dispense as written was more common in the northeast section of the country (OR 1.76 vs west, P<;.001) and when submitted to mail-order pharmacies.

The likelihood of patient dispense as written requests also varied by therapeutic class and region. Compared with oral antidiabetics, patient dispense as written requests were more common for ulcer agents (OR 6.1), hypnotics (OR 4.3), migraine medications (OR 14.4), contraceptives (OR 3.7), thyroid medications (OR 16.5), estrogens (OR 3.6), anticonvulsants (OR 4.8), anticoagulants (OR 4.5), and analgesics (OR 4.5). Patient dispense as written was requested most frequently in the west; there were 32.4% greater odds for having a patient-assigned dispense as written in the west than in the northeast (P<;.001). Dispense as written was most commonly requested by patients who were 55 to 74 years of age, for maintenance medications, and at retail pharmacies.

For each eligible prescription submitted, we constructed explanatory variables to assess the relationship between physician, patient, treatment, and pharmacy characteristics and dispense as written use and prescription filling. Physician variables included primary specialty, practice type (primary care, specialist, non-physician prescriber), and prescriber age. Patient characteristics included age (in years), gender, and US census region of residence. Treatment variables included the dispense as written assignment, GPI4/GPI2-designated therapeutic class, brand/generic status, and patient out-of-pocket cost (in dollars per 30-day equivalent prescription). Pharmacy characteristics included the type of dispensing pharmacy (retail or mail). Prescriptions were categorized as either acute or maintenance (chronic) using the First Data Bank designation. Maintenance medications were further categorized as either an “initiation” or “continuation” of therapy. Initiation prescriptions were defined on the basis of no paid pharmacy claims for a drug in the same therapeutic class in the 6 months before the index prescription claim. Maintenance continuation prescriptions were preceded by 1 or more paid claims in the previous 6 months, indicating recent use.
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Analysis Plan
We used descriptive statistics to evaluate patient, physician, pharmacy, and prescription characteristics. We described rates of dispense as written for both single-source brands and multi-source brands, despite the fact that dispense as written for single-source brands may not have any effect on prescription delivery. We also present rates of prescription reversals, prescription claims approved by a payer and then reversed by the pharmacy because they were not purchased by the patient and went unfilled, stratified by dispense as written designation and prescription type.

To assess the relationship between physician, patient, prescription, and pharmacy characteristics with physician and patient dispense as written requests, we used generalized estimating equations to adjust for clustering at the patient level. Our outcomes, at the submitted prescription level, were the presence or absence of physician dispense as written in one model and the presence or absence of patient dispense as written for the other. We studied whether physician, member, treatment, and pharmacy characteristics were associated with the submission of prescriptions with a dispense as written designation. When comparing rates of dispense as written requests by drug class, we selected oral diabetes medications as our referent category because they are essential medications, commonly prescribed, and include both generic and brand-name options.

Multivariate generalized estimating equation models were used to estimate the relationship between patient and physician dispense as written selection and whether the claim was reversed, indicating the medication was not purchased by the patient and went unfilled. In these models, we were interested in the relationship between dispense as written designation and rates of multi-source brand medication filling, because these are the medications for which dispense as written designations most clearly affect the medication received. Thus, in our primary model, we included only multi-source brand and generic medications. We ran a distinct model with single-source brands as a neutral control because we did not expect that dispense as written designation would have any effect on the medication that was delivered and, as a result, the likelihood of actual purchasing. In these models, we controlled for patient, physician, and pharmacy covariates and adjusted for clustering within patients. We included interactions between physician and patient dispense as written designations and prescription characteristics (initiation of a chronic medication, maintenance medication continuation, or acute medication), because we hypothesized that dispense as written designation may have the greatest effect on purchasing rates in new prescriptions or acute prescriptions, when patients first learn about the medication costs. Statistical evaluations were performed using SAS Version 9.1 with SAS/STAT(r) (SAS Institute Inc, Cary, NC) and Stata SE 9.1 for Windows (StataCorp LP, College Station, Tex).

Dispense as written requests may have important implications for patient adherence. Patients are more adherent when they are initiated on generic or lower-cost medications.9 Although dispense as written requests would seem to reflect a conscious decision by patients or their physicians to use a specific agent, the increased cost-sharing that results from a dispense as written designation may decrease the likelihood that patients actually fill their prescriptions.

Little is known about how frequently physicians or patients request dispense as written, the medications for which dispense as written is most commonly used, and the physician and patient characteristics associated with dispense as written requests. Previous descriptive analyses of this practice were conducted when generic use was far less common and have limited applicability to current practice.10, 11, 12 No prior studies have investigated the effect of dispense as written requests on patients’ likelihood to fill their prescriptions or on overall health system costs. By using transactional data from a large national pharmacy benefits manager, we assessed rates and correlates of dispense as written requests and the relationship between these requests and rates of filled prescriptions.

Materials and Methods

Sample
We identified all patients enrolled in employer-sponsored health plans who received pharmacy benefits from CVS Caremark in calendar years 2008 and 2009. From this sampling frame, we selected all members with a) continuous eligibility for pharmacy benefits between July 1, 2008, and January 31, 2009, and b) a valid entry for gender and date of birth in the administrative record. We limited our sample to patients who submitted a prescription claim from any retail or mail-order pharmacy for adjudication between January 1 and 31, 2009, the identification period. We excluded all clients who were enrolled in a plan that imposed penalties for dispense as written requests, because dispense as written requests in these settings may not reflect those in the general population.

For patients who submitted multiple eligible prescriptions within a class, we selected the prescription with the latest date during the identification period, which likely eliminates accidental or erroneous prescriptions that were delivered. If a member submitted prescriptions in multiple therapeutic classes, each was deemed eligible and included in the analysis. We included all therapeutic categories defined by MediSpan’s Generic Product Identifier (GPI-2).

We identified the dispense as written assignment and the brand status from the submitted claim record. We categorized claim records into 1 of 3 mutually exclusive categories: a physician-assigned dispense as written (Physician Dispense as Written); a member-assigned dispense as written (Patient Dispense as Written); or no Dispense as Written. Brands were listed as either single-source brand, indicating no generic equivalent was available at the time of the study, or multi-source brands, which are branded medications with a generic equivalent. For every eligible prescription, we also determined whether the prescription was purchased (“filled”) or reversed. Reversed prescriptions are those that the patient chose not to purchase, and therefore were not filled.

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.