Then I ended the episode and left you with it.

That’s been bothering me since, because it’s the easiest thing in the world to make somebody unsettled and the hardest thing to hand them what to do next. So this one is the tool.

THE THING NOBODY TOLD ME

Twenty years in pharmacy. Nine different practice settings if I’m honest about the count. Retail, independent, long-term care, MTM, hospital staff, rounding, management, consulting, and whatever you’d call what I do now.

In all of it, not one employer, preceptor, or professor ever said the words: you have control inside situations that are out of your control.

Not once. We get taught disease states and guidelines and workflow and metrics. Nobody teaches the part where a thing lands on you that you didn’t pick and you still get a say in what happens next.

I ran a long time without knowing that. I assumed I was a product of my environment and largely along for the ride, and I was wrong about that in a way that cost me years.

THE SPLIT

About twenty percent of what happens in a working life is collateral damage. Somebody else decided it, it landed on you, you can’t move it.

The other eighty percent is how you answer, and that has always belonged to you.

I want to be careful here, because this is the point where this kind of talk usually turns into a poster about attitude. I’m not talking about deciding to feel better. I’m talking about the specific, findable, actionable pieces of a bad situation that are genuinely within reach, which is nearly always more than it looks like from inside it.

A THOUSAND PRESCRIPTIONS

Every pharmacist reading this knows the morning.

You walk in and there are a thousand scripts in the queue. You didn’t set that number. Corporate set it before you got out of your car. Mindset is not going to make it nine hundred.

But you set the tempo.

You decide whether every one of those goes out with a genuine safety check behind it, because your name is on it and not the district manager’s. You decide whether the day runs on nitpicking or on a team actually covering each other. You decide what that room feels like for eight hours.

And I understand there are jobs you have to work. We need the income. We need the benefits. We need the thing that leads to the next thing. All of that is real and none of it is weakness.

But inside that job, the tempo is yours.

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THE FOUR QUESTIONS

Take a decision that’s been sitting on you, the one where you feel like you have no room at all, and run it through these in order.

What do I want.

What do I not want.

What can I control.

What can’t I control.

Write them down. Four questions, four answers, on actual paper.

Here’s the part most frameworks skip, and it’s the part that makes this one usable: you will almost never get all four to line up. Three is usually what you get. Knowing which one you’re giving up is the whole difference between making a decision and drifting into one.

IF THE FIRST QUESTION COMES BACK BLANK

It will, sometimes. It did for me for years.

I could not have told you what I wanted out of pharmacy, because I didn’t know what existed. You can’t want a thing you’ve never seen. The four corners I’d been shown were retail, hospital, industry, and academia, and none of them fit, and I assumed that meant the problem was me.

But I could have given you the other list in four seconds flat.

I do not want volume metrics crammed down my throat. I do not want to give vaccines all day, every day. I do not want to spend a twenty-year career two percent of the way inside the work I actually trained for.

That list is not nothing. Start there. It draws the picture from the outside in, and the shape that’s left in the middle is usually what you wanted all along.

THE THING I PICKED

When I was floating, I never once walked into a clean store.

You inherit the day before. Patients still angry about something that had nothing to do with you. Technicians who got treated badly by a pharmacist you have never met. Somebody else’s queue, somebody else’s mess, somebody else’s mood.

None of that was mine and none of it was moveable.

So I picked the one thing that was. What I wanted out of every shift was peace in that store. That was the whole goal. I’d come in and ask what I could do for them and what they could do for me, and we’d build the day out of that.

It didn’t fix the volume. It fixed the eight hours.

You will not always get to choose the work. You almost always get to choose what you walked in there to protect.

FIVE MINUTES

There’s a rule in my house and my kids can recite it.

When something lands on you that you didn’t pick, you get five minutes. Cry about it. Scream about it. Kick something if you need to. I’m not going to talk you out of that part and I’d never ask them to skip it, because pretending it doesn’t hurt is its own kind of trap.

Then the five minutes are up.

And you make one choice you can control that makes the situation better. One. Not a plan, not a life overhaul. One choice inside the eighty percent.

I wish somebody had handed me that at fifteen. I’d have gotten here a lot faster and with fewer detours.

WHAT I’M ASKING

Pick the decision. Run the four questions. Do it on paper, today, before this feeling wears off, because it will.

If what comes out the other side is that you’re staying, stay on purpose. That’s a real answer and it counts.

If what comes out is that something has to change, you now know which part of it is actually yours to move, and that’s a different morning than the one you woke up to.

IF YOU’RE STARTING TO WONDER WHAT ELSE IS OUT THERE

The pharmacists who come to me are almost never short on clinical skill. They’re short on two specific things: how to have the conversation with a physician, and the math on what a real month of this work looks like so it’s a business and not a hobby.

Find out where you actually stand before you spend a dollar on it. The assessment takes a few minutes: tmrx.care/tbo-assessment

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If this one landed, send it to the pharmacist you thought about while you were reading it. They’re staring at a queue right now thinking none of today belongs to them.

Twenty percent of a working life is decided for you. The other eighty is how you answer it, and nobody in twenty years of pharmacy ever told me that part was mine.

Inside: the four questions I run every hard decision through, why you should write the do-not-want list first if the first question comes back blank, what I decided I actually wanted out of a floating shift, and the five-minute rule my kids can recite.

Take the assessment: tmrx.care/tbo-assessment

If this one lands, send it to the pharmacist you thought about while you were listening.

About twelve years ago I left a bad marriage.

I left with two kids, three bags, and a truck I couldn’t afford. No job. We landed on my mother’s floor and we stayed there a while, and I want to be careful not to make that sound braver than it was. It was not brave. It was the only door that was open.

Then a health system hired me.

I had never done hospital pharmacy. Rotations, that’s it. I had spent my whole career assuming I’d be a retail pharmacist, somebody’s community face, the person you catch in the OTC aisle at the grocery store. That job was not the plan and it was not the thing I was trained toward, and it picked my entire life up off the floor.

I will say for as long as I live that taking it was one of the best decisions I have ever made.

I stayed eleven years.

I knew at year five.

THE THING I DIDN’T HAVE A WORD FOR

For a long time I couldn’t explain to anybody, including myself, why I was still there.

The work had stopped fitting. I’d gone from staff to rounding to management, and every rung up that ladder took me further from a patient and closer to a meeting. I was climbing a bureaucracy ladder while telling myself it was a care ladder. I knew. I stayed.

The word I eventually found for it was loyalty.

Loyalty is a sense of duty, an obligation to uphold a commitment. That’s the definition, and there is nothing wrong with it. It is a good trait in a good person.

It was also, for me, the single most expensive belief I have ever held.

Because they picked me up. Because I was on my mother’s floor with two children and three bags and they handed me a badge and a schedule and a paycheck and a way back. How do you leave that?

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THREE WAYS TO SAY THE SAME SENTENCE

Somewhere in year eight or nine I started hearing the difference between three sentences that sound identical.

This was a great chapter and I need to move along.

This was a great chapter and I’m afraid to move along.

This was a great chapter and I owe it to them to stay.

Every pharmacist I coach says one of these to me eventually. Almost all of them say the third one, because the third one sounds like character instead of fear. Loyalty. Gratitude. Paying it back.

But the third one and the second one are usually the same sentence wearing different clothes. I owe them is easier to say in public than I’m scared.

I lived in the third one for six years and I’d have told you with a straight face that it was the first one.

THE TRAITS THAT TRAPPED ME

There’s one rule in my house, and my kids can recite it. Be kind, be humble, and always stay teachable. I believe in it enough that I built a journal around it.

And I have had to sit with the fact that those three exact traits are what kept me in a job I’d already outgrown.

Humble kept me grateful long past the point where gratitude was serving anybody. Kind kept me staying for the coworkers, for the patients, for the team that would be short if I left. Teachable kept me finding new ways to reframe it as fine, one more year, one more project, one more reason.

The things that make you a good person are the same things that make you easy to keep. Nobody tells you that.

BOTH DOORS HAVE A PRICE ON THEM

Here is the sentence I would drive back and hand to myself at year five if I could.

If you stay, it costs you something. If you go, it costs you something.

We’re very good at pricing the second one. Leaving has an obvious bill. The salary, the benefits, the certainty, the people, the thing you’d have to explain at Thanksgiving.

Staying feels free, and it isn’t. The bill just arrives in installments. One year at a time, in the work you didn’t do and the people you didn’t reach and the practice you never built.

My bill was six years of impact I could have been making in my own community, in a rural county that had nobody doing it. Six years of patients who didn’t get called. I didn’t open that envelope until I was already out.

WHAT I AM ACTUALLY ASKING YOU

I’m not telling you to quit. I want to be clear about that, because this is the part where people expect the pitch.

Plenty of pharmacists love where they are. If that’s you, that’s a real answer and it counts and I mean it.

What I’m asking is that you figure out which of the three sentences you’re living in. That’s the whole assignment. If it’s the first one, stay, and stay on purpose instead of by default. If it’s the second or the third, you know something this afternoon you didn’t know this morning, and you get to decide what to do with it.

Your coworkers will still be your friends if they were ever going to be. That part I promise you. Chapters end and the real ones follow you into the next one.

Your patients are not better served by a pharmacist who checked out six years ago.

And if the loudest voice in your head right now is saying it could be worse, I’d gently ask when not bad became the standard you’re measuring a career against.

IF YOU’RE STARTING TO THINK ABOUT WHAT’S NEXT

The pharmacists who come to me are almost never short on clinical skill. They’re short on two things: how to have the conversation with a physician, and the math on what a real month of this work looks like, so that it’s a business instead of a hobby.

Find out where you actually stand before you spend a dollar on it. The assessment takes a few minutes: tmrx.care/tbo-assessment

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If this one landed, send it to the pharmacist you thought about while you were reading it. They’re in year five right now and they don’t have a word for it yet.

Is there any way this scale can tell me what my weight is?

I said it shows you, right there on the screen.

He said yeah. I can’t see it. I’m blind.

I about fell out of my chair. I had been calling this man every month. I had enrolled him myself. I had built his entire program around a number displayed on a small screen, and I had never once asked him whether he could read it.

It was in his chart. Third screen deep, one sentence, sitting in the middle of a report the way important things always sit in the middle of reports.

THE SENTENCE I CAN’T SHAKE

He told me it wasn’t a problem.

Said it happens all the time.

I told him it doesn’t happen for me.

I have thought about that exchange more than almost anything else in eight years of doing this work. He was not angry. He was not even disappointed. He had priced in being overlooked so completely that he was reassuring me about it.

That is what the gap looks like from the patient’s side. Not a service that’s missing. A person who stopped expecting one.

WHAT WE DID ABOUT IT

The vendor doesn’t make a talking scale. I asked. They said no, and they were right, there wasn’t a product.

So I stopped asking for a product and started asking about the plumbing. The platform already sends automated texts for low batteries and missed readings. The trigger was sitting there, pointed at the wrong event.

I asked whether they could fire it when a reading came in, with the reading in it.

They came back a day later and just did it. I found out because he texted me first. His phone read the message out loud to him, the way his phone reads everything out loud to him, and for the first time in three months he knew what he weighed.

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FOUR AND A HALF YEARS LATER

More than 1,500 readings. Adherence above 97%. Somewhere north of 300 documented interactions and close to 50 hours of logged time with one human being.

Here is the number I left out of the podcast, because I was telling the warm version of this story and not the whole one.

On February 22 of last year, his reading came in 23 pounds above baseline.

Twenty-three pounds. In a man who cannot see, living rurally, managing more than one chronic condition at once. We had him on the phone inside a day. It spiked again in March. Through April the numbers stayed up and we stayed on him, week after week, until they came down.

Nine months later he was 41 pounds below that peak.

He has not been admitted for a weight-related crisis in the entire time we have monitored him. Not once.

And the thing I keep coming back to is that in a normal care model, nobody sees February 22. There is no visit that day. There is no reason for anyone to look. That number surfaces in April at a scheduled appointment, or it surfaces at three in the morning in an emergency department, and by then the conversation is a very different conversation.

WHAT THIS ACTUALLY COST

A single admission for a patient with his profile runs $15,000 to $30,000.

Four and a half years of monitoring costs a fraction of one of them.

I am not going to pretend I can prove a counterfactual. I can’t tell you which admission didn’t happen. What I can tell you is that we caught a 23-pound spike the day it appeared, and that the alternative to catching it was not catching it.

THE PART THAT MAKES PEOPLE UNCOMFORTABLE

He does not call his doctor first anymore. He calls our team.

Some people hear that and think it sounds like overreach. I think it sounds like the system working the way it was supposed to, because we call him every month and his physician sees him twice a year, and trust follows contact. It always has.

None of this took clinical genius. I am not board certified. I never had provider status. What I had was a phone, a monthly obligation I kept for four and a half years, and an unwillingness to let a vendor’s first answer be the last one.

Support them, educate them, hold them accountable between office visits. Do that long enough and the patients are unstoppable.

Then everybody assumes the pharmacist did something clever.

IF YOU’RE READING THIS THINKING YOU COULD DO THIS

You probably could. That is not encouragement, it’s arithmetic. There is nothing in this story that requires a credential you don’t have.

What it requires is knowing which patients to take, how to build the physician relationship that sends them to you, and how to run the month so that fifty hours with one patient is a business and not a hobby. That last part is where most pharmacists stall out, and it is the part I go deep on with the people I work with.

Start by finding out where you actually stand. The assessment takes a few minutes and tells you which skills you already have and which ones you’re missing:
tmrx.care/tbo-assessment

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If this one landed, share it. Somebody in your feed has a patient who has stopped expecting anything.

In this episode of The Dose, Dr. Thea Blystone shares how meeting one legally blind patient exactly where he was transformed his care. It’s a real-world look at what pharmacist-led care management can do when we simply show up, educate, support, and hold patients accountable.

Two days before the meeting, I prayed for a stepping stone.

Not a breakthrough. Not a contract. Not some grand opportunity.

Just a stepping stone.

The funny thing about praying for stepping stones is you usually have no idea what one is supposed to look like.

I certainly didn’t.

Then, on a Thursday morning, I saw a Facebook post.

It was simple. A local legislator was holding constituent hours at a district office. No appointment required.

I almost scrolled past it.

After all, what business did I have walking into a state senator’s office?

I’m not a lobbyist.

I’m not board certified.

I don’t have provider status.

Nobody in Washington had invited me.

But I kept thinking about that prayer.

Maybe this was the stepping stone.

So I called.

The intern who answered the phone had no idea I was coming. Three hours later, I was sitting in a Senate office.

I had prepared the way pharmacists always prepare.

I led with my credentials.

Clinical pharmacist.

Years of experience.

Programs I’d built.

The outcomes.

The work.

And none of it mattered.

Not because it wasn’t impressive.

Because that’s not why I was there.

I realized, sitting across that desk, that legislative offices don’t start by asking who has the longest résumé.

They start by asking who’s willing to show up.

That’s the gap I think we’ve misunderstood as a profession.

We keep waiting for permission.

Provider status.

Another certification.

Another title.

Some official recognition that says now you’re qualified to have a voice.

But that office didn’t ask me whether I had provider status.

They didn’t ask whether I was board certified.

They asked what I was seeing in my community.

What patients were experiencing.

What pharmacists needed.

My credentials got me into pharmacy.

My experience gave me something worth saying.

But neither one was the reason I was sitting in that chair.

I was there because I was a constituent.

That’s it.

For years, I’ve watched pharmacists convince themselves they’re powerless because they don’t have the “right” title.

I’ve done it too.

We mistake authority for permission.

They’re not the same thing.

When I took the pharmacist’s oath, nobody said:

“Care for patients... but only after someone tells you you’re important enough to speak.”

The oath never came with that footnote.

Sometimes the next step isn’t waiting for the invitation.

Sometimes it’s realizing there never needed to be one.

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Three hours later I was sitting at their table.

I didn't have talking points. I've lobbied in D.C. before and I'd rather have a root canal. I don't want a spotlight, I want to be left alone taking care of my community.

But CMS has proposed changes to remote patient monitoring that would make that a lot harder, and so far the only version of this work they've heard about is the bad apples.

In this episode: what it's like to walk into a room you have no business being in, why the oath we all took says show up anyway, and the one sentence that sat a Senate staffer back in his chair.

It wasn't pretty. It wasn't perfect. I did it anyways.

If you know a pharmacist who thinks nobody in Washington would listen to them, send them this one.

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For the first few months, I was pretty sure that farmer could not stand me.

She was short with me on every call. Polite, but short. She was busy, she had actual work to do, and here I was on the phone again asking about her blood pressure. She didn’t want the personal stuff and she didn’t want a checklist of health questions either, which does not leave a person much room to work with.

Then late winter came and something in her voice changed. Flatter. Slower. The kind of low that shows up in February and that nobody ever calls their doctor about.

So I asked her what she liked about summer.

That was a clinical question, even though it doesn’t sound like one. I wanted to know whether I was hearing seasonal depression or just a hard week, and I was not going to find that out by asking her to rate her mood on a scale of one to ten.

Gardening was the bullseye. She lit up. She had seedlings started and a plan for what was going in the ground come Memorial Day, and for the first time in months she talked to me like a person instead of an obligation.

After that we talked about the garden. What was coming in, what she was putting up next, what had gone sideways that year. The blood pressure conversation still happened. It just stopped being the reason for the call.

We did that for two years.

Eventually the contract with her provider ended and I stopped working with that office entirely. No chart, no standing, no reason for either of us to think about the other again.

Months later she ran into some problems.

And she called me.

Not the practice. Not whoever had her chart now. She called the pharmacist who had no authority over her care and never had any to begin with, because two years earlier I had asked her about her tomatoes.

No credential got me through to that farmer. She could not have told you a single thing about my training and would not have cared if she could. I want to be clear about that, because I spent a good part of my career believing the opposite.

What I kept reaching for instead

I had eight or nine different jobs in pharmacy before I stopped looking.

Some of them came with real standing. On rounds at the health system, every year the new residents would hesitate to lean on the pharmacist until an attending said out loud, no, they know what they’re talking about, we work with them. Same in the ICU. You work right alongside the physicians and the nurses lean on you and it works.

And then there were the rooms where none of it transferred. When I was starting out in care management I brought the whole model to a department inside my own health system. They took the information. They did not want me.

Every time that happened, I reached for the same thing. Another credential. One more set of letters. One more certification that would finally make me legitimate enough to be taken seriously.

That was never it. I’m not board certified. I have no provider status. Nobody in Washington has handed me a thing, and for eight years I’ve run a care management practice with over a dozen physician partners while more than 800 patients in my community have had somebody calling them between office visits.

Authority is a permission structure

We have spent decades fighting for authority. Provider status, the seat at the table, the recognition. We’re still fighting. E-caps came through, we can do some immunizations now, and we keep going.

But authority is granted. Somebody above you decides you get it, which means somebody above you can decide you don’t.

That is a permission structure. It is not a value structure.

Influence is a completely different animal. Nobody grants it. You build it one useful thing at a time, and once it’s built there’s no committee that can take it back, because no committee ever gave it to you.

We already have it. Pharmacists are still one of the most trusted healthcare professionals in this country, and that isn’t authority, it’s access. It’s the same patient walking up to your counter over and over and you answering the question, even in a big store, even on a bad day.

And we keep trying to trade it in for a title.

Waiting looks like professionalism

I hear it constantly. I’m waiting for provider status. I’m waiting until we can bill directly. I’m waiting until, fill in your own blank.

It feels like patience. It’s a decision you’re making every day not to build, dressed up as being responsible.

I did it too. After the eighth job stopped fulfilling me I sat there for months. I looked at real estate. I looked at healthcare administration. I looked at getting an MBA so I could be a director somewhere. And I remember thinking, wait a second, I have a doctorate in pharmacy, why isn’t that enough?

It was always enough. I just hadn’t done anything with it yet.

More knowledge does not equal a business. More letters do not equal appointments.

Meanwhile physicians are seeing their patients about every 18 months for seven minutes. They’re drowning. And there’s a whole profession of clinicians standing right next to them, in the pharmacies and the call centers and specialty, running prior auths and patient assistance programs and making sure the medications are right, already helping them every single day, waiting for someone to say we’re allowed.

That’s not a small gap. That’s not cheesecloth. That’s whole Swiss cheese.

What changed for me

The way I built Tendco should be illegal for how simple it is. I work under general supervision. I bill under the physician’s office, not under my own authority, because I don’t have any and I don’t need any.

Sit with that. The entire model runs on not having authority.

And that department that turned me down came back around, though not the way you’d expect. After the COVID vaccine push, the CEO of the health system found out I was doing this work in private practice and asked why I wasn’t doing it for them. I told him it was because they didn’t have a job for me. So they sent me to go talk to him.

I walked into that office with heart palpitations. Then I remembered he’s a person, same as me, and I went and shared my value.

He had no idea a pharmacist was capable of any of it. What he pictured was the basement by the cafeteria, dispensing, making sure the medications are safe, no line item on the P&L. So I gave him one. Ten pharmacists over a two-year pilot.

I had a job with that health system in about two hours.

Nothing about my license changed that day. Perceived value changed, because I brought it to the right person.

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You already have the network

One of the pharmacists I’ve worked with is 65, a director of pharmacy at a small rural health system, ready to be done but sure she had more in her. She stood up a practice like mine. On her first ask, she got six providers.

Six. Because she had spent years influencing those people’s working lives from inside her job, and saying yes to her was the easy part.

You already have a network of people who know you and trust you. You have never asked them the question.

One favor before you go. You know a pharmacist who has been saying they’re waiting for provider status. Send them this. Not because I need the share, but because that’s the person this was written for and they’re not going to find it on their own.

If all 300,000 of us took 250 Medicare patients each, every Medicare patient in this country would have somebody. That’s sitting right there.

Your assignment this week

Not someday. This week.

Figure out who in your network would actually listen if you told them you wanted to show up in pharmacy differently. One person. That’s all you need, one ear to hear what’s in your heart about why you became a pharmacist, because I can about guarantee the job you’re doing today isn’t the reason.

They can withhold the title. They have for decades and they probably will keep doing it. They cannot withhold your influence.

So stop waiting for them to give you authority. Build the kind of influence they have to reckon with anyway.

If you’re wondering whether care management is built for you, I made an assessment for exactly that. It’s the Cosmo quiz of pharmacy and it takes a few minutes.

Take the Assessment

Two weeks ago I told you there was a way out that isn’t “stay miserable” and isn’t “quit.” Today I’m opening it.

Two weeks ago, I wrote that it isn’t you — it’s the system. And at the end of that piece, I told you there was a third door.

Today I’m going to open it.

But first I have to tell you about the two doors you already know. Because you can’t see the third one until you’re honest about how small the first two really are.

When work stops feeling like yours, it looks like you have exactly two options.

Door one: endure it.

Get another certification. Chase the leadership title. Take on more, do more, prove more. Tell yourself the next rung will be the one that fixes the feeling.

It won’t.

I know because I walked through door one more times than I can count. Eight different kinds of pharmacy. Retail. Hospital. Administration. Consulting. Long-term care. Different buildings, different badges, different metrics.

Same feeling every time.

Maybe this one will finally feel right.

And every time, eventually, it didn’t.

Door two: exit altogether.

Throw out everything you built. Walk away from the license, the debt, the years. Decide the whole thing was a mistake.

I looked hard at door two, too. I thought about getting an MBA. Becoming a healthcare administrator. Going back for more school.

And I kept hitting the same question:

For what? I already have a doctorate.

Why wasn’t what I already was good enough?

I didn’t want to leave. I wanted to keep showing up for my rural community in the way I was actually trained to. But I didn’t want to buy a pharmacy either — I didn’t want that overhead, those headaches. And as far as anyone ever showed me, buy-a-pharmacy or leave-the-industry were the only two ways to stop enduring.

So here’s what I want you to really sit with:

When you hit the wall, you are handed exactly two doors. Endure, or exit. And you’re told those are the only two.

That’s the lie. Not the wall — the doors.

The fringe and the floor

Most people never take the third door for one reason: it’s unknown. It isn’t woven tight. You can’t see exactly where your foot lands.

I think about it like the fringe on an area rug.

Picture it. The fringe hangs off the edge — loose threads, not woven together, no clean surface to step on.

Now ask yourself: does the fringe mean the floor isn’t there?

No.

The floor is absolutely there. The fringe just isn’t woven tightly enough for you to trust it yet.

That fringe is everything you already know how to do. Every skill from every one of those jobs. It doesn’t feel solid because nobody’s shown you how it holds together outside the box you learned it in.

But underneath the fringe is the floor.

And the floor is you.

I’ve been a failure plenty of times in my life — but almost always as collateral damage to someone else’s choices. Left to my own devices, with my own skills, on my own two feet?

I have never failed me.

Neither have you.

So when you look at a door that isn’t black-and-white, that isn’t endure this or exit that, and your stomach drops because you can’t see the whole floor — remember what’s under the fringe.

You’re not stepping off a ledge. You’re stepping onto ground you’ve been standing on the whole time.

Here’s exactly what’s built on it.

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In this episode, I make the case for a third door most of us were never shown — and I get honest about the eight kinds of pharmacy I worked before I stopped trying to survive inside the box and started blowing holes in it.

In this episode:

• Why “endure it” and “exit altogether” are both the wrong door

• The area-rug fringe — and why stepping toward the unknown isn’t stepping off a ledge

• “For what? I already have a doctorate.” — the question that changed everything

• 300,000 pharmacists, 250 patients each, and the Medicare patients waiting for us right now

This one’s for anyone — in pharmacy or not — who’s ever felt stuck between staying miserable and starting over. You’ve never failed you. Don’t start doubting the floor now.

New episodes of The Dose every Monday 🎧 → https://theablystone.substack.com/subscribe?params=%5Bobject%20Object%5D

You’ve heard how I started.

You’ve seen where I am now.

But there are eight years in between that I’ve never told you about — and they’re the part that almost didn’t work.

I want to tell you about them today. Not the polished version. The real one. Because I think the reason so many pharmacists quit five feet from something good is that nobody ever showed them what the middle actually looks like from the inside.

So here it is.

The doubt years

For the first twenty-four months, I was trying to figure this out completely alone.

No model. No one ahead of me on the trail. No one to tell me whether the thing I was feeling — this is hard, this is slow, maybe I’m not built for this — was a sign I should stop, or just a sign I was in the middle.

I didn’t know. So I assumed the worst. I assumed the slowness meant I’d gotten it wrong.

I want to be honest about how close I came. I almost walked away. I “one-more-time’d” my way through it — I’ll try one more time, I’ll give it one more month — more times than I can count. Not because I had some special reserve of grit. I didn’t. I just couldn’t quite make myself quit on a day when quitting felt final.

The long line of no’s

Here’s the part the highlight reel never shows: the first physician who said yes came after a long, quiet line of no’s.

Not dramatic no’s. Worse — the ordinary kind. The office that never called back. The “let me think about it” that went nowhere. The conversation where I could feel, halfway through, that it wasn’t going to land, and I had to finish it anyway.

Every one of those made me question whether I was doing something wrong. Whether I was missing some obvious thing everyone else already knew. From the outside, a long stretch of no’s looks exactly like failure. It has the same shape. It feels the same in your chest.

But it wasn’t failure. It was the middle. It’s just that no one had told me the middle would feel like that.

What I know now that I didn’t know then

I’m recording and writing this halfway up the mountain. Hair up, gross after physical therapy for my hip, still very much in the thick of it — still reaching out to providers, still enrolling patients, still hiring, still answering every email and text myself.

I don’t tell you that so you’ll feel sorry for me. I tell you because I need you to see that “still in the middle” and “building something real” are the same sentence. The middle didn’t end when it got successful. Some of the problems just changed shape. The financial worries got bigger, not smaller. The lonely part didn’t disappear — it moved.

And I’ve made peace with something because of that:

The slow part is the normal part.

We scroll everyone else’s highlight reels and quietly decide that our own pace is evidence we’re failing. It isn’t. Nobody’s overnight success was overnight. They just stopped posting during the middle.

When it gets hard and the voice in your head says I can’t make it — you’re not wrong that it’s hard. You’re just wrong about what the hardness means. It doesn’t mean you weren’t built for this. It means you’re growing. Those are not the same thing, and learning to tell them apart is most of the battle.

Here’s the one thing I’d go back and tell myself at month four, sitting in the thick of it, sure I’d gotten it wrong:

You don’t have to do it the lonely way I did.

I climbed the first two years with no map and no one ahead of me, and that’s precisely what made it take two years. Not the work — the work was always doable. It was the alone that cost me the time. And that part, it turns out, is the part you get to skip.

So let me hand you what I wish someone had handed me at the start: what the build actually looks like, stage by stage.

The build, stage by stage

If the middle is so normal, the useful question isn’t how do I avoid it — you can’t. It’s how do I recognize where I am in it, so I stop reading a normal stage as a personal failing.

Here’s the honest map.

Stage one — the groundwork (roughly months 0–3)

This is modules-and-mindset. You’re learning what care management actually is, which programs bill and how, and — the harder part — you’re wrestling with the idea that you have to walk into a physician’s office and lead with your value instead of your resume.

What the milestone looks like: not a signed anything. It’s the moment you can explain, in one clean sentence, why a pharmacist standing in front of a doctor is an asset and not a favor. That clarity is the deliverable of stage one.

What it feels like from the inside: like you haven’t started, because there’s no revenue and no patient yet. That feeling is a liar. You’re building the only thing that makes the next stage possible.

Stage two — the first yes (roughly months 3–6)

Now you’re having provider conversations. This is where most people stall, because this is where the no’s live — and, as I said above, they come before the yes, not instead of it.

What the milestone looks like: your first signed partner. Usually it’s not the biggest or most prestigious office. It’s the one you already have a relationship with — often the practice you’re already calling constantly because something’s always a little bit of a mess. They know they need help. Start there.

What it feels like from the inside: like rejection, right up until it doesn’t. The stretch of no’s before the first yes is the single most misread part of the whole climb. It looks like the model isn’t working. It’s actually the model working exactly as it does for everyone.

Stage three — the first panel (roughly months 6–12)

You have a partner. Now you have to enroll and manage real patients — and this is where a different muscle gets built: the enrollment conversation, the monthly rhythm, the reps that turn a script into something that sounds like you.

What the milestone looks like: a first cohort of enrolled patients and the first patient who tells you, in their own words, that you changed something for them. That sentence is worth more than the revenue at this stage, because it’s the proof you’ll build everything else on.

What it feels like from the inside: slow and repetitive and occasionally like you’re not moving. You are. Every rep is lowering the time it takes and raising the enrollment rate. The tedium is the progress.

Stage four — reliable revenue and the beginning of a team (roughly months 12–24)

The work is working. Now the questions change: how do I keep this compliant, how do I get the billing right every time, and how do I stop being the only person doing every touch?

What the milestone looks like: revenue you can count on, clean enough documentation to survive an audit without panic, and the first person you train to do what you’ve been doing alone.

What it feels like from the inside: honestly, like a whole new middle. Bigger problems, bigger stakes. This is the part nobody warns you about — that “successful” has its own messy middle. It does. That’s not a sign you did it wrong. It’s the next section of the same trail.

What “looks like failure” actually is

Let me name it plainly, because this is the reframe that would have saved me months:

• A long run of no’s isn’t rejection of you. It’s the normal cost of finding the right first partner, and it’s teaching you the conversation.

• A slow-filling patient panel isn’t a broken model. It’s the reps that make the model fast later.

• The loneliness isn’t a verdict. It’s the predictable feeling of doing something before you have anyone around you doing the same.

• “Successful but still stressed” isn’t a bait-and-switch. It’s just a higher, better-paid section of the climb.

Every one of those, from the outside, wears the costume of failure. From the inside — if you know the map — they’re just mile markers.

The two things that cut years off the climb

I spent twenty-four months in stages one and two because I was solving them from scratch. If I’d had these two things, I’d have spent a fraction of that:

One — a proven model. Not theory. The actual sequence, the actual contract, the actual enrollment script, the actual billing structure that survives an audit. Most of my lost time wasn’t spent doing the work — it was spent inventing the work before I could do it. A proven model deletes the inventing.

Two — someone ahead of you on the trail. The single most expensive thing about my first two years wasn’t any mistake. It was the alone. Having someone a few feet up who can look back and say “that no you just got? Normal. Keep going.” — that alone is worth more than any framework, because it stops you from quitting on the days the middle feels like failure.

That’s the whole reason I built what I built — PIVOT, the community, the alliance. Not because the work is so complicated you can’t learn it. You can. But because you shouldn’t have to climb the lonely way I did to find out that the slow part was normal all along.

The middle is messy. That’s not a detour from the path. It is the path.

And you don’t have to walk it alone.

🎧 Listen to the full episode of The Dose — “The Messy Middle” — Listen here. Recorded raw, hip surgery recovery and all. Left exactly as it came out, because that felt like the only honest way to publish this one.

That’s what this episode is.

I recorded it with my hair up, gross after a physical therapy session for my hip, still very much in the thick of it — still reaching out to providers, still enrolling patients, still hiring, still answering every email and text myself. Not because I have it all figured out. Because I don’t. I’m halfway up the mountain, same as you.

Here’s what I’ve come to believe about that middle: the slow part is the normal part. We scroll everyone else’s highlight reels and decide our own pace means we’re failing. It doesn’t. When it gets hard and you think I can’t make it — you’re not wrong that it’s hard. You’re just wrong about what the hardness means. It’s not a sign you weren’t built for this. It’s a sign you’re growing.

I almost gave up at 24 months. One-more-time’d my way through it. And I can tell you from five feet past that point: the middle is messy, it’s lonely, and it’s worth it — and you don’t have to climb it alone.

This one’s a little rawer than usual. I’m leaving it exactly as it came out. 🎧 Listen to The Messy Middle

A pharmacist posted recently that they couldn't remember why they chose pharmacy in the first place. Another said they regretted the debt. Another said they felt broken.

Not tired. Not burned out. Broken.

And honestly? I sat with those words longer than I should have.

Because I know what it's like to look at a profession you once loved and wonder when it stopped feeling like yours.

I know what it's like to have Sunday night sadness seep into every part of your life. To feel like everything ahead of you turns blue because Monday is coming. I know what it's like to spend years in school, take an oath to care for patients, graduate with hundreds of thousands in debt, and realize you're using maybe 1% of what you were trained to do.

I had eight different pharmacy jobs in twelve years. Eight.

Retail. Hospital. Administration. Consulting. Long-term care.
Different titles. Different organizations. Different metrics.
Same feeling.

Maybe this one will finally feel right.

And every time, eventually, it didn't. Not because the people were bad. Not because I wasn't grateful. Not because pharmacy itself was wrong. Because what we were taught to do and what we were asked to do were completely different things.

We were trained to motivate.

To educate.
To problem solve.
To understand behavior.
To support patients.
To hold them accountable.
To care for human beings.

Then we graduated into systems designed around volume.
Dispensing.
Efficiency.
Productivity metrics.
More prescriptions.
More vaccinations.
More tasks.
Less humanity.

And somewhere along the way, pharmacists started internalizing the problem.

“Maybe I'm not resilient enough."
"Maybe I just need another certification."
"Maybe everyone else is handling this better than I am."
"Maybe I chose wrong."

No.
You didn't choose wrong. You chose pharmacy. The system changed around the oath.

And then it asked you to believe that your dissatisfaction was a personal failure instead of an organizational design flaw.

Recently, I tried sharing this perspective in a discussion where pharmacists were openly grieving what the profession has become.

Not attacking anyone. Not tearing pharmacy down.
Just offering another possibility. A little hope. A reminder that there are pharmacists out there building practices where they actually get to do what they were trained to do.
And someone with a little power decided that message wasn't welcome.

The implication was clear:

Put your hand down.
Stop talking about alternatives.
Stop giving people hope.
Accept reality.

But here's what I believe.

When pharmacists are saying they regret the debt, regret the profession, regret the years they invested... We don't need less hope. We need more. Because telling pharmacists to stop imagining something better doesn't protect the profession.

It abandons it. And it abandons the next generation too.

The oath we took wasn't just about us.
It was about fostering the growth of pharmacy.
It was about moving the profession forward.
It was about leaving it better than we found it.

So no.

I won't stop talking about what's possible. Because pharmacists aren't broken.
They're grieving a profession that promised patient care and delivered production quotas. They're grieving a version of themselves they thought they would become.
And grief isn't weakness. It's what love looks like when something you believed in didn't keep its promise.

So maybe the most important thing I can tell you today is this:

If you've forgotten why you chose pharmacy –
If you're staring at student loans wondering if this was all a mistake –
If you're showing up as a fraction of who you really are because work takes everything you've got –

It isn't you. It's the system.

And systems can change.
People build systems. People rebuild systems. People create third doors.
And pharmacists can too.

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We’ve been waiting for provider status for 30 years.

Thirty years of resolutions, lobbying, white papers, position statements, and conference panels. Thirty years of “it’s coming.” Thirty years of pharmacists sitting in break rooms saying “once we get provider status, everything will change.”

It hasn’t come. And I’m done waiting.

Here’s what I’ve learned in 8 years of building a care management practice without provider status, without new legislation, and without anyone’s permission:

The permission slip doesn’t exist. You don’t need one.

CCM, RPM, and PCM are live billing codes. They don’t require a pharmacist NPI. They don’t require provider status. They require a physician partnership and a qualified healthcare professional delivering documented care. You are that professional.

190 pharmacists signed up for the Innovative Pharmacist Alliance in three weeks — with a Google Form. No website. No ad spend. 70% of them weren’t members of ANY national pharmacy organization. They were out there building, alone, with no network, no advocacy, and no professional home.

Why? Because the existing structures were built for dispensing. And these pharmacists are done dispensing their careers away.

Below the paywall, I’m breaking down what’s actually changing in the regulatory and payer landscape right now — and how to position yourself before the rest of the profession catches up.

🎧 This is the final episode of The Dose this season. I talk about why 193 pharmacists matter more than 30 years of waiting. Listen here.

🎆 PIVOT enrollment opens this weekend for the July cohort.

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I almost built PIVOT as a self-study course.

Record the modules. Build the portal. Set up the payment page. Automate the delivery. Collect the revenue. Move on.

That’s what the online business world tells you to do. Scale yourself out. Remove the bottleneck (you). Sell the course while you sleep.

And I couldn’t do it.

Not because I don’t understand the model. I understand it fine. It’s efficient. It’s scalable. It’s profitable.

I couldn’t do it because someone did it to me.

During my 24 months of being stuck, I bought a program that promised to show me how to build a consulting practice. It was a course. Modules, videos, worksheets. And when I got stuck — which was immediately — there was no one there. No mentor. No phone call. No one walking the road with me.

I paid for theory and got left alone with my fear.

And I swore I would never do that to another pharmacist.

That’s why PIVOT is mentorship, not a course. Yes, there’s curriculum. Yes, there are frameworks. But the core of PIVOT is me — walking the road with you, in real time, through the hard parts that a video module can’t solve.

The first physician conversation. The moment you freeze on a discovery call. The week you want to quit because nothing is happening. The contract negotiation you’ve never done before.

Those moments need a human. Not a module.

Below the paywall, I’m breaking down the structural difference between a consulting practice built on a course model versus one built on a partnership model — and why the structure you choose determines whether your practice survives year one.

🎧 This week on The Dose, I talk about both sides of the coin — Tendco and PIVOT — and why the oath of a pharmacist drives everything. Listen here.

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