I never rented a car from Avis.  I’ve rented from other companies, like Hertz or Enterprise when I’ve gone on vacation.  But never from Avis.

I’ve heard of Avis, though.  Actually, I’ve heard of most of the major car rental companies: Avis, Hertz, Enterprise, National, Dollar, Budget, Alamo, and Thrifty.  I’m sure they’re all fine, reputable companies.

I think Hertz is the largest, and I don’t know who’s the smallest.  But I’m pretty sure that Avis is No. 2.

When I was growing up, Avis car rental trailed behind Hertz.  Hertz was No. 1, Avis was No. 2. So Avis’ advertising people devised a campaign based on Avis’ No. 2 status.  Their motto pointed out that Avis was No. 2, however “we try harder”.

Their advertising campaign was quite successful.  Avis touted many things that they were doing or needed to be done since they were No. 2.  They were true underdogs. But that was okay, because I think they really relished that role.

For the most part, I can’t remember those who were in the No. 2 position.  I can’t tell you who was the second person to walk on the moon (Neil Armstrong was the first).  I don’t know who the second person was to sign the Declaration of Independence (John Hancock was the first).  And being a true Met fan, I know Pete Alonso hit the most home runs this baseball season, but I don’t know who the No. 2 person was.

But I do remember Avis.  The car rental company that was No. 2.

There’s nothing wrong with being No. 2.  I was teaching at my career school job. Several months prior, the school had started a GED program.  I was one of the two instructors teaching the course.

The Campus Dean called me into his office.  He shared with me a five-page report on the GED program that he received from corporate.  I’ll be honest, to me it looked like number city. There were forty schools across the country.  Each one of them had recently started a GED program.

This report was simply a listing of numbers.  There were the:

1. Number of students who originally took the GED course.
2. Number of students who took the GED test.
3. Number of students who passed with an A or B.
4. Number of students who passed with a C or D.
5. Number of students who failed.
6. Number of questions that each student got right.
7. Number of questions that each student got wrong.
8. Number of questions that were left unanswered.

The Campus Dean asked me what I thought.  I focused on a listing of numbers on the third page.  This data listed the number of students who passed the GED test and received their diploma.  Next to this listing was the number of students who enrolled in the various programs in a given school.  It provided this information for all forty schools.

The No. 1 school had 36 students who took the GED course and then enrolled into their school.  We were the No. 2 school with 21 students who took the GED course and then enrolled into a program in our school.  Of the 38 schools remaining, the school with the highest number of students who took the GED course and then enrolled into the school was “7” (with most schools obtaining far less).

I told the Campus Dean that even though we weren’t No. 1, that we were the No. 2 school of the forty schools.  We were the No.2 school in the country. Therefore, we should have no problem with being No. 2.

Becoming a Second Banana

There’s a term called “second banana”.  It’s attributed to a 1920’s comedian named Harry Steppe.  He used the term “top banana” to refer to the main comedian and “second banana” to refer to the secondary comedians in the show.  Later, comedian Phil Silvers popularized the terms in his 1950 musical “Top Banana”.

It should be noted that second bananas are very important.  In addition, they are quite vital to a top banana’s success.  Ed McMahon was a perfect second banana with his timing as he set Johnny Carson up with the funniest jokes.  Steve Allen had some of his best routines while interviewing Don Knotts, Tom Poston, and Louis Nye. And Carol Burnett’s funniest moments came when Harvey Korman and Tim Conway digressed from the script.

This is the role of a good second banana.  It is their job to make the top banana look good.

For most of my career, I was the second banana.  I enjoyed being the second banana, the No. 2 person, if you will.  My goal as a No. 2 person was to make my boss look good.

I let my boss be the one in the forefront.  My boss would pose for pictures and receive hospital awards.  He would be the one to accept accolades from other departments.  My boss was the face of the pharmacy.

As a good No. 2 person, I was always behind the scenes.  I was glad that I was in this role. And my boss was glad too.

Developing My Short Term Philosophy

My title changed amongst my hospitals.  Originally I was an Assistant Director of Pharmacy.  In another hospital, I became a Pharmacy Manager. Then, my third hospital, I was a Pharmacy Supervisor.

But regardless of my title, my role was always the same.  I was second-in-command. I performed the job of a No. 2 person.

I always viewed the position of the No. 1 and No. 2 persons differently.  I felt that the Director of Pharmacy (the No. 1 person) was always looking toward the future.  The director was always thinking about tomorrow.

The director decided where the pharmacy was going.  Did it need a new piece of equipment? Did it need to expand or modernize?  Did it need to update its technology? It was the job of the No. 1 to make certain that the pharmacy was heading in the right direction.  They needed to think how the pharmacy could make itself better and how to help the pharmacy reach its goals.

The No. 2 person’s job was different.  As a No. 2 person, my goal was to get through the day.  I arranged for proper staffing to ensure that the meds were promptly delivered to the nursing units.  I addressed the doctors’ needs. I helped (and sometimes battled) the nursing staff. I dealt with work-arounds  when computers and other systems weren’t working properly. I put up with the daily aggravation to best serve the patients.

My boss was long term.  I was short term. Quite often, our roles overlapped.  But for the most part, we kept on our specific paths.

I enjoyed my role as the No. 2 person.  Here are two of the things that I learned.

Devising a Decision-Making Style

I had been an Assistant Director of Pharmacy for about a month, when I got the call on the weekend.  It was an intensive care nursery (ICN) neonatologist. They had a very sick infant on their unit. They had tried other antibiotics but they simply didn’t work.

The neonatologist heard about a new antibiotic that just came onto the market.  He did some research. He found out that there was a treatment protocol in which this new antibiotic was used successfully to treat this disease in infants.  He wanted to use this new medication.

We did not have this medication on the hospital’s formulary.  In fact, we didn’t even have it in the hospital. Even if we ordered it, the drug wouldn’t come in until Tuesday, or maybe Monday at the earliest.

The neonatologist said that he spoke with my pharmacist in the pharmacy.  The pharmacist stated that he might be about to borrow the medication from another major medical center.

But what the doctor was really asking was whether I would authorize the use of this non-formulary drug on the neonatal patient.  And he wanted to begin today. I told the doctor that I would get back to him.

I immediately called my boss.  Now this was the early 1980s. It was way before cell phones and probably before answering machines as well.  The phone rang about ten times and no one picked up. And I was unable to leave a message.

I called the pharmacy and spoke to the pharmacist.  The pharmacist explained that he had a friend who was a pharmacist in another hospital pharmacy.  His friend was willing to let us borrow two one-gram vials of this new antibiotic. What’s more, the patient was on an 80 milligram dose.  So we could draw this dose from the one gram vial several times until our own stock arrived.

So the question became, was I going to allow this to be done?

In hindsight the answer was easy. Would I allow a doctor to use a drug specifically made to treat a patient’s condition?  Of course I would. But at the time it was a tough call.

Here were the points that made me hesitant:

1. The drug was very new and we had other drugs that did the same thing.
2. We did not have the drug on formulary.  It had not been approved for use by our Pharmacy and Therapeutics Committee.  It had never been used in our hospital.
3. The drug was being used on a neonatal infant with a dose determined by the doctor.
4. I had only been an assistant director for one month.  I could not get in touch with my Director. I was making the decision solely on my own.

 

So I made my decision.  It was a difficult decision to make.  But I decided to obtain the drug, calculate the dose, and administer it to the patient.  And it would start today.

 

By Monday, the patient had received several doses of the antibiotic.  They were much better. I was much worse.

I had worried about my decision all weekend long.  I thought it was the right decision. But there were a lot of rules and protocols that I violated.

When I got to work that Monday, I found my boss speaking with one of our pharmacists.  The pharmacist told my boss that a neonatal physician wanted to use a non-formulary medication on one of the ICN patients.

My boss immediately said “no”.  The pharmacist then told my boss that this neonatal physician said that he (the physician) got permission to use the drug.  My boss shook his head and stated that “the doctor didn’t call me”.

I listened to the conversation.  Neither my boss or this pharmacist had all the facts.  I was still quite nervous. I asked my boss to step into his office so that I could speak with him.

I told my boss that the reason that he never got the call was that I got the call.  I explained the entire situation to my boss.  How this was an ICN baby that had this horrible condition.  How the doctor and staff tried all alternative antibiotics and how none of them worked.  How this neonatologist called me and made a case for this new non-formulary medication. How our pharmacist had obtained the drug from a nearby neighborhood facility.  How we calculated the drug’s dose for the infant and how the baby was getting better.

My boss listened attentively to what I had to say.  Finally, he smiled. He said that I made the right decision.  I breathed a sigh of relief.

I’ll admit that it was hard making my first major decision.  Yet, what made it even tougher was that I made it solely on my own.  I didn’t have the luxury to think about it for a day or so. And I didn’t have anyone to bounce it off of.  I was quite nervous about my decision since I second-guessed myself all weekend long.

For the most part, I try to keep a level head and get all the facts.  I’m usually a very logical (as opposed to emotional) person. I’ve always been fair and consistent.

When making a decision, I stay within the confines of the rules.  Except when I feel it’s important to digress from them.

Encountering Those Who Are Wrong

I worked as an Assistant Director of Pharmacy for a revolutionary hospital system in the 1980s.  We were the first hospital to use gamma globulins in pediatric AIDS patients. We had a pediatric oncology clinic. We had a neonatal physician who split IV nutritional solutions so they would not precipitate when being administered to neonatal infants.   We had an extensive orthopedic center.

We also had a state-of-the-art eye and ear institute where physicians practiced ground breaking therapy.  I was a good friend of the physician-in-charge.

This doctor had published many cutting edge therapies in several ophthalmology journals.  But his forte involved injecting antibiotic solutions directly into the eyeball after eye surgery.  This procedure reduced the risk of developing infections in the eye.

In the 1980s, I’ll admit this practice sounded pretty radical (and pretty gross too).  Yet, his procedures were quite successful. The doctor would numb the eyeball. Then he would inject one of two specific antibiotics directly into the eyeball.

Which is why it struck me as unusual when the pharmacy received an order for an injectable antibiotic that was not one of the two.  I thought this was strange. Why would the doctor suddenly deviate from the two injectable antibiotics that he always used?

I went upstairs to his unit.  There were two residents sitting at the nursing station.  He was not there. The residents did not know when he was going to be back.

It’s not that I dislike residents.  Some of them are very good. It’s just that some of them treat me like I’m the lowly pharmacist and they’re the all-powerful resident.  This was unfortunately the case in this situation.

I found out that one of the residents had written the order (not my good friend— the doctor).  The resident had obviously made a mistake and selected an injectable antibiotic which the doctor had never used.  I wanted the resident to change the order to the appropriate injectable antibiotic. I did not want to embarrass the resident. I tried to be as professional as possible.

I showed the resident the order that he had written.  I explained that the doctor had never used this particular injectable antibiotic in the eye. I (politely) asked the resident to change the order.

The resident became very snippy.  He claimed that I did not know what I was talking about.  He stated that the doctor had used this specific antibiotic hundreds of time.  He demanded that I fill this injectable antibiotic for this patient.

I was really at a standstill.  The order surely was valid. The resident had examined the patient and wrote an order for what he thought was the right therapy.  Only it wasn’t. I knew the resident was wrong.

Yet by my filling the order, I would be giving an incorrect medication to the patient.  And it might help the patient. Or it might harm the patient.

I made my decision.  I stated that I was not familiar with the use of this particular medication being injected into the eyeball.  I therefore requested some sort of documentation for injecting this antibiotic directly into the eye.

The resident became furious.  He accused me of delaying treatment for the patient (which I was).  I remained calm. I explained that I was returning to the pharmacy to perform my own research.  I would search for some documentation to use this injectable antibiotic in the eye. If the resident found appropriate documentation, I would accept it as well.

I left a very angry resident at the nursing station and returned to the pharmacy.

I researched this antibiotic to be injected into a patient’s eyeball.  I found nothing.

About an hour later, my friend the doctor, came to the pharmacy.  He was pleasant, but wanted to know what the problem was. I showed him the medication order.

He became very solemn as he read it.  He shook his head and admitted that the order was wrong.  He stated that he only used two particular injectable antibiotics in a patient’s eye.  And this wasn’t one of them.

I asked him to speculate what would happen if this particular antibiotic was injected into a patient’s eye.

He paused.  Finally, he said one of three things would occur:

1. The patient might get better,
2. The patient might get worse (and possibly lose an eyeball),
3. Or absolutely nothing would happen.

And the doctor was not willing to take a chance.

The doctor asked for the order and I gave him a copy.  Ten minutes later I received an order for the correct injectable antibiotic.  The order was written in the resident’s handwriting.

I’m not here to gloat.  Nor am I here to trash the resident.  He made a mistake. And it was corrected at no harm to the patient.

Whenever I’ve made decisions, I always listen to the other person’s decision.  And I truly listen. I don’t have my mind made up without hearing what they have to say.

Sometimes what they have to say makes sense and I end up altering or changing my decision.  Sometimes it doesn’t make sense and my decision stands.

I made the right call in delaying therapy that day.  I saw something that didn’t look quite right and decided to put the medication on hold.  I’m glad I did, for it best served the patient.

I’ve made many decisions throughout my career.  Some easy and some not too easy. Some required a little thought.  Some were quite nerve wracking.

Yet, I’ve learned that that regardless of the decision, that there are two things that I need to do:

1. I’ve always tried to be fair and consistent and
2. I’ve always tried to do what’s best for the patient regardless of the rules.