Have you ever woken up one morning and thought “I am going to give eight years of my life and potentially go into $300,000 of debt to count pills behind a counter and not talk to a single person all day?” No? Me neither. I think it’s safe to say that nobody has ever had this thought. And the reason for that is while pharmacy school provides a great training and a doctorate level education it also requires a high amount of communication. Pharmacists talk to technicians, physicians, nurses, store managers, and of course patients all day long. And while being a doctor of pharmacy means we have a high degree of knowledge about medications, it doesn’t mean we have great communication skills.
Pharmacists started formally counseling their patients due to OBRA 90. This was a huge law passed in 1990 (passed in 1990… OBRA 90… noticing a theme?) that changed the profession of pharmacy forever. Obra 90, among many other things, was the first ever to mandate patient counseling. Now pharmacists have been practicing since way before 1990, and of course they had been counseling patients since before this time too. However, this law was enacted to help the federal government (and thus the American taxpayers) save money. Their theory was that if pharmacists did more counseling, there would be fewer adverse drug events and interactions, better care for the patients, and less healthcare spending. This is absolutely true. This study shows that when pharmacists provide structured counseling:
- Confusion about when to take medications declined from 4% to 2.5%.
- The average number of prescription drugs and the number of doses taken per day decreased.
- Hospitalization frequency decreased from 39.8% to 31.3%.
Numbers like this show that counseling really can work. Yet another study showed that only 47.3% of pharmacists and 34.0% of patients were satisfied with the current medication counseling service. How many times have you gone to pick up a prescription, and the pharmacist didn’t even counsel you? How many times have you gone and picked up a prescription, the technician asks if you want to speak to the pharmacist, and you say no? You rush out of the pharmacy and don’t even look back. Or worse, the pharmacist comes over, counsels you, and you end up even more confused than when you started. I have heard over and over again from patients that counseling with a pharmacist can be a waste of time.
My theory is that it really isn’t a waste of time, if we are doing the right type of counseling. Our counseling sessions are so inadequate that they often go like this:
Pharmacist: “Hi Mr. Smith Are you picking up your medication today?”
Joe Smith: “Yes, it’s right there.”
Pharmacist: “Great! What did the doctor tell you about the medication?”
Joe Smith: “She told me it is for my high blood pressure.”
Pharmacist: “Yep, this is lisinopril, you take it once a day, and it helps with hypertension. You can take it with or without food. Do you have any questions about your medication?”
Joe Smith: “No, not really.”
Pharmacist: “Okay, here you go. Have a nice day.”
Joe Smith: “Thanks, you too.”
This may seem like a perfectly good counseling session, but in reality it is absolutely terrible. Let’s look at a proper counseling session using motivational interviewing:
Pharmacist: “Hi Mr. Smith, are you picking up your medication today?”
Joe Smith: “Yes it’s right there.”
Pharmacist: “Great! What did your doctor tell you about this medication?”
Joe Smith: “She told me it is for my high blood pressure.”
Pharmacist: “Yes it is for high blood pressure. This medication is called lisinopril. Have you taken it before?”
Joe Smith: “Yes, I’ve taken it for at least a decade now.”
Pharmacist: “That’s a long time. How have you been taking the medication?”
Joe Smith: “I take it once a day.”
Pharmacist: “That’s good, have you had any side effects?”
Joe Smith: “No, it works well for me.”
Pharmacist: “Good, what have your blood pressure readings been like?”
Joe Smith: “I don’t know. I don’t check them. My doctor does.”
Pharmacist: “When you are on this medication, it is very important to know what your blood pressure readings are. If you know your blood pressure, you can know if you are meeting your goal. What is your goal with taking this medication?”
Joe Smith: “Well my goal would be to not take the pill. I don’t like taking pills.”
Pharmacist: “That’s a great goal, and one that I think you can reach if you work hard. Definitely let your doctor know before you stop taking this medication, but there are non-pharmaceutical ways that we can use to decrease your blood pressure so hopefully you won’t have to take this medication long term.”
Joe Smith: “Non-pharmaceutical ways? Like aromatherapy? I don’t believe in that stuff”
Pharmacist: “No, like eating right and exercising. I know it seems silly, but it really can make a difference. If you want, we have a blood pressure machine right over there. I can show you how to take your blood pressure, and once we know what your numbers are, I can help you come up with some ways we can possibly reduce your blood pressure.”
Joe Smith: “Yeah I’ve heard all the speil before about eating healthy and losing weight. Every time I go to the doctor, she tells me I need to lose weight.”
Pharmacist: “What do you think is keeping you from losing the weight?”
Joe Smith: “I drink too many sodas. I can’t give up my Dr Pepper.”
Pharmacist: “I totally understand. If losing weight is a goal of yours, we can come up with ways to lose weight that don’t involve giving up sodas.”
Joe Smith: “Really? My wife is always telling me I need to give up sodas. If I could lose weight and still drink my sodas, that would be great. My kids are running circles around me, and I just want to be able to keep up with them again.”
Pharmacist: “Keeping up with your kids is a great goal to work towards. Let’s check your blood pressure and brainstorm ways we can help get there.”
~ Then the pharmacist helps the patient take his blood pressure and sets a goal of walking with his kids around the block after dinner to increase his exercise. ~
See how much different those two counseling sessions were? Now, I know what you are thinking. Of course they are different; one is longer. I would love to be able to help more patients, but I can’t afford the time to help every patient take their blood pressure, and not every patient is going to want to anyways. These are the typical arguments that a pharmacist, especially at a large chain store, is going to give. But I would argue that you can’t afford NOT to take the time. You may not always get a positive response, but I have seen patients break down and cry in the pharmacy because a pharmacist took 5 minutes out of their day to listen to a patient. Sometimes this is the first time a healthcare professional has done that for a patient ever. When I was in pharmacy school working for a large chain pharmacy, I made so many changes to a patient’s medication regimen just by talking to them and calling their doctors office. I would never do anything without their prescriber being notified, but it made such a difference in my patients lives they were so thankful for it. I have come up with a few tips and tricks for motivational interviewing to help you better communicate with your patients.
There is a whole art to motivational interviewing and if your pharmacy school was anything like mine the chances of them teaching you motivational interviewing in a meaningful way is not exactly high. APhA has a great (and short) book on motivational interviewing (Get a copy here) that I highly recommend. There is also a great series of videos on motivational interviewing put out specifically on tobacco cessation here. But in case you are looking for something shorter let me give you the highlighted version.
Meet the patient at their level:
One of the most surprising moments for me was when I was talking to one of my professors, a Pharm.D., and she went on a 20 minute rant about how much she hated being counseled.
She is an adrenaline junkie, and had had an accident where she fractured her pelvis. An incredibly painful event by all accounts, leading her to spend an extended amount of time in the hospital. She eventually made it out of the hospital to pick up her pain medication from the pharmacy. When it came time to check out the pharmacist politely checked her out at the register, and began to counsel her. She politely explained that she was a pharmacist and understood how to take the medication.
The pharmacist continued to counsel her and kept her standing at the register with a line forming behind her. She finally had enough of the pain and said “Can I see that prescription for a moment?” The pharmacist said yes and handed her the bottle. She opened it, took out a pain pill, and put it in her mouth. She said “You have about 30 minutes before this kicks in and I can’t drive home anymore. Can you please finish so I can go home?”
If we cannot even get pharmacists to want counseling we are doing something wrong. In her case she had very clearly declined counseling (something patients have a right to do) however the pharmacist ignored her request and continued to talk about her personal medical record in a public space. This is not how counseling should be done. There is a reason in both counseling examples up above the first question asked was “What did your doctor tell you about this medication?” A large part of motivational interviewing is meeting the patient where they are at in their education level.
The pharmacist above did not need to know about the medication side effects, she already knew them. She needed to know if the doctor wrote for refills and what else she could do to control her pain besides the medication. In the example with the high blood pressure it was the same scenario. The patient knew how to take the medication and knew the side effects. They did not know how that medication affected their blood pressure and how they could use alternative therapies to reduce their blood pressure. This is critical to listen to the patient.
Treat the patient with respect and use their language:
You will notice that in the blood pressure example the pharmacist used the term high blood pressure instead of hypertension. This is important to use patient friendly terms. The pharmacist also used Mr., and showed respect for the patient. They did not get offended when the patient rejected their idea of alternative therapies as aromatherapy that they did not believe in. The pharmacist simply talked to them about therapies that may be a better fit for this particular patient.
Separate pharmacists from point of sale:
One idea that I would love to see happen would be to separate pharmacists from the point of sale. When we are having to worry about collecting a patient’s money (Something virtually no other doctor would ever do) as well as counseling a patient that has potentially just gotten out of the hospital and is in pain it’s no wonder we aren’t getting heard. We should be meeting the patient in a private area (not the cash register) and sit down with them. This would not only give pharmacists a chance to sit but would also let the patient sit. Setting the expectation that there is time to talk and making a comfortable environment instead of standing with a visible line forming behind you.
Ask open-ended questions:
When I wanted to go to prom with my boyfriend in high school. I knew getting my mom to agree was going to be a tough sell. I did not ask my mom if I could go to prom with my boyfriend for an evening of dancing at a hotel that was known for not checking IDs with it’s liquor sales. The answer would be an absolute no. So I came up with a pretty crazy scenario, where me, my boyfriend and some friends were going to camp on a beach all weekend in a large tent. Having a whole group of teenagers in a tent for a whole weekend sounded worse than me and my boyfriend who she knew and trusted dancing for one night. When presented with the two options, my mom was much more agreeable to one night than an entire weekend. It’s all about perspective. The exact same can be said about counseling patients.
Instead of asking “Just picking up the one medication?” you could ask “What brings you in today?” These completely different questions will yield completely different answers. One will give you a simple yes. The other will lead the patient to discuss their headaches, or ask you about over the counter medications. It can’t be answered with a simple yes or no. Asking “Do you have any questions?” is the equivalent of asking your mom if you can go to prom with your boyfriend with no parental supervision. The answer will almost always be no. Asking “What other questions do you have for me?” is forcing your mom to choose between letting you be gone for one night with one trusted person or a whole weekend with a wild group of teenagers. It forces her to think and give a much better answer.
I hope these tips have been helpful to you. Please feel free to comment below or contact us if you have any other counseling tips. We would love to hear more advice on connecting to our patients!