Should we insist on counseling patients?

March 7, 2005

Q: An impatient senior citizen pushes several OTCs and his credit card across the pharmacy counter. The pharmacist begins to say, "The side effects of this drug include..." and the patient replies, "I don't have time" and snatches up the bottles. Is there an ethical duty to counsel him, despite his lack of cooperation?

A: Many of us who practice in urban areas often face busy patients with little time to listen to any consultation from their pharmacist. Even retired patients may fire off several questions in a single breath and may offer several possible answers to each one! Few of these patients get much out of the minute or two they have allocated to picking up their prescription, and most will toss out the verbose patient information sheet with their pharmacy bag.

Pharmacies routinely make a note when patients refuse counseling at the pharmacy, which fulfills the legal requirements in pharmacy law.

We may need to reevaluate the efficacy of point-of-purchase counseling, and restructure the setting and the speed with which we communicate.

Some pharmacies use antibiotic callbacks to promote their services, but calls may also detect critical drug compliance issues. In one month, I prevented four elderly patients from rehospitalization for an acute illness, when callbacks caught absolute contraindications with foods, critical compliance issues, or even reluctance to start a medication after the patient read something on the Internet.

The pharmacist callback affords an opportunity to review that the patient's drug is appropriate; assess the patient's understanding, competence, and compliance with drug treatment; determine the patient's current status; and surmise the potential outcome if a problem is not remedied. This is all accomplished over the phone, while the patient is comfortable, instead of in a rushed retail setting.

Pharmacists have also tried setting up shop at the patients' residence. A group of pharmacists and physicians in Oregon has created a volunteer team that has conducted brown bag reviews at assisted-living centers. Even though this service is very convenient, inexpensive, and has intercepted several serious medication problems, professionals were surprised that very few patients used this advertised program.

Why was it so underused? Just like the four elderly patients I intercepted last month, most patients become aware of the gaps in their medication self-management only after a crisis has occurred. Medication review should not be triggered only by hospitalization, it should be a routine part of pharmaceutical care, since the cost of medication misuse is so high for both patients and insurers.

My state of Oregon recently passed a measure that promotes the practice of pharmacy counseling. The methamphetamine crisis in Oregon has sparked a "third class" of drugs, whereby all pseudoephedrine-containing products were recently moved behind the counter. Patients must now show a photo I.D. before they can purchase these items.

The major chains predictably resisted this action by the pharmacy board, but almost every patient who describes his symptoms to the pharmacist will leave with an appropriate OTC product or two and essential self-care information. One solid experience with professional pharmaceutical information will often predispose the patient to really listen the next time the pharmacist counsels on the use of a new prescription. Now, that's customer service.