By Michael Ross, Founding Partner, ROAMcare
Recently I was having my morning coffee and scanning the online local bulletin boards where I spotted “Wanted, in exchange for a reasonable price the use of a pick-up truck to move a piece of furniture. Local. One morning or afternoon.” A reader already had commented that all the major truck rental companies have pick-up trucks available for $20 a day and you couldn’t get much more reasonable to secure a safe, well-maintained truck for a day. The truck hunter replied that yes, that was true, but it was just easier to go to the internet than to go through the trouble of going to a garage and picking up a truck. And that made me think, has our profession gotten to the point where it is easier for somebody to go to the Internet with their medication questions rather than to go to the pharmacy safe, well-informed information.
As a pharmacist I should know my medications or where to go for legitimate drug information on the Internet if there arises a question that I cannot answer myself if my pharmacist didn’t pro-actively counsel me. Yes, my pharmacist. Although I am a pharmacist, I have not worked in a retail pharmacy or a facility with a retail pharmacy service for some time, so I patronize a local pharmacy for my medications. I am also an end-stage renal disease patient and I take immunosuppressants and an anti-coagulant so there are several opportunities to address potential interactions, OTC med use cautions, and routine vaccine implications. Yet the only routine counselling I receive is when there is a brand change in the warfarin I take. Oddly, although each time I am told to please wait, that the pharmacist wants to see me, I am then told of the brand change by the pharmacist but not the importance of having this information, nor signs to be alert of for possible adverse effects due to the altered response because if the change of brand, even at the same dose.
It is not only the retail pharmacy passing on the opportunity for direct contact. Hospital, long-term care, and even specialty pharmacies are trading away personal interaction for convenience. In May 2019, I was in a position where few health care providers find themselves, in a recovery room following kidney transplant surgery as the one recovering. All through the transplant evaluation process it was mentioned that a pharmacist is part of the team although except for one brief meeting at the very beginning of the process, I had no contact with a transplant pharmacist. As a recipient patient, and one with a variety of confounding conditions, I was happy to see finally a pharmacist among the care team to visit my room on post-op day 1. Unfortunately, the brief meeting merely confirmed the pharmacist’s routine verification responsibilities and ended with “the nurses here are really good and can answer any questions you have about your medicine.” I did not see another pharmacist during that hospital stay, including on discharge when the medication instructions were transmitted to me by the unit nurse.
As a director of pharmacy in a small hospital without twenty-four hour pharmacy operations, I had to assign pharmacists to rotate through emergency call duty outside service hours. While orienting a new hire to the on-call responsibilities I noted that although returns to the hospital were not common, calls for formulary information, ordering and dosing assistance, and general drug information were routine and to expect those inquiries nearly daily. The newly hired pharmacist questioned why the pharmacist on call had to “be bothered” with routine drug information and dosing when DI references and dosing algorithms and templates were available on the hospital intranet. Although it was not a frequent question by orientees, neither was it the only time it was asked.
The retail pharmacy is a busy place, and much is being asked of the ambulatory care pharmacist that takes time away from potential interaction with the patient. Still, every patient communication should be approached as if one is talking to a six year old – in that they always want to know “why?” With every extra instruction, every extra communication, every extra notification, anticipate the patient’s first response will be “why?” and add the “because” to the discussion as a matter of course. Consider this message:
“We had to change brands on your warfarin. Every brand may be absorbed a little differently than any other brand, in fact even different lots of the same brand may show differences. Even if your numbers have been steady for months, you might see a slight variation. Do you measure your INR at home, or go to the lab routinely? I already checked your drug profile and there are no new interactions but you might see a difference in your test results and the brand difference might be the cause. If you don’t remember all this when you have your next INR drawn or you are concerned about your numbers looking different, call me and I’ll go over it again with you.”
Isn’t that better that, “I want to let you know we changed brands on your warfarin. Do you have any questions?” Chances are the patient doesn’t even know what questions to ask.
Hospital pharmacists are also busy, as are long term care pharmacists and any other pharmacist. But so are hospital nurses and hospital doctors and nursing home nurses. References, templates, dosing scales and algorithms are aids to drug therapy, not replacements for professional contact. Physicians with multiple hospital privileges often rely on facility personnel to remind them of the allowances and limits of your service detailed in your formulary, and pharmacy is the custodian of that information. There is a saying that the smartest don’t know all the answers but do know where to go for the answers. The pharmacy should be that place to go!
The solution to improve pharmacist viability as a team member is to improve pharmacist visibility as a team member and place the pharmacist squarely in everybody’s mind that we are the valuable clinicians we so often tell ourselves.