Don’t Worry be Happy

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Over the past year I have asked my staff to pay particular attention to the reasons patients give for wanting to transfer their prescriptions over to our pharmacy.  Despite being a small, independent pharmacy and being surrounded by competitors offering incentives and points programs, patients regularly transfer their prescription files over to us from neighbouring pharmacies.  I consider these patient comments to be priceless information to guide the direction of our practice.

 

Here is what we hear most often about the pharmacies patients are leaving:

“When I go in there, I feel like I’m bothering them.”

“They said they couldn’t help me.”

“They don’t explain things to me.”

“They don’t seem to have time for me.”

“They didn’t seem to be listening when I was talking to them.”

 

There are many variations of the above sentiments, but what it points to is patients who feel a lack of care or empathy from the pharmacy staff.  While there can be many contributors to a patient’s poor experience in their previous pharmacy, I have looked as well to the reasons patient’s give for choosing our pharmacy.  Most often I hear from patients that my staff seem to really care about them, they go above and beyond to help them, they take time to really hear what is important to them.

Now, I’m no hiring wizard, and by no means am I able to always hire people who simply excel naturally at great customer service.  However, what I do think has been a key to our success is that, for the most part, my employees are happy.  They take pride in their work and genuinely care about the people we serve.

Let’s face it, your staff are the face of your business.  If your employees are not happy, your patients will know it!  Why are patients often treated poorly or made to feel like they are a bother?  Most often it is from interacting with employees who are unhappy in their jobs and would rather be elsewhere.

Your employees really are your best advertisers.  No matter what the message is on your website or your bag stuffers, your logos or slogans, a patient’s experience of your business all comes down to the staff they interact with.

Here are three key areas to increase staff positivity and retention:

  1. Allow staff to work to their full potential. Working to their fullest potential is empowering for pharmacists as well as technicians.  Move your professionals away from tasks best suited to support staff and provide the structure required for them to work at the top of their license.
  2. Provide vision and leadership. Team members are happier if they have purpose and meaning in their work.   Be sure to voice your vision and encourage your team to see the bigger picture in their daily tasks.
  3. Involve your staff in decision making. Having a say in some operational decisions creates a sense of ownership for team members.  Ultimately, they will be more satisfied with their position and more likely to stay with your business.

 

Shared Care

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We healthcare professionals seem to chase around the dream of patient compliance.

“What’s the compliance of this patient?”

“Well, that patient is not very compliant.”

“How can we improve compliance?”

“Here’s a great ‘gizmo’ to help with compliance.”

I was recently in a room with a group of physicians and pharmacists discussing this very topic.  Most of the physicians in the group assumed that as long as the medication was picked up at the pharmacy, the patient was actually taking the drug exactly as prescribed.

While the pharmacists in the room had a silent chuckle over this, we cannot forget our own illusions of patient compliance.  Pharmacists can easily believe that if we just sync up patient’s refills or put their medications into blister packs, this will improve compliance.

The bottom line is, if a patient does not want to take a medication, no tool, technology or compliance aid is going to fix this.

It is the patient who will ultimately decide whether they take the drug.

Mr. V is a great example of patient “non-compliance”.  Mr. V had a cardiovascular event 5 years ago and afterwards was put on a statin.  He had been told over and over again by his physician that it was important for him to take this drug every day.  The pharmacist put it in his blister pack and the doctor checked the fill history on the provincial electronic record which showed consistent filling of his prescriptions.  All was well, except for one major problem: Mr. V’s LDL had been climbing in the last two years.  Mr. V’s doctor, out of concern, added an additional lipid lowering agent to improve the situation.

In sitting down with Mr. V for a medication review, he disclosed to me that he was punching his statin drug out of his compliance pack.  Indeed, he had hardly been taking it for years.

After some conversation, which was mostly listening on my part, Mr.V trusted me enough to tell me how he was ACTUALLY taking his medications. From that discussion I was able to discern why he didn’t like taking them.

I presented to him the science of reducing LDL post heart attack. I looked up his cholesterol levels and give HIM the numbers on a piece of paper to compare for himself. Ultimately the decision was his. What we agreed on was to reduce the dose of his statin and test again in six months.

Had I simply said “you need to take your medication” and left it at that he would still be punching out his pills.

This is the essence of shared decision making. If we don’t involve patients in decisions about their own health (for example what medications to take, whether therapy should be intensified, or what screening or testing should be done), they will often make their own decisions, and it will be without the guidance of their health care professional.

Simple open ended questions can accomplish this by inviting the patient to share their thoughts and experience.  Asking a patient, “Do you know why you are taking this medication?” or “How do you feel this medication is working for you?” can open up a vast window of opportunity to engage a patient in their own care.

The key to compliance, or the more politically correct term “adherence”,  is the degree to which a patient understands the importance of therapy. I can make all kinds of changes to therapy from reducing the number of doses per day, reducing cost, improving timing to make things easier, etc. Ultimately if the patient does not understand the importance of the WHY, compliance will be lagging.

Lessons Learned

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When I left pharmacy school over 20 years ago, I thought I had attained all the knowledge I needed in order to care for patients.  The one thing that all those years of studying didn’t teach me was that my patients were going to become my greatest teachers.

Here are the five most important lessons I have learned from my patients.

 

  1. Listen first. In school we are often taught the importance of “telling” a patient what they need to know about a drug or a medical condition. We practice over and over imparting the top five or so points about a medication, from how to take it to the myriad of possible side effects.  How many times have I spit out the knowledge in my head, then after listening to the patient I realize that it was either too much information, not applicable to their daily life or they just didn’t understand.  Over the years I have become a much better listener.  My patients have taught me that each person and situation is unique and to truly care for them means to simply listen.

 

  1. Trust requires work. When a patient comes to me for advice, they are trusting my assessment of their current condition and medical history. They trust I am not simply giving them random advice; that what I advise is backed by science, is evidence based and supported by my education, training and experience. Upholding this trust requires work. As much as possible I need to keep up with recent guidelines, studies and lines of inquiry in evidence based medicine.

 

  1. Many patients over the years have demonstrated amazing perseverance throughout incredible pain, suffering and loss. They have taught me to keep finding the positive and most especially, to endeavor to live with a posture of gratitude.

 

  1. Look beyond the surface.  As health professionals we often don’t see beyond the immediate presentation of the person in front of us. A patient’s short temper, harsh words or impatience is often directed at us or our staff. Over the years I have learned that the root of behavior is far different from what I see. Patients have taught me that behind the behavior is often a myriad of other issues such as pain, inability to cope, grief, and other emotions or life circumstances that have nothing to do with me, so I don’t take it personally.

 

  1. Empathy goes a long way. Even if I cannot directly relate to being held captive by addiction or have unrelenting pain, I can still express empathy for the human suffering of my patients.  Even in tough situations such as a person going through narcotic withdrawal, the care I provide is much more effective and meaningful when patients feel that first, I am on their side, even when I have to say no or make a tough call.

 

Ultimately, the human side of patient care cannot be taught in school, it can only be taught to us by those we care for, and I look forward to my continued learning.

 

 

Flu shots? They make me sick!

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Ever get tired of hearing people tell you they won’t get the flu shot because it made them sick?  Or people who say they’re really healthy so they don’t need it, or it doesn’t work anyway so why bother?

These are just a few of the many things pharmacists will hear from their patients over the coming few months.  Talking with patients who see myths regarding vaccines as fact is one of the most challenging aspects of vaccination.

It always surprises me when I see patients in my travel clinic, their willingness to get vaccines costing hundreds of dollars for rare diseases but will not accept the free vaccination for influenza.  Every one of these patients are more likely to encounter influenza than Japanese Encephalitis or even Hepatitis A.

A couple of years ago I started to change how I approach people regarding influenza vaccination.  Whether it be patients refusing the vaccine or those who come in for vaccination somewhat reluctantly, I realized that by providing a few pieces of scientific fact, in language they can relate to, vastly increased the uptake and acceptance of flu shots.

Here are my top 5 points to increase patient uptake of flu shots:

1-Explain what it is. Make a point of telling patients you are protecting them from a “serious lung infection”. This infection, influenza, gives you a high fever, likely a cough and makes you feel like you’ve been hit by a truck.  It comes on fast and you will likely be sick for at least a week.  The danger with influenza is it leaves your lungs vulnerable and pneumonia can set in, or it makes medical conditions critically worse.  This is what puts people in the hospital and causes death.

2-Explain what it is not.  It is essential to tell patients what the flu shot is NOT protecting them from.  My usual spiel goes something like, “This shot does not protect you from nausea, vomiting, diarrhea, “stomach flu”, colds or sinus infections.  Those are all caused by other viruses that spread person to person.  You can, and likely will, get some of those illnesses this winter.”  I give this information even as I am giving the shot to people who ask for it.  This helps to prevent the person who got the stomach flu a few days later from blaming it on the shot.

3-Take away the mystery. Vaccine are not easily understood by the general public.  Using imagery is a great way to help people understand what vaccines do.  “I am giving you a killed off version of the virus.  Your body recognizes it as an invader, even though it is dead, and makes antibodies to protect you against the virus.  Antibodies fit like puzzle pieces on the virus.  If you get sick with the real thing, those antibodies will fit on the virus and get rid of it before it makes you sick.” Simply put, vaccines cause a natural immune response in the body, making the immune system “stronger” against this particular virus.

This also helps to explain antigenic shift to a patient and why they need to get the vaccine every year.  The virus “changes its shape” and the antibody will not “fit any more”.

It also explains how sometimes the vaccine is not a good match.  I tell patients that science is not perfect.  Experts do their best at matching the circulating strains.  But whether it is a 20% match or an 80% match, 20% protection is better than no protection given the extremely low risk of vaccination and the high risk in getting influenza.  Which brings me to my next point.

4-Give a personal example if you have one. If it is suitable, share a personal story of someone you know who encountered influenza and suffered from its consequences.  My neighbor and good friend, a perfectly healthy 40-year old mom of two boys, was on life support for over a month and nearly lost her life from influenza.  She is lucky to be alive, though she lost her voice permanently from the prolonged intubation and her lungs are irreversibly damaged.  If you don’t have a story, feel free to share this one.  Her name is Jocelyn and she has given me permission to share with anyone who will listen. 

5-Express empathy and Roll with Resistance. I often say, “It’s my job to present to you the science and facts so that you can make an informed decision.”  In the end, it is the patient’s choice, but I want to ensure I’ve done my best to help them make an informed decision based on facts.

When a patient tells me they don’t get the flu shot, I always ask them why.  This helps me pinpoint what type of information to provide.  For example, if refusal is because it “made them sick”, I want to know “what kind of sick.”  Often I hear that they had the “stomach flu” or a winter full of bad colds.  Of course, those illnesses have nothing to do with influenza so I can address that gap in knowledge at that time.  If they say they don’t “believe in it” or they think they don’t need it, I use open ended questions to ascertain why they feel that way.

In expressing empathy, understanding and then providing facts in patient language, we can go a long way in increasing vaccination rates and ultimately the health of our patients and our community.

3 Tech Tips to Save Time 

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Let’s face it, pharmacists are time crunched.  Not a day goes by in my practice where I don’t wish for more time to complete the ever growing pile of work in front of me.

Some of you from the “pre-computer” generation, such as myself, may remember that when we were in grade school, the promise of computers and “robots” on the horizon touted a future of an easier work life. Disappointingly, this has not been so.  While computers have made some things easier (eg. no more typewriters for prescription labels), it has also meant an overwhelming amount of information to sift through.  So how do we simplify things and make technology work for us in our clinical practice?

While pharmacy software has continued to evolve in terms of dispensing, pharmacists are moving away from technical skills to being more engaged with patients, and this means needing to access different types of tools quickly.  When I’m upfront assessing a patient’s drug therapy or creating a care plan or medication review, I need fast access to things like therapeutic guidelines, risk calculators and drug dosing tools.  I don’t have time to google and search for what I’m looking for.

Here’s my top three tips for using technology to create efficiency in clinical practice:

1- Clean up the desk top.  Nothing is more frustrating than having a desk top so full or cluttered that you cannot find the icons you need.  Use folders and a clean looking background to simplify each station.

2- Be consistent.  With multiple stations and multiple users in a pharmacy, each terminal can have different short cuts and book marks and icons.  To make things easier for my pharmacists, I strive to have all our terminals consistent.  That means being able to access the same short cuts, icons and tools in the same place no matter what station they are using.  It saves an immense amount of time if pharmacists can find, in mere seconds, the CDA chart for renal dosing or a Framingham calculation tool, or any other resource or reference they need.  We use Dropbox to achieve this, though it is by no means the only tool that can accomplish this task. All our references and short cuts are available in the one location and categorized according to therapeutic area.  Pharmacists and technicians can also easily add documents and references and have it appear on all terminals for all team members.

3- Use technology in patient care.  Pulling out the iPad or tablet to show a patient a quick video (for example, on a device technique or to reinforce education) can buy valuable time for things like documenting the patient encounter or completing the paperwork for a service. Make sure you watch any videos first to ensure they reinforce the message you want to get across and are reflective of best practice.

 

Intake: Where it’s at

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Typical day in our pharmacy.  Pharmacists are at intake engaging with patients.  Yes, we did not tidy up before I snapped this candid of my staff!

When I graduated from pharmacy over 20 years ago, the buzz and excitement at the time was “pharmaceutical care”.  I can remember carrying to my first job a copy of Hepler and Strand’s “Opportunities and Responsibilities in Pharmaceutical Care”(1990).  Such was my enthusiasm to provide this type of care to patients.

What ensued was 20 years of practice where the majority of my time was spent signing my name on the plethora of prescriptions presented to me.  Mixed in with some counselling on new prescriptions or a smattering of other tasks such as dealing with drug plans, inventory, orders and narcotics, what’s striking is that about 80% of my time was spent on technical tasks which did not require the university degree I had worked so hard to attain.

Pharmacy practice has largely remained unchanged over the past 20 years.  Pharmacists still perform technical tasks a large majority of their time, tasks more suited to registered technicians and assistants.  Often the only interaction pharmacists have with patients is to give verbal and written information about new drugs.

It is not surprising that real change has not occurred in pharmacy practice as the profitability in pharmacy has historically depended on the drug product going out the pharmacy door as quickly as possible. Pharmacists, as the final check, were the rate limiting step for profitability, thus honing our skills for fast, efficient dispensing was paramount.

Today however, with the convergence of expanded scope practice and the changing landscape of pharmacy reimbursement, billable and cash paying services, the time is ideal for pharmacists to step out front and fully embrace our role as pharmaceutical care providers.  Medication reviews, care plans, adapting therapy, chronic disease management are all about optimizing drug therapy and solving drug related problems (DRPs).

However.…we simply cannot do this on the back end of work flow when we’re checking prescriptions.

Pharmaceutical care requires that we work WITH the patient, engaging them in their own care and decision making, becoming involved in their therapy, taking responsibility for drug therapy decisions and collaborating with other care providers.  To do this we need to be out front.  We need to dialogue with patients when they present to allow for assessment of their medications, chief complaints and chronic disease therapy.   The “pharmacist at intake” model has yet to be widely adopted, but initial pharmacist assessment is absolutely critical to providing patient centered care.  Here’s my top 5 reasons why:

  1. It is nearly impossible to find and resolve DRPs with only a patient profile and a prescription hard copy in front of you (ie: the most common “pharmacist checking” scenario). The vast majority of problems are not discovered due to a lack of discussion with the patient. Assessment of the patient (not just the patient’s file) and shared decision making along with the patient are essential.
  2. Checking prescriptions can be done at a fraction of the cost by a registered technician. Pharmacists are no longer needed for back end checking. Therapeutic assessment of the prescription can be done on the front end of work flow along with the patient.
  3. If our only interaction with a patient is to provide information (ie: counselling), we will shortly be regarded as irrelevant. This is the information age and approximately 92% of adults aged 18-39 now carry a computer in their pocket.  Information is at our patients’ fingertips and pharmacists are no longer the only source of drug information.
  4. Profitability from drug product is shrinking (low fees/margin, PPNs, loss of rebates/pan-Canadian, cuts on short fills/blister packaging). Profitability from expanded services is increasing.  Identifying opportunities and providing expanded scope service requires assessment and engagement of the patient by the pharmacist.
  5. Pharmacist on the back end is highly in-efficient.  If a pharmacist does discover a DRP through back-end counselling, the prescription has already been entered, prepared, checked, and the patient has waited.  Now the team must go through the entire process again to fix the problem and the patient waits yet again.  This is a highly inefficient use of staff resources.

 

Pharmacists have an incredible opportunity to step into their true role. No other profession has the expertise to guide patients and engage in shared decision making to optimize drug therapy.  Pharmacists have unique knowledge of therapeutic guidelines, patients’ current drug therapy, alternative drug therapy options, drug benefit lists, drug administration solutions, and previous response to medications. We cannot afford to wait another 20 years.  We need to step out from behind the counter and engage our patients where they’re at.

My Practice

PharmacyU recently came in and produced a short video on my practice at Meridian.  It is really well done and highlights how we use expanded scope in patient care.  Kudos to PharmacyU for their superb editing skills and to my staff for their efforts in this production.

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Video Link Here under “Innovators”

Magazine Feature Here

 

 

 

 

Pocket Wisdom

I was rifling through a box of papers from the days of my first few years of practice in the small town of Chemainus (1994-1998).    The beginning of learning how to care for patients and fit into the medical system.   I came across a folded up piece of paper that I recognized as one I had carried in my lab coat pocket for many of those early years…

Ode to Patient Care

If we speak with the tongues of specialists and consultants,

and have not love, we will have nothing more than the noise

of our own voices and the clanging of pet ideas.

If we develop new methods, write new curriculum,

and learn new techniques,

and if we understand all about the five stages of dying

so that we are not surprised when a patient is angry or depressed:

and yet we have not love, we are useless.

If we give up our old anxieties about talking with patients

concerning their true feeling,

but we have not love, we gain nothing.

Love never ends.

As for tumour conferences,

they will pass away;

As for workshops,

they will cease;

As for inservice training,

it will change.

For our methods are always imperfect

and our plans often don’t work out.

When I first became a helper, I thought like an idealist

and talked like an expert.

As I began to mature, I realized that I too was afraid

and the patient often taught me.

For now we see only reflections of sickness and death,

but someday we will see them face to face.

And the time will come when we will know for sure what it is like,

and we will be sorry we ever judged.

So methods, techniques, case conferences, care plans,

seminars, small group experiences, counselling-

There is all this and much more we would suggest for

gaining insight and increasing effectiveness:

But greater than all of these is love.

Dan McEver

Now posted once again where I practice daily so I can be reminded of what really matters….