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.

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.

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.

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.

Video Link Here under “Innovators”

Magazine Feature Here

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….