Worthy Praise

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Some of us are better at recognizing our own gifts and talents more than others.  Most people, if pressed, could list two or three of their own talents.  Usually they are obvious ones; personal skills or expertise that has contributed to our career, or positive personality traits we have developed.

What might not be obvious are the gifts you have that impact other’s lives.  Just like those around us may not be aware of the gifts we feel they have.  Humans can be slow to praise and general in our thanks.

The people we work alongside, those we run into day-to-day, probably have no idea that we appreciate them or recognize their contribution and hard work.  I was involved in a virtual chat with health leaders/practitioners across the globe (although mostly North American) and we were tossing around what the essential qualities were for showing appreciation and thankfulness.  Some of the prevailing thoughts were that praise should be:

  • Genuine:  Praise that is not genuine feels contrived.  If you don’t actually recognize the value of and appreciate the person, don’t say it.  This involves some reflection on our part, as everyone has value and talents.
  • Specific:  One of the most meaningful compliments I ever received was being told that I put people at ease, help them feel  comfortable.  That’s specific, and something I didn’t know. Referencing a specific incident or particular skill is valuable when offering praise.  It shows you recognize specific qualities and often encourages personal growth for the person being praised.
  • Generous Praise to colleagues, staff and friends should come with no strings attached, no “to-do” list at the end.  It should just be what it is, an acknowledgment of hard work, contribution, or talent.
  • Personal  What came up over and again is that praise which is personal means more.  Praising colleagues or staff publicly in newsletters, staff meetings, in posts online, all are important.  But so is the handwritten note, or the phone call or the one-on-one thanks.

We all need to feel acknowledged and appreciated.  Remembering to show gratitude or praising our colleagues and staff is an important part of team and community building.

Disillusioned?

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I remember the day I realized I was caught in the prescription mill and it seemed there was no way out. I was standing in the pharmacy, just a couple years out of university, with some of Linda Strand’s writing in my hand. I knew without a doubt that “Pharmaceutical Care” was what I should be doing. I also knew that I had no idea how to “do” medication management. I didn’t know any pharms who were doing it, was not really taught it in university, and I had ALL these prescriptions to deal with non-stop all day.

Okay, so that was 1996… but I know I’m not the only one who had a rude awakening once they started their professional practice. Wasn’t I supposed to help patients manage their medications and optimize their therapy? Make sure patients who needed drug therapy received it and those that were receiving unnecessary drugs were identified?

Yup, that’s really our job. The prescription mill? A trained tech can produce an accurate Rx from a hard copy. As a matter of fact there’s probably a computer out there that can read an Rx and spit out an accurate product. It’s not rocket science.

But looking at the over all picture of a patient from their labs, self reporting of chief complaint, previous response to meds and current drug therapy, etc. and deciding whether the Rx in front of you is really the BEST therapy for that patient…or if they really even need drug therapy at all? That’s the art and science of Pharmacy. Making the clinical decision to adapt (change) that prescription or prescribe for that patient, when you know therapy can be improved, then following up on that care…no machine can manage that. It takes knowledge, clinical experience, triage skills, sourcing of info, patient interview skills, ability to refer and knowledge of your own personal skill set and boundaries.

In considering all that, what I often hear from colleagues is that it isn’t possible. We have no time, not enough support staff, our software isn’t capable of what we need it to do, it takes too much paperwork, etc.

And really…when you’re stuck churning out hundreds of scripts a day it’s easy to slowly drift into apathy, or feel burnt out…tuck your head down and do a great job of at least searching out drug interactions (or assessing the clinical validity of the ones the computer caught), checking doses that look way out there, answer patient’s questions… Just be accurate, make no mistakes and go home.

Over the years as I worked at top speed in the mill, I lost a lot of my clinical skills. What you don’t use you lose, right?  I hadn’t looked up an A1C on a patient or applied the newest Otitis guidelines in so long I was afraid to start.

If I was given the perfect circumstances, all the time I needed, the ideal practice setting…would I be able to do the job I wanted to? Could I take responsibility for a patient’s medication management, make recommendations on drug therapy, solve complex drug related problems? Well…I wasn’t sure.

We know that care of the patient is our primary task.  Pharmacists have no problem putting patient’s first. I see it every day. We’ve never been paid to talk to patients or assess medical issues and make recommendations, but we do it.

Where we can be our own worst enemy is in lacking the confidence to make the shift into medication management:  to take responsibility for clinical decisions, make the call, sign our name to the decision.  And sometimes we know that our skills need to be sharpened and our knowledge refreshed but we don’t know where to start.

Mentorship and good learning opportunities are essential for practice change;  Assessing for yourself what you need in order to shift your practice and feel comfortable doing it, and finding the energy and passion to embrace change.

We now have the framework, have a start at being paid to manage patients’ medication therapy, not just handle prescriptions; and it’s up to us as a profession whether we take it up, change our mind set, our focus and move forward.

Patient Gratitude

A few weeks ago a colleague warned me that in the first year of owning and running a new pharmacy I would conclude that I had made a huge mistake.

Yup….that happened well before turning the sign to “open”!

The two weeks leading up to my opening day were chaos.  I’ve never slept so minimally, had my “to do”list grow so fast, nor seen my children so little.  As I heard repeatedly, “Mom, are you coming home late again today?” I figured I had made a mistake.  I am a clinician; I love the “care” part of health care, and here I was, steeped in putting a business together. Spending hours on end away from my family, and even when with them my mind was racing with all the things I needed to handle.

So when I walked into my brand new pharmacy on day one and flipped the sign to open, I wondered whether I had jumped into something I would resent, or at the very least not enjoy.

Then came patients through my door.  Just a few at first, and a few more each day, and I found myself in a place of privilege.  As I provided health care, I heard their stories.  Stories about caring for terminally ill spouses, stories of how difficult it is to live with chronic pain, journeys through chemo and disappointment with the system.  Even stories of past jobs and places they had visited in their life time.  As I immunized many against the flu I also shared a lot of my own story.  How I came to be in this new pharmacy, growing up in Saskatchewan, how I had started a pharmacy in Chemainus when I was very young.

It struck me once again that the connection made and the care given are what brings me joy.  Having my own pharmacy means I can structure and set up to practice the way I want.  I have control over how I care for the people who walk through my door.  There is no one to tell me I must meet a certain quota or promote sketchy treatments or unproven products.  In the end, it is worth all the headaches that I am sure will come.  So it is to the people who came through my door this week that I am grateful to, for reminding me what it’s all about.

Care of the Patient

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This post has stuck with me for weeks, and while I blogged about it on my personal site, I feel it has a lot to say to me as a health professional.  So often, as we concentrate on our patient’s heath issues, solving drug related problems and working to optimize their therapy, we can overlook the big picture.  We forget that what is simple to us can often be overwhelming or beyond understanding for our patient.

A Reason To Celebrate

–posted by Dodo on Jul 7, 2012

Numbly, I left my husband, Marty, at the hospital where I had been visiting two of my children and headed for the grocery store. Since it was eleven p.m., I drove to the only store I knew was open twenty-four hours a day. I turned my car motor off and rested my head against the seat.

What a day, I thought to myself. With two of my young children in the hospital, and a third waiting at Grandma’s, I was truly spread thin. Today I had actually passed the infant CPR exam required before I could take eight-week-old Joel home from the hospital. Would I remember how to perform CPR in a moment of crisis? A cold chill ran down my spine as I debated my answer.

Exhausted, I reached for my grocery list that resembled more of a scientific equation than the food for the week. For the past several days, I’d been learning the facts about juvenile diabetes and trying to accept Jenna, my six-year-old daughter’s, diagnosis.  In addition to the CPR exam I’d spent the day reviewing how to test Jenna’s blood and give her insulin shots. Now I was buying the needed food to balance the insulin that would sustain Jenna’s life.

“Let’s go, Janet,” I mumbled to myself while sliding out of the car. “Tomorrow is the big day! Both kids are coming home from the hospital. … It didn’t take long before my mumbling turned into a prayer.

“God, I am soooo scared! What if I make a mistake and give Jenna too much insulin, or what if I measure her food wrong, or what if she does the unmentionable—and sneaks a treat? And what about Joel’s apnea monitor? What if it goes off? What if he turns blue and I panic? What if? Oh, the consequences are certain to be great!”

With a shiver, my own thoughts startled me. Quickly, I tried to redirect my mind away from the what ifs.

Like a child doing an errand she wasn’t up for, I grabbed my purse, locked the car, and found my way inside the store. The layout of the store was different than what I was used to. Uncertain where to find what I needed, I decided to walk up and down each aisle.

Soon I was holding a box of cereal, reading the label, trying to figure out the carbohydrate count and sugar content. “Would three-fourths a cup of cereal fill Jenna up?” Not finding any “sugar free” cereal, I grabbed a box of Kellogg’s Corn Flakes and continued shopping. Pausing, I turned back. Do I still buy Fruit Loops for Jason? I hadn’t even thought how Jenna’s diagnosis might affect Jason, my typical four-year-old.  Is it okay if he has a box of Fruit Loops while Jenna eats Kellogg’s Corn Flakes?”

Eventually I walked down the canned fruit and juice aisle. Yes, I need apple juice, but, how much? Just how often will Jenna’s sugar “go low” so she will need this lifesaving can of juice? Will a six-year-old actually know when her blood sugar is dropping? What if…? I began to ask myself again.

I held the can of apple juice and began to read the label. Jenna will need fifteen carbohydrates of juice when her sugar drops. But this can has thirty-two.  Immediately I could see my hand begin to tremble. I tried to steady the can and reread the label when I felt tears leave my eyes and make their way down the sides of my face. Not knowing what to do, I grabbed a couple six-packs of apple juice and placed them in my cart. Frustrated by feelings of total inadequacy, I crumpled up my grocery list, covered my face in my hands and cried.

“Honey, are you all right?”  I heard a gentle voice ask.  I had been so engrossed in my own thoughts that I hadn’t even noticed the woman who was shopping along side of me. Suddenly I felt her hand as she reached towards me and rested it upon my shoulder. “Are you all right? Honey, are you a little short of cash? Why don’t you just let me…?”

I slowly dropped my hands from my face and looked into the eyes of the silvery haired woman who waited for my answer. “Oh, no, thank you ma’am.” I said while wiping my tears, trying to gather my composure. “I have enough money.”

“Well, Honey, what is it then?” she persisted.

“It’s just that I’m kind of overwhelmed. I’m here shopping for groceries so that I can bring my children home from the hospital tomorrow.”

“Home from the hospital! What a celebration that shall be. Why, you should have a party!”

Within minutes this stranger had befriended me. She took my crumpled up grocery list, smoothed it out, and became my personal shopper. She stayed by my side until each item on my list was checked off. She even walked me to my car helping me as I placed the groceries in my trunk. Then with a hug and a smile, she sent me on my way.

It was shortly after midnight, while lugging the groceries into my house, that I realized the lesson this woman had taught me. “My kids are coming home from the hospital!” I shouted with joy. “Joel is off life support and functioning on a monitor. Jenna and I can learn how to manage her diabetes and give her shots properly. What a reason to celebrate.” I giggled to myself. “I have a reason to celebrate!” I shouted to my empty house.

“Why you should have a party,” the woman had exclaimed.

And a party there will be!

The human side of patient care cannot be learned in school.  It can only be taught to us by those we care for… our patients. 

Starting Out

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Lately I’ve had several colleagues ask me about practice change.  How do we boldly move forward in a new era where we are taking responsibility for drug therapy decisions and prescribing for our patients?  How do we brush up on our clinical skills and learning if we feel unprepared or not knowledgeable enough to take on this role?

I don’t know about you, but for many years I would do the basic CEUs, get them done for credit, and move on.  Need 15?  Got ’em.  I may have picked up the odd lesson in something I’m interested in or read a monograph for a new drug out of necessity because I was dispensing it more, but the learning often didn’t translate into my practice.  After the credit, much of the learning is forgotten.

What I have discovered in the course of changing my practice is that learning has to be relevant and integrated into my daily work for it to be useful.  For example, I don’t know how many CEUs I’ve done over the years on Diabetes…but I never could remember the incretin system.  DPP4 Inhibitor verses incretin mimetic?  Nada… Until I had a patient I was managing who was started on one.  Then when I re-read the guidelines, the monographs, re-learned the incretin system, etc.  I never forgot it again.  I had probably looked up the product monographs of each of the gliptins and liraglutide a dozen times when needing to counsel a patient, but it stuck with me now because it mattered.  Because I wasn’t simply counselling on side effects, I was making decisions regarding drug therapy for the patient.  I had chosen to take on the responsibility of medication management  which involved making changes in therapy. ie/ the buck stopped with me.  It created a learning curve that I had to dive into.  But now I make those type of recommendations on a regular basis.  And when I follow-up with those patients, find out how my therapy changes have affected them both for outcome and ADRs, my learning is multiplied.

What I am saying is that it has to start somewhere.

In the course of talking with colleagues I always ask them what their passion is within pharmacy.  If they don’t know, I ask them what medical condition or drug class is most interesting to you.  Did you love microbiology? (I hated it!)  But if you do, then start there.  Find out what the indication is for the antibiotic prescriptions you are dispensing (a convo with the patient will usually do) and create a learning curve for yourself.  The first few times you may need to look up the empiric therapy for a pediatric bladder infection.  But after a few, it will be automatic to adapt an Rx from Amoxil to Suprax for a child who had no urinalysis done.  After engaging that parent and making the choice to take that responsibility, you’ll never forget what you’ve learned and will apply it to other patients.

That’s the beginning of practice change.  Will you make some mistakes & occasionally feel foolish or incompetent?  Sure you will.  Think of all the mistakes from other prescribers you make calls on every day.  Our entire career we keep learning and improving, but the end result is better health care and knowing that you are making a huge difference in the lives of your patients.

Burn out

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Burn out …. who hasn’t experienced it working in health care?  We are under the gun, trying to deliver health care to the maximum amount of patients in the least possible amount of time.

I recently read a great post written by Dike Drummond on “Compassion Fatigue”. I had never heard the term before, but it resonated with me as a truth. Compassion fatigue is a signal that burn out is approaching. What struck me was the way it was described. Not the typical symptoms of just being tired and unenthusiastic.

Compassion fatigue is when you find yourself challenged to care about your patients in the way you know is proper and expected in your position. One of the key components of quality healthcare is the ability for you to connect with your patients and for them to sense that connection….

Cynicism, sarcasm and feeling put upon are the first signs

If you find yourself being cynical or sarcastic about your patients you have compassion fatigue. It can come in the little voice in your head, or mumbling under your breath or “venting” to your colleagues or staff.

There have definitely been times in my professional life when I have felt this way. When an “interruption” by a patient was a bother while I was trying to complete other work.  There are times when I have definitely felt my empathy was out of reach.

Sometimes the signs are there, but I don’t recognize them. It’s easier to just keep going, be exhausted, unenthusiastic and get through the week.  Easier to stay in the place where you aren’t happy doing what you’re doing, can’t be in the moment, and wish you were anywhere and doing anything else.

At those moments I’ve lost the passion for my work, that spark, the reason I got into this gig in the first place.

And mix that with being physically exhausted and feeling like your work has no bigger purpose or meaning…that’s burn out.

Drummond has many suggestions for battling compassion fatigue including scheduled rest, exercise and personal time.  I would also add that as health professionals we need to feel our work is making a difference.  If we feel we are simply handing T3s to the next addict, managing drug shortages and talking to insurance companies… it is difficult to see the real difference we are making in the lives of our patients.  That can leave us unenthusiastic and just plain tired.

So, I would add to Drummond’s suggestion that as health professionals we need to find meaning in our work.  We need to see tangibly that we are making a difference for our patients.  The easiest way to do this is by being as involved as possible in patient care.  Get involved in improving patient  therapy, not just the solving of all the technical problems.  We need to rediscover our role as experts in medication management., carve out minutes in our days for those follow up phone calls, and keep on learning as we move forward in our practice.

E =

cc licensed flickr photo shared by chrisinplymouth

E = EXACT

Health Care is not an exact science.  That’s right.  We want it to be…and I see much frustration, disappointment and even desperation because of this fact, but it’s the truth.  Despite all the medical advances and advertising of drugs that seem to point to the opposite, there really isn’t a “pill” for every illness or a test to diagnose every medical condition.  Sometimes there is no clear cut answer to a health problem, nor a solution.

Medicine and Pharmacy are applied science which means we take science and apply it to people.  We take everything we know about anatomy, microbiology, pharmacology, biochemistry, therapeutics, etc., and apply it to individuals who have their own unique physical, biological and genetic differences (not to mention the social, cultural, and psychological aspects).  From this application of knowledge to each individual situation, diagnosis is made and treatments are decided upon.

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E = ERRORS

This applying of science also means that medical care is not perfect.  Combine that with the speed at which this knowledge needs to be applied to patients and situations, errors are inevitable.  Here’s a quote from Dr. Brian Goldman that had me thinking this week.

What I’ve learned is that errors are absolutely ubiquitous. We work in a system where errors happen every day.  Where 1 in 10 medications are either the wrong medication given in hospital or the wrong dosage…  In this country as many as 24,000 Canadians die  [every year] from preventable medical errors. [which is a gross underestimate]

We all know someone who has had sub-optimal medical care or errors made in their care.  Often there is anger towards the professionals that made the mistake.  I’ve been on both ends of that situation.

There is an expectation of perfection in health care.  As patients we expect our health professionals to be competent, and so we should.  But as a health professional I know we are all human and lack perfection.  We all fall short and can make mistakes.

I’ve made mistakes in my career and will most likely make a few more before I am done.  Fortunately I have never made a mistake that has seriously harmed someone or caused a death.  But I know each time I put my lab coat on it is a real possibility.

cc licensed flickr photo shared by chrisinplymouth

E= e-PATIENT

The possibility for error is why I continually encourage people to be engaged in their health care.   Not because you shouldn’t trust your health providers.  Quite the opposite.  You need to be an active partner so a trust relationship is essential. Working as a team is the best way to ensure optimum health care.  How can you do this?  Get to know your own body, your medical conditions, your medications.  Ask questionsWe need you to be as educated as possible.

More and more patients are getting health information over the internet.  (Interestingly, Health Professionals are often divided over this.  Some thinking this is great and others not so much).  I think the more knowledge you acquire about your own health the better.  And this is where the trust relationship comes into play.  Yes, there can be some bad information out there.  So you check it out with your doctor or pharmacist.

Last week I had a patient in tears because she had read on the internet that her diabetes medication could give her seizures and she didn’t know what to do.  Was that good information?  No.  It wasn’t true.  But I didn’t advise her to stay away from internet health information.  I provided her with some reputable sites and encouraged her to learn more about her disease and contact me in a week to go over what she had learned.   As one e-patient says in this video, “When push comes to shove you check with your [health professional]. They’re there for a reason”

Here’s an example of the growing movement of “e-patients.”  As you’ll see, the “e” stands for many great attributes that can lead to a safer, more participatory, less paternalistic model of health care.

Dr. Oz and the Ruby Slippers

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I really wish Dr Oz would just put on his ruby slippers and go home. Just click those heels three times and retire.

That may sound harsh, and I usually don’t make such blanket statements, but honestly, he’s starting to do some real damage.

Like Oprah, when Dr. Oz speaks, millions of people listen. His level of influence in the average North American household has become almost iconic. Millions turn to him for advice. That would be a good thing if he was a health professional with integrity and his advice was backed by science. The reality is quite the opposite. Here’s my beef with Oz.

Dr. Oz puts profit before people.

When Dr. Oz first started out on Oprah, his information and health recommendations were fairly standard, typical of your family doctor with some Hollywood spin. Over the years, however, he has become more “Hollywood”and less “doctor”. He sensationalizes medicine, often offering quick fixes with unproven therapy. It makes for great sound bites (like the un-workout workout) and it sells, but it’s not based on science. In fact, coming soon is his own product line of unproven supplements. It doesn’t matter that he lacks the science to back up his claims. His name sells and so will his unproven products.

His advice can be dangerous

Diabetes can be prevented with vinegar and coffee. Really? If that were true, I know many of my patients would be reaching for more pie; just add a cup of coffee and it’s all good. Instead, what is proven by science is that weight management and good nutrition can delay Type 2 Diabetes.
If a person needs to lose weight to reduce their risk of having a heart attack or stroke and Dr. Oz says all they have to do is take white kidney bean pills and they can eat all the cake they want…that’s dangerous.
How about having a doctor on his show that believes cancer can be cured with baking soda? Not kidding.

Dr. Oz presents “Pseudo-Science” as fact

Pseudo-science is presenting a claim or belief as scientifically valid without having the scientific supporting evidence. Here’s what we mean by science:

What we mean by “science” is simply rigorous methods of observation. Good science looks at all the evidence (rather than cherry picking only favorable evidence), controls for variables so we can identify what is actually working, uses blinded observations so as to minimize the effects of bias, and uses internally consistent logic. Steven Novella, MD

Are there some studies showing coffee has an effect on diabetes risk? Yes. Can we use these studies to make sweeping statements that affect people’s health? No. That would be irresponsible. All that is proven by a few small studies is that more studies in that area need to be done.

Dr.Oz takes “bad science” or limited science and presents it as fact. That’s irresponsible.

I’ve been in health care long enough to see really good studies point to facts that we incorporate into our practices as health care professionals. But 10 years later (after more studies with larger numbers of people, going on for a longer time), the original studies are proven to be misleading or even point to the opposite conclusion. Studies need to be examined with the eye of a sceptic and there is a science in itself to evaluating the strength and validity of scientific studies.

When people come to me with health concerns looking for advice, they are in essence sharing a trust. Patients expect me to be honest and to have their best interest at heart. They expect that my advice will be based on scientific evidence, not on anecdotes, popularity or profit. Patients should expect that from all their health providers.

Dr. Oz fails on all fronts. So, Dr. Oz, if the ruby slippers don’t fit, perhaps you can take the job of the original Oz behind the curtain. After all, he was a charlatan too.

5 Must Ask Questions About Your Prescription

When you are handed a prescription by your physician or your pharmacist there are many questions you should know the answer to before walking out the door. Below I highlight my top five.

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  1. What is this medication for?

This may seem obvious, but countless times when I ask a patient if they know what their prescription is for they tell me they have no idea.  When someone doesn’t know what a medication is for, there is little motivation to take it correctly or even at all.  Most drugs have more than one indicated use.  Know what yours are being used for.

2. What will happen if I don’t take this medication?

This may seem a strange question, but the reality is that over 50% of medication prescribed is either taken incorrectly or not at all.  (Health professionals are a little vain- we tend to think if we prescribe it, you will take it.) If you don’t take your high blood pressure medication, you have a higher chance of having a heart attack or damaging your kidneys.  If you don’t take an antibiotic for a nasty cold…well, really nothing is going to happen because antibiotics do not work for colds.  There are many prescriptions that are unnecessary or could be avoided with “watchful waiting” and there are some prescriptions that can be deadly if you do not take them exactly as prescribed.

3.  When can I expect this medication to work for me?

An important piece of information.  Will it treat my problem/condition in an hour or in 2 months?  Knowing what to expect is essential.  Someone being treated for clinical depression needs to know that the medication they are getting may not start to work for 2 to 6 weeks.  That’s a long time if you are expecting to feel better tomorrow.  Equally important is a person in acute pain to know that the pain medication should start working in an hour or so.  If not, it may need to be adjusted.  And if after 3 days of antibiotics your skin infection is spreading, don’t wait for the ten days of pills to be over.  You need to be reassessed right away. Know what to expect and always ask questions if you are unsure.

4.  What do I do if I have a problem with this medication?

Not all problems or side effects require another appointment.  Many issues can be solved by tweaking the dose, timing, formulation or way of taking the medication.  Sometimes a change of medication is necessary.  Find out what some of the common problems or side effects of your medication are and what you can do about them if they happen.

5.  Can I take this medication with all my other medications?

I find that most patients will ask me about this.  What is often missed though are the non-prescription medications, vitamins or herbal products they are taking.  Patients tend not to mention these as they are often viewed as “safe” and not harmful.  But in fact, there are many vitamins and “natural” products that can interact with prescription medications.  It is important to mention them all.

We all know it is impossible to remember everything your doctor or pharmacist tells you.  And that is where follow-up and communication comes in.  When I see a patient I advise them of any follow-up that is needed or how to reach me for questions. Typically by phone or email, but for more complicated learning I’ll see the patient in the office. Whether your nurse, pharmacist or physician provides you with your prescription, ensure you receive proper follow-up and educate yourself.  You are the person with the most vested interest in your own health.