Why Aren't More Pharnlacists Counseling? by Richard Herrier, PharmD, and Robert Boyce
Since pharmacists' counseling of patients was mandated by the Omnibus Budget Reconciliation Act of 1990 (OBRA '90) and other state and federal regulations, patients and advocates of counseling have frequently asked, "Why aren't more pharmacists counseling patients?"
Barriers to Counseling "Pharmacist-Patient Counseling Program I, " a workshop sponsored by Pfizer Inc., provides insight into practicing pharmacists' perceptions of the barriers preventing them from counseling. Nearly 30,000 pharmacists have participated in the fourhour workshops since they were flrst offered in 1991. Each workshop begins with participants frankly discussing and listing potential problems or barriers to patient counseling at their practice sites. Not surprisingly, participants consistently report the same problems. The most frequently mentioned barriers to counseling can be grouped into flve major categories: phannacy environment, phannacistrelated barriers, patientAMERICAN PHARMACY
related barriers, infonnational!philosophical barriers, and miscellaneous barriers. Future columns will discuss ways to overcome these barriers. Phannacy Environment: Participants identilled excessive workload, or lack of time and staff (a different expression of the same problem), as the most serious barrier to patient counseling. Pharmacists tended to significantly overestimate the time required for counseling, placing the average counseling time per prescription at more than flve minutes. (The Indian Health Service indicates that counseling averages about two minutes per outpatient visit.) The physical layout of the pharmacy was frequently listed as a problem. High counters, glass partitions, and other obstructions or design flaws make counseling individual patients difficult. Another design-related problem is existing work-flow patterns that were developed for processing prescription orders efficiently rather than interacting with patients. In some cases, work-flow patterns prevented counseling; in others, adding counseling created inefficiencies that increased overall workload.
(Overcoming this barrier will be addressed next month.) Other environmental problems cited as limiting pharmacists' ability to communicate with patients included lack of privacy, distractions (particularly answering the telephone or co-workers' questions), proxies (people picking up prescriptions for patients), and home delivery of medications. Phannacist-Related Barriers: Participants identilled lack of formal education or experience in patient counseling as a barrier to becoming more active counselors. Specillc areas mentioned included: inadequate knowledge of the prescribed drug, poor counseling skills, lack of familiarity with what they should say to the patient, discomfort in talking with
patients, and fear of saying the wrong thing, which might result in litigation or conflict with physician instructions. Less frequently listed barriers to counseling were: pressure from co-workers not to counsel, not wanting to get involved with patients' problems, not seeing counseling as a professional responsibility, and professional burnout. Patient-Related Barriers: Pharmacists frequently noted that patients do not want to be counseled, stating: "Patients are in a hurry, " "They already know about their medicines and are insulted by counseling," "They have to struggle with small children," or "They are embarrassed by the counseling topic." Other
Resolving Counseling Barriers Phannacists throughout the countty have been working since 1990 to provide the patient counseling services that must be offered to Medicaid patients tmder the Omnibus Budget Reconciliation Act of 1990. Because of our experience with interactive counseling techniques in the Indian Health Service, we conduct workshops to teach phannacists these skills and to help corporate .phannacy organizations implement effective patient counseling programs. During the workshops, sponsored by PflZer Inc., phannacists share their frustrations, skepticism, and concerns about planning and implementing these value added services. This column is designed to be a forum for discussing problems, sharing solutions, and offering practical tips that busy phannacists can use to implement and maintain effective patient counseling services. Future columns will include burning questions, comments, concerns, and success stories in an open dialogue about patient counseling that we hope will improve phannaceutical care services. We encourage you to send us your questions and solutions-handwritten notes or prepared papers-on counseling topiCS that affect your practice. Write to us in care of "Out Front," American Pharmacy, 2215 Constitution Ave., NW, Washington DC, 20037-2985. Richard Herrier, PharmD Robert ("BiZr) Boyce
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communication barriers listed include cultural or language problems, hearing or vision problems, mental impairment, and alternate health beliefs. One barrier regularly listed was low patient expectations. Pharmacists felt that patients were not open to counseling because they did not expect it. PhilosophicaVInformationa! Barriers: In the early workshops(1990-92),phar macists questioned the need for counseling and its effectiveness in improving compliance. Some even cited the literature to support their positions. Now that the OBRA '90 regulations have been in force for nearly two years, this issue is less frequently mentioned. Another common problem cited is lack of management support of patient counseling activities-ranging from not providing additional resources to directing practitioners not to counsel. Lack of adequate information about the patient was frequently listed. For example, pharmacists often do not know the disease or symptom for which a medication is prescribed or the names of all the medications that patients are taking. The pharmacists felt that without this knowledge they might give patients information that conflicted with physicians' instructions or they might tell patients something that the physicians did not want known. Occasionally, pharmacists noted that some physicians philosophically Vol. NS34, No. 11
disagree with pharmacists acting as patient educators. Miscellaneous Barriers: Participants' concerns over increased liability caused by counseling activities were voiced in each workshop. Participants also cited lack of reimbursement as a barrier to providing these counseling services.
Summary Clearly, the answers to the question "Why aren't
more pharmacists counseling patients?)) are complex.
Factors affecting counseling vary by practice site, geographical region, and pharmacists' attitudes. Advocates of patient counseling may label many factors mentioned by workshop participants as "just excuses not to change" or may question their validity. However, our experiences have shown that these are real problems with logical explanations and relatively simple solutions. By focusing this column on the steps for overcoming these common barriers to coun-
seling, we hope to help pharmacists expand their role in patient care. Richard Herrier, PharmD, is assistant professor, University of Arizona College of Pharma0', Tucson. Robert (,Bill))) Boyce is director ofpharma0' services, Chemewa Indian Health Center, Indian Health Service, Salem, Oreg. The opinions expressed in this column are those of the authors and are not necessarily those of the Indian Health Service or the U.S. Public Health Service. Table 1
Overcoming Barriers to Counseling Counseling Barriers
Action Steps to Overcome Barriers
Too till1e consull1ing
• Change prescription filling process, integrating counseling into work flow (to be discussed in column 2). Don't try to add on to existing procedures. •
Delegate more dispensing duties to technicians.
• Use interactive counseling techniques to reduce counseling time needed.
Lack of privacy/ access to patients
• Create private areas and improve access by changes in work flow, innovative shelving arrangements, or remodeling.
Inadequate pharll1acist skills
• Learn interactive counseling techniques through workshops (such as Pfizer workshop on "PharmacistPatient Counseling Program I." • Practice, practice, practice. • Develop drug-specific counseling guidelines.
Poor patient acceptance
• Publicize counseling activities before implementing them. • Recognize the natural history of implementation of patient counseling. •
• Improve counseling skills through continuing education. • Attend continuing education workshops to learn skills and techniques for dealing with these situations (such as Pfizer's workshop on ILDealing with Challenging Situations," the second part of the "Pharmacist-Patient Counseling Program"). • Practice, practice, practice.