Exam 2

Pharmacist Mission (ASHP)

• The pharmacist’s mission is to provide pharmaceutical care → medication-related care to improve definite outcomes + patient quality of life.

- To count as pharmaceutical care:

• Medication-related

• Directly provided to the patient

• Produces definite outcomes

• Improves quality of life

• Provider accepts responsibility for outcomes (meaning: responsible for teaching correctly, NOT responsible for forcing adherence)

Patient Counseling

 individualized guidance + problem solving

Patient Education

bigger umbrella →Counseling is PART of Education (Dr. Klug said: we use them interchangeably for class)

Patient education sessions should be loosely structured to ensure they can be tailored to which of the following?

Patient

What does OBRA'90 mandate?

Patient counseling standards

OBRA ’90 Requires:

1. ProDUR (Prospective Drug Utilization Review)

2. Offer to counsel

3. Counseling by pharmacist or intern

4. Maintain patient records

ProDUR – What MUST pharmacists check?

• Drug–drug interactions

• Drug–disease interactions

• Drug-allergy interactions

• Over/under-utilization

• Incorrect dose or duration

• Clinical abuse/misuse

• Therapeutic duplication

OBRA ’90: Required Counseling Elements

Know this list cold:

• Name of drug (brand + generic) and dose/dosage form

• Intended use & expected action

• Route, schedule, Refill info

• Common side effects + how to avoid + what to do

• Self-monitoring techniques

• (M) What to do if dose missed

• (I) Potential interactions (drug–drug, drug–food)

• (S) Proper storage

OBRA ’90 Recordkeeping — MUST KNOW

Pharmacist must document:

• Offer to counsel

• Accepted or refused

• Perceived level of patient understanding

GOALS & BENEFITS OF PATIENT EDUCATION

a. increases….

b. decreases…

a. Increase patient:

• Attitudes, behavior, involvement

• Knowledge

• Satisfaction

• Skills

b. decreases: 

• Adverse drug reactions

• Non-adherence

• Errors

• Healthcare costs

Why is patient education interactive?

• After 2 weeks people remember only:

  • 90% what they say + do ← THIS is why we demonstrate devices

Pharmacist Expertise

• Drug therapy knowledge

Pharmacist role

• verify understanding

•  You are NOT responsible for outcomes → just responsible for teaching accurately.

Patient Expertise

• Daily routine

• Personal experience with illness

Patient role

• Adhere

• Self-monitor

• Report experiences to healthcare team

Which one of the following methods of learning when used alone provides the lowest retention of information?

Reading

ESSENTIAL COMMUNICATION SKILLS (Exam Loves This)

• Establish trust and rapport

  • Interactive approach

  • Avoid medical jargon

  • Sit at eye level

• Ask open-ended questions

  • Use elicit → provide → elicit

• Listen actively

• Use nonverbal communication

• Show empathy

• Tailor counseling

  • Pharmacist controls structure, but patient should talk the most

  • Organize info in a logical flow

  • May need multiple sessions

  • Have materials ready

• Motivate patients

• Remain clinically objective (NO bias)

• Provide privacy & confidentiality

What does PRINT INFORMATION not do?

• Does not replace counseling

• Does not increase adherence by itself

• Not appropriate for everyone (language/literacy issues)

If using print materials:

• Must be scrutinized

• Must be accurate, unbiased

• Should be customized (grade level 5–6 reading level)

Developing Written Material — MUST KNOW Formatting

• Common, lay words

• Short, active sentences

• Affirmative phrasing

• Specific (e.g., “take with 8 oz water”)

• Headings, subheadings, white space

• Pictograms helpful

• ≥14-point font

Why AUDIOVISUAL + DEMONSTRATION DEVICES matter:

• Improve retention

• Essential when time is limited

• Patients learn 90% of what they say + do

• Useful for: inhalers, injectables, insulin, GLP-1s, etc.

What MUST you do when using AUDIOVISUAL + DEMONSTRATION DEVICES

• Explain the audiovisual aid

• Use placebo devices when possible

• Have patient demonstrate back technique (RPh evaluates and corrects)

What settings did we talk about in PATIENT EDUCATION

• community

• hospital

• ambulatory

a. PATIENT EDUCATION IN community

b. focus on…

a.

• Required to offer counseling for all new prescriptions

• Workload/time constraints are common

• Alternate follow-up (phone, return visit) helpful

b. Focus on encouraging adherence, monitoring

10-Step Modified Counseling Encounter (memorize)

Intro → Identify → Verify → Assess → Teach → Info → Concerns → Teach-back → Written → Close

patient education in AMBULATORY CARE SETTING

• Collaborative with physicians

• Joint Commission requires med management teaching and written information

AMBULATORY CARE SETTING focus on

• Narrow therapeutic index drugs

• Complex regimens

• Adherence barriers

• Stringent monitoring

• Significant interactions

• Samples → MUST educate because there is no pharmacy counseling later

patient education in  HOSPITAL SETTING

• Usually done at discharge

• Shown to decrease readmission and improve adherence

• Must complete final med reconciliation

HOSPITAL SETTING focus on

• Newly prescribed meds

• Discontinued meds

• Dose changes

• High-risk medications

THE THREE PRIME QUESTIONS

1. What did the doctor tell you this medication is for?

2. How did the doctor tell you to take it?

3. What did the doctor tell you to expect? (benefits + side effects + self-monitoring)

purpose of the THE THREE PRIME QUESTIONS

Reveals patient baseline knowledge → lets you fill in gaps.

The “Three Prime Questions” format of patient education sessions as defined by Indian Health Services was originally designed for use in which setting? 

Counseling in community pharmacy setting

The “Three Prime Questions” format is structured around the use of what type of questions?

Open-ended questions

What’s a great supplement to the prime questions:

DRUG Counseling Acronym (DRUG)

• D – Drug name/use and dosage (how to take, timing, missed dose, clarify technique)

• R – Results (What to expect in side effects/not working, Self-monitoring)

• U – Underlying issues (BBW, interactions)

• G – General info (storage, refills, who to call)

What are the 2 frameworks when helping a patient choose an OTC medication.

1. QuEST - 4 STEPS FOR OTC COUNSELING

2. SCHOLAR-MAC - HOW YOU INTERVIEW THE PATIENT

QuEST

• Q – Quickly assess (using SCHOLAR-MAC)

• E – Establish appropriateness for self-care

• S – Suggest therapy

• T – Talk with the patient to ensure understanding

SCHOLAR-MAC

• S Symptoms

• C Characteristics

• H History

• O Onset

• L Location

• A Aggravating factors

• R Remitting factors

• MAC: Medications, Allergies, Conditions

define Self-care

Self-care = when patients manage their own health on their own, including:

• Staying healthy (health promotion)

• Preventing sickness

• Detecting issues

• Treating minor problems
  — without needing a healthcare provider every time.

Risks of self-care:

• Misdiagnosis

• Brand extensions confusion

• Misunderstanding OTC labels

• Drug interactions

• Overuse/misuse

Benefits of self care

• Saves money

• Reduces healthcare workload

• Convenient

• Many OTC options available

Why NOT family members when UTILIZING INTERPRETERS

• Add opinions

• Patient may hide sensitive info

• Limited English

• Emotional burden (like children)

• Summaries instead of full interpretation

• privacy issues

Proper use of interpreter:

• Sit in triangular positioning (you ↔ patient ↔ interpreter)

• Make eye contact with patient, not interpreter

• Speak in short segments

• Ask one question at a time

• Pause for interpretation

• Check understanding frequently

• Debrief after

• Document type of interpreter + ID number

 COMMON PITFALLS (Professor emphasized these)

• Not greeting/explaining purpose

• Not asking patient’s concerns

• Assuming what they mean

• Using closed-ended questions

• Using medical jargon

• Not verifying understanding

• Missing nonverbal cues

• Allowing interruptions

• Rushing

• Giving incomplete information

SHOW-AND-TELL METHOD

• Gives the patient a visual association

• Helps clear up confusion, especially:

  • When manufacturers change

  • When language barriers exist

what not good about SHOW-AND-TELL METHOD

patients may over-rely on pill appearance → must warn them

When is SHOW-AND-TELL METHOD useful?

• Useful as a final verification for the pharmacist to ensure what's in bottle is correct

How to COUNSELING DIFFICULT PATIENTS

✔ Try again
✔ Explain why counseling helps
✔ Offer another time
✔ Stay nice
✔ Give written materials
✔ DOCUMENT refusal

Culture = NOT just…

race or ethnicity

Culture includes…

• Age

• Gender/Sexual orientation

• Disability

• Religion

• Nationality / Immigration background

• Language

• Socioeconomic status

• Health beliefs

How many cultures can a person have?

A person has MANY cultures (not just one).

Culture influences what?

health beliefs

illness perception

treatment decisions.

Stereotyping =

 BAD

What you should NOT assume about every member of a cultural group?

behaves the same.

Culture is…

dynamic → people move in/out of cultures across their life.

Failure to understand a patient’s culture can cause:

• Poor adherence (Not explaining meds in patient's language)

• Ineffective treatment

• Miscommunication

• Health disparities

• Toxicities

• Safety issues

Healthcare providers form what type of culture

Healthcare providers form a “biomedical culture,” which includes:

• Medical jargon

• Belief in technology/science

• Pathophysiology-focused view

• Increasingly patient-centered today

Any provider–patient conversation is…

cross-cultural

Cultural Competence meaning

Cultural Competence = ability to respond respectfully + effectively to people of all cultures.

NOT:

• A certificate

• One-time achievement

IS:

• A lifelong skill

• Requires practice

• Requires self-awareness (your biases, your worldview)

Cultural competence is not the same as

 Cultural blindness- treating everyone the SAME → WRONG

Minorities have:

• Lower quality care

• Poorer access

• Disparities independent of income, insurance, or location

US projection of health disparities

By 2050 → ≥50% of population will be racial/ethnic minorities.

what did the Patient Perspective (Survey Highlights) show?

From 23,000 patients:

• Most felt respected

• Nonwhite, uninsured, low-income patients = feel less respected

• BUT only ~50% said providers ask about their beliefs or opinions

• Many patients WANT providers to understand or share their culture

Cultural Competence Continuum (VERY TESTABLE)- Levels (low → high):

1. Cultural Destructiveness

   • racist, hostile, harmful

   • Example: Tuskegee Syphilis Study

2. Cultural Incapacity

   • Inability to serve diverse groups

   • Example: manager avoids hiring someone with accent/skin color

3. Cultural Blindness

   • “I treat everyone the same”

   • Fails to recognize differences that matter

4. Cultural Pre-Competence

   • Knows there is a need for improvement

   • “We need cultural training here.”

5. Cultural Competence

   • Acceptance + respect for differences

   • Adapts services

6. Cultural Proficiency

   • Actively advocates

   • Builds organizational cultural competence

   • Eliminates disparities

Seven Components of Culturally Competent

1.  Self-assessment of your own beliefs + biases

2. Understanding the cultural context of your population

3. Effective communication with diverse populations

4. Culturally responsive drug therapy management

5. Build community linkages

6. National/Professional Initiatives

7. Evaluate your progress

examples of Effective communication with diverse populations

• Eye contact = respectful (U.S.) but rude in many Asian/Native/African cultures

• Some Muslim/Arab patients avoid opposite-gender touch

• Some want family involved in decisions; others do NOT

What does  Culturally responsive drug therapy management mean?

Adjust therapy based on:

• Religious dietary rules

  • Ex: Pork-derived meds (heparin, armour thyroid) unacceptable for some

  • Alcohol in liquid meds

  • Capsules made from gelatin/pork

• Fasting (Ramadan) → adjust insulin/diabetes meds

• Herbal use → check interactions

• Patient’s belief about illness → accommodate when safe

 National/Professional Initiatives

• Healthy People 2030

• CLAS Standards (language access, translated materials)

Tools for Cultural Assessment

A. Patient Explanatory Model

B. LEARN Model

 Patient Explanatory Model

Ask:

• “What do you call your illness?”

• “What do you think caused it?”

• “Why do you think it started now?”

• “What treatments do you think will help?”

B. LEARN Model

L – Listen

E – Explain

A – Acknowledge differences/similarities

R – Recommend

N – Negotiate

(VERY testable)

Kids age range

 0–18 years, HUGE range of physical, cognitive, emotional abilities.

Why Pediatric Communication Matters

• Communication MUST match developmental level.

In peds you talk to:

• Child

• Parent / caregiver

• Multiple clinicians (neurosurgeon, nurse, geneticist, etc.)

50%+ of medication errors →

from incorrect home liquid medication use.
➝ Clear counseling is essential.

Kids vary because of:

• Physical differences

• Cognitive development

• Emotional development

• Environmental factors (trauma, illness, loss)

• Cultural differences (responsibilities, roles in family)

Key Challenges in Pediatrics

• Misunderstanding instructions

• Parent–child communication differences

• Poor adherence

• Fear/anxiety

Core Principles of Pediatric Communication-

ALWAYS:

• Get on the child’s physical level (kneel, squat)

• Speak TO the child first, then the parent

• Simple words

• Short sentences

• Warm tone

• Active listening

Core Principles of Pediatric Communication-

NEVER:

• Talk over them

• Use medical jargon

• Use scary metaphors (e.g., “medicine kills the bugs” → makes them think bugs crawl inside them)

Core Principles of Pediatric Communication

 Build trust:

• Ask about their interests (Bluey, Paw Patrol, sports, books, TikTok)

• Engage them — kids feel proud when included

• Smile, use gentle body language

Tools for Effective Communication With Children

A. VISUALS

B. TASTE matters

C. Distraction Techniques

A. VISUALS

Kids understand:

• pictures 🖼

• iPad videos

• flavor options

• smiley scales (pain scale)

• sun vs. moon for morning/night doses

TASTE matters

• Kids DO care how medicine tastes.

• Acknowledge it honestly (“not too bad,” “a little cherry taste”)

C. Distraction Techniques

Highly effective during:

Highly effective during:

• vaccines

• procedures

• counseling

Examples:

• Blowing bubbles

• Light-up toys

• Stuffed animals

• “Who can blow the pinwheel the longest?” → Gold standard technique

Pediatric vs Adult Care — KEY Differences

Pediatrics

• Family-centered

• Preventative care focus

• Kids can’t consent ⇒ they assent

• Milestones matter

Adults

• Patient-centered

• Chronic disease focus

• Adults consent themselves

• More abstract thinking

 Developmental Stages

Ages 0–2 (Infants & Toddlers)

Ages 2–7 (Toddlers & Preschoolers)

Ages 7–12 (School Age)

Ages 12–18 (Adolescents)

Ages 0–2 (Infants & Toddlers)

Communication abilities:

• Crying → different types (pain vs hunger)

• Learn via 5 senses (touch, taste, sight, sound)

• 2–5 months: cooing, smiling

• 4–8 months: babbling

• 6–12 months: repeat words

Ages 0–2 (Infants & Toddlers) - Counseling strategy:

• DO:

• Use play (peekaboo)

• Distract (singing, tapping, rhythmic sound)

• Let parents hold the baby

• Use soft tone

Ages 0–2 (Infants & Toddlers) - Counseling strategy:

• DO NOT:

• Take the baby away

• Talk too much (parents need to listen)

Ages 0–2 (Infants & Toddlers) - Most important:

Parents must have proper measuring tools → NO kitchen teaspoon.

Ages 2–7 (Toddlers & Preschoolers)

Abilities:

• 8–18 months → first words

• By 4 years → fully understandable speech

• VERY concrete thinkers

• Don’t understand cause & effect well

• Tons of imaginary play

Ages 2–7 (Toddlers & Preschoolers)-

Counseling strategy:

• Use visual aids

• Avoid metaphors (“kill bugs”)

• Ask simple questions:

  • “What questions do you have?”

  • “Does it taste okay?”

• Distract during vaccines

• Use teddy bear/role-play:

  • “Can you give your teddy a pretend dose?”

Ages 2–7 (Toddlers & Preschoolers) - Most important:

Kids want to know TASTE and how it will make them feel.

Ages 7–12 (School Age)-

Abilities:

• Concrete but improving reasoning

• Start understanding cause + effect

• Can explain symptoms

• Increasing vocabulary

• Can be separated from parents for short conversations

Ages 7–12 (School Age)-

Counseling strategy:

• Explain simply but honestly

• Use calendars, stars, reward charts

• Give responsibility (“You remind Mom when it’s time”)

• Teach-back with devices (inhaler, spacer)

Ages 7–12 (School Age)- most important

They understand literal meanings → avoid figurative language.

Ages 12–18 (Adolescents)

Abilities:

• Abstract thinking

• Logic, debate skills

• Risk-taking behavior

• Peer influence > parents

• Want autonomy

• Care about privacy

Ages 12–18 (Adolescents)-

Counseling strategy:

• Speak to THEM first

• Be direct, non-judgmental

• Allow private conversation (if safe/legal)

• Respect confidentiality

• Use future-oriented counseling:

  • “This helps prevent long-term lung damage.”

• Use their technology:

  • Alarms on phones

  • Apps

  • Health reminders

Ages 12–18 (Adolescents)- most important

Treat adolescents like adults

BUT still involve parents respectfully.

When a child asks difficult questions (Ex: “Am I going to die?”)

You respond with:

• What do you think? What have they told you?”

• Follow the family's lead — don’t break bad news as the pharmacist.

How do you build comfort when Managing Emotions & Hard Conversations?

• Warm environment

• Fun colors in pediatric hospitals

• Toys, books, distraction items