Notes on Pharmacy Communication, Information Gathering, EBM, and Decision Making

Background and Context

  • Two lectures in series; first lecture provides background and sets up focus on OTC information gathering and communication in pharmacy.
  • Presenter: Carl, a pharmacist who emphasizes moving from a transaction-based dispensing model to a relationship-based, consumer-centric, and collaborative model. He notes curriculum changes: potentially five years for the degree, and six with management.
  • Emphasis on gathering information for over-the-counter requests; acknowledges that pharmacists can sometimes make mistakes and that critical thinking is required.
  • Personal trajectory: pharmacist with nursing background; discusses evolving scope of practice and the importance of patient-centered care in addition to pharmacology.

Learning Objectives

  • Define communication and give examples of different types.
  • Describe benefits of patient-focused communication.
  • Give an example of open-ended questions.
  • Describe elements of appropriate information gathering.
  • Identify environmental barriers to effective communication and patient barriers, and discuss solutions.
  • Describe components of therapeutic decision making and evidence-based medicine (EBM).
  • Formulate a research question and distinguish primary, secondary, and tertiary sources.
  • Understand the PSA (Pharmaceutical Society of Australia) framework and related protocols.
  • Recognize common biases and heuristics in decision making and strategies to mitigate them.
  • Appreciate the role of shared decision making, patient values, and the impact of communication on adherence and safety.

Key Concepts and Definitions

  • Communication: the imparting or exchange of thoughts, opinions, or information; includes verbal and nonverbal cues (eye contact, body language, silence).
  • Patient-centered vs person-centered care: focus on the person first, then drug therapy; pharmacists often emphasize drugs, nurses emphasize person care.
  • Service quality in community pharmacy: connection, willingness to listen, understanding patient lifestyle, and respect.
  • Open-ended vs closed-ended questions:
    • Open-ended often starts with a W word (who, what, where, when, why, how).
    • Closed-ended often elicits yes/no or a specific short answer.
  • Information gathering frameworks:
    • WAM (Who is the patient? What are the symptoms? How long have the symptoms been present? What action has been taken? What medication has been taken? What medication are you currently taking? What other medication/history?)
    • WAMA (WAM expanded to include Allergies and Medication history; can help ensure safe supply)
    • PSA protocol (What, who, duration, symptoms, side effects, special needs, risk of overuse/abuse, etc.)
  • Health literacy: the ability of patients to obtain, process, and understand basic health information; a barrier to effective communication.
  • Evidence-based medicine (EBM) and evidence-based practice: integrating the best available evidence with clinical expertise and patient values.
  • PICO: Problem/Patient, Intervention, Comparison, Outcome; used to formulate research questions.
  • Primary vs secondary vs tertiary sources:
    • Primary: original research (e.g., RCTs, trials).
    • Secondary: reviews and summaries of primary sources.
    • Tertiary: textbooks and handbooks summarizing material from primary/secondary sources (e.g., AMH).
  • RCT (Randomized Controlled Trial): gold standard for evidence, but not always feasible due to ethics, cost, or rarity of condition.
  • Patient-oriented outcomes vs disease-oriented outcomes: outcomes that matter to patients (e.g., heart attack prevention) versus laboratory or surrogate endpoints (e.g., blood pressure reduction).

Information Gathering Frameworks

  • WAM (What, Who, How long, Action, Medications): initial checklist for primary care consultations; limitations include not addressing social history, family history, or safety in supply.
  • WAMA (What Allergies, Medications, Medical history, Additional factors): an enhancement over WAM to capture allergies and broader medical history.
  • PSA protocol (Pharmacist/PSA prevention protocol): structured approach focusing on presentation, potential risks (overuse/abuse), special needs, social circumstances, and safety in supply; emphasizes asking about symptoms, side effects, and potential interactions.
  • UK and Australian findings: more questions in information gathering correlate with safer non-prescription supply, but generic checklists alone do not capture social, lifestyle, or family history.
  • ENCORE method (Explore, No medication, Care, Observe, Refer, Explain): US-based framework; considers appearance and social factors but still has limitations.
  • ASS method (Age, Appearance, Self or someone else, Supplements): broad framework for OTC assessment; acknowledges consumers may not recognize non-oral routes (injections, patches, eye/nasal applications).
  • Generic checklists (e.g., sit-down, patient presenting complaint): helpful for structure but insufficient for red flags or social history.

Open vs Closed Questions and Interview Techniques

  • Open-ended questions: encourage descriptive answers; likely to start with W words.
  • Closed-ended questions: yield short, specific answers; useful for clarifying but risk missing nuance.
  • Practical tip: if in doubt, use open-ended first and follow with closed-ended questions to confirm details.
  • Interview technique example: distinguishing the presence of a headache and differential diagnosis highlights the need for comprehensive information gathering to guide treatment and referral.

Barriers to Effective Communication and Enabling Solutions

  • Environmental barriers:
    • Pharmacy counter layout and seating arrangements; presence/absence of a counseling room; privacy concerns.
    • In many setups, brief interactions at a counter can impede thorough counseling.
  • Social/psychological barriers:
    • Biases (racial, age, gender, ethnicity, religion, socioeconomic status) can affect patient interactions and outcomes.
    • Nonverbal cues and power dynamics (e.g., hospital bed conversations) influence patient perception and openness.
  • System-related barriers:
    • Time pressure (pharmacy consultations ~1.5 minutes on average vs GP six minutes).
    • Distractions and interruptions that degrade the quality of information gathering.
  • Literacy and health literacy barriers:
    • Patients may have limited understanding of medicines and terminology; jargon used by professionals can hinder communication.
  • Privacy concerns:
    • In studies, privacy perceptions affected what patients shared; many were satisfied but still withheld some information.
  • Solutions and best practices:
    • Move out from behind the counter; counsel at equal level; use a private counseling room when possible.
    • Speak clearly, avoid over-reliance on jargon; use language appropriate to patient literacy.
    • Present information one item at a time; use active listening; acknowledge and repeat back important details.
    • Use patient-focused approaches to demonstrate care and avoid making patients feel their time is wasted.
    • Practise communication skills; consider using written checklists but recognize they do not replace nuanced interviewing.
    • Involve pharmacy staff (e.g., assistants) as part of a collaborative team to move from system one to system two thinking.

The Patient-Centered Approach and Outcomes

  • When communication is effective, symptoms may resolve more quickly, psychological well-being improves, and treatment adherence increases.
  • Patient recall of information improves with good communication and rapport.
  • A patient-focused approach can reduce medication errors, improve safety, and enhance loyalty and trust.
  • Privacy and confidentiality are critical to enabling patients to share sensitive information.

OTC Medication Safety, Red Flags, and Misuse Risk

  • Several over-the-counter medications have potential for misuse or adverse effects if used inappropriately:
    • Sympathomimetics (e.g., pseudoephedrine) and nasal decongestants with misuse potential.
    • Certain cough syrups (containing codeine or dextromethorphan) and other controlled or restricted substances.
    • Pseudoephedrine-based products: regulation and supply controls to reduce illicit manufacturing (e.g., Breaking Bad references).
  • Pharmacists should assess for risk of overuse or misuse and consider whether a patient should be supplied, advised, or referred.
  • Emphasis on “not just supply, but safe supply” and when to refer for further assessment.

Therapeutic Decision Making and Evidence-Based Practice

  • Megan Anakin’s model (an adaptation used in this course):
    • Step 1: Information gathering
    • Step 2: Reasoning
    • Step 3: Judgment
    • Step 4: Enacting a decision
  • Common weak link: making the final decision (enacting) can be challenging; fear of error may lead to defaulting to physician consultation.
  • The PSL (Quality Use of Medicines) framework: select, use, and manage medicines wisely; ensure safety and effectiveness.
  • Formulating a research question using PICO:
    • P: Patient/problem
    • I: Intervention
    • C: Comparison
    • O: Outcome
    • Example: A 72-year-old woman with osteoarthritis and hypertension; daughter wants a new COX-2 inhibitor; concern about cost and GI bleeding risk; question could compare GI risk and cost between COX-2 inhibitor vs traditional NSAID.
  • Evidence-based medicine (EBM) foundations:
    • Ibn Sina’s early ideas on testing hypotheses; modern EBM emphasizes well-defined questions, selection of evidence, and applicability to the patient.
    • James Lind’s 1797 scurvy trial: randomized allocation of treatments; highlighted the importance of controlled experimentation; modern implementation takes time to translate into practice.
  • Evidence sources hierarchy:
    • Primary: original research papers (RCTs, trials)
    • Secondary: systematic reviews, meta-analyses
    • Tertiary: textbooks and handbooks (e.g., AMH – Australian Medicines Handbook; Rutters & Newby textbook for OTC guidance)
  • Limitations of evidence and practice:
    • Not all medicine is tested via RCTs (e.g., parachute example demonstrates ethical/practical limits).
    • Some outcomes are more patient-oriented; others are disease-oriented; both matter but patient-centered outcomes often drive decisions.
  • RCT considerations and ethics:
    • Ethical concerns may prevent placebo use (e.g., chemotherapy), rare diseases, or small patient numbers.
    • Alternative trial designs and pragmatic trials may be used when ideal RCTs are not feasible.
  • Translating evidence to practice:
    • Implementation of evidence into daily practice is slow; education and awareness are needed.

Formulating and Answering Research Questions (PICO)

  • Example scenario:
    • A 72-year-old woman with osteoarthritis and moderate hypertension; daughter requests a COX-2 inhibitor; cost is a concern; GI bleeding risk is a consideration.
    • P: 72-year-old woman with OA and HTN; I: COX-2 inhibitor; C: alternative NSAID or non-NSAID therapy; O: GI bleeding risk and monthly out-of-pocket cost.
    • Research question: In older patients with OA and HTN, does COX-2 inhibitor therapy reduce GI adverse events compared with non-selective NSAIDs, while considering monthly cost?
  • The decision-making process involves balancing benefits, harms, patient preferences, and cost in a shared decision-making framework.

Historical Foundations and References to Evidence

  • James Lind’s scurvy trial (1797): six groups; fresh fruit (two oranges and one lemon daily) prevented scurvy; exemplifies early randomized experimentation.
  • Parachute example: never been tested in an RCT; illustrates limitations of RCTs for certain life-saving interventions.
  • Primary, secondary, and tertiary references: used to classify literature and evidence hierarchy; primary literature is the source; secondary and tertiary synthesize and summarize.
  • Australian Medicines Handbook (AMH): a tertiary reference; excellent for drug information but less comprehensive for non-prescription medicines; complement with specialty textbooks for OTC guidance.

Heuristics, Biases, and Dual-Process Thinking in Pharmacy Decision Making

  • Kahneman, Slovic, and Tversky (1974) identified three heuristics:
    • Availability: ease of bringing examples to mind biases judgement.
    • Anchoring and adjustment: initial anchor influences subsequent estimates; adjustments may be insufficient.
    • Representativeness: likelihood judged by similarity to a known category, ignoring base rates (base-rate fallacy).
  • Examples from the lecture:
    • Availability: guessing which letters are more common as starting letters of words; often misleads judgments.
    • Anchoring: initial numbers influence later estimates (e.g., euro price anchoring exercise).
    • Representativeness: Steve the librarian example illustrating base-rate neglect.
  • Framing effects:
    • Outcomes framed as “2/6 saved” vs “4/6 not saved” can reverse preferences despite identical probabilities.
  • Law of large numbers (Yes Prime Minister discussion): expectations about sample means; a single data point does not change the overall mean of a large population.
  • Law of small numbers: a small sample may mislead; one outlier does not define the population mean.
  • System 1 vs System 2 thinking (Kahneman):
    • System 1: fast, automatic, intuitive but error-prone.
    • System 2: slow, deliberate, analytical but effortful.
  • Application to pharmacy:
    • Routine dispensing often relies on System 1; high-stakes decisions (referrals, complex interactions) require System 2 engagement.
    • ETTO principle (Efficiency-Thoroughness Trade-Off): balancing quick actions with thorough assessment; organizational and cognitive load influence which mode dominates.
  • Collaboration and team-based decision making:
    • Assistant involvement can shift decision making toward System 2, improving referral accuracy and safety when appropriately engaged.

Case Examples and Empirical Findings from the Lecturer’s Work

  • PhD studies in Western Australia involved mystery shopping to evaluate OTC supply decisions and protocol effectiveness:
    • Fluconazole (S3) vs Clotrimazole (OTC) for vaginal discharge: many red flags were present; non-supply with proper referrals was suboptimal.
    • Ventolin (salbutamol) protocols: results showed protocols alone did not guarantee improved practice; written checklists helped but did not fully change behavior.
    • Emergency contraception (morning-after pill): written checklists increased checklist usage and non-supply decisions, but some clinicians still supplied when not medically required.
  • Key takeaway from these studies: information gathering is essential, but simply having a protocol or checklist is not enough; engagement, judgment, and collaboration influence outcomes.
  • Practical implication: training should emphasize context, clinical reasoning, and patient-specific factors rather than rote protocol application alone.

Practical Takeaways and Skills to Practice

  • Emphasize patient-focused communication to improve adherence and safety.
  • Use open-ended questions to gather richer information; follow with targeted closed questions for clarification.
  • Move counseling into private spaces when possible; sit at equal level with the patient; show empathy and active listening.
  • Practice repeat-back and reflective listening to confirm understanding.
  • Be mindful of health literacy and use plain language; avoid unnecessary jargon.
  • Combine information gathering with critical thinking and collaborative decision making; don’t rely solely on protocols.
  • Consider system 1 vs system 2 thinking and use teamwork to engage System 2 when appropriate.
  • Recognize cognitive biases and use structured reasoning (PICO, evidence hierarchies) to guide decisions.

Quick Reference: Acronyms, Frameworks, and Tools

  • WAM: Who is the patient? What are the symptoms? How long? Action taken? Medications taken? Other meds/history?
  • WAMA: WAM + Allergies + Medications + Additional medical history
  • PSA protocol: Patient, Symptoms, Actual symptoms, Side effects, Special needs, Overuse risk, etc.
  • ENCORE: Explore, No medication, Care, Observe, Refer, Explain
  • ASS method: Age, Appearance, Self/Someone else, Supplements/other medicines
  • AMH: Australian Medicines Handbook (tertiary reference)
  • PICO: Problem/Patient, Intervention, Comparison, Outcome
  • EBM/Evidence-Based Medicine: integrate best evidence with clinical expertise and patient values
  • RCT: Randomized Controlled Trial
  • OTPS/OTC taxonomies: S2 (pharmacy-only) and S3 (supervised selling) categorizations in Australia
  • ETTO: Efficiency-Thoroughness Trade-Off

Suggested Readings and Resources

  • Ruta and Newby (community pharmacy/OTC guidance)
  • Australian Medicines Handbook (AMH)
  • James Lind, Scurvy Trial (historical example of RCT)
  • Kahneman, Thinking Fast and Slow (dual-process theory)
  • Yes Prime Minister: survey design and framing lessons
  • General references on evidence-based medicine and PICO formulation

Final Practical Reminders

  • Communicate with patients as partners; listen, understand their lifestyle, and respect their circumstances.
  • Use structured information gathering but tailor questions to the individual; don’t rely solely on generic checklists.
  • When in doubt, refer to a colleague or use a patient-centered approach to shared decision making.
  • Stay aware of biases and practice deliberate, reflective thinking in complex cases.
  • Leverage collaboration with the broader healthcare team to optimize patient outcomes.