VIEWPOINT

Counseling in the real world

Let me make it perfectly clear that I am 100% in favor of counseling. Counseling saves lives. Lots of errors are caught during counseling.

To be honest, I'd much rather counsel patients than fill prescriptions. Unless a pharmacist suffers from social anxiety disorder (a.k.a. shyness), counseling is the easiest job in the pharmacy. I am totally exhausted at the end of most days when I fill 200 Rxs, but I bet if I did nothing but counsel all day, I'd feel like I had the day off.

Boards of pharmacy seem incapable of understanding that many pharmacists don't counsel not because they don't want to counsel but because there is simply inadequate time and staffing for counseling. Since counseling is the easiest and most fulfilling job in the pharmacy, it should tell the pharmacy boards something when they discover instances of "failure to counsel."

I wish the boards would pass a rule that mandates that R.Ph.s have enough staffing so that counseling is possible. Instead, the boards are doing nothing to address our dangerous working conditions. Pharmacy boards say that they can only pass regulations to protect the public safety. But surely unsafe working conditions endanger the public safety.

Many pharmacists are upset when pharmacy boards threaten disciplinary action for failure to counsel. The boards readily tell us that our job entails counseling. Yet, when we say the boards should perform their job (protect the public safety by addressing pharmacists' working conditions), we're met with inaction.

Our pharmacy professors do a brilliant job of preparing us to counsel our patients—in a sterile environment. Don't these professors realize what the real world is like? Our professors and boards need to instruct us on how to counsel patients in a hyper-stressful environment in which we're running an hour or two behind—patients are yelling at us, people at the drive-through window are honking their horns, all four phone lines are for the sole R.Ph. on duty, we haven't had a meal or bathroom break, and customers are telling the register clerk, "I've waited long enough. I want my prescriptions back so I can go somewhere else to get them filled."

Proper counseling technique involves such things as asking open-ended questions. Don't tell the patient what the drug is used for. Instead, ask him if he knows what it's used for. Open the Rx vial and show the patients the pills. That way we can catch errors. This is all magnificently good advice, and most R.Ph.s would love to practice this type of pharmacy. When we protest that there's simply no time, board officials and pharmacy professors tell us, "Well you'd better find the time! It takes only a few seconds."

The legal experts tell us, "You'd better find the time to counsel because a jury won't believe you when you say you didn't have enough time to tell Mr. Jones his anxiety medication would make him too drowsy to drive."

What legally constitutes adequate counseling? Is it when you verbally list the most common uses of the drug, side effects, warnings, contraindications, best time to take the drug, and what to do if you miss a dose? If that is the case, then the vast majority of pharmacists in America are breaking the law. How many possible side effects do we need to mention? The top two, top five, top 10?

Legal experts tell us that we need to give our patients what seems like an ever-increasing volume of information. We are told that our medication leaflets need to be the most detailed ones available anywhere. With an oversupply of lawyers in America, pharmacists run a high risk of being sued for failure to list less common side effects in our leaflets and to verbally warn patients about them.

Our employers and managed care are pushing pharmacists in one direction (speedily herding patients), while lawyers are pushing us in the opposite direction (giving more warnings to our patients).

Nothing makes me angrier than reading about some hired-gun pharmacy professor who testifies that an R.Ph. did not adequately perform his legal duty to warn of a potential adverse reaction. I'd like to put my pharmacy professors and heads of pharmacy boards in a high-volume store and see how well they counsel patients. I'd like to see them thoroughly counsel every customer without having a dozen misfills and lines all the way to the parking lot.

I bet that most pharmacists are more exhausted after a day's work than heads of pharmacy boards or pharmacy professors. One pharmacist told me that she goes home each day after her shift and sits in a dark room just to decompress. I wonder how many board members and professors do likewise.

Employers advertise that their pharmacists are eager to counsel patients about medications. The truth is that many employers don't value pharmacists who spend too much time counseling patients. Employers can tolerate counseling only as long as it doesn't slow our processing of patients. Employers give lip service to counseling, but most pharmacists learn quickly that our No. 1 job (by far) is filling Rxs as fast as we can (i.e., faster than we should).

Each time I shop at Home Depot, it never ceases to amaze me that all their salespeople have plenty of time to discuss home improvement with their customers. Pharmacists would love to have as much time to discuss medications with their patients. The difference is that the big pharmacy employers have adopted the fast-food model.

Our pharmacy leaders say that R.Ph.s must assume more liability if we want to be recognized by third parties as independent professionals and compensated for our cognitive services rather than just for the products we dispense. This means acceptance of a duty to warn patients about potential dangers associated with drug therapy. With an increased counseling role and a duty to warn come increased liability and lawsuits. Even though I am absolutely 100% in favor of counseling, I'll bet that the people advocating all this increased liability for R.Ph.s aren't actually filling Rxs all day long. Educators and pharmacy boards are good at promoting regulations that affect others, not themselves.

I think pharmacy boards need to acknowledge the real world when they find instances of "failure to counsel." The enormous problem of understaffing needs to be fixed before pharmacists are disciplined over this issue.

Dennis Miller, R.Ph.

The AUTHOR, a community pharmacist in Delray Beach, Fla., encourages feedback at dmiller1952@aol.com. Please also send a copy of your comments to drug.topics@medec.com.

 

Dennis Miller. Counseling in the real world. Drug Topics Dec. 8, 2003;147:24.