Enhancing Patient-Pharmacist Relationships Through Conversation

Bruce Berger, PhD, does not like the term active listening. “If it’s listening, it’s active,” said Berger, an emeritus professor at Auburn University in Alabama, and president of Berger Consulting LLC, a company that trains health care professionals in motivational interviewing and helps them make health behavior changes. “The difference between listening and hearing is the active part. If it’s just hearing, you’re on autopilot. And with patients, you have to show authentic interest.”

Pharmacist communicating with patient about medication / C. Davids/peopleimages.com - stock.adobe.com

Indeed, listening—especially when it comes to patient concerns about medication adherence—is crucial for pharmacists. According to a 2019 article published in the Journal of Managed Care and Specialty Pharmacy, nonadherence to medication represents a $100 billion to $300 billion annual burden in the United States, whereas nonoptimized medication therapy, inclusive of the effects of nonadherence, costs a staggering $500 billion annually.¹

“It’s a huge problem,” noted Berger. “I tell pharmacists, especially when you have a patient with a new prescription and a new diagnosis, [to say], ‘Would you mind telling me in your own words, what does your diabetes mean to you?’ The reason that’s important is, it gives you an idea of how motivated this patient is to do something. One patient might say, ‘My doctor told me if I don’t take care of my diabetes and get my blood sugar down, I’m going to have kidney problems, and possibly eye problems.’ That tells me we’ve got a patient who’s probably motivated to take their medication properly. On the other hand, if you get a patient who says, ‘I don’t know. I’ve got blood sugar problems, but I feel OK, so I’m not sure I want to do anything right away.’ Then you’ve got a different [kind of] patient.”

When faced with the latter example, Berger suggested exploring with the patient their understanding of their disease. “We’ve got to say, ‘Tell me more about your understanding of what diabetes can do,’” Berger explained. “We had a patient not long ago who brought a new prescription into the pharmacy for diabetes, and said, ‘Keep this on file. I’ll start taking it when I feel bad.’ We needed to [make] the patient understand that if they wait until they feel bad, the damage may already be done.”

It is crucially important, in the case of patients who both adhere to their treatments and those who don’t, to never shame a patient or make them feel badly about how they are managing their disease. Empathy, forging a connection, and never talking down to patients are key in building trust, and that is the best chance for patient adherence.

“If a patient has a new prescription, I’m not going to assume that just because they’re bringing it in, they’re motivated to do something, right? On the other hand, I might say, ‘Tell me in your own words how important is it for you to treat your blood pressure, your diabetes, your cholesterol,’” Berger said. “I want to listen carefully to how they’re making sense about this.”

This understanding and empathy are crucial, particularly in the face of the misinformation spread during the COVID-19 pandemic. Berger recalled the conspiracy theory some believed that the government was putting microchips in COVID-19 vaccines.² “Even though we know that was not true, you’ve got to be able to respond in a respectful way.”

Berger suggested using language that acknowledges the patient’s dual concerns about COVID-19 and privacy. “That can open the door to a conversation in which I’m saying to the patient, ‘I get you.’ If I look at that patient and say, ‘That’s ridiculous. They don’t put in a computer chip,’ that can just shut the conversation down. And, unfortunately, too many health care professionals do that.”

“There is a lot that goes unsaid,” added Lea Wolsoncroft, RPh, a compounding pharmacist at Remedies Pharmacy in Hoover, Alabama, and the current president of the National Community Pharmacists Association. “We often discover things by watching the patient closely: If a patient is limping or seems unsteady or out of breath with simple ambulation, that can be a big clue as to some things that may be going on,” she said. In those cases, asking questions as simple as, “How are you feeling? Do you have any health challenges currently?” can open the door to some genuine conversation.

When it comes to addressing and managing adverse effects, direct conversations are key. “I was in a doctor’s office one time when a patient called in and said she started [having a] persistent cough,” Berger recalled. “It turned out that she had been put on a new medication for high blood pressure that in some patients can cause such a cough.” If she hadn’t been aware of that adverse effect, he explained, the patient may have taken a cough suppressant, rather than address the root cause of the problem. “We’ve got to ask good questions,” he added.

“[Adverse] effects are a big issue with patients,” Berger said. “We don’t always know what the [adverse] effects might be, if there will be any, or if the patient might have read about some [potential adverse] effects online.” In those cases, it’s important to remember that everything pharmacists do should be in the spirit of trying to make the patient feel comfortable. For adverse events, “what I would do as a pharmacist is tell the patient the most common 2 or 3 [adverse] effects that patients experience with this medication,” Berger said. “I would also tell them what they can do to alleviate those effects, and what to do if those [adverse] effects become problematic.”

Finally, if a patient seems confused by a medication’s instructions—or by their illness in general—pharmacists may sometimes need to dig deep: Wolsoncroft pointed out that when asked if they have any questions, patients may say no, but still seem confused. “If you ask, ‘How will you be taking this medication?’ and they just repeat the question, rather than correctly answering, you can then ask something like, ‘Does this all make sense, or does it still seem confusing?” to draw them out and see where the confusion is.”

In the end, said Berger, “there are 2 main things we must do when it comes to patients: We’ve got to develop that rapport and [we’ve got to] take their concerns seriously—meaning respect their concerns—even if we know that they’re not an issue. Because to them, they are.”

References

1. Campbell PJ. Adherence: an important metric to assess pharmacist value in quality care. J Manag Care Spec Pharm. 2019;25(10):1044-1045. doi:10.18553/jmcp.2019.25.10.1044

2. Black E, Tarasov K. Why the COVID vaccines can’t contain a tracking microchip or make you magnetic. CNBC. October 1, 2021. Accessed March 7, 2024. https://www.cnbc.com/video/2021/10/01/why-theres-no-5g-tracking-microchip-in-the-covid-vaccine.html