Making ethics work: Manage your counseling time
All patients’ needs are not equal. The trick is finding the ones who need your services the most.
Every year I ask my students, “How many of you came to pharmacy school to be the least pharmacist you could possibly be?” Not a single hand has ever gone up. The point is to explain the difference between pharmacists’ legal duty and their ethical duty.1
The legal standard is usually said to be what the “reasonably prudent” pharmacist would do under the same circumstances. It is the minimum every pharmacist is legally required to do. There is a higher standard - a professional, ethical standard. Every pharmacist aspires to this higher standard. We all want to be, not the least, but the best pharmacist.
Nothing in pharmacy practice today illustrates that point better than pharmacist counseling, particularly at the community, retail level. Every state requires the pharmacist at least to make an offer to counsel. In these states, the pharmacist who asks, “Do you have a questions for me?” has met the legal duty.
Several states today require actual counseling for all patients who receive drugs that they have not previously taken. In these states, the pharmacist is to tell the patient what the medication is, what it is normally used to treat, how it is to be taken, and other information the pharmacist believes is important, including common severe side effects and what to do if a dose is missed.2
The time crunch
Over the years, pharmacists’ attitudes toward counseling have changed. Today one is more likely to hear pharmacists complain that they do not have the time they need to give counseling to patients who need it. In one study, 29% of pharmacists said they thought “not enough time to counsel patients” was a cause of prescription errors.3 In other studies, 84% of pharmacists blame high prescription volume for medication errors.2,4
While most studies have not found a direct correlation between prescription volume and errors2,3, one fact does seem clear. Pharmacist counseling can improve compliance and increase the effectiveness of drugs, particularly drugs used to treat chronic illness.2,3 The problem in a busy pharmacy is how to find the time to do the counseling pharmacists would like to do.
Most pharmacists, like my students, aspire to be the best pharmacists and to make a difference in patient’s lives.3,5 The problem is not that pharmacists do not want to live up to their ethical duties, but how they can organize their time to do so.
Try an algorithm
One answer may be to find a way to select those patients who need the pharmacist’s advice and counsel the most. Consider making an algorithm to identify these most needy patients. An algorithm is defined as “a set of rules for solving a problem.”6 In a pharmacist’s counseling algorithm, the pharmacist makes a form noting the disease states, patient characteristics, and drugs that could signify a patient who would particularly benefit from counseling. An example might be a fictional Sam Jones:
Sam Jones
• Patient over 65
• On Coumadin
• On more than 5 meds
• Heart condition
• High blood pressure
All patients’ needs are not equal. The trick is finding the ones who need your services the most.
References
1. Mr. Baker teaches Ethical Decision Making at Midwestern University College of Pharmacy, Glendale, AZ.
2. See for example Arizona Board of Pharmacy Rules R4-23-402 (E) through (J).
3. Gianutsos, G, Identifying Factors That Cause Pharmacy Errors, U.S. Pharmacist, December 1, 2008, citing Massachusetts Board of Registration in Pharmacy. Medication Error Study. Massachusetts Office of Health and Human Services. www.mass.gov. Accessed by the author October 1, 2008.
4. Phillips DP, Jarvinen JR, Phillips RR. A spike in fatal medication errors at the beginning of each month. Pharmacotherapy. 2005;25:1-9.
5. See Phillips, DP, supra “The results of several studies suggest that up to 10% of hospital admissions and 23% of nursing-home admissions are related to non-compliance (McKenney and Harrison,1976; Strandberg , 1984). A review of published studies of drug-related hospital admissions reported that 22.7% of adverse drug reaction hospitalizations were induced by noncompliance (McKenney et al., 1973).”
6. See Merriam Webster Dictionary, http://www.merriam-webster.com/dictionary/algorithm (accessed 8/21/2013).
Ken Bakeris a pharmacist and an attorney consulting in the areas of pharmacy error reduction, communication, and risk management. He is an attorney of counsel with the Arizona law firm of Renaud Cook Drury Mesaros, PA. E-mail him at ken@kenbakerconsulting.com.
