In a recent interview with Inside Patient Care: Pharmacy & Clinics, James S. Beaumariage, RPh, Principal, Beaumariage Consulting, LLC, Nashville, TN, discussed key issues and trends in pharmacy education, and ways to effectively communicate with patients.
What are some key issues and trends in the pharmacy education curriculum?
A: The situation is, today, that a pharmacist can graduate from pharmacy school and qualify, have the requisite internship hours, to sit for the board exams without having been an employee of a pharmacy.
A lot of the expansion from the 5-year curriculum into the 6-year curriculum was really providing academic oversight to what, in my generation, we did as interns. When I went to pharmacy school, it was a 5-year program. You had to have 1500 hours to sit for the board examinations; approximately 400 to 500 of those hours were through controlled or managed externships. It was 4 to 6 weeks at the beginning of your last 2 semesters of school.
The balance was spent working in a real pharmacy environment, whether that was a retail drugstore, a hospital pharmacy, long-term care facility, or any number of pharmacies. You were on your own. That entailed working nights, working evenings, and working holidays.
An overwhelming majority, I would suggest, of my pharmacy classmates had part-time jobs. They may have done it during school, maybe not. But certainly on holidays, summers, weekends, a lot of kids would go home and work in a drugstore, or at a hospital pharmacy.
They got the real-world exposures, and understood that as a pharmacist you are going to be working on a holiday. You are going to be working Sundays, every other weekend. They also understood that when it was raining outside on Saturday afternoon, you cleaned the shelves and things of that nature.
In today’s curriculum, in the last year you are in pharmacy school, it’s really a series of rotations of internships. A lot of those are rather clinical.
I just know, having managed innumerable drugstores and pharmacists over the years, that the interns who are in those programs tend to get treated with white gloves. They are 9:00 to 5:00—“Oh, go ahead and go out to lunch.” Unfortunately, I think we are doing them a disservice, because they are not really being exposed to the reality of the role and the life of a pharmacist, particularly in a retail environment.
What happens to these students who do go into retail?
A: There are young pharmacists who have had exposure to the real-world retail background. They know what they are getting into and they have a vocation—this is their vocation. They wanted to do that. Others came at it from a very academic perspective, and, although they are brilliant, may be taken aback by it.
Some pharmacists don’t realize some of those things that need to be done. Among the staff in the pharmacy, the pharmacist is looked up to as the leader, the manager in a sense of the word. They may not have that title, but they need to lead their shift. They need to provide the general direction of the staff. But if they don’t know things need to be done, there are those staff members who will wait until you tell them to do something. Now others will take the initiative and say, “Hey, we’ve got to do this,” or, “Hey, we have to do that.” But there are a lot who don’t. They don’t have that real-world background and experience to know what needs to be done.
At the end of the day, the goal of the pharmacist is to provide medications to the patient, but also ensure that they take them home and take the medication. A lot of that is in how you approach that customer or that patient. You have to talk in their terms and help them to understand, “Look, the medicine works. Your job is to take it, and I’m here to help you. To remind you or help you to find ways to remind yourself.”
How do you level with the patient and get them to take their medication?
A: I had a situation with a farmer with type 2 diabetes, who wasn’t taking his medicine. He’s a big, strapping guy, and he’s scared to death of needles. He says, “How can I remember to take my medicine?”
I just said to him, “You’ve got to take it twice a day. What have you been doing twice a day since you were 4 years old? Do you have cows?” “Yeah” “Do you milk them? How often?” “Twice a day.” “Do you have a milk book?” A milk book is where they record how many pounds of milk they get. It’s how they get paid. “Put the bottle on the milk book, out in the barn. Take it every time you go to your milk book.” “OK. I can do that.”
Sometimes, you have to go beyond the mechanism of action and the clinical discussion point and get real. Just talk to the patient. Say, “Hey, look.” Do it in a way that they can remember. That’s the ultimate objective, for them to take the medicine. If the medicine works, they just have to take it. That is something that I found naturally, and I always have looked for pharmacists who could come across that way.
Do you think that students should get more exposure to patients?
A: Preceptors really do need to get students in front of patients—real-world patients, not a demonstration project or some program in the school environment. And not only get them in front of patients, but also encourage them.
My understanding of patient counseling as it is presented in school, it is for pharmacists to follow a certain regimen. You do this. Then you do that. At the end of the day, you have to be able to take those skills, put them into a conversation, not a regimen. You just have to walk out and talk to the person, and say, “Hey, Mary. How’s it going? How are the grandkids? Good. Great. Hey, look. You are starting this new medicine. You have got to be sure to take it every day. Here’s how my mom remembers how to take hers.”
Spin it, so that it is not overly professional, overly esoteric. It is not you telling them, but rather it is you chatting with them. Once you create that dialogue, they are going to do whatever you tell them to do because it’s presented differently. A lot of that’s personality, honestly.
How can retail pharmacists effectively communicate with patients?
A: It’s a self-appraisal. Are you cut out to do that or not? Not everybody is. It does not make them a bad pharmacist, from a technical and professional perspective. But if they recognize that that is the case, then they really need to work with their technicians to try to bring them up a notch so that they know how to do that.
That is very possible, too. I have worked with terrific technicians over the years, who could nearly run the pharmacy in many respects. It was interesting. As a young man, I came into a town, I didn’t live there, nobody knew me, and took over a very busy store. As soon as my technician told a customer, “This guy’s really good” or “We like Jim a lot,” I was gold. It is the same way on compliance, really. In other words, there is reinforcement. Often that is very important. Many times the technician staff may have been in the pharmacy and generally is more familiar with the customer, because they are out there at the register. Whereas the pharmacist isn’t always available to do that with today’s volumes.
It is very important that you work as a team, and that your technician staff support whatever message the pharmacist delivers.
Is there a role for community pharmacy to provide support to caregivers?
A: I think that first you have to recognize that the healthcare system is very deliberate, and they have to be from a cost-containment perspective. They are pushing people down, down the healthcare continuum.
In other words, people are released from the hospital much sooner than they had been in the past—if they even go to a hospital. There are a lot of procedures that are now done in outpatient, day surgery–type situations. The drive—particularly as patients age—is to keep them at home as long as they possibly can, or longer than they have in the past. There is a general shift in a sense out of the healthcare system into the home environment. We are seeing a trend where families are becoming much more involved and required to participate in their parents’ or elders’ healthcare.
We as healthcare providers, although we are going to serve a gatekeeper role into primary care, we are also going to need to serve as a support mechanism for caregivers. It’s interesting, and if you stop to think about it, as an adult, you are a caregiver. You only get off the caregiver hook for about 4 or 5 years. The first 20 or so years of your children’s lives, you are their caregiver, and it seems as though, at least from personal experience, there is only approximately a 4- to 5-year gap until you need to become a caregiver for your parents.
I think that the pharmacy industry is the most accessible element of healthcare from a patient access and convenience perspective, the industry really needs to position itself to support caregivers. If you think about it, you can encompass both ends of that spectrum. From the parents of children to the children of parents, that is becoming much closer. Drug delivery, drug therapy, and drug misadventures. Your parents simply taking their medicine correctly becomes an ever-increasing problem. It is a significant problem and it is the reason why people are entering the other facets of healthcare, including going to the emergency department, being hospitalized, and going into assisted living.
If we can, as an industry, position ourselves to be a better provider of care and support for the caregiver, I think that’s absolutely key. You start thinking about packaging. How do we package? Is it really easy for your 78-year-old mother who is starting to show signs of dementia to go home with 11 vials of medication, and take them correctly? I would suggest not.
What is the role of pharmacists in medication reconciliation after hospitalization?
A: Start and stop is a huge issue. The other piece of it is, and it is really a function of the managed care world in that to the extent that older adults, the elderly, or the preelderly, now is a much later age than it used to be.
One of the things that is out there today is that a lot of retirees have a 90-day prescription drug benefit. When they access and they refill their medications, they are getting a 90-day supply. But in that 90 days it’s not at all uncommon for their physician to have changed the directions. Their vial still says take it 3 times a day; however, their doctor, who they visited a month ago, said to taper it to 2 a day. They may or may not have remembered to do that.
I have seen situations, personally, where postsurgery, we had a visiting nurse in to set up my father’s medication for him. She’s reading off the prescription vials, and where he was to have actually discontinued a medication for 4 weeks, he continued taking that medication because the physician’s notes, the follow-up notes from his physician visit, never got to the visiting nurse.
Despite that level of care, despite that healthcare provider coming out into the home environment, and the costs associated with that, they’re still not getting dosed properly.
I think that starts to get into interoperability in terms of the electronic data interchange information coming out of the physician’s office to, for a visiting nurse–type situation, etc. It’s a real dilemma, and you don’t really stop to think about it. Or a lot of people don’t until you experience it. There’s a huge challenge there, and I think there’s an opportunity there for pharmacy to play a role.
Again, it gets into interoperability and connectivity. To the extent that a pharmacy is able to reach out and touch a consumer at home to remind them to get a prescription refill, could they have a means by which they announce or they remind a patient of a dose?