By Eamonn J. Murphy, Pharm.D., PGY1 Pharmacy Practice Resident, Georgetown University Hospital
A key concept that I learned during pharmacy school is the importance of communication. Several classes in the pharmacy curriculum put a strong emphasis on communication. There were therapeutics labs that incorporated one-on-one counseling of mock patients on medication adherence, side effects, and techniques for using inhalers and medical devices. However, working with various students and teachers in lab is quite different than practicing as a pharmacist. This practice was a great stepping stone, but it is vital that students get structured counseling and feedback while interacting with actual patients.
I recently read an article, Improving communication skills of pharmacy students through effective precepting, by McDonough and colleagues.1 This article emphasizes the importance of students developing and practicing their communication skills during their advance pharmacy practice experiences (APPEs), especially their community-based rotation. This article brings up an interesting concept, “see one, do one, teach one”. A pharmacy student is going to shadow a preceptor and follow their example. Every interaction a pharmacist has on a daily basis goes back to the principles of communication, and the student will be influenced by these observations. Whether talking to a patient, a physician, a nurse, or another pharmacist, these skills will used every day.1
To help develop and teach professional communication during the APPE, it would be beneficial to students to have the preceptor introduce all staff members and their respective roles (or position) in the pharmacy. This would be the first step in creating professional relationships in which the student would feel comfortable relaying information and asking questions to staff.1
Now that I am in the fifth month of my pharmacy residency, I have had precepting experiences and I will be responsible for co-precepting P4 pharmacy students in the future. I have been thinking about some lessons that a preceptor should teach to a student. Even though this article by McDonough focuses on community pharmacy, several of the lessons are equally applicable in hospital pharmacy and precepting in that setting. A pharmacist in an institutional setting should perform medication reconciliations every day and go into patient rooms to discuss new medications that have been prescribed. One style of teaching is through direct observation of a preceptor conducting medication reconciliations and discharge counseling. While conducting medication reconciliations and discharge counseling on new medications, it would be appropriate to use the Indian Health Service questions. A pharmacy preceptor should make sure to teach these questions to their APPE student. Before the student first observes the preceptor patient counseling, time should be spent discussing and rehearsing the Indian Health Service questions with the student. These questions focus on the patients understanding of what medications they are taking, why they are taking them, and what they can expect.
Indian Health Service questions:1
Prime Questions to ask patients who are receiving a new prescription:
- What did your doctor tell you the medication is for?
- How did the doctor tell you to take it?
- What did the doctor tell you to expect?
Final verification or asking the patient for feedback
- Just to make sure that I didn't leave anything out, please tell me how you are going to take your medication.
Strategy when a patient is receiving a refill
- What do you take the medication for?
- How do you take it?
- What kind of problem are you having?
As a preceptor, you could demonstrate the use of these questions in front of a student, and then have them counsel patients once they are ready. Through discussion, memorization, practice, and then observation, an APPE student can become comfortable using these Indian Health Service Questions. Other important aspects of communication that could be focused on and discussed with P4 students while precepting is using open ended questions, good eye contact, and active listening. The responses to these open ended questions will help show what the patient truly understands about their medication and help direct a student or pharmacist toward what should be addressed.2 This is especially important because, as Kripalani and colleagues state, only 12% of adults in the United States are proficient health literacy.3
Additionally, in an institutional or hospital setting it is important at the beginning of the APPE to discuss appropriate interactions with physicians. As a pharmacist, there may be several medication-related interventions that need to be communicated directly to the prescribing physician. A preceptor should spend adequate time discussing how the APPE student should interact with a physician. One method to teaching this type of communication is for the students to write up a series of hypothetical scripts they would use during telephone calls or face-to-face interactions. Hasan4 describes this method of teaching where the pharmacy students writes three scripts for telephone interaction with physicians. The script types including: passive, aggressive, and assertive. The purpose of this is for the student to think critically and to explore the various types of communication skills and determine which would be most effective. Once the student writes these, a preceptor can discuss the pros and cons of each of these styles. Having a student listen to several phone calls and interactions with physicians would also be appropriate. McDonough includes a brief list of things that should be discussed with a student.
Additionally, in an institutional or hospital setting it is important at the beginning of the APPE to discuss appropriate interactions with physicians. As a pharmacist, there may be several medication-related interventions that need to be communicated directly to the prescribing physician. A preceptor should spend adequate time discussing how the APPE student should interact with a physician. One method to teaching this type of communication is for the students to write up a series of hypothetical scripts they would use during telephone calls or face-to-face interactions. Hasan4 describes this method of teaching where the pharmacy students writes three scripts for telephone interaction with physicians. The script types including: passive, aggressive, and assertive. The purpose of this is for the student to think critically and to explore the various types of communication skills and determine which would be most effective. Once the student writes these, a preceptor can discuss the pros and cons of each of these styles. Having a student listen to several phone calls and interactions with physicians would also be appropriate. McDonough includes a brief list of things that should be discussed with a student.
How to Communicate Information to Physicians:1
- Keep patient focused
- Provide the physician with meaningful background information
- Clearly and concisely outline the problem the patient is experiencing with the drug therapy
- Propose a solution
- If face-to-face, request physician feedback regarding the solution
In order to be a pharmacist today, effective communication with patients and all members of the interprofessional team is vital. Preceptors play an important role by helping APPE students acquire the knowledge and skills needed to be effective communicators.
References:
1. McDonough RP, Bennet MS, et al. Community pharmacy improving communication skills of pharmacy students through effective precepting. Am J of Pharm Educ. 2006; 70 (3) Article 58. 1-12.
2. American Society of Health-System Pharmacists. ASHP guidelines on pharmacist-conducted patient education and counseling. Am J Health-Syst Pharm. 1997; 54:431–4.
3. Kripalani S, Jacobson KL, et al. Strategies to improve communication between pharmacy staff and patients: a training program for pharmacy staff. AHRQ Publication No. 07(08)-0051-1-EF. 2007
4. Hasan S, et al. A tool to teaching communication skills to pharmacy students. Am J Pharm Educ. 2008; 15; 72(3): 67.