Patient Counseling FINAL (2nd half)

• 1. establishes professional relationship
• 2. can obtain subjective information on medical problems
• 3. can assess drug efficacy and toxicity
• 4. can assess patient's knowledge, attitude toward, and pattern of medication use
• 5. helps formulate a problem list
• 6. helps formulate plans for medication teaching and pharmceutical care

• 1. obtain a current medication list (prescription and OTC medication)
• 2. obtain a history of past medication usage
• 3. intended purpose or indication for each of the current medications
• 4. assessment of therapeutic benefit of current medications
• 5. assessments of adverse effects from any of the current medications
• 6. assessment of medication compliance
• 7. obtain history of drug allergies and adverse drug reactions

(1) greet the patient warmly --> (2) introduce yourself --> (3) verify identity of patient and caregiver(s) if present [direct questions to the patient unless he/she is unable to give valid information] --> (4) state the purpose of the interview and the expected outcome for the patient [ex: 'Mrs. Smith, I want to speak with you about your medications you are taking, how they are working, and if they are causing you any side effects."]

• 1. Read the chart or patient profile first
• 2. If previously unplanned, let the patient know how the interview will last to determine if it is a convenient time
• 3. Make the setting as private as possible
• 4. Know and complete the 6 ground rules for conducting an interview

• 1. arrange furniture to allow face to face communication at eye level
• 2. sit 2-4 feet from the patient

• 1. do not appear rushed
• 2. be polite
• 3. be attentive
• 4. be nonjudgemental
• 5. listen more than you talk
• 6. maintain good nonverbal communication
• - maintain good eye contact
• - slightly forward lean and open body posture

• to start data gathering
• open-ended questions start with who, what, where, and why
• ex: Tell about the medications you are currently taking

• for discriminating details
• closed-ended questions can be answered with a yes or no
• use sparingly - limit patient's response and do not allow for other information to be revealed

if pertinent

• after obtaining a block of related information
• ex: "Mrs. Smith, you've told me that you are taking HCTZ and digoxin for your heart, and you used to take potassium, but you're not on it right now and you're concerned that you need it. Is that correct?

• to let the patient know you are asking about a different type of information
• ex: after taking a current medication history, the pharmacist might say, "Now I'd like to ask about your allergies or reactions to medications you've had."

• 1. know what needs to be asked and politely defer questions that are not pertinent to the drug history
• 2. look for openings to bring the subject into focus
• 3. when it becomes necessary to interrupt, address the patient by name and simply state your need to ask a certain question

• 1. current prescribed medications
• 2. current non-prescription medications
• 3. past medication usage
• 4. drug allergies and adverse reactions
• 5. medication compliance
• 6. possibility of pregnancy/breastfeeding in women of child-bearing age
• 7. social history

• 1. drug name
• 2. purpose
• 3. dose
• 4. duration
• 5. beneficial effects/efficacy
• 6. adverse effects/toxicity

• Start first by saying, "Tell me more about it."
• 1. onset/timing: when did you notice this? when did it start?
• 2. duration: how long have you had this problem?
• 3. content: under what circumstances does this symptom appear?
• 4. quality: what does it feel like?
• 5. quantity: how much, how often do you notice it?
• 6. treatment: what makes it better? what have you done about it?
• 7. aggravating factors: what makes it worse?
• 8. associated symptoms: what other symptoms are you having?

• 1. drug name
• 2. purpose/symptoms treated
• 3. dose and frequency of use
• 4. duration
• 5. beneficial effects/efficacy
• 6. adverse effects/toxicity

• 1. drug name
• 2. purpose
• 3. time period of use
• 4. reason for discontinuation (why and who)

• 1. drug name
• 2. date of reaction
• 3. type and severity of reaction

• 1. nicotine usage - quantity; duration; If stopped, when?
• 2. alcohol usage - quantity; type; duration; If stopped, when?
• 3. illicit drug usage - quantity; type; duration
• 4. dietary habits
• 5. exercise - type of activity; frequency
• 6. occupation
• 7. stressors
• 8. financial situation- insurance vs. out of pocket
• 9. social support system

• (1) give brief summary of the most important points
• 1. note concerns that you or the patient has about the medications and recommendations for resolution of problems
• 2. ask patient to verify agreement on the issues
• --> (2) ask if the patient has anything else to ask or add --> (3) thank the patient for meeting with you- call them by name

• 1. current prescription and OTC medication list
• 2. past medications
• 3. drug allergies and reaction type
• 4. social history

True.

• builds: escalating emotion
• 1. part of being human
• 2. sometimes for good reason, sometimes not
• 3. very difficult emotion
• 4. may result in unclear thinking and impaired ability to solve problems

• 1. no quick fixes or easy advice
• 2. how do you respond to anger?
• 3. do your responses escalate others?
• 4. do your responses focus on solving problems? should be.

• 1. just a feeling
• 2. not inherently good or bad
• 3. no worse or better than joy, hurt, or fear
• 4. feeling angry is not what causes the problems
• 5. it is what we choose to do when we feel angry
• 6. almost always a secondary emotion
• 7. fear and hurt are often the primary emotion trigger
• 8. often used to block off physical or emotional pain
• ex: getting angry when publicly criticized because it feels better and more powerful than the primary emotion (primary emotion = embarrassment, fear of being different) - address the primary emotion and talk to the person in one-on-one time instead of for show.

• 1. we use it to escape the core feelings we use it to mask - not addressing the fear/underlying problem - solve by privately discussing it. (problem-solving)
• 2. we suppress or repress anger or express it inappropriately

• -builds up and is eventually released in some form of an explosion
• -a lot of little anger > a little of a lot of anger (blow-up)
• -linked with development of medical conditions (PUD, CVD) - when not expressing anger (holding it in)
• -causes us to lose information about who we are - need to be able to recognize when we are hurt or afraid so we can grow and mature (so angry and losing sight of the origin of problem)

• 1. rage
• 2. passive-aggressive behavior
• 3. defensiveness
• results: cause damage to others and real issues do not get addressed

• 
• primary --> trigger --> secondary

• 1. physical stress
• 2. emotional stress
• ex: a patient who complains (stressor) a lot, and pharmacist says he/she cannot deal with it (self-fulfilling prophecy). (core feeling = ignorance, powerless, fear, dread) due to: bias?, or last experience.
• problem solving: only address problems that have some control over (this case: no control)

• comments we make to ourselves (sometimes out loud) in response to the stressor or painful core feelings which then turns core feeling into anger because beliefs, expectations, values are not how we believe they should be (the plane is in a holding pattern due to weather).
• -"why does he always have to complain?"
• -"why does he always come in when I am working?"

• 1. once you decide to practice pharmacy, you make the decision to serve people
• 2. to operate effectively as professionals, the patient is not always right
• 3. "The patient is always right" should be replaced with "The patient deserves respect"

• you enter into a nonreciprocal relationship with your patients (don't expect anything in return- give and never expect to receive)
• you do not lose your self respect (come up with your own line)

• if patient says there was a shortage of tablets, yet profile said counted was done three times, who is right? not the patient, you are the professional
• upper management cannot have it both ways

• respect for people cannot be diminished by bad behavior and is not dependent on accomplishments
• do not have to like behavior and do not have to put up with it - clean slate next visit when patient acknowledges and willing to change. (respectfully tell them that they are wrong, don't say right if they aren't)
• you do not deserve to be disrespected either - you need guts (don't ignore- inappropriate).

• 1. listen
• 2. be empathetic
• 3. respect the other
• 4. respect yourself
• 5. remain separate from others - just a job/not life
• 6. communicate assertively

• how well a patient knows the medical procedures and terminology
• literacy: ability to read and write
• health literacy: ability to read and understand health literature or health information provided to a patient. The patient's ability to read and understand the information that is provided to them that is related to health, wellness, and medicine.

21%

• 8th or 9th grade level
• bias sample because those who can afford any healthcare or even care about health will come

> 10th grade

1/4; 25%; a quarter

more than 66% or more than 2/3rds

True

2/3rds

19%

false. most are adept

• patients with marginal literacy:
• 1. make more significant medication or treatment errors
• 2. far less likely to adhere to their medication regimens
• 3. fail to seek preventative care more
• 4. less preventative overall in their health, don't engage in any form of preventative care like nutrition, diet, and exercise

• 1. when you ask them to fill out forms or complete medication history and they ask many questions, want to bring it home, complain about font, or have someone else do it, etc)
• 2. making excuses for not reading labels when asked to do so
• 3. patients doesn't know names of the medications they've been taking for a long time
• 4. registration or other types of forms are filled incompletely or incorrectly
• 5. overall expressed disinterest and show that they don't care about it

• 1. reading consent forms
• 2. registering for care or filling out patient history forms (difficult for them)
• 3. filling out financial aid forms is difficult/payment issues
• 4. reading medicine labels
• 5. understanding other types of written health information like brochures, monographs
• 6. even understanding a complex medication regimen

• 1. bring someone who can read
• 2. mimicking behaviors
• 3. asking help from medical staff
• 4. asking other patients

• 1. pictures, symbols, diagrams (since brochures and monographs are usually in all words)
• 2. any material should be written at 5th grade level
• 3. use common words
• 4. ask them to watch videos (check credibility first)

• 1. encouragement (ex- to bring someone)
• 2. for directions- use pill boxes, identifier for blind, color coded, associating with daily events vs time to make it more relatable
• 3. follow-up with patient
• 4. speak more slowly

• 1. the absence of conflict is not harmony, it's apathy
• 2. conflict is essential to innovation
• 3. conflict is natural, even necessary
• 4. reasonable people, making decisions under conditions of uncertainty, are likely to have honest disagreements over the best path
• *conflict is not always bad; a disagreement
• *not important enough or have fear

• 1. focus on people rather than problem at hand
• 2. people saying you're not good enough, personalize it and we feel afraid

• 1. moan about it
• 2. avoid it - absence of decision can be a problem
• 3. solve it - can be a problem if you oversimplify and not listen to others
• *key: be honest with yourself

• the cultural problems especially in America is that we don't show grief well or afraid to show grief
• neurosis: disorder we use to substitute legitimate suffering which is the better way.

• 1. lack of awareness
• 2. incompatible goals
• 3. scarce resources - doing more with less like having less staff
• 4. dependence
• 5. values (morals)
• 6. resistance to change

for a healthy conflict, you are not always right

• 1. be descriptive rather than judgmental (try to not make it personal)
• 2. be specific rather than general
• 3. deal with things that can be changed (past grievances should be kept in the past)
• 4. give feedback when it is desired - when someone is willing to listen
• 5. consider the motives for giving and receiving feedback (to help them or to make you feel better?)
• 6. try to give feedback at the time the behavior takes place, if possible
• 7. if necessary, give feedback when its accuracy can be checked with others (get others involved for evidence).

• 1. education
• 2. communication
• 3. participation
• 4. problem solving (best one- this is the only win-win strategy for managing conflict)

• 1. when engaged in a conflict over a problem, focus on the problem, not the person
• 2. provide feedback rather than accusations

• 1. identify the problem - define it exactly and specifically and determine who is responsible for the problem
• 2. identify all possible solutions - requires brainstorming with others because the more possibilities = better chances of finding best solution
• 3. decide which solution is the best - no perfect compromise
• 4. determine how to implement the solution
• 5. assess the outcome of your solution

like confidence, is always a good thing vs. arrogance and cockiness

• 1. engage in problem solving
• 2. face conflicts and seek solutions of mutual accord

• traditional - command-and-control
• due to changing times:
• 1. busy
• 2. globally-available information (information from internet)
• 3. global communication
• 4. little generational tolerance for unquestioned authority

not just, "what should I do?", but "Why should I do it?"

• 1. form of manipulation (devious <-- don't do it)
• 2. selling products and closing deals

• always involving compromise, leading others to a problem's shared solution
• a negotiating and learning process

• 1. preparation
• 2. proper framing of arguments
• 3. presentation of supporting evidence
• 4. proper emotional match with your audience

• 1. beliefs which lead to
• 2. attitudes which lead to
• 3. behaviors - the focus, but must effectively affect all (if there are conflicts) for persuasion

• unknown answer. she might be too busy. don't know her behavior.
• *This shows that persuasion:
• -involves compromise
• -it's likely no one will compromise due to Mary's busy lifestyle and the pharmacist who doesn't intervene = dec. adherence of patient
• -compromises that could be made include finding other alternative medication

False. keep --> adjust; not --> will

• 1. establish credibility
• 2. frame goals in a way that identifies common ground with those you intend to persuade
• 3. reinforce position using vivid language and compelling evidence (best way)
• 4. connect emotionally

• has nothing to do with your degree
• research shows that most professionals considerably overestimate their credibility vs. from patients
• grows from 2 sources:
• 1. expertise - proven by track record over degree
• 2. relationships - honest, steady, reliable
• *can be built!
• *step back and honestly assess this

• position must appeal strongly to the people you are trying to persuade like convincing Dr. Stolte to chase lightning
• effective persuaders must be adept at describing their positions in terms that illuminate their advantages
• critical: identify your objective's tangible benefits to the people you are trying to persuade
• when no mutual benefits exist, persuaders must adjust their position.

• credibility and common ground must first be identified
• studies have shown that numerical evidence is not sufficient, regardless of discipline
• numerical data should be supplemented with examples, stories, metaphors, and analogies (listeners absorb information in proportion to its vividness and to make an emotional impact through power of language)

• good persuaders are aware of the primacy of emotions
• 2 important characteristics of good persuaders:
• 1. show their own emotional commitment to the position they are advocating (don't overdo it because they'll doubt your clearheadedness, but show that you are also emotional in heart and gut)
• 2. have a strong and accurate sense of the audience's emotional state (intuition, networking like through DSM programs), scare them with stats and information and they'll want to know you'll be there to help them like with their children getting better and they aren't being troubled.

• complex
• can be dangerous when mishandled
• can be a force for enormous good:
• 1. pull people together
• 2. move ideas forward
• 3. galvanize change
• 4. forge constructive solutions
• must be viewed as learning and negotiating rather than convincing and selling
• must be seen as an art from requiring commitment and practice

challenge is not necessary, just to the work.

yes

behavior

• Possibly.
• ex: insurance for everyone, jump in prescriptions

copays don't really change. problems with angry patients.

• 1. fear, anxiety, and ambivalence
• 2. anger, blaming, and scapegoating
• 3. going numb or avoiding
• 4. excitement, joy and relief
• 5. frustration
• 6. depression
• 7. feeling out of control
• 8. shame or guilt
• 9. feeling alone
• *ambivalence is worst = not thinking about the changes or ramifications.

• 1. lack of confidence in ability to make transition (pharmacists don't counsel even if required by law back then because they don't see it as their role)
• 2. lack of understanding of what is needed
• 3. lack of involvment
• 4. inability to see personal of professional benefits
• 5. thinking things are fine as they are
• 6. wondering whether something you have done wrong has led to the change
• 7. "I'm too old for this." It won't matter anyway.

Most addiction therapy is actually based on.

• 1. pre-contemplation
• 2. contemplation
• 3. preparation
• 4. action
• 5. maintanance

• 1. characteristics:
• unaware, unwilling, cons outweighs pros, not ready to try anything within the next 6 months
• (not thinking about anything at all).
• ex- want to quit smoking? no
• 2. interventions by pharmacist:
• listening, empathetic responses, effective questioning, identifying barriers, nonjudgmental approach, persuasive strategies generally not effective at this point

• 1. characteristics:
• open (from being closed) to information and education, thinking about trying something within the next 6 months; low self-efficacy; high perceived temptation to stay the same
• 2. interventions by pharmacist:
• listening and empathetic responding, educational interventions (area to provide education), emotional support, social support, discuss strategies to remove barriers (assess subconsciously at least of where they are at).

• 1. characteristics:
• ready to engage in behaviors in the next month (ready to do it), have made one prior attempt in the past year, beginning to set goals
• 2. interventions by pharmacist:
• listening and empathy, praise for readiness (for even thinking about changing; Fluid Model- progress or relax), assistance in goal setting, discussion of plan of action, identification of pitfalls, asking about support from those around person

• 1. characteristics: taking steps, engaging willpower, developing sense of autonomy, improved self-efficacy; experiencing guilt, failure, personal freedom limits; very stressful stage
• 2. interventions by pharmacist: listening and empathy, reinforcement of self-efficacious behavior, encouragement, emotional support, especially in the face of relapse, ID reason for relapse, confrontation may be necessary

• 1. characteristics: engaged in new behaviors for at least 6 months, sense of accomplishment established, able to ID behaviors that lead to relapse (unlike New Year's resolutions)
• 2. interventions: listening and empathy, help assess situations likely to produce relapse, continued support and positive reinforcement

• What is it?
• -helps you identify patient's readiness to change and understanding
• -used to negotiate (compromise) behavior change with patient
• -counters ambivalence
• --------
• similar to counseling but instead of just talking about medications, one would help patients change behaviors (big behaviors = quitting smoking, exercising)
• taking the Transtheoretical Model of Change that the people go through and guiding them through the process. How can we or any healthcare professional get the people to make the change that is beneficial to them and what we want out of it. This will be outside of patient counseling because it will include all the stuff we have talked about like about conflict.

6 strategies - not all required for every patient

• 5-15 minutes if you skilled and used only on patients who expressed strong desire to change and employed each time a patient is seen
• if you are not skilled it could take you hours

• chit chat with a purpose.
• talk about patient's lifestyle from patient's perspective (getting the context of the behavior)
• Find if whether or not they know what they are doing/is it healthy or unhealthy? ex- what do you eat? what should you think you should be eating?
• in reality, people don't know what to do.
• like/dislike? diet is hard to talk about since everyone likes bad food.
• aspects needed to change
• provides general picture and desire to change and identifies what education to provide to the patient to address the misinformation they may have.

• ask the patient to describe in specifics a typical day related to the behavior in question.
• what should we identify and how often and more importantly, when.
• allows pharmacist to design/tailor intervention to the patient.
• helps improve adherence
• helps build rapport with patient

• pharmacist ask questions of the patient to determine which beliefs are accurate and which need to be corrected (developing discrepancy is a key aspect to motivation interviewing)
• once one decided what is accurate and what is not, ONLY beginning at this point, you will provide information which is different than prior practice. need to target that information. It is more interesting and applicable if you know what the patient wants or needs to know. Education in the form of just providing information does not solve problems by itself which is partly cause of lack of adherence.
• -helps pharmacist build rapport
• -allows corrections of misconceptions and current practices
• -aides in identifying barriers and facilitators of desired behaviors

• NOW we will help with decision making WITH the patient. This is after all the questions.
• Pharmacist provides information related to how to perform a desired behavior and what to do if they do not perform a desired behavior
• only provide additional information if patient wants it.
• provide information in an unbiased nonjudgemental manner.
• ask them what they want to change today. figure out the "why"

• patients discuss their goals as a result of a behavior
• patients concerns and dissatisfaction will become known at this stage
• the goal of patient counseling- take the right medicine, at the right time, at the right dosage. empathy is most important.
• Excuses/barriers- listen to them for this so you can find what appeals to them and what they want as a result.

• first step of intervention
• ask the patient what he/she plans to do now
• pharmacist can then help patients make decision about managing illnesses.
• pharmacist should attempt to remain neutral and nonjudgemental
• patients will likely be weighing whether to change or stay the same.

• 1. express empathy (very important and is more than in patient counseling)
• 2. develop discrepancy
• 3. avoid argumentation
• 4. roll with resistance
• 5. support self-efficacy

• do you view the patient as lazy and uncooperative or struggling with the process of change
• lack of cooperation and interest with or without active resistance is a method of coping with a change
• try to understand reason for this time from the patient's perspective - open-ended questions, reflective listening, empathetic responding

• compare patient's current behavior with the desired behavior/personal goals
• better than straightforward persuasion in precontemplation and contemplation
• create discrepancies without making patient feel threatened
• let the patients come to the reasons a change is necessary
• ---
• the patient has to acknowledge and realize what to do. You can give SOME information to help but the patient needs to know before the plan is put in effect.

• good form of conflict
• motivational interviewing is confrontational
• -actual behavior vs desired behavior
• argumentation usually arises when patients:
• 1. persuaded they have a problem
• 2. are labelled
• arguing fortifies resistance to change
• ----
• ultimate barrier- builds the wall
• avoiding rational behavior - not admitting fault or wrongness during argument.
• conflict- getting them to change (good if done right)
• persuade that they have a problem, don't just tell them they do

• work around with daily circumstances = their excuses
• in the end, the change is the patient's job.
• -when patients express problems or resistance, express understanding of the problem
• -frustration and anger at the patient will lead to fortified resistance
• -remember, in the end, the change will be the patient's job, and it is not your responsibility
• so why get mad (get glad) ... you can't change their minds for some things are out of our control

patients have to believe that they have the knowledge, skills, and abilities to carry out a treatment plan

• 1. providing and clarifying information
• 2. offer realistic hope
• 3. express confidence in patient's ability to succeed
• 4. notice and point out successful attempts
• 5. praise patient ideas (pat on the back regardless if they have failed because they tried at least)
• 6. emphasize and support two-party responsibility and eventually to their own control

• Short answer: majority of applications.
• How apply principles of motivational
• interviewing to patient who wanted to change x. write out scenario of how you
• get the person to change.
• Application and practice. Won’t tell
• behavior x yet.
• You can write anything.
• Q: script out a counseling scenario for drug
• x. describe how to counsel with 3 key questions, etc. No need to know info on
• drugs
• Focus on process and practice.
• NO FILL IN THE BLANK. Be legible.