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Patient worldview may influence drug counseling
Direct questions can be best to understand barriers
During their education, pharmacists learn about possible barriers to counseling patients on their medications. IV poles may get in the way; background noise can distract all participants. The patient may have a physical difficulty or speak another language.
Little is said, however, about personal barriers between the pharmacist and patient. These barriers arise from how each interprets the world — and each other. "The effects [of these barriers] are more insidious, but they are powerful, partly because they are not largely recognized," says Lynnette Ridley, RPh, a critical care pharmacist at Windsor (Ontario) Regional Hospital.
Unrecognized barriers can result in a pharmacist leaving a counseling session feeling satisfied that the correct information about a drug regimen has been delivered to a patient, without realizing that the patient has reservations about taking the drug that have prevented the patient from receiving the information.
Ridley has spent several years researching the psychology and neurology of how personal expectations can affect communication between individuals. "We are usually not aware on a cognitive level that we have these expectations, but they are still operating in background and affecting how we perceive the world and interact with people. In psychology, this set of expectations is called a model of the world,’" Ridley says.
The expectations begin forming at birth as every experience and bit of knowledge forms a new pathway between nerve cells in the brain. This continues at an explosive rate until about age 2. At that point and throughout life, the brain begins to prune away the pathways that aren’t used. "The pathways that we use all the time get reinforced on a cellular level," she says. "The ones that we don’t use fall away."
Individuals’ inherent mindsets are strengthened through experience. "[The mindsets] exert a powerful but largely unconscious influence on our interactions with others," she adds. "What we are taught and what we experience structure our belief system, and then the belief system channels our behavior and limits the number of possibilities our brain will consider. It’s a self-perpetuating cycle."
The brain also categorizes people based on the belief system. "If I walk into the room of a frail, slow-moving, white-haired person with wrinkled skin, my mind is already putting her in categories," she explains. "I may speak loudly and use simple words because my mind has categorized her as having limited comprehension or dementia. It’s perfectly possible that she’s a retired physicist with perfect hearing and intact faculties. But my brain has categorized her, and I am now operating from that category."
The brain even fills in gaps based on the person’s previous experience and knowledge. "We register information about other people, such as appearance, quality of voice, and mannerisms. We’ll put that person in a category. If information is missing, our brain fills it in, whether it is true in this individual or not."
The same mechanism works in the patient, as well. For example, a patient who is in pain may have had a significant male figure in childhood model that taking painkillers is a sign of weakness.
"Any information that I give him on side effects or drug interactions would be completely useless if he has already decided not to take this drug," Ridley says. "These built-in expectations can affect how we approach the client and how they perceive us, including what they expect about the services and products we provide."
Being aware of expectations on both sides is an important first step in relating to patients, Ridley says.
The next step is more challenging but also more productive. "If we are able to temporarily step outside our belief system, then we can experience what patients are experiencing, thus identifying and circumventing any barriers to compliance."
This is an active, not passive, process. The pharmacist must have a deliberate intent to foster empathy for the patient, she explains. For example, the pharmacist can decide to act as if he or she doesn’t have any data about patients, and resist the categorization process until more information is gathered.
"Often our intellect gets in the way. We think we know the answer to a question so we don’t ask it in the first place," Ridley says. "If we do ask that question, we might get unexpected information."
Asking questions is key to determining the patient’s model of the world, she says. She usually begins by evaluating patients’ nonverbal cues. Can they look her in the eye? Do they seem like they just want to get the counseling over with? Are they engaged in the process? Are they asking questions? Do they seem irritated, restless, or frustrated?
If the patient is indicating a resistance toward some aspect of the counseling interaction, Ridley then turns to the direct question, which she has found to be the most effective with patients. She forms her questions so they are pointed, without being aggressive or intrusive.
"I might just come out and say, Does the thought of taking this drug disturb you?’ Often this kind of open-ended direct statement will get me more information that I can use to get closer to what their issue is."
She was initially concerned that patients would be uncomfortable with such directness and even become offended and withdraw. Instead, the opposite has happened. "When I focus on that aspect of the [problem], which has been underground to that point, they are relieved that they can now voice their concerns or voice their hesitancy."
Identifying and navigating within the patient’s model of the world is probably the most challenging aspect of difficult patient counseling sessions, Ridley says. "Since we are the drug specialists, it’s our responsibility to promote adherence to drug regimens in all patients, not just the readily compliant ones. It’s incumbent on us to practice and master those skills that help us communicate with the challenging patients."
The goal is either to shift patients’ belief systems into one that accommodates adherence to the drug regimen or to find a way to work within their belief systems to promote effective drug therapy. Ridley continues. "Not only is such an interaction rewarding for the professional and the client, it also results in fewer drug-related hospitalizations, whether from drug mishaps or noncompliance. And that means improved patient health and reduced health care costs."