patient choice

Are we selling our souls Over The Counter?

There's something beautifully logical and satisfying about a good Over The Counter consultation.

I know what you're thinking, and yes, I should get out more. But it is true. The way I think of it is in a stepwise approach, using a systematic series of questions to eliminate products leaving you with a limited number of options to recommend. I suspect the way a patient views it may vary somewhat from "hey! I'm really being listened to!" to "oh for goodness sake shut up, I'm going to be late for the bus.".

A good consultation goes like this:

Step One: Establish the symptoms and check diagnosis.

Fairly self explanatory: to decide what medicine to select, I need to know what I am trying to treat in the first place. I'm also finding out if the patient has any danger symptoms which might be suggestive of a serious illness, so I can signpost them appropriately to the right services. 
Once I know what the problem is, I think about what products are available to treat it over the counter

Step Two: Find out about the patient's medical history.

I'm looking for anything that means the patient is at high risk of complications of the problem, meaning they need to be referred. I'm also thinking of the cautions and contra-indications of the available products to treat the problem and eliminating any products that these apply to.

Step Three: Find out about the patient's drug history.

I'm thinking about what drug interactions each of the available products has, and whether or not they are relevant to what the patient is already taking. I'm also thinking about whether or not any of the patient's medicines contain the same or similar ingredients to any of the OTC products- i don't want to risk an overdose. I then eliminate any products that have relevant drug interactions.

Step Four: Consider the evidence.

At this point, there may be only a couple of products that are suitable for the patient. If there aren't any left, I refer them to their GP or other appropriate healthcare provider.Out of the ones that are left, I think about which ones the evidence says are more effective and safe and I'll steer the patient towards that one. If there's no good evidence for at treatment, I'm always clear with the customer about it. Sometimes they listen, sometimes they don't, but its an obligation that I think needs to be done in order to sell medicines honestly and with integrity.

Step Five: Consider the price. 

Where two products are equally efficacious, I always recommend the cheapest. Because I don't want to waste a patient's hard earned cash, and I think patients appreciate that.

Step Six: Counsel the patient.

This involves giving them all the useful little snippets of information about how to use the product effectively and -crucially- safely. It might be pointing out that the product contains paracetamol, or that it causes drowsiness, or that it works best taken at a particular time of day. 

Hopefully all pharmacists will recognize this process, although everyone does-and should- have their own style to go about it with. These sorts of encounters can be really satisfying for both pharmacist and patient, and its often in these moments that I have the most amount of pride in my role. Here I am, giving the patient trusted, evidence based advice which will hopefully bmake the patient feel better. However, you also need a willing patient, and I'm finding more and more often that patients are unwilling to engage in such exchanges. I've also noticed through personal experience as a customer, that some pharmacies are using what i consider to be a cop-out approach to OTC sales. An offhand "you should read the leaflet" whilst I'm handing over my money does not, in my opinion, constitute provide expert advice on medicines. 

So why am I on about this at the moment? Well, there's the Which? report, which has found a disappointing quality of over-the-counter information being provided in some pharmacies. Others have given a more detailed analysis of this report, so I won't go into it too much, except to say that yes, there are methodological problems with it. However, it may well be indicative that in a world where pharmacists are under massive pressure to deliver services and dispense ever-increasing numbers of prescriptions whilst working longer hours for less pay, some are starting to lose pride in the basics. Its understandable. In the rush to get everything done, its easy to start seeing the patient as an inconvenience, who we need to get in and out of the door  as quickly as possible. I'm not saying this is what is happening in every pharmacy or in every case, but based on how I used to feel when I managed a pharmacy, I suspect it is a factor. 

The other reason I've been thinking about this is the issue of self-selection of pharmacy medicines. In my humble opinion, this is a giant backwards step for the pharmacy profession. Self selection reduces the process I described above down to a bare minimum, and reduces the possibility of introducing quality into it. Sure, we can say there will be information on the packs, but lets be realistic about this. Patients very rarely read the leaflets before purchasing, and if they have to do so in the middle of an aisle in a high street pharmacy or supermarket, i think it becomes even more unlikely. In my experience, if a patient has a preconceived idea of the product they want to buy, its very difficult to persuade them otherwise, even when there is a safety concern with their chosen product.

I remember one customer asking for Sudafed, when she was also taking phenelzine. A combination of these drugs could provoke a potentially fatal hypertensive crisis, but no matter how much I explained this, the customer was adamant that she still wanted it. It turned out her daughter, a medical student, had advised her to use this product, but when I spoke to the daughter it turned out she thought that Sudafed just had paracetamol in it.

Now imagine this situation in a self-selection age. The customer picks up the pack, wanders to the pharmacist, who then has to try to wrangle it from their fingertips in order to ensure their safety. Okay, maybe not that dramatic, but the fact that the customer has the product in their hand, and has been able to "choose" it themselves, reinforces to them that it is their right to buy it. But in pharmacy, the fact of the matter is that the customer isn't always right, and its poor customer service- and downright dangerous- to always allow them to think so. 

Imagine that self-selection scenario is also coupled with a curt "read the information leaflet first" as the only form of counselling. Why would the patient bother reading the leaflet, when she already thinks its safe for her to use? And so, what appeared to be a quick, convenient shop for the customer could so easily turn into a fatal drug interaction.

The shopping experience is becoming more and more depersonalised. With chip and pin and contactless payments, you barely even have to glance at the cashier during a transaction- if you're even in contact with a cashier at all. This may be fine when you're buying groceries, but medicines are not commodities. We're different to other shops in that the wares we sell can have fatal effects if they're not used in accordance with expert knowledge and instruction. We simply cannot safely reduce the over the counter consultation to the bare minimum of words required to take money from people as quickly as possible. 

Of course, its not like we pharmacists, will get that much say in the matter, and we'll carry on regardless if self selection goes ahead. Indeed it seems to be a near certainty, despite support from "very few" pharmacists. And it may even be the case that such scenarios never happen in real life. But all I want to do is make medicines safer for people, and to do so we have to identify areas of risk before they happen, and take action to minimise them. 

When it comes to patient care, just hoping the worst doesn't happen isn't good enough.


Let's talk about death, baby

Yep, settle in, dear friends, and lets have a think about death. Specifically, assisted suicide. 

This subject has come up quite a bit recently in the field of pharmacy and medicine. The PJ online are asking me to vote on whether or not I would refuse to dispense a prescription as part of an assisted suicide. The GMC is revisiting guidance to Drs. It's time to have a bit of a think about how we as pharmacists feel about playing a part in death.

There's a word which I think should be associated with death, and that word is dignity. People on the brink of death are still people, and I think in such discussions that fact is often forgotten,. We talk about our professional ethics, our religious choices, the impact it would have on us and our consciences, but I think we should talk-and think- more about the thoughts and needs of each dying patient. 

We're all frightened of death of course. I've been lucky enough that I haven't had much experience of it so far, but I've had enough to have experienced the lack of control one feels when faced with the death of a loved one. And all the bizarre rituals, funerals, cremations, all of these things that we do are desperate attempts to claw some control and dignity back from the situation. 

And so it is that I personally don't really need to think that much about this decision. I wouldn't hesitate to dispense medicines for assisted suicide, if it is going to give someone the dignity that they so richly deserve. 

People who believe in a god may think this is a typical example of an immoral atheist wanting to go on a legal murder rampage, playing god and interfering with when someone's "time" is. But in actual fact i think it's more about caring for the person involved, giving them respect for the person they are-and were. We need to remember that they remain a person to the end- and so should be allowed the right to choose, right up until the end.

Hopefully that makes sense. 

A childhood story

I was a fairly robust, risk averse nipper. But, like all kids, I got the odd sniffle and sickness now and then. And, like most parents, my Mum would usually take me to see the doctor when I was poorly.

I have a really vivid memory of going to see the doctor. He was a kindly, soft-spoken chap who, as I recall, had a caring manner. And what I remember more than anything was his large leather case, filled with pastel-coloured vials of what he described as "magic crystals". 

Depending on what was wrong with me, I was able to choose from a selection of colours of "magic crystals", which were then administered to me and which, in my head, made me feel a bit better. I think I only got one dose, when I was there in the surgery. Neither my mother nor I have any recollection of me taking home any "magic crystals" or having repeated doses.

Now, here's the thing. At no point did my dear darling mother actually bother to ask what the "magic crystals" were. We now assume (hope!) that they were some sort of homeopathic thing. They definitely looked like coloured sugar crystals and tasted like sugar. Or were they some sort of elaborate placebo designed to soothe children into believing they felt better? Or were they some suspicious hallucinogens? The point is, at no point did my mother think to question the doctor: he was in a position of caring authority and he knew best what would make me better, right? And from my perspective, a nice, caring man who my mother had trust in was letting me pick pink sweet-tasting crystals so YAY GIVE ME THE SUGAR! 

Out of interest, my memory is that yes, magic crystals did make me feel momentarily better. But this is a vague memory, which may well have been clouded by nostalgia and the many years that have since gone by. why could this have been? Well, power of suggestion and placebo. As a child I knew doctors made me better: ergo, I felt better when I was at the surgery seeing the doctor.

We hear a lot about patient choice in debates about homeopathy. I guess my point here is that this doesn't always come into the conversation with patients or their carers, and that's worrying. Admittedly it was longer ago than I care to admit, but I'm pretty sure similar practices go on today. I really do hope that medical homeopathists do allow their patients more informed consent, and I also sincerely hope that all homeopathists do the same. But they can't offer them full informed consent because the data isn't there to back up their claims, or they have misunderstood the data that is there, and most importantly, the science and theories don't make sense. What sort of benefit vs risk decision can happen for a patient when they simply pick up a pack of arnica 30C from the shelves of Boots?  What kind of choice was my mum able to make when it didn't occur to her to ask any questions, and no explanation was forthcoming?

Health care professionals have a duty of care to their patients. A large part of this is about communication. What homeopathists (and herbalists, and traditional chinese herbalists, and halotherapists, and anyone else who purport to change people's health) need to realise is that, in the eyes of the public, they hold the same amount of trust and duty of care. And even if regulatory bodies aren't in place to take you to court if you harm someone, your personal morals should step in before you sell a remedy made merely of hope for monetary gain. 

The air is nice up here on the moral high ground.Of course, it could always be the case that it's actually just the mind-altering effects of whatever mind control agents were in the magic crystals....

H xxx