Pharmacists’ discussions of medication side effects: a descriptive study

Abstract

To improve efforts to assist patients in making informed decisions regarding medications, current methods of providing information, such as patient counseling by pharmacists, must be examined. This will require attention not only to what content is delivered, but also how it is phrased by this group. Ten community pharmacists were videotaped while providing their customary patient counseling to two standardized patients receiving new prescriptions within staged scenarios. All of the pharmacists discussed side effects and management strategies. Vague, verbal descriptors of frequency—rather than numerical indicators—were used which may inhibit accurate risk assessment by patients. Additionally, pharmacists focused on safety aspects of using medications and spent far less time discussing potential therapeutic benefits. Patient decision-making regarding medication may be affected by how pharmacists communicate such benefits and risks, meriting further investigation into patients’ interpretations of information received.

Introduction

Patients have become increasingly involved in their own medical care and are now recognized as key decision-makers in many aspects of personal health, from seeking medical attention to the ultimate (and often daily) choice of taking prescribed therapy. In order to facilitate effective decision-making, it is important to provide the patient with evidence-based information about medications and to assist him or her in weighing the potential risks and benefits.

The expanded role of community pharmacists in today’s healthcare arena positions them well to fill this need. The standards of practice for Canadian pharmacists (as in many other countries) require educating patients on prescription drug therapy. Such communication includes but is not necessarily limited to: a confirmation of the identity of the patient; drug allergy status; name, general description of the drug dispensed, and directions for use; the intended therapeutic response; common or important side effects and appropriate management; and storage requirements [1]. Certainly, patients are interested in receiving this information, with side effect information ranked high in terms of importance, along with when and how to take the medication [2].

Research indicates that improvements are required and that patients are still somewhat dissatisfied with the quality and quantity of information received [3], [4]. The situation, as it relates to pharmacists, may even be exacerbated during this time of pharmacist shortages. From a research perspective, one possible factor is that while what to say (the content) during patient exchanges regularly receives attention, how to convey such information to the public (the process) continues to be underrepresented.

How to present information about adverse drug effects is a critical component of the counseling process and has been an issue of debate for health care professionals. On one hand, patients should have an accurate picture of a medication’s drawbacks while, on the other, maximum confidence that adhering to medical advice will achieve the desired results. Ziegler et al. surveyed 2500 adults for feedback on side effect information. Although the authors felt explaining every possible side effect would be too time consuming and of questionable advisability, the participants held a different view [5]. Most subjects (76%) would want to hear of any side effects, no matter how rare. When involving ‘serious’ adverse effects, 83% indicated they would want to be informed, regardless of rarity. Almost 75% of the sample felt that physicians were never justified in withholding any information. Other investigators have also reported that patients wish to be made aware of any potential adverse drug effects [2], [6]. The United States Food and Drug Administration, however, has taken the position that long, exhaustive lists of side effects need not be included in patient information [7].

A Finnish study found that while patients definitely want to hear about side effects, the majority of pharmacists held the opinion that it is sometimes necessary to withhold such information [8]. General practitioners have rated side effects as the least important piece of information to include in a medication leaflet [9]. Health care practitioners’ reluctance to fully disclose potential side effects likely stems from concern that such information will predispose patients to experiencing problems with their medications. While it has been demonstrated that detailed risk information may make some patients more anxious about their treatment, side effects do not appear to occur any more frequently in patients informed about them than those who are not [10].

How to best express the potential for medications to cause adverse reactions has been the subject of several investigations. It appears that patients may prefer numerical (1.0, 0.1, 0.01%, etc.) rather than verbal (rare, infrequent, common, etc.) frequency descriptors and are able to use that informational format to make more accurate predictions of their personal likelihood of experiencing a particular reaction [11], [12], [13]. There is a tendency to overestimate side effect frequency when verbal descriptors are used [14], which has been shown (at least in hypothetical scenarios) to negatively impact patients’ intentions to comply with prescribed therapy [15]. How information is framed—in the context of a potential gain or loss—for a given patient will likely play a part in this decision process as well [16].

While considerable attention has been paid to medication counseling in the pharmacy arena, most have tended to focus on content and an implied assumption that more information is better than less. Yet, it has been demonstrated that too much information is also problematic for patients and has given rise to feelings of frustration or information overload [17]. Tailoring medication information to the individual patient (as much as possible) is likely the most important piece of the how to (process) puzzle. Such an approach has been shown to be of therapeutic value when compared to giving patients standardized medical facts and treatment rules [18].

A critical look at the process of pharmacist-conducted patient counseling may provide direction as to where current efforts to educate patients may be improved. One research tool available is the use of conversation analysis (CA), which examines the conventions or common understandings used to organize and interpret what is said during conversation. Investigators record, transcribe and scrutinize in detail “naturally occurring” conversations typical of the type of interaction of interest. Only three reports to date have documented CA studies involving pharmacists [19], [20], [21].

John and Housley published an abstract drawn from a community pharmacy setting [19], perhaps the first of its kind for this segment of practice. The focus of the abstract, however, was more on the acceptability of the methodology rather than the reporting of data. Pilnick carried out CA of interactions from a pediatric oncology clinic [20]. She reported that pharmacy counseling is more on the order of a sequence of instructions rather than ‘counseling in its broader sense’ [21]. Accordingly, a set of instructions tend to be delivered over a series of turns with the recipient commonly repeating the instruction or uttering a response token such as “okay” or “mhmm”. Pharmacists rarely treated even these minimal acknowledgments as potentially problematic from the viewpoint of evidence for patient understanding.

This study looked at staged counseling sessions involving two medications, one for a chronic condition and one for an acute illness. Areas of interest included topics discussed by pharmacists; question-asking behaviour; organization of information presented; and communication skills demonstrated by the pharmacists. A report of these results have been published [22]. For the purposes of this paper, pharmacists’ discussions of adverse effects including how the information was framed and their use of printed medication leaflets were considered.

It is our plan to conduct conversation analyses of actual pharmacist–patient interactions in the future. To test and streamline the methodology, this pilot study was undertaken before the significant step of taking audiovisual equipment into places of business.