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Schwinghammer’s Pharmacotherapy Casebook: A Patient­Focused Approach, 12th Edition

Chapter 3: Patient Communication: Getting the Most Out of That One­on­One Time

Krista D. Capehart

Instructors can request access to the Casebook Instructor's Guide on AccessPharmacy. Email Customer Success
(customersuccess@mheducation.com) for more information.

INTRODUCTION
Talking with patients is a crucial component of the medication use process. Regardless of practice area, healthcare providers have the opportunity to
teach and learn from people they interact with each day. In addition to having a wealth of scientific knowledge and clinical skills, providers must also
possess excellent communication skills. This chapter focuses on key elements of communication in various practice settings. The intricacies of
interpersonal communication can be found in other resources.1­3

PATIENT­CENTERED CARE AND THE ROLE OF COMMUNICATION

With the movement toward value­based, accessible, high­quality care, provision of interprofessional, team­based care is vital. The Patient Protection
and Affordable Care Act of 2010 fostered development of accountable care organizations (ACOs) and patient­centered medical homes (PCMHs). The
National Center for Quality Assurance defines a PCMH as “a way of organizing primary care that emphasizes care coordination and communication to
transform primary care into ‘what patients want it to be.’”4 A team­based approach that includes pharmacists with medication expertise and good
communication skills can optimize the medication use process and ensure that the patient truly is at the center of care.

In patient­centered care, the patient participates in his/her own health care through shared decision making with healthcare providers. Shared
decision making involves decision aids or a process to facilitate patient understanding when multiple treatment options could be used.5 Shared
decision making increases knowledge and improves patient understanding of the risks of their care and makes patients more likely to receive care that
is consistent with their values and beliefs.6

Consequently, the patient–clinician interaction must involve more than simply collecting information during a medication history interview or
conveying verbal or written information about a prescription. Active listening skills must be employed to understand the patient’s concerns about
medication therapy, engage the patient in his/her care, and develop the trust required for a positive longstanding relationship. Establishing a trusting
relationship is necessary for effective communication, but trust does not come quickly or easily. In the community pharmacy, it may result from a
caring pharmacist always taking the time to ask how a patient’s medications are working. In an ambulatory clinic, it could come from a nurse
practitioner or pharmacist teaching about diabetes care and improving A1C levels. Pathways to a trusting relationship may vary, but the ultimate goal is
for patients to feel that they can confide in and rely on their healthcare providers about medication­related needs.

Patient interactions vary depending on the practice setting, clinician training, the purpose of the interaction, and other factors. In 2015, the Joint
Commission of Pharmacy Practitioners (JCPP) published the Pharmacist’s Patient Care Process, which is similar to the patient care process used daily
by other healthcare providers and is intended to standardize the patient’s experiences in each encounter with the pharmacist.7 The steps of the
Pharmacists’ Patient Care Process include: (1) Collect, (2) Assess, (3) Plan, (4) Implement, and (5) Follow­up: Monitor and Evaluate (see Chapter 4, Fig.
4 – 1).

Optimal communication is necessary in the Collect, Implement, and Follow­up parts of the process. During the Collect portion, the pharmacist gathers
information about the patient and the present medical situation. The information available may vary by practice site, but the process remains the
same. During the Implement stage, the pharmacist has the opportunity to educate the patient about the care plan. This may include new medications,
lifestyle modifications, changes in therapy, or referrals to other healthcare providers. Monitor and Evaluate can involve gathering information from the
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patient regarding how the medication is working, whether any adverse events have occurred, and vital adherence data. The key to successful use of the
Chapter 3: Patient Communication: Getting the Most Out of That One­on­One Time, Krista D. Capehart Page 1 / 10
patient care process is collaboration with the patient and other healthcare team members.
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IMPROVING THE PATIENT ENCOUNTER

4 – 1).
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Optimal communication is necessary in the Collect, Implement, and Follow­up parts of the process. During the Collect portion, the pharmacist gathers
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information about the patient and the present medical situation. The information available may vary by practice site, but the process remains the
same. During the Implement stage, the pharmacist has the opportunity to educate the patient about the care plan. This may include new medications,
lifestyle modifications, changes in therapy, or referrals to other healthcare providers. Monitor and Evaluate can involve gathering information from the
patient regarding how the medication is working, whether any adverse events have occurred, and vital adherence data. The key to successful use of the
patient care process is collaboration with the patient and other healthcare team members.

IMPROVING THE PATIENT ENCOUNTER

Talking with a patient and collecting information require patience, empathy, and the ability to direct the conversation. The clinician should use open­
ended questions, which start with who, what, when, where, why, or how. Close­ended questions are those that permit the patient to respond with a
simple yes or no and tend to leave much unsaid. With a close­ended question, the patient may not provide complete information. For example, if a
provider asks, “Have you been taking your warfarin as the doctor prescribed?” the patient may simply respond, “Yes.” However, it could be that the
patient understood and adhered to the one­tablet­daily directions that were initially prescribed but did not realize that the directions were recently
changed to one tablet Monday, Wednesday, Friday, and Saturday, and one­half tablet the other days of the week. An open­ended question such as,
“How are you taking your warfarin each day?” requires more explanation from the patient, allowing the clinician to collect more accurate information
to assess the patient’s medication/medical history and status. There is a place for close­ended questions; after most of the information has been
collected, close­ended questions can be used to narrow down the details about the patient’s situation.

Healthcare providers must be exceptional listeners, open to what the patient is sharing and not sharing. Becoming an active listener is not always easy
in busy patient care environments. It includes removing distractions, empathizing with the patient, acknowledging the patient’s individuality, and
recognizing nonverbal signals from the patient.

Regardless of practice setting, distractions should be minimized to ensure that the patient is the primary focus of the provider’s attention. In
community pharmacies, separate counseling rooms may be used, if available. Attempts to maintain privacy help demonstrate the pharmacist’s focus
on the patient.

Empathy and sympathy are often confused. Empathy is the ability to understand the patient’s feelings and share them, whereas sympathy is feeling
sorry for the patient. Acknowledging emotions, reassuring the patient, and providing answers to questions helps to improve the interaction and
outcomes. Each patient enters the medical encounter with a set of experiences, beliefs, and expectations; understanding them through active listening
facilitates creation and implementation of the therapeutic plan.

Nonverbal communication can be as important as what the patient relates verbally, and clinicians must recognize these as well. Nonverbal cues may
include body language, use of time, tone of voice, touch, distance, and physical environments. Body language clues include crossing the arms (a sign
the patient is closing themselves off) or nodding the head (an indication the listener is paying attention or agreeing). Time can be used to delay (as with
dramatic pauses) or to rush through situations that may be uncomfortable. Tone of voice is revealing because it includes pitch and intonation and can
relate anger, fascination, confusion, and a variety of other emotions. Touch, distance, and physical environment are specific to the individual. Some
patients are comfortable with a touch on the arm for reassurance or to show concern, whereas others require much greater personal space and shy
away from physical contact. Generally, people prefer approximately 2 feet of personal space when having a one­on­one encounter. Maintaining an
appropriate distance that makes the patient comfortable may take time to master, and it’s important to maintain awareness of the patient’s reaction to
your proximity to them. The physical environment the clinician creates for the encounter serves as a nonverbal cue. For example, an open room with
chairs arranged in a circle creates a welcoming space for individuals to gather for conversation. A lecture­style setup creates a more formal setting
where the focus is on the presenter with less individual sharing. The clinician must be aware of the nonverbal cues he or she is giving as well. Egan
developed a mnemonic to assist in demonstrating nonverbal cues for good listening (SOLER), which can help build a trusting patient relationship
(Table 3­1).8

TABLE 3­1
Nonverbal Cues to Demonstrate Good Listening

Letter Meaning

S Squarely face the patient (do not have your body angled in another direction)

O Open posture (do not cross your legs and arms)

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show interest Page 2 / 10
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E Eye contact
chairs arranged in a circle creates a welcoming space for individuals to gather for conversation. A lecture­style setup creates a more formal setting
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where the focus is on the presenter with less individual sharing. The clinician must be aware of the nonverbal cues he or she is giving as well. Egan
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developed a mnemonic to assist in demonstrating nonverbal cues for good listening (SOLER), which can help build a trusting patient relationship
(Table 3­1).8

TABLE 3­1
Nonverbal Cues to Demonstrate Good Listening

Letter Meaning

S Squarely face the patient (do not have your body angled in another direction)

O Open posture (do not cross your legs and arms)

L Lean toward the patient (not encroaching on personal space) to show interest

E Eye contact

R Relax

EXAMPLES OF COMMUNICATION WITHIN THE PHARMACIST–PATIENT RELATIONSHIP

Although the principles discussed in this section are directed toward pharmacy practice, many of them can also be used by other healthcare providers
in any environment in which medication counseling and education occur. The opportunities to talk with patients vary with practice settings and
expectations. For example, hospital pharmacists or nurses may perform counseling on all discharge medications or discuss injectable medications
being started with the patient. The community pharmacist may counsel on new or refill medications or help select an over­the­counter (OTC)
medication for a particular problem. Pharmacists communicate with patients to undertake medication therapy management, participate in
collaborative drug therapy management, and perform medication reconciliation.

THE MEDICATION AND MEDICAL HISTORY

It is important to collect comprehensive information when conducting a patient medication interview. Using the tips presented previously, information
can be gathered from the patient to improve patient care and safety.

Initially, collect demographic information about the patient, including name, address, and date of birth, unless this information is already available.
Use an open­ended question to inquire about the patient’s allergies (medication, environmental, and food), such as, “What medication allergies have
you experienced in the past?” Be sure to document what happened when the patient experienced the reaction. It may be necessary at some point in the
future to evaluate risk versus benefit and determine if a true allergy exists. Query the patient regarding social history related to drug and substance
use, including tobacco use, alcohol consumption, recreation and medical marijuana use, illicit drug use, and caffeine intake. Asking about social
history can sometimes make both the clinician and the patient uncomfortable. One method to ease tension is to advise the patient that some
medications interact with alcohol or tobacco, and that it is important for information to be complete to evaluate drug–drug interactions. Remember to
identify the type of substance, quantity, and frequency of use as well.

When verifying the patient’s current prescription medications, it is helpful to start by asking whether the patient has either brought their medications
or a written list to the visit. This is a good practice in the emergency department and many other clinical settings. Regardless of whether the patient has
a list, ask, “What prescription medications do you take?” For each medication, specifically document the name, strength, route of administration,
prescriber, and how he or she takes the medication. The way the patient actually takes each medication can be compared to the label directions to
assess patient adherence. Remember that nonadherence could be due to misunderstanding the correct directions, attempting to save money, or any
of a number of reasons other than simply choosing not to take the medication as directed. Also, be sure to ask the patient why each medication was
prescribed. Remind each patient about nonoral routes of administration also. This could be a close­ended question followed up by an open­ended
one, such as, “Do you use any medications that you apply to your skin? What other medications do you use that you don’t swallow by mouth?” This
may prompt the patient to remember some medications they may have forgotten.9

Patients should be asked about nonprescription items used, including OTC medications, herbals, vitamins, and dietary supplements. Patients may
have the misconception
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Pharmacists and other providers conducting medication interviews must also have or collect information on diagnosed medical conditions, but there
is flexibility in when this occurs. One option is to address medical conditions after asking about allergies and before beginning questions on
prescribed. Remind each patient about nonoral routes of administration also. This could be a close­ended question followed up by an open­ended
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one, such as, “Do you use any medications that you apply to your skin? What other medications do you use that you don’t swallow by mouth?” This
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may prompt the patient to remember some medications they may have forgotten.9

Patients should be asked about nonprescription items used, including OTC medications, herbals, vitamins, and dietary supplements. Patients may
have the misconception that OTC or “natural” substances do not interact with prescription medications or medical conditions. This is an opportunity
to educate the patient about the potential dangers of incorrect use of these products.

Pharmacists and other providers conducting medication interviews must also have or collect information on diagnosed medical conditions, but there
is flexibility in when this occurs. One option is to address medical conditions after asking about allergies and before beginning questions on
medications. This gives the interviewer an idea of the therapeutic categories of medications the patient may be taking. The other option is to cover
diagnosed medical conditions after collecting the list of prescription and nonprescription medications. Using this order of questioning enables the
interviewer to ask the patient “What are you taking X medication for?” if the patient fails to list an indication for a medication named earlier.

The comprehensive medication interview is optimal for the provision of medication reconciliation, medication therapy management, and collaborative
drug therapy management. However, it is not always feasible to perform an interview directly with the patient. Sometimes, the information may need to
be collected from the pharmacy dispensing record, a family member, or another source. Information not obtained personally from the patient may
need to be reconfirmed later.

COUNSELING ON A NEW PRESCRIPTION

The Omnibus Budget Reconciliation Act of 1990 (OBRA 90) was passed, in part, to help ensure safe medication use for Medicaid patients. While OBRA
90 is often considered to be the law that mandated the offer to counsel on medications, it also gave rise to new record­keeping requirements and
mandated that pharmacists complete a prospective drug utilization review for all Medicaid patients. Requirements vary by state regarding what must
be done for drug counseling, but OBRA 90 required making an offer to counsel, not that counseling must actually be performed.10 Since 1990, some
states have passed various additional requirements for patient counseling and education from merely complying with OBRA 90 to not permitting a
patient to decline the offer of counseling. It is important to be familiar with your state’s patient counseling requirements.

Counseling on medications increases the patient’s knowledge and comfort level in using their medication correctly.11 Part of the patient’s comfort can
derive from the process as well as from the information. The counseling should occur in a private area, if possible. If a separate room is not available,
use a divider or area that makes the counseling space relatively easy to maintain patient confidentiality and privacy. A patient may be uncomfortable
receiving counseling on certain types of medication, such as a medication for a vaginal infection; speaking in a confidential tone in a private area will
improve patient satisfaction with the encounter.

Educating the patient on new medications should start by assessing what the patient already knows about the medication that has been prescribed.
The Indian Health Service (IHS) began providing patient medication counseling services in the 1970s and 1980s.12 The IHS would go on to develop a
commonly used method for counseling on new and refill prescriptions. The method is referred to as the Three Prime Questions technique (Fig. 3­1).13

FIGURE 3­1.

Indian Health Service Three Prime Question counseling method. (Reproduced with permission from Lam N, Muravez SN, Boyce RW. A comparison of
the Indian Health Service counseling technique with traditional, lecture­style counseling. J Am Pharm Assoc (2003). 2015;55(5):503­510.)

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Chapter 3: Patient
Asking “What Communication:
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an excellent way Time, Krista
to begin D. Capehart
the session. Page about
After determining the patient’s knowledge 4 / 10
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the medication, state the medication name (including whether it is generic) and strength. Then ask, “How did the doctor tell you to take the medicine?”
Next, provide information about the route of administration, dosing schedule, duration of treatment, storage, and administration. Inquire about the
FIGURE 3­1.
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Indian Health Service Three Prime Question counseling method. (Reproduced with permission from Lam N, Muravez SN, Boyce RW. A comparison of
the Indian Health Service counseling technique with traditional, lecture­style counseling. J Am Pharm Assoc (2003). 2015;55(5):503­510.)

Asking “What did your doctor tell you the medicine was for?” is an excellent way to begin the session. After determining the patient’s knowledge about
the medication, state the medication name (including whether it is generic) and strength. Then ask, “How did the doctor tell you to take the medicine?”
Next, provide information about the route of administration, dosing schedule, duration of treatment, storage, and administration. Inquire about the
patient’s daily activities and attempt to incorporate the schedule into routine daily activities to increase adherence. Finally, the third question enables
the pharmacist to provide information regarding adverse effects and how to monitor effectiveness. Explain the medication in terms of what condition it
is intended to treat, what the expected action is, and how the patient can self­monitor for efficacy. The patient should realize if and when he/she
should “feel different.” For example, with medications for hypertension and dyslipidemia, the patient may not notice a difference in how they feel and
should be counseled about the importance of laboratory testing or other monitoring. Potential adverse effects can be discussed by dividing them into
two categories: (1) those that are more likely to occur but are not serious, and (2) those that are rare but serious. Provide guidance on how the patient
can avoid some of the most common adverse effects, if possible, and what should be done if a serious one occurs. Also inform the patient about other
drugs or conditions that interact with the medication and how to manage the interaction. In finishing this portion of the session, discuss storage
information, what to do if a dose is missed, and any pertinent refill information.

As the counseling session is concluding, verify the patient’s understanding of the information covered during the session. One of the best methods for
this is the “teach­back method,” which is used to determine what the patient understands and to correct any misunderstandings.14 To avoid the
impression that you are testing the patient, a good approach is to say, “I have covered quite a bit of information about your new medication. Just to
make sure that I did not forget anything, how are you going to take the medication when you get home?” This places the appearance of responsibility
for remembering everything on the healthcare provider and reduces stress for the patient. Studies have compared lecture­based counseling and
interactive counseling similar to the Three Prime Questions style for preference and retention of information. Approximately two­thirds of
standardized patients who experienced both types preferred interactive counseling over lecture­based counseling.13 Another study examined
retention among actual patients and found them to be four times more likely to correctly answer how to take their medication than those who received
traditional lecture­based counseling.15 The style of counseling may need to be individualized to a particular patient by picking up on nonverbal cues
and the patient interaction.

COUNSELING ON A REFILL

Counseling on a medication refill is an abbreviated process of counseling for a new medication. The IHS has an additional three prime questions for
refills (see Fig. 3­1). The purpose of the medication and how to take it is reviewed, but the focus changes from how to take the medication to
monitoring the patient with queries such as, “What kinds of problems are you having?” Counseling on refills is especially important when the use of a
device is involved. For example, metered­dose inhalers are difficult to use correctly. Correct inhaler use decreases over time, even in as little as 2–3
months, and studies show that pharmacist counseling improves correct inhaler technique and adherence.16 Additionally, it is important to follow up
with the patient to answer any questions that have arisen since the last fill and to provide contact information for any future questions that arise.

OVER­THE­COUNTER MEDICATION SELECTION

Assisting a patient with selection of self­care products also requires effective communication skills. The first steps are to assess the patient’s
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self­management with OTC medications is appropriate or whether referral is needed. There are a variety of
Chapter 3: Patient Communication: Getting the Most questions
mnemonics to assist clinicians in asking all necessary Out of That One­on­One
before Time, Krista
recommending D. Capehart
a product.
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These include: (1) CHAPS­FRAPS (Chief complaint,
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History of present illness, Allergies, Past medical history, Social history, Family history, Review of Systems, Assessments, Plans, and SOAP); (2) The
Basic Seven (location, quality, severity, timing, context, modifying factors, and associated symptoms); and (3) PQRST (Palliation and provocation,
months, and studies show that pharmacist counseling improves correct inhaler technique and adherence.16 Additionally, it is important to follow up
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with the patient to answer any questions that have arisen since the last fill and to provide contact information for any future questions that arise.
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OVER­THE­COUNTER MEDICATION SELECTION

Assisting a patient with selection of self­care products also requires effective communication skills. The first steps are to assess the patient’s
complaints and evaluate whether self­management with OTC medications is appropriate or whether referral is needed. There are a variety of
mnemonics to assist clinicians in asking all necessary questions before recommending a product. These include: (1) CHAPS­FRAPS (Chief complaint,
History of present illness, Allergies, Past medical history, Social history, Family history, Review of Systems, Assessments, Plans, and SOAP); (2) The
Basic Seven (location, quality, severity, timing, context, modifying factors, and associated symptoms); and (3) PQRST (Palliation and provocation,
Quality and quantity, Region and radiation, Signs and symptoms, Temporal relationship).17–19 The most comprehensive mnemonic is the
QuEST/SCHOLAR approach.20 This method enables the clinician to evaluate the patient and most accurately select the best nonprescription product.
The QuEST/SCHOLAR process includes:

1. Q uickly and accurately assess the patient.

Ask about the current complaint (SCHOLAR), other medications, and allergies:

✓ Symptoms

✓ Characteristics

✓ History

✓ Onset

✓ Location

✓ Aggravating factors

✓ Remitting factors

2. Establish that the patient is a self­care candidate.

✓ No severe symptoms, symptoms do not persist or return, patient is not using self­care to avoid medical care

3. Suggest appropriate self­care strategies.

✓ Recommend the medication and nonpharmacologic therapy

4. Talk with the patient.

✓ How the drug is going to work, when it should be taken, expected adverse events

For example, Joe comes into your pharmacy requesting assistance in selecting an OTC product for heartburn. Utilizing the QuEST/SCHOLAR process,
you could:

1. Q uickly and accurately assess the patient: “Let’s talk a little about the type of problems you have been having.”

Ask about the current complaint (SCHOLAR), other medications, allergies:

✓ Symptoms: “What symptoms are you having?”

✓ Characteristics: “How would you describe the pain…burning, sharp, shooting?”

✓ History: “Have you experienced this before? What have you tried already? Did it work?”

✓ Onset: “When did the symptoms start?”

✓ Location: “Where is the pain you are describing as heartburn?”

✓ Aggravating factors: “What makes it worse?”

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2. Establish that the patient is a self­care candidate:

✓ “Based on this information, I think it would (or would not) be appropriate for you to use OTC treatment.”
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✓ Location: “Where is the pain you are describing as heartburn?”

✓ Aggravating factors: “What makes it worse?”

✓ Remitting factors: “What makes it better?”

2. Establish that the patient is a self­care candidate:

✓ “Based on this information, I think it would (or would not) be appropriate for you to use OTC treatment.”

3. Suggest appropriate self­care strategies:

✓ “I would recommend ________ and some non­medication strategies, too.”

4. Talk with the patient:

✓ “You can take ___ tablet(s) every ___ hours to help with symptoms. This medication will work by ______. You should start to notice
improvement in _____ minutes. Also, try lifestyle changes like avoiding spicy foods and raising the head of the bed. If your symptoms persist
for more than 2 weeks or do not improve, see your doctor. The OTC medications can cover up symptoms that need to be checked out further
by your doctor.”

The QuEST/SCHOLAR method provides a technique for systematically assessing patients in the pharmacy and providing a thorough but efficient
evaluation. It is vital to maintain the patient’s privacy (using a private area, if possible) and be cognizant of topics that make patients uncomfortable.
These occur with OTC items, too; recognizing this and being prepared will help put the patient at ease. Try to employ the teach­back method with
OTCs, herbals, and dietary supplements to ensure patient understanding of the information discussed.

BARRIERS TO COMMUNICATION
Patient communication does not always happen the way we plan. There are common barriers to communication, and knowing them can help you to be
prepared. Communication barriers can be divided into three common categories: (1) patient barriers, (2) clinician barriers, and (3) healthcare setting
barriers. Patient barriers may include the patient literacy level, misconceptions regarding the purpose of the visit, aging, or visual/hearing difficulties. A
clinician may lack training with certain types of patient encounters or have a negative attitude about patient counseling. A patient and clinician
combined barrier can include misconceptions regarding cultural beliefs and household influence on healthcare decisions. Healthcare setting barriers
posing communication issues can include lack of privacy, space, or resources to serve their specific patient population.

Because the patient is ultimately in charge of his/her health care, patient barriers can be some of the most difficult to overcome. Lack of education and
poor health literacy can be substantial barriers. The aging patient brings unique challenges to communication, such as changes in physical health,
depression, cognitive decline, and changes in hearing, vision, voice, and speech processes.21 Also, you may be communicating with the caregiver and
not the patient, and he/she may be in a rush or may not have all of the patient information needed.

HEALTH LITERACY

Health literacy is defined as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services
needed to make appropriate health decisions. It is not enough for patients to simply “understand” information about their health. They must be able
to make decisions about what to do—to be able to navigate the healthcare system and be somewhat confident about it. Health literacy may or may not
be tied to the level of education completed. For example, a patient with an MBA degree who is highly educated and very successful in the corporate
world may not realize that it is unsafe to take OTC acetaminophen and an OTC cough and cold product also containing acetaminophen. On the other
hand, a woman who only completed the 10th grade and has a young child with a pediatric cancer may be well versed in the healthcare system and able
to tell you more about her child’s medications and medical needs than some members of the healthcare team. Simply put, clinicians cannot determine
the level of health literacy by looking at a patient and making assumptions about his/her education or social status.

A sense of shame often accompanies a patient’s low health literacy. Because patients do not typically volunteer their lack of knowledge, identifying low
health literacy is important, especially in light of its association with medication nonadherence.22 Some indicators that health literacy may be a
problem with a given patient are leaving forms partially filled out, referring to medications by their color (instead of by name), opening the bottle to
look at the medication rather than the label, making excuses like “I forgot my glasses,” postponing appointments, chronic nonadherence, failing to
look at written materials, or bringing someone with them.
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Once you recognize that a patient presents health literacy concerns, it is vital to remain respectful, considerate, and maintain privacy. Failure to be
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sensitive to the needs of these patients can result in loss of the relationship that was forming
©2023 McGraw Hill. All Rights Reserved. Terms of Use • Privacy Policy • Notice • Accessibility and loss of an opportunity to impact the patient’s health
outcomes. Recognizing that time is a limitation, there are some tips to help with patient understanding. First, limit the number of main counseling
points to two or three. Covering too many topics can be overwhelming. Second, demonstrate the procedure or technique. One example of this is to
A sense of shame often accompanies a patient’s low health literacy. Because patients do not typically volunteer their lack of knowledge, identifying low
Birzeit
health literacy is important, especially in light of its association with medication nonadherence.22 Some indicators that health literacy may be University
a
problem with a given patient are leaving forms partially filled out, referring to medications by their color (instead of by name), openingAccess Provided by:
the bottle to
look at the medication rather than the label, making excuses like “I forgot my glasses,” postponing appointments, chronic nonadherence, failing to
look at written materials, or bringing someone with them.

Once you recognize that a patient presents health literacy concerns, it is vital to remain respectful, considerate, and maintain privacy. Failure to be
sensitive to the needs of these patients can result in loss of the relationship that was forming and loss of an opportunity to impact the patient’s health
outcomes. Recognizing that time is a limitation, there are some tips to help with patient understanding. First, limit the number of main counseling
points to two or three. Covering too many topics can be overwhelming. Second, demonstrate the procedure or technique. One example of this is to
show the patient how to use an inhaler and spacer device. Then ensure that understanding is complete with the teach­back method discussed
previously. Pictures can also be used to convey information about medication instructions and safety. Standard pictograms created by the United
States Pharmacopeia are available for download at http://www.usp.org/usp­healthcare­professionals/related­topics­resources/usp­
pictograms/download­pictograms. Finally, summarize the information and be positive, communicating in an open manner while maintaining eye
contact.

Using plain language is one of the most important tenets for working with patients with low health literacy. This involves using common words instead
of medical jargon to improve understanding of complex situations. An example is to use “water pill” instead of “diuretic”, “a medication that helps
open the airways” instead of “bronchodilator,” and “sore” instead of “abscess.” Additional examples can be found at
http://www.plainlanguage.gov./populartopics/health_literacy/index.cfm under the Plain Language Thesaurus.

AGING

The aging patient may experience many physiologic changes such as cognitive decline and dementia that can make communication more difficult.
Sensory loss, including both hearing and vision, may also occur with aging.21 Because these are challenging in their own right, living with them while
navigating the healthcare system can be frustrating for patients.

Some general techniques can make the encounter with these patients more effective. Know the patient’s strengths and weaknesses and cater to them.
Select educational materials that are most appropriate for that patient. Be prepared to take some extra time with the patient to ensure full
understanding and buy­in of the information. Use an environment that is conducive to the conversation—a place with minimal distractions. If the
patient has difficulty hearing, speaking louder will not help; it will only distort the sound. Speak slowly and simplify your sentences. Use plain language
when speaking, making sure to avoid medical jargon that can be confusing and overwhelming. Finally, if the patient has visual difficulties, ensure that
they have their glasses and be prepared to provide the materials in a larger font. You may also want to determine whether your prescription filling
software can print prescription label information in a larger font for easier reading.

CULTURAL COMPETENCE AND PATIENT BELIEFS

Patients come to healthcare visits with a set of personal beliefs and strongly held cultural backgrounds. Clinicians should be prepared with training on
cultural competence and cultural humility to understand that a patient’s ultimate healthcare decision will not be based solely on what the clinician
says. Successful communication strategies involve not only being aware of the patient’s beliefs but endeavoring to honor their beliefs and values.23
Studies show that when both the clinician and the healthcare organization take steps including education about the cultures in the patient population,
hiring a diverse population, and having culture­specific programs that both patient outcomes and satisfaction can be improved.24,25

TEAM­BASED CARE AND PATIENT COMMUNICATION IN THE FUTURE

With the widespread implementation of electronic health records, more patients requiring chronic care management, and a value­based
reimbursement system, a clinician’s ability to develop masterful patient communication skills is becoming essential. Employing a collaborative, team­
based approach to patient care and the tips for patient communication can help to ensure optimal health outcomes. Maximizing use of technology
such as the electronic health record for referral to and communication with other clinicians who provide necessary services can meet needs that may
seem impossible in a single clinic or pharmacy. Each healthcare team member brings special skills and communicates with the patient to obtain
additional information. The best care is provided when providers come together at the same location (or virtually) to collaborate and meet the overall
needs of each patient. In some settings, this may be collaborative drug therapy management working with the healthcare team to optimize medication
therapy and overall health outcomes. In other settings, it may include clinicians working to coordinate with health educators in the community to
provide services such as diabetes self­management classes.

CONCLUSION
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the patient’s complaints, involving the patient in the decision­
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needs of each patient. In some settings, this may be collaborative drug therapy management working with the healthcare team to optimize medication
Birzeit University
therapy and overall health outcomes. In other settings, it may include clinicians working to coordinate with health educators in the community to
provide services such as diabetes self­management classes. Access Provided by:

CONCLUSION
Effective patient communication is a mandatory skill for all healthcare providers. Good communication involves developing a positive clinician–patient
relationship, demonstrating a real interest in the patient’s health, listening carefully to the patient’s complaints, involving the patient in the decision­
making process, and providing education in a way that the patient can understand. The ultimate goal is to improve the patient’s health, and effective
communication is the key to making this happen.

REFERENCES

1. Patterson K, Grenny J, McMillan R, Switzler A. Crucial Conversations. 2nd ed. New York, NY: McGraw Hill; 2012.

2. Rantucci M. Pharmacists Talking with Patients: A Guide to Patient Counseling. 2nd ed. Philadelphia, PA: Lippincott, Williams, & Wilkins; 2007.

3. Berger B. Communication Skills for Pharmacists: Building Relationships, Improving Patient Care. 3rd ed. Washington, DC: American Pharmacists
Association; 2009.

4. Ncqa.org. Patient­Centered Medical Home (PCMH). 2018. Available at:

http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH.aspx . Accessed August 30, 2021.

5. Shafir A, Rosenthal J. Shared­Decision Making: Advancing Patient­Centered Care through State and Federal Implementation. 1st ed. Washington,
DC: National Academy for State Health Policy; 2012. Available at: http://www.nashp.org/sites/default/files/shared.decision.making.report.pdf .
Accessed October 28, 2021.

6. Stacey D, Bennett C, Barry M. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev.
2011;10:CD001431.

7. Bennett M, Kliethermes M. How to Implement the Pharmacists’ Patient Care Process. Washington, DC: American Pharmacist Association; 2015.

8. Egan G. The Skilled Helper. Belmont, CA: Brooks Cole, Cengage Learning; 2010.

9. Ahrq.gov. Figure 9: Tips for Conducting a Patient Medication Interview. Agency for Healthcare Research & Quality. 2012. Available at:
http://www.ahrq.gov/professionals/quality­patient­safety/patient­safety­resources/resources/match/matchfig9.html . Accessed October 28, 2021.

10. Drug Diversion Toolkit. Controlled Substance Integrity­Documentation from Drop­off to Pickup, 1st ed. Baltimore, MD: Center for Medicare and
Medicaid Services; 2016. Available at: https://www.homestatehealth.com/content/dam/centene/home­state­health/pdfs/drugdiversion­
controlledsubstancedoc­booklet.pdf . Accessed October 28, 2021.

11. Erickson S, Kirking D, Sandusky M. Michigan Medicaid recipients perceptions of medication counseling as required by OBRA 90. J Am Pharm
Assoc. 1998;38(3):333–338.

12. Fisher R, Brands A, Herrier R. History of the Indian Health Service Model of Pharmacy Practice: Innovations in Pharmaceutical Care. Pharmacy in
History. 1995;37(3):107–122.

13. Lam N, Muravez S, Boyce RW. A comparison of the Indian Health Service counseling technique with traditional, lecture­style counseling. J Am
Pharm Assoc. 2015;55(5):503–510.

14. Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch
Intern Med. 2003;163(1):83–90. [PubMed: 12523921]

15. Guirguis LM, Nusair MB. Standardized patients’ preferences for pharmacist interactive counseling style: a mixed method approach. J Am Pharm
Assoc. 2016;56(2):123–128.

16. Mehuys E, Van Bortel L, De Bolle L, et al. Effectiveness of pharmacist intervention for asthma control improvement. Eur Respir J. 2008;31(4):790–
Downloaded 2023­7­7 10:49 A Your IP is 156.203.233.77
799. [PubMed:
Chapter 18094011]
3: Patient Communication: Getting the Most Out of That One­on­One Time, Krista D. Capehart Page 9 / 10
©2023 McGraw Hill. All Rights Reserved. Terms of Use • Privacy Policy • Notice • Accessibility
17. McCallian DJ, Cheigh NH. The pharmacist’s role in self­care. J Am Pharm Assoc. 2002;42(5 Suppl 1):S40–S41.
Intern Med. 2003;163(1):83–90. [PubMed: 12523921]
Birzeit University
Access Provided by:
15. Guirguis LM, Nusair MB. Standardized patients’ preferences for pharmacist interactive counseling style: a mixed method approach. J Am Pharm
Assoc. 2016;56(2):123–128.

16. Mehuys E, Van Bortel L, De Bolle L, et al. Effectiveness of pharmacist intervention for asthma control improvement. Eur Respir J. 2008;31(4):790–
799. [PubMed: 18094011]

17. McCallian DJ, Cheigh NH. The pharmacist’s role in self­care. J Am Pharm Assoc. 2002;42(5 Suppl 1):S40–S41.

18. Boyce R, Herrier R. Obtaining and using patient data. Am Pharm. 1991;31:65–71.

19. Bates B, Bates B, Northway D. PQRST: a mnemonic to communicate a change in condition. J Am Med Direct Assoc. 2002;3(1):23–25.

20. Leibowitz K, Ginsburg D. Counseling self­treating patients quickly and effectively. In: APhA Inaugural Self­Care Institute. Washington, DC: American
Pharmacist Association; 2002.

21. Yorkston K, Bourgeois M, Baylor C. Communication and aging. Phys Med Rehab Clin North Am. 2010;21(2):309–319.

22. Ngoh L. Health literacy: a barrier to pharmacist–patient communication and medication adherence. J Am Pharm Assoc. 2009;49(5):e132–e149.

23. Stubbe D. Practicing cultural competence and cultural humility in the care of diverse patients. Focus. 2020;18(1):49–51. Available at
focus.psychiatryonline.org . [PubMed: 32047398]

24. Clifford A, McCalman J, Bainbridge R, Tsey K. Interventions to improve cultural competence in healthcare for indigenous peoples of Australia,
New Zealand, Canada, and the USA: a systematic review. Int J Quality in Health Care. 2015;27(2):89–98.

25. Handtke O, Schilgen B, Mosko M. Culturally competent healthcare—a scoping review of strategies implemented in healthcare organizations and a
model of cultural competent healthcare provision. PLoS ONE. 2019;14(7):e0219971. [PubMed: 31361783]

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