Relating to the Patient: My Most Influential Experiences

A pharmacist offers her observations on patient-centered care.

“Drugs don’t work in patients who don’t take them.”— C. Everett Koop, MD

It was an honor to interview Dr. C. Everett Koop in 1989 for an article I was writing on the Omnibus Budget Reconciliation Act of 1990 (OBRA ’90) for The Consultant Pharmacist. He repeated the above quote to all of us as we recorded our experiences with him. For me, his words rang particularly loudly. We chatted about how great OBRA ’90 was going to be for increasing the quality of medicine delivered to the Medicaid population, the importance of drug utilization review, and how the law would expand pharmacists’ counseling to all patients. Little did Dr. Koop realize that we would still be quoting him 25 years later as we strive for medication adherence.

Yes, the pharmacist’s role in patient-centered care has evolved. I will argue that we as a profession are circling back to a simpler time, a period when local “druggists” took their time to talk to their patients face-to-face, creating relationships with clients who visited their establishments for cards, gifts, ice cream sodas, OTC remedies, advice, and prescriptions.

In the 1960s, I grew up 6 blocks from a local “corner” drugstore that we rode to on bicycles to buy penny candy or sit at the soda fountain for a treat! Mr. Gimmy (the owner and pharmacist) always came out from behind the tall prescription counter and spent time with his patrons. These individuals were the very same patients he shared with Dr. Taylor, whose office was right next door. Mr. Gimmy and Dr. Taylor were a team, and their community of shared patients did well with their collaborative relationship and friendship—dare I say “medical home model”—in 1968.

Initially, I just thought pharmacist Gimmy was very talkative and bursting with interesting trivia about drugs. I now know he was brilliant, and I loved hanging out at his pharmacy and listening to him chat with his patients. “How are you doing, Hazel?” Mr. Gimmy would ask. “You were a bit late calling us for your refills. Tell me how you are doing. Are all those grandchildren distracting you?” Hazel would then explain her current life issues. Mr. Gimmy would reinforce how important it was for Hazel to stay on the medications Dr. Taylor had prescribed for her blood sugar and blood pressure. Mr. Gimmy and Dr. Taylor were working in team-based care—and before the proliferation of third-party claims adjudication and the modern pharmacy benefit management construct.

Observation 1: We need to establish a relationship with the patient in order to monitor medical/medication adherence through enhanced communication and face-to-face contact.

I may have only been 10 years of age, but Mr. Gimmy’s patient-centered services impacted my entire professional development. Seven years later, I began my journey into pharmacy and my quest for pharmacist-driven, patient-centered care. Over the past 30-plus years, I have experienced a diverse pharmacy practice in the areas of drug information, hospital pharmacy, community pharmacy, community psych, rehabilitation, long-term care, medical writing, health care and public policy, Medicaid drug utilization review and quality assurance, and employer-based chronic disease management. These settings gave me access to a wide array of patients and insight into what they need to empower themselves in order to understand their chronic diseases and navigate the prescribed treatments and medications.

Observation 2: Medicine is regional and local.

When all the health care professionals within a community work together as a team with patients, the relationships help improve health outcomes and patient empowerment.

Unfortunately, in our most recent health-system environments, I have watched health care professionals lose the time they were able to spend face-to-face with patients—precious time needed to reinforce and educate good health behaviors and identify poor adherence to medical advice or medications. Patient accountability, in my opinion, can only be accomplished through a good patient—professional relationship and face-to-face contact. Our population needs a positive relationship with its health care providers in order to better translate and navigate the health care experience and to act on the advice that is given.

“The brick walls are not there to keep us out. The brick walls are there to give us a chance to show how badly we want something.” —Randy Pausch, The Last Lecture

Observation 3: We all need a break through the “brick wall” to precipitate behavior changes in patients, providers, and policymakers.

Patients should realize that they need to seek and follow educated health care advice; adhere to their medications; learn more about their health benefit, the treatments recommended, and the medications prescribed; and thereby empower themselves to become active participants in their own health and wellness.

Health care professionals should realize that they need to improve their communication skills with their patients. Health and insurance literacy is real and is not about how much schooling you have had. I have had patients with master’s degrees who failed to understand their prescription directions and their health benefit packages.

Policymakers should realize that patients have free will and free choice. While creating policies that require the health care community to be totally responsible for ensuring good patient outcomes, policymakers must understand that patients cannot be forced to completely comply with a set of rules they may not understand or believe in.

Observation 4: Technology is great, but does not solve the true internal adherence issues with human beings.

If technology were the answer, pharmacy benefit managers would have solved medication adherence problems in 1970 when they began managing prescription benefits. Patients are more confused when they receive their medications by mail, accompanied by documents with lots of words that confuse them about their pills. It adds to the confusion when the color and shape of the medication has changed since the last refill. In addition, patients may still receive refills for a dosage strength that their physician discontinued 3 months earlier. Most of my patients, even those gainfully employed, do not have immediate access to the Internet or a smartphone. We cannot assume that those who have access to technology understand it or know how to use it. We now have 3 areas of literacy to be mindful of—health, insurance/benefits, and technology.

Starlin Haydon-Greatting is currently serving as the Illinois Pharmacists Association’s (IPhA’s) director of clinical programs, working primarily to create and establish the Illinois Pharmacists Network, developed to implement IPhA’s vision to improve patient-centered care. She serves as the IPhA Patient Self-Management Program (PSMP) Pharmacy Network coordinator, which includes programs for diabetes, prediabetes, and cardiovascular health, with asthma and depression modules in development. The IPhA PSMP is modeled after the Asheville Project and based on the American Pharmacists Association (APhA) Foundation’s HealthMapRx program. Besides managing the network, Ms. Haydon-Greatting, through SHG Clinical Consultants, also coaches patients in the pharmacist-based care management program in prediabetes, diabetes, cardiovascular health, asthma, and depression.Ms. Haydon-Greatting’s pharmacy degree was earned from the St. Louis College of Pharmacy. Her list of honors and awards includes the American Lung Association of Illinois Outstanding Volunteer Award; Smithsonian Award for Information Technology in Medicine; Illinois Council of Health-System Pharmacists’s President’s Award; IPhA’s Innovative Pharmacy Practice 1997; the 2008 Pharmacist of the Year Award by the IPhA; and the 2011 St. Louis College of Pharmacy’s Distinguished Alumni Award for Service to the Profession. In 2013, the APhA named her a Fellow of the APhA-Academy of Pharmacy Practice and Management. She serves on the Pharmacy Quality Alliance Adherence workgroup and the National Quality Forum Endocrine Steering Committee. Most recently, she was selected to serve as a member of the Board of Pharmacy Specialties Specialty Council on Ambulatory Care Pharmacy.