COUNSELING TIPS By: Nelly Crawley 4-B (Act.

13 Dispensing) In the perfect pharmacist-patient self-care situation, the pharmacist always approaches the patient with a friendly "May I help you find something" This lets the patient know that the pharmacist is available to provide the needed advice, facilitating communications. However, in busy retail establishments, pharmacists often cannot cruise the nonprescription aisles to converse with patients at their leisure. More often, it is the patient who seeks assistance and initiates the dialog when considering purchase of an OTC remedy. In these cases, pharmacists may give the unfortunate impression that they have been interrupted while carrying out a more important duty. The patient may initiate the self-care conversation with several general types of questions that call for different types of pharmacist aid. For example: What do you have for diarrhea? (provide relief for a patient's symptom) What is the best antacid? (choose a specific product from a category of nonprescription products and/or devices) Do you carry Latrimin AF Cream? (locate a product for the patient) As the pharmacist assesses the question and brings the various product- and patient-related decisionmaking factors to that specific situation, several important tips can be used.

EXERCISE ACTIVE LISTENINGThe patient should be allowed to state the problem completely, and the pharmacist should provide the undivided attention

that is necessary to minimize misperception and misunderstanding. The pharmacist should mentally summarize what the patient has said and provide positive feedback that conveys an understanding of the problem, with empathy and concern. Using the patient's own words or paraphrasing them demonstrates a full understanding of his problem(s). Rewording and paraphrasing also force the pharmacist to focus on the situation and understand its various aspects. This process also facilitates and enhances personal relations between the pharmacist and patient by exhibiting the concern expected of a caring professional. QUESTION THE PATIENT THOROUGHLYQuite often, the patient provides incomplete or contradictory information, much of which is necessarily subjective. To make the appropriate triage decision, the pharmacist must thoroughly ask: Does the condition come and go at certain times during the day? How severe is the problem? If it is recurrent, is it worsening? Do you have any other symptoms? Have you noticed a specific trigger that worsens your symptoms or causes them to recur? Questioning should be direct and to the point. With experience, the pharmacist should be able to gather needed information in a period of minutes. If the situation is more complex and time consuming, the pharmacist can ask patients to return at a mutually agreeable time, contact them by telephone, or refer them directly to a physician.

INTERPRET VERBAL AND NONVERBAL COMMUNICATION Every question asked of the patient should be phrased carefully to facilitate interpretation. The patient should be able to understand that the questions asked come from a genuine interest and desire to help. The pharmacist may ask two types of questions: 1. Open-ended questions, which draw forth infbrmation regarding the medical problem. For instance, " Can you tell me about your symptoms?" This question type provides flexibility for patient response and encourages more than a simple yes-or-no answer. 2. A direct question, which is useful when the information is a specific inquiry, eg, "How long have you noticed the burning sensation in your stomach?" Nonverbal communication skills also serve a vital role in this situation. Body posture, facial expression, and distance maintained by the patient all provide perception of the patient as a whole. At the same time it is important to be aware of the patient's nonverbal behavior. Physical barriers to communication should be eliminated whenever possible. The pharmacist should make every effort not to talk down to the patient, neither verbally (ie, use the vernacular) nor physically (ie, the pharmacist and patient should be at the same eye level). These exchanges should be as private and uninterrupted as possible. Many pharmacies lack a private consultation area, but privacy can be achieved readily without expense

by simply forming a triangle using the patient, the pharmacist, and the wall shelf or gondola as partitions. This automatically signals others that the consultation is private and should not be interrupted. Whenever possible, the pharmacist should assess the patient physically, through observation or inspection. For example, the skin is assessed easily by inspection and palpation. However, the lung requires percussion and auscultation, not a realistic practice for the practicing retail pharmacist. The clear majority of pharmacists obtain physical data (eg, number of comedones per side of the face) exclusively through the use of observation. Further, there are clues to the overall state of health of the patient, and these provide insight into the seriousness of the problem. Facial expressions mirror pain and discomfort, pallor and lethargy may indicate an infectious process, and persistent coughing may be a sign of some systemic illness. SPEAK TO A RESPONSIBLE CAREGIVERWhen counseling the patient, the pharmacist may hear phrases such as: "I can't do that without talking to my parents." "My husband won't let me go to the doctor; we don't have insurance," "I'm not sure what it looks like; it's for my grandmother,' In these situations, it may be prudent to call the individual from whom more information is necessary or who needs to be convinced of the serious nature of the problem. GAINING THE PATIENT'S COOPERATION

After the pharmacist has questioned the patient thoroughly and considered various courses of action, the time comes when a recommendation must be made. The triage decision and its ramifications fall into several categories. THE PHARMACIST CHOOSES NOT TO RECOMMEND ANY PRODUCT OR DEVICEMany patients are simply worried that a product might be necessary. The pharmacist may inform them of the fact that their condition is likely to recede without any intervention and that no product will relieve their symptoms. An example would be to discourage smoking cessation to help coughing symptoms rather than purchasing a cough product. Some patients will be dissatisfied with this type of advice and remain convinced that a product will help them. They may simply purchase the product in another establishment in an effort to ignore the helpful advice of the pharmacist. RECOMMENDING A SPECIFIC NONPRESCRIPTION PRODUCT OR DEVICEWhen the pharmacist recommends a specific nonprescription product or device, most patients take the advice and purchase that product. However, a small group of patients insist on their first product choice, even though it clearly may be inappropriate. The pharmacist may urge them to reconsider, with the precaution that it is not the best product. When pharmacists recommend a drug treatment for a condition amenable to self-therapy, they should tell the patient of the condition itself, the monitoring guideposts to remember, and the duration of time before the patient should notice

the benefit of treatment. With acne vulgaris, for example, the objectives of topical treatment are to control an existing condition, impede acne in the developmental stages, and relieve the discomfort (ie, physical or psychological). The patient should be advised that continual, daily application of the medication to the entire face will gradually reduce the number of lesions, but that 2 to 3 weeks may elapse before any noticeable improvement. Indices that demonstrate acne may be worsening and require medical attention should be incorporated into the discussion. Adverse effects and potential toxicities should be noted. Using benzoyl peroxide as an example, the acne patient should understand that some skin redness and irritation may develop. RECOMMENDING REFERRALThis is one of the most difficult groups for which to provide advice. They enter the pharmacy asking for relief from what they perceive as a minor complaint, but are confronted with unwelcome advice to consult another health care professional. The pharmacist may even insist that they make an immediate visit to an emergency room.

These medical alternatives involve an expenditure of money and time. All of the persuasive powers of the pharmacist must be brought to bear in this situation. Phrases such as the following maybe used: "If he were my child, I would take him to the emergency room immediately,'

"The consequences of this could be as severe as loss of sight." "I have heard of this type of problem resulting in a ruptured appendix if it is not diagnosed by a physician." The goal of these and similar phrases is to impress upon the patient the potential gravity of the problem. Patient harm may ensue when a pharmacist recommends a product until a patient can be checked by another health care professional. Some patients simply will not follow through and make the appointment, particularly if the product seems to work initially for his/her condition. An example is the patient who requests a nonprescription analgesic for tooth pain, promising to "visit the dentist tomorrow." FOLLOW-UPWhenever possible, the pharmacist should follow up with the patient, consistent with the concept of pharmaceutical care. To facilitate follow-up, pharmacists might note the patient's name and telephone number, after requesting permission to make a follow-up call. Patients might also be asked to share the results of the suggested triage decision back to the pharmacist. If the patient does not respond to the treatment plan, additional information and data assessment (eg, did the patient follow instructions correctly, taking the correct dose for the recommended duration?) may help determine a new course of action.

Frequently, this reevaluation culminates with the referral of the patient to the physician for further treatment. If at all possible the pharmacist should share information attained from the initial and the followup evaluation with the physician. PRECAUTIONS The pharmacist providing advice in self-care must take great caution in recommending products that lack proof of safety and/or efficacy. Examples include the numerous herbs and "dietary supplements," ear candles, athletic aids, obesity treatments, and other quack products and devices. Another example of products that should not be recommended is homeopathic products. Homeopathy is an outdated branch of medicine that was developed in the early 1800s.' Reference: Remington 21st Edition