Are We Really Teaching Student Pharmacists How to Counsel Patients Effectively?

By: Mark P Wolf Jr., PharmD and Jeff Cain, EdD, MS

Imagine that you’ve been admitted to the hospital for 4 days. During your hospital stay you’ve had multiple specialists come in and out of your room, been hooked up to machines, and had countless changes to your care plan. The day finally comes, the team tells you that you can go home. The discharge process takes hours. Right before you leave, the pharmacist visits to discuss your new medications.  You now find out that you’ve been started on multiple new medications. You feel overwhelmed and you can’t remember what the pharmacist told you. Did the pharmacist simply do a poor job of counseling on your medications or is there something else that might explain why you didn’t grasp it?

Are We Teaching Everything Students Need to Know About Counseling?

This is the reality for many counseling encounters. The Joint Commission’s National Patient Safety Goals require healthcare organizations to, “accurately and completely reconcile medications across the continuity of care. ”The need for effective education is obvious. Almost half of patients do not take their medications as prescribed and approximately one-fourth of patients fail to even pick up their prescriptions.^“1 These poor results may possibly be attributed to cognitive load. Cognitive load is defined as a multidimensional construct representing the load that performing a task imposes on a person’s cognitive system.  Health regulatory agencies and others are advocating incorporation of discharge reconciliation and medication counseling.² However, one challenge is that a single counselling session at discharge may be contributing to high cognitive load by relying on patients’ finite and limited working memory.³ We must have a critical eye and ask the question if single counselling sessions is pushing the finite ability of working memory.

Repeated Patient Counseling Has Shown to Work 

 Colleges of Pharmacy teach students the most effective way to counsel in a single session such as utilizing the three-prime questions and patient teach-back. While this approach may be effective at teaching the skill, it does not adequately address the findings from cognitive sciences that illustrate the importance of cognitive load. Learning theories are applicable to more than just classrooms. In this specific example, not only can we incorporate concepts from cognitive psychology, but we can also draw from the theory of repetition on learning.  Repeated exposure is important to students as learners in the classroom, but also in their roles as future practitioners as they teach and counsel their patients. A study by Bromage and colleagues found that repetition produces both a quantitative increase in amount learned and qualitative change in the reader’s processing strategy.⁴ Programs that stress continual education (which corresponds nicely with the theory of repetition) have been shown to work. A reengineered hospital program created a Discharge Advocate whose sole job was to repeatedly educate patients along with a clinical pharmacist for post-discharge follow up. This program showed 30% lower readmission rates within 30 days of discharge along with 33% lower hospital cost. Medication-related issues post-discharge were discovered by the clinical pharmacist 65% of the time with 53% needing corrective action.⁵ 

We Can Incorporate Cognitive Sciences in Pharmacy Education

The argument can be made that expecting students to excel with a single counseling session is unrealistic and not best practice. Faculty should consider teaching simple concepts from the fields of cognitive psychology in order to improve our students’ ability to provide medication counseling with improved outcomes. The fix can be simple, in addition to teaching students the three-prime questions and patient teach back methods, we must instill the idea of repeated counselling sessions in the clinical setting.  A large part of being a pharmacist is to educate patients to safely and appropriately administer their medication. If our students understand the concepts of cognitive load and the theory of repetition, they can apply them to patient counseling in a clinical setting. There are many avenues that pharmacists can take to instill this idea in students outside of the classroom and possibly improve outcomes. 

Included are some recommendations of how to incorporate repeated counselling sessions in practice. What methods have you seen utilized that worked?

• During rounds with the team, ensure time is allotted for discussion of what and why medications are being utilized.
• During medication therapy management sessions at the community pharmacy setting, take time to educate patients on their medications
• When refilling medications or completing medication histories, note potential compliance or adherence issues. Be sure to prioritize these patients and counsel on their medications.

References

1. Gold et al. Parent Perception and Experiences Regarding Medication Education at Time of Hospital Discharge for Children with Medical Complexity. Hosp Pediatr 2020;8:679-685.
2. Walker et al. Instructional Design and Assessment: An Advanced Pharmacy Practice Experience in Transitional Care. Am J Pharm Educ 2010;74:1-6.
3. Pusic et al. Seven Practical Principles for Improving Patient Education: Evidence-based ideas from cognition science. Paedeatr Child Health 2014;19:119-122.
4. Bromage et al. Quantitative and Qualitative Effects of Repetition on Learning from Technical Text. J Educ Psychol 1986;78:271-278.
5. Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med 2009;150:178–187.

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Pulses is a scholarly blog supported by a team of pharmacy education scholars