The Pharmacist Prescriber: A Psychological Perspective on Complex Conversations about Medicines: Introducing Relational Prescribing and Open Dialogue in Physical Health
Abstract
:1. Introduction
“By far the most frequently used drug in general practice was the doctor himself, i.e., it was not only the bottle of medicine or the box of pills that mattered, but the way the doctor gave them to his patient—in fact the whole atmosphere in which the drug was given and taken.” [6].
2. Meaning and Medication: The Evidence Base
2.1. Relational Prescribing
2.1.1. Avoid Mind–Body Split
2.1.2. Know Who the Patient Is
“It is much more important to know what sort of a patient has a disease than to know what sort of a disease a patient has.” (attributed to Sir William Osler, cited in [33])
2.1.3. Attend to the Patient’s Ambivalence
2.1.4. Cultivate a Pharmacotherapeutic Alliance
2.1.5. Attend to How the Patient Uses Their Medication
2.1.6. Identify, Contain, and Use Feelings the Clinician Feels towards the Patient
- ▶
- Empathy
- ▶
- Warmth
- ▶
- Caring/Helpful/loving/competence
- ▶
- Frustration/anger
- ▶
- Helplessness/despair
- ▶
- Anxiety/sense of persecution/incompetence
- ▶
- Shame
- ▶
- Repulsion/disgust
2.2. In Summary: Relational Prescribing
3. Open Dialogue
4. Shared Decision Making and Coaching
5. Moving Forward—The Cultural and Educational Imperatives
6. Vignette
- Transactional:
- I explained that there was a limit to how much we can control our cholesterol in this way. For some people, medication is the only way to reduce it enough to make a significant difference, and he was reassured by this.
Armed with this information and the medication, would he now be happy to start taking it? What further discussion might be of benefit?
- Relational prescribing:
- I said that it seemed like he had tried very hard to take control of his health and asked how it felt that his cholesterol was still not in the normal range. He said it had felt like a failure not to have been able to reduce his cholesterol with diet and exercise. He had tried to manage it by swimming three times a week, reducing fats in his diet, using plant-sterol spread, and taking a plant-sterol-containing drink every day. He said that he thought he could do it because he had been successful at avoiding the need for medication for his type two diabetes through diet and exercise.
6.1. Avoid Mind–Body Split
6.2. Know Who the Patient Is
6.3. Attend to the Patient’s Ambivalence
6.4. Cultivate a Pharmacotherapeutic Alliance
6.5. Attend to How the Patient Uses Their Medication
6.6. Identify, Contain, and Use Feelings the Clinician Feels towards the Patient
6.7. An Open Dialogue Approach
- Pharmacist:
- “Something in me feels that the idea of taking a statin for life may feel uncomfortable for you?”.
- Patient:
- “Yes, I feel like an old man and a failure as I really thought that my diet and exercise could sort out my cholesterol, I don’t want to take pills till I die”.
- Pharmacist to wife:
- “I know you initiated this consultation, have you got concerns you want to share?”.
- Wife:
- “Well, I know he probably needs them, but my brother died from a stroke at 53 whilst taking statins, so I feel really conflicted as the doctor said that once on them, he will never be able to stop them”.
The wife may then cry and reach out to hold her husband’s hand.
- Wife:
- “Robert may say start them but remain vigilant regarding exercise and diet”.
- Pharmacist to both:
- “The evidence is that cholesterol doesn’t always respond to lifestyle changes and often needs statins”.
- Patient to wife and pharmacist:
- “I know she [looking at wife] is concerned, and I appreciate how hard she… well we all took Robert’s death at such a young age”.
- Wife:
- “Yes, it has been and still remains hard, Robert left two teenage girls and our kids miss their uncle and they are very close to their cousins”.
- Pharmacist (with a better understanding of the context):
- “Medicines do not need to be taken with a view to never stopping, would it feel comfortable to start for twelve weeks, and then return for a review so that we can then think together again?”.
- Patient:
- “So you’d monitor me that regularly?”.
- Wife:
- “And could we all meet together again for the review?”.
- Pharmacist:
- “Yes of course, and we can then check how you are responding and do continue the exercise and diet regime”.
7. Summary
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Rogalski, D.; Barnett, N.; Bueno de Mesquita, A.; Jubraj, B. The Pharmacist Prescriber: A Psychological Perspective on Complex Conversations about Medicines: Introducing Relational Prescribing and Open Dialogue in Physical Health. Pharmacy 2023, 11, 62. https://doi.org/10.3390/pharmacy11020062
Rogalski D, Barnett N, Bueno de Mesquita A, Jubraj B. The Pharmacist Prescriber: A Psychological Perspective on Complex Conversations about Medicines: Introducing Relational Prescribing and Open Dialogue in Physical Health. Pharmacy. 2023; 11(2):62. https://doi.org/10.3390/pharmacy11020062
Chicago/Turabian StyleRogalski, David, Nina Barnett, Amanda Bueno de Mesquita, and Barry Jubraj. 2023. "The Pharmacist Prescriber: A Psychological Perspective on Complex Conversations about Medicines: Introducing Relational Prescribing and Open Dialogue in Physical Health" Pharmacy 11, no. 2: 62. https://doi.org/10.3390/pharmacy11020062