Narrator - Dr. Abel 00:00 Welcome to HelixTalk, an educational podcast for healthcare students and providers, covering real life clinical pearls, professional pharmacy topics and drug therapy discussions. This podcast Narrator - ? 00:11 is provided by pharmacists and faculty members at Rosalind Franklin University, College of Pharmacy. Narrator - Dr. Abel 00:17 This podcast contains general information for educational purposes only. This is not professional advice and should not be used in lieu of obtaining advice from a qualified health care provider. Narrator - ? 00:27 And now on to the show. Dr. Sean Kane 00:31 Welcome to HelixTalk. Episode 116 I'm your co host, Dr. Kane. Dr. Khyati Patel 00:36 I'm Dr. Patel, and today with us, we have our all time favorite, Dr. Srivastava, as well as the first time joining Dr. Danielle Candelario. Dr. Danielle Candelario, as well as Dr. Sneha Srivastava, are our clinical skills faculty at the College of Pharmacy, and in this episode, we are hoping to partner with them to discuss some tips, tricks and common pitfalls that we should be avoiding when performing medication counseling. Dr. Sean Kane 01:04 And the title of today's episode is taking your patient counseling skills to the next level, clinical pearls and pitfalls to avoid. So welcome to the show, and we really hope to have a great conversation today about really how to improve patient counseling skills. You know, I would say that the target market here for today's episode is partially the p4 student who is now seeing patients live as we're going on to their API rotations, or perhaps that recent graduate. But I think even the veteran pharmacist out there is going to find a lot of value in what we talk about today, and maybe change their approach to how they counsel patients in a good way and improve that. Dr. Khyati Patel 01:40 And what we're talking today, it comes really from our experiences as being patients, being caregivers for our friends and family members, being pharmacists and being obviously the educators we are at the College of Pharmacy. Dr. Sean Kane 01:52 So Dr. Srivastava, why don't we start off with you, and you know, before this episode, before we started recording, we kind of brainstorm some ideas, and I think that you had one overarching key theme that is a really good one to kind of bring to the attention of the audience. And we'll start with that one. Speaker 1 02:09 Thank you, and thank you for having me. You may have heard about this book for parents, and it's about how you can talk so your children listen and listen, so your children talk. And that really hit home with me when it came to our patients as well. Like, of course, our communication skills are so important, and we want to be able to talk in a way that our patients feel empowered to make the best choices for their care. But really important, I would say, is how we can listen and listen actively, so our patients talk to us as well. And so when we're counseling our patients, we have to make sure that we're thinking about both of those, and the biggest way to do that, and I think the central theme with everything else that we're going to say is really bringing the patient to our table. I know we have tons of information that we want to share with our patient, because we care, and we want to make sure they're taking their medication correctly and kind of know what to do if side effects occur, etc, but we really need to have them at the center or counseling and education and have conversations with our patients that are conversations, rather than just giving them information. And so it shouldn't be this one way exchange of information. So what Dr. Sean Kane 03:14 are some examples that come to mind, like more practical examples of how a provider might do it the right way and then the wrong way? Speaker 1 03:21 So one of the ways I can think of is sometimes we have this kind of checklist in mind. You know, we want to make sure we tell the patient during what time to take the medication or what side effects, and we just kind of list everything out, or we tell them where to store their medication. But rather than doing that, talking with your patients, so maybe saying if a medication is supposed to be once or twice a day and it's supposed to be with food, asking them, okay, this is typically taken twice a day with food. So there's your information giving, but now engaging your patient back. So when do you normally eat breakfast and dinner? And do you kind of have a typical schedule and then work with them, which I think when they go home, it'll be much easier for them to be like, Okay, well, I usually eat breakfast at nine, and that's when I'm going to take medication a And dinner is typically at seven, and that works for me, so I'll take it and so they're actually taking the information, the facts that you gave them, and now incorporating it into their Dr. Khyati Patel 04:10 own life. I think that point is really good point. Dr. Srivastava, more of an umbrella point to keep in mind that we are talking with our patients and not at our patients. Another thing that I've commonly noticed is kind of shooting big words at the patient. You know, you're in a hurry, maybe you're not making that translation of being a clinician to a patient educator. So can you tell us about something that our students can be mindful when speaking with the patients? Definitely. Speaker 1 04:39 So we obviously have our medical terms, and that's kind of what we're used to. And I think a lot of our patients actually, especially these days, when they have access to information like at their fingertips, also know a lot of these medical terms. But what we really have to be careful is that we're embracing this concept of health literacy, and so when we think about blood borne pathogens and universal precautions like. When we are going to be dealing with blood, we have no idea about that button, so we always take those precautions, like wearing those gloves, etc. And so say the same thing with health literacy. When a patient walks in, there's no telltale sign that tells you Okay, their health literacy is high that so you always want to make sure you're talking with patients in a language that all your patients can understand. And I promise that doesn't mean dumb it down, because you don't ever want to do that. You want to talk in a way that you explain your thoughts to your patients, or if you're telling them you know this is going to be for your hypertension. Say, Hypertension is also the same thing as high blood pressure, and so just really using those concepts health literacy when you are talking with your patients. Dr. Sean Kane 05:43 Dr. Candelario, know, in your previous job, when you were on the East Coast, I know that you had a lot of experience with patients with anticoagulation who are kind of being discharged from the hospital in a transition of care environment. I would assume that this came up quite a bit in terms of how you're talking to patients and a way that they can understand it, regardless of their health literacy, right? Speaker 2 06:04 Yeah, I think it's important to utilize your open ended questions to determine where they are, not all patients start at the same point, and if we go into our conversations assuming where we believe they should be or where they are based on the duration of their comorbid condition or their diseases, then I think we're already at a disadvantage using our open ended questions to assess where they are and what they understand and what they know really can help us provide the best education for our patients, and yes, patients with anticoagulation, I think, present a specific type of challenge for us. So that's always an exciting patient population to deal with. Dr. Sean Kane 06:45 You know, I'm going to interject one of my pet peeves, if you will, which is counseling on sedating medications. So if you think about it, opioids, benzodiazepines, especially sleep aids. You know, oftentimes I hear mostly students say something like, don't operate heavy machinery when taking this medication. And it makes me laugh, because such a small portion of our population actually ever operates heavy machinery. And a patient, again, thinking back to health literacy, a patient may not connect heavy machinery with driving or doing something that requires a lot of attention to detail. So really, I don't see any role of saying that almost ever to any patient. So instead maybe saying something like, you know, avoid doing things that require mental concentration, like driving until you know how the medication affects you. And that second part is also really important, because there are plenty of people who can drive just fine and are not impaired as they gain tolerance to a sedating medication, and that's okay. It doesn't mean that they can never drive. And if you said you can never drive when taking this medication, that's also inappropriate to emphasize with a patient as well. Speaker 2 07:53 And I think you have to understand the context of where you're practicing. So previously practicing in an urban setting, in New Jersey, you didn't necessarily have heavy machinery beyond driving, but now, being in the Midwest, you have to understand the context in which your patients live. And so perhaps farming machinery is something that needs to be incorporated into your discussions, but identifying who your patient is through open ended questions, I think, is going to help you tailor this to what your patient actually needs totally and then I think also providing context for how to manage adverse events is really important. So not only telling them avoiding activities that require mental concentration, it's also understanding what to do with these adverse effects is important. So I always liken it to imagine receiving a recipe with all the ingredients, and then you don't get a list of what to do with them, or instructions on how to do with it. Or you buy a piece of furniture and you get all the parts, but they don't tell you how to assemble it. I think it's the same thing with adverse events. They give you a list, shortness of breath, nosebleeds, face swelling, diarrhea, headache, but without any instructions, and the patient is wondering, how do we actually manage these things? So is the management of diarrhea the same of shortness of breath? Shortness of breath could be self limiting, like in the case of Brilinta, so providing perspective and instructions for the patient is key so they can put that furniture together or make that recipe. You shouldn't just provide them a list of ADRs or side effects Speaker 1 09:27 and to your point, like what's normal and what's expected and what's not right. When we have certain medications, some of them, it may be normal to have a little bit of diarrhea, and you don't need to call right away. But if that diarrhea is lasting, I don't know, multiple times a day for multiple days, then it's no longer normal, which we know that, right? But like a patient may feel on one end, oh, I have a little bit I need to call because I'm worried, or on the other end, which I think is more dangerous, not call at all, because they're like, oh, this was expected, so this is what should be happening. And in reality, as we know that's not. Case at all, and so absolutely, like really giving them context and instructions is so important. Dr. Khyati Patel 10:06 And I think this, I know we are talking about safety here, but in terms of efficacy, this is also very important. And I'll give you an example of metformin. We know diarrhea and gi side effects are common when somebody is initiated on a Metformin if they weren't told that this is expected, that you don't need to do anything different, but try to take this medicine, perhaps with food, you know, in order to make it better, they may just think like, oh my god, I spent last two days, you know, in the bathroom. I missed my days at work. I'm going to stop taking the medication. And so telling them how to manage the side effect not only helps from safety perspective, but in some instances, like Metformin, can help from efficacy perspective too, absolutely. Speaker 1 10:48 And then it also, I always joke like, if you don't tell your patients this, they're going to hate you, they're not going to trust you, and we want them to trust you, right? And so knowing what to expect and what to do that also improves your relationship with them as well, and their trust in the healthcare system. Dr. Sean Kane 11:03 You know, moving on to another topic that I think is really important, is how you're conveying that information to the patient. Is is critical, you know, for certain medications, anticoagulants being one of the more common examples, Warfarin probably being the pivotal example here. There's a reason why we have Coumadin clinics and why a Warfarin session for initial education can take, you know, half hour or an hour or longer, over multiple sessions. These are really complicated drugs, right? So it's not appropriate to give your patient a ton of information all at once, and maybe how that information is delivered is really important, specifically in terms of how you communicate that information to the patient. Speaker 1 11:43 Yeah, we want to make sure that we are communicating in a way where we are delivering the facts, but we're also then linking those concepts. So instead of just saying, this is a blood thinner, because what does that really mean, explaining how that works and why having to take having to take a blood thinner helps with whatever condition they're treating so or instead of just saying this is for your diabetes, saying This lowers your blood sugar, and it works by helping your insulin work better, or helping yourself make more insulin, you know, depending on what it is. But I really think giving your patient that knowledge helps link all the information together for them. Dr. Sean Kane 12:20 And if you think about it like when you learn a concept, you learn so much better when you know the why behind it, right? So why not give your patient and empower them in the same way, where now they can remember it and recall it better because you've linked it for them, just like you healthcare provider, also learn that information. Obviously you're putting it at a different level, but the why is so important, Dr. Khyati Patel 12:42 and so talking about empowering patients is equipping them with the knowledge you know, and that knowledge needs to be needed to know, and that's where we're going to go into the second part is we can't tell them that they need to be monitoring certain side effects when it's really the job of their health care provider to do so with that. Dr. Kane, can you expand on that a little bit? Dr. Sean Kane 13:03 Yeah, one of my favorite examples here is when a student may say like, monitor for hyperkalemia or monitor for arrhythmias or QTc prolongation, even if you explain what that is to a patient, monitor for hyperkalemia, there is no specific sign or symptom that a patient can reliably do at home. That's going to be an adequate monitoring parameter for that. You're just going to scare them. You might tell a patient, we have to monitor your potassium, because this medication can make your potassium go up, and that's why we have to draw blood from you. You might say your doctor is monitoring XYZ, especially if they ask about it. But I think need to know is really important here that you know, as a healthcare provider, your job as part of that counseling session is to take all of this massive amounts of information and condense it down to what the patient needs to know at the time that you're counseling them, you're going to have lots more information in your brain that is not important for the patient to know at that time of the counseling session, And that's where you really have to discriminate what's important. Dr. Khyati Patel 14:03 This one ties really well with what you just said. Dr. Kane, it's like the bookish answer, right? Because I found it in Micromedex or Lexicomp. I'm going to tell it to the patient, and I get that a lot of time with lifestyle modification. I know when we talk about medications, we really don't dive into this. But on the clinic side, I get to see students do this, and they will provide answers that are more bookish. Well, according to the ADA, you got to walk, you know, 150 minutes per week, but not really assessing where your patient comes from. Maybe they haven't done any exercise. And so perhaps asking them, what's your current routine? Can you do 10 minutes? You know, let's them. Let them take baby steps or not assume at all, you know, just because they're not flexing their muscles, maybe they're spending two hours at the gym, you know, swimming, exercising, walking with their friends. So really find out where they are, rather than just giving or throwing a book answer at them. Dr. Sean Kane 14:57 And this is also common, and I. I actually view this more as a symptom of a problem, and the problem is not individualizing your counseling to the patient, so not having that conversation of tell me about how you're currently exercising or your physical activity, instead of just again, making the assumption, giving them the book answer, not thinking about having that genuine conversation with the patient. And I totally get especially in school, students are so stressed out that they want to hit all of the items on the rubric and they want to get through it, then they kind of are at risk for losing that personal touch where they're then talking to the patient and understanding who that patient is, and developing that rapport and that relationship. Speaker 2 15:36 I think another symptom of not asking open ended questions is derived from lack of time, or at least perceived lack of time. And I found that it actually takes less time to be able to counsel a patient specifically with regards to their needs, rather than being general. So to Dr. Patel's point saying walking at least 150 minutes per week, if the patient is active in your discussion, they're going to come back with, well, how do I do that? Or that's not possible for me, and then you're going to lose that trust, is what Dr. shavastava said. So it actually probably takes more time on the front end to tailor your suggestions to the patient, rather than having to backtrack your suggestions because you didn't tailor it to that patient Absolutely. Speaker 1 16:21 And then, like, just the whole concept of that shared decision making, right? Your patient wants to be a part of the plan. Like, I don't know about all of you, but I don't like being told what to do. I'm guessing most of us don't. And so it's most likely the same for our patients as well, where they want to be part of that decision making, and depending on where you are working and practicing, there may be things that you can do to help tailor your patients medication management, or help tailor and create plans for their goals, or maybe just having the conversation with them, seeing you know why they're not taking a certain medication or why They don't want to be titrated up on this other medication. And even if you can't make that change, you can empower them to say, hey, you do have choices. Let's talk this through. And then whether you call the provider yourself, or you tell the patient, okay, you're going to be seeing them next week, consider having these conversations with them like we had, and then that lets them truly be a part of their own care. And if you're committed and you're part of your own care, I would say you're more likely to help improve and optimize your care too. Dr. Sean Kane 17:30 I think all too often, some patients don't appreciate that this is even a thing. They assume whatever their doctor tells them is the law, and I just must do or ignore whatever they say. And they don't view it as an opportunity that there can be a conversation to occur, that they themselves are empowered to make their own healthcare decisions as well. And I think just opening that door for some patients to acknowledge that that's even a thing is really important. Dr. Khyati Patel 17:54 I think all too often, I find this a very good opportunity to address some of the non accurate information that patients might be finding on internet or, you know, news items or blog posts, and try to really talk with them and say, hey, you know that supplement that you heard and you're about to take, it's not really a good idea, because it interacts with so and so of your medications, you Know. So it really again, going back to Dr. Srivastava point creates that trust relationship with pharmacist that in future, if they're considering any such medications or supplement, they will come and ask you first. Speaker 2 18:33 And I think this works with monitoring too, right? So we always talk about that patients with heart failure should weigh themselves on a daily basis. Do we ever ask them about where their scale is, or do they have a scale? And are they ever included in the shared decision making process of when and how to weigh themselves? And so we know they should weigh themselves in the morning, but are we truly allowing them to be a part of that decision so I think even monitoring parameters are important when we talk about shared decision making Dr. Sean Kane 19:03 and speaking of monitoring parameters, I think another kind of pet peeve of mine deals with especially opioids, and given the opioid crisis and things like that, I think it's really easy to talk about respiratory depression with patients and especially with students. A very common pitfall that I observe is a student saying something like, monitor for difficulty breathing or shortness of breath, or worse, of that would be monitor for respiratory depression. You know, what does that mean to a patient? And if you even think about like, what is the pathophysiology of why respiratory depression happens? Really, what's going on there is that they took a sedating medication that depressed the respiratory drive, and they're not alert or awake enough, especially that respiratory drive component of their brain to make them breathe faster when they need to. So really, if a patient gets to the point where they're not breathing enough, they are way too sedated to recognize the fact that they're not breathing enough. This is not a monitorable self monitorable at. Reverse effect. So really, I don't think that this even kind of plays a role in that discussion with a patient. In terms of monitoring their respiratory status, you could potentially talk to a loved one, especially if you're talking to them about like Narcan administration and things like that. But in terms of self administration, this has really no role, in my view, because it's not something the patient can monitor. And again, I think it drives the scariness of something that they can't do anything about, that you're already counseling on the sedation quality. Anyway. So if Dr. Khyati Patel 20:31 that's the case, Dr. Kane, then what are your suggestion? What? How should we frame it? Dr. Sean Kane 20:36 Well, I would definitely focus on the sedation aspect. So you can also frame this as this opioid that you're picking up makes you sleepy, and if you drink alcohol with it, you can get so sleepy that you won't breathe adequately, and that can cause problems. Or you could link it to other sedating medications that they're taking and say you're at a higher risk for this. And of course, if, especially if you're talking about Narcan with the patient or a patient's loved one, that's where that plays a role, where if you think that the patient is not breathing very fast, that this would be a sign that maybe you should consider administering the Narcan to the patient Speaker 1 21:09 the way that you can incorporate into it. If your patient's coming to pick it up, just asking them, is there somebody that you live with, or that you're around? And these are some of the points that you should share with them to look out for, since you're not the one that's going to be able to or even offer to say, hey, if your loved one, or whoever it is, wants to call me, we can talk about it as well. And so once again, giving them the information so then they know what to do with it. Dr. Khyati Patel 21:33 So segueing from all the monitoring parameters and how to really engage the patient and empower them, we have a few other points to generally talk about more so kind of bring out our implicit biases. Dr. Candelario, this is one of your pet peeve and I'll let you take the lead on this one. Speaker 2 21:52 Yeah, I think very often we should remember that not all of our prescribers are doctors, so we need to acknowledge that mid level practitioners and collaborative practice agreements have really agreements have really changed prescribing patterns, so we're seeing more prescriptions from nurse practitioners, physicians assistants and even pharmacists. So in order to capture this more accurately, we should probably consider restructuring our three prime questions. Our Indian Health Services have wonderfully provided us a framework for counseling. If you recall, what did your doctor tell you this medication was for? How did your doctor tell you to take this medication and what did your doctor tell you to expect? That's traditionally the three prime questions that we've always taught students and practicing pharmacists to utilize in their counseling session. But I really think that those statements are not inclusive, so perhaps we can change those questions to what did your provider tell you this medication was for? I also think that we should be including the other information sources that patients receive information from. They get it from TV. They get it from their neighbors and from their friends and family members. So now it's not only what did the provider tell you, but what do you understand this medication is for, which is really inclusive of all the areas that a patient can receive information. Dr. Khyati Patel 23:14 That's an excellent point to be made. Dr. Sean Kane 23:16 And I think on top of that, just thinking about assumptions. Again, you know not all providers are men, right? So when you use the pronoun he or him, that's really not appropriate unless you know that it's a he or a him provider, right? Speaker 2 23:29 Yeah, perhaps we should even consider eliminating those pronouns as well. Not all providers or prescribers are males, so yeah. So perhaps to make our discussions more inclusive, we should consider removing those pronouns. Again, it's not inclusive of men and women who may be prescribing medication. So if we're unsure of the gender of the prescriber, perhaps we just say prescriber or provider when referring to them. Dr. Sean Kane 23:56 Going back a little bit to some side effect oriented discussion, we actually covered another kind of pet peeve that Dr. Patel and I had all the way back in episode 70, which seems so long ago now. And the title of that episode was, Does rosuvastatin really cause 42 adverse drug reactions? And the issue that was at the core of that episode dealt with the fact that it's so easy to come up with a laundry list of side effects for any given medication, and oftentimes things like UpToDate, Lexicomp, Micromedex will have side effects that the drug actually doesn't cause, but it's just background, adverse effects that occur with anyone throughout the course of time, diarrhea, headache, nausea being common examples, and what I commonly see is especially when a pharmacist or a pharmacist student is not sure about a medication, they go back and just rely on these, oh yeah, it might cause headache, nausea and diarrhea. So look out for that, even if the medication doesn't cause that, because they're going to see those words in Micromedex and UpToDate. And that's just an easy crutch to rely. Speaker 2 25:00 On. Another great example of that is when side effects include something that is a result of the disease state itself. So for example, beta blockers do not traditionally cause MI, but you will see that in the laundry list of side effects. So perhaps discontinuing the beta blocker increase their risk of having an MI if they were on it for that reason, but it is not a specific side effect associated with beta blockers. Dr. Sean Kane 25:31 And really the way that you fix this problem is again, and we covered this back in episode 70, instead of relying on that adverse effect section in micro, medics are up to date. If you go to the package insert, which is free through daily med or any other resource, other sections in that package insert, like boxed warnings, Warnings and Precautions, adverse effects, where you actually have the comparator in a table where you see the ADR rate of your drug next to the ADR rate of a comparator that really helps identify what ADRs actually occur, or what are ADRs that are really, really rare, but are well known to be associated with a given drug. That way, you're not relying on this crutch of headache, nausea and diarrhea, but you're actually giving the patient relevant and accurate information about the side effects to expect. Speaker 1 26:18 And if I can just add to that, outside of our communication, like oral communication or written communication. So Right? We're always giving the patients these pamphlets that now also cover those 100,000 and so just making sure that when we're doing that, of course, we need to, and it is important that we just give context to the patient. Hey, especially if you know your patient, somebody that's going to read all of it, saying there is a lot of information I've tried to cover, you know, the most pertinent stuff, but if you're reading something and you have any questions about it later, once again, call us, letting them know that some of this information that they're getting is a laundry list and not something that they need to actually be afraid of. Speaker 2 26:55 And you can even mark up that written information to your point. Dr. Srivastava, right? You can highlight, you can mark on it. You can draw their attention to certain ones that perhaps require more immediate intervention versus those that require follow up or a phone call. So don't be afraid to use that in your education, but providing more context to your point. Dr. Khyati Patel 27:16 I think the next one we're going to talk about that's something I'm really passionate about is we do everything and making sure our patients at that center, you know, we're providing the right information, providing the context and everything, but we forget to provide instructions on how to dispose of the medication. Of course, as pharmacists, we want patients to take all their medications, you know, not miss any doses. But hey, dose changes occur all the time, right? Sometimes, patient end up developing the side effect and they no longer are continued on that medication. How are they going to get rid of that? Sharps are another examples. What do they do with some patches they haven't used? And you know, perhaps, I guess the NEMO swimming in your fish tank is not affected by it. But we need to be aware from public health perspective that you know, these medications do not end up on wrong hands, right for abuse purposes or polluting the environment, right? So we need to teach patients on how to get rid of unwanted tablets or capsules, other forms of medications, like canisters, vials, patches and sharps too, right? That those become a big safety problem if we are the one dispensing the product, then we should empower patient with the knowledge on how to get rid of those products. Plenty of resources are available out there that could be just generally mentioned very quickly that there are certain pharmacies with take back receptacles. There are DEA drug take back days. There are nationally held by local law enforcement agencies. Local law enforcement agencies will have their own days, their mail back envelopes, disposal kits available, obviously, sharps containers and so stuff like that could further be disposed at preferable locations, and you can find those locations at safe needle disposal.org Dr. Sean Kane 29:06 so you know, as you start wrapping up that patient counseling conversation, something that I see a lot of, and it's probably driven in large part just because of the rubrics that are commonly used for assessing student counseling sessions is a student saying something like, Could you please repeat back everything I just said to you? Now, if you're a patient, how does that make you feel? Dr. Khyati Patel 29:31 You're quizzing me whether I paid attention or not. Unknown Speaker 29:35 Where to start. You just gave me so much information. Dr. Sean Kane 29:37 Yeah, especially after you know, 10 minutes of counseling on medication. You want me to take 10 more minutes to reiterate everything back to you. This is a point of contention. And you know, even if you go to the APhA-ASP National Patient Counseling Competition rubric, part of that rubric is that there is some verification that the patient understands through a feedback mechanism so they sit. Suggest that there's some question, like Mrs. Jones, just to be sure that I'm clear, could you please tell me how you're going to take your medication, something like that? I think while it's important to emphasize that the patient actually understood, I think if you had a genuine conversation with them, that alone is part of that process, as opposed to waiting till the very end. But I think there's also other ways that you can make sure that you're reiterating to the patient without making the patient feel like they're being quizzed at the very end of that counseling session. Absolutely. Speaker 1 30:33 And you know, part of health literacy and the approach to it is using this Teach Back component, but doing it at the end, like you said, it just makes somebody feel like, not sure where to start, and that they're being tested, and so you want to be respectful. And so some of the things, like, if you're teaching them administration, have them show it back to you, right? Or when you are to your point talking about when they're going to take their medication, you don't have to say, Okay, so now tell me, Mrs. Jones, when are you going to take it again? But had you had that conversation where they talked about when they're going to actually be taken, incorporated into their daily schedule? Well, then that's your teach back in and of itself. Dr. Sean Kane 31:06 And I think again, this goes back to that individualization. If you're not individualizing your patient counseling session, and you always ask the same question at the very end of tell me how you're going to take this medication. If you've just had like, an in depth conversation about how Mrs. Jones is going to do this right after her cribbage match and then before she has lunch like that makes no sense to ask her again, because she's pretty clearly got it right. So again, getting out of robot mode and having that individualization, I think, is one easy way to fix that, if for whatever reason, having that active learning Teach Back reiteration isn't possible or doesn't naturally fit another way to do this, and this is actually one of my preferred methods, is at the end having, you know, a summarization of, like, the three most important things that you just talked about. So even after a 30 minute Warfarin counseling session, at the end, I'm going to pick three things that I thought during that conversation the patient wasn't sure of, or maybe I felt like I didn't hit as well, or just really that important, I'm going to hit those again, three quick points, less than 30 seconds, just to leave the patient with some of the most important things before that counseling session is over, Dr. Khyati Patel 32:17 and talking About just ending the counseling session approach, right? Dr. Candelario, can you tell us what's one fantastic way to end the session? What's the more preferred method? Unknown Speaker 32:28 What questions do you have? Speaker 3 32:31 So are you sure have any questions Unknown Speaker 32:35 you don't have questions? Do you Speaker 2 32:39 I think? No, I don't, right, and that leads to just a very quick refusal. We need to opt that. We need to then consider how to close our sessions with a more open ended approach. So what questions do you have? This is going to invite your patient to be curious, and then they're probably going to have to think about, well, do I have any questions? And take that moment so this can this should be incorporated into any and all practices, regardless of counseling style setting. It's a great way to end and wrap up your counseling sessions. Absolutely. Speaker 1 33:13 And I think just with that, it's yes, we end it, but also throughout, we're engaging the patient, so they're asking questions, hopefully along the way. But what's a pet peeve of mine is when we just leave it up to the patient to ask questions. You know, you don't know what you don't know. And so that's where our communicating with them, you know, being proactively discussing at least, gives them a baseline of what kind of questions they may have based on what you're saying. And so I really think it is important that we always engage the patient back and say, Hey, what questions do you have? But we don't leave that responsibility to have questions just on them. Dr. Khyati Patel 33:51 Yeah, a little bit of empathy can help here as well, right? Maybe it's a new diagnosis, and they're just so wrapped up with the fact that they're being diagnosed with a new condition, let alone they have to take all of a sudden, two new medications. Maybe they don't come up with questions at that time. Maybe we leave that opportunity and say, Hey, I know this is a lot right now for you to intake. You know, we covered a lot of information. It's okay for you to not have any questions, but here's my number. Call me if you have any questions coming up in future, right? So that leaves you more of an open counseling session. They can always call you and ask further questions. Speaker 2 34:26 And I know we've talked about a lot today, and it seems as though to implement something like this may be time consuming, but I think in the way that if it's implemented appropriately, it doesn't really take all that much time to be able to incorporate some of these best practices. The practice of it takes time incorporating different elements into each session intentionally. May take time, but overall, your counseling sessions are much more effective and much more cohesive if you take the time to implement some of these best practices. Dr. Sean Kane 34:59 So. So a little time up front can really pay off down the road as you're starting to practice and things like that. Unknown Speaker 35:05 Think that's a bubble sticker or something. Yeah, Dr. Khyati Patel 35:09 American students at the clinic too, you know, they're a little bit rigid. They're doing this maybe a first or second time. And what I my first advice to them is, you know, relax a little bit, and you're not going to be the perfect the first time, I wasn't perfect as a practitioner the first time or the second time it took us practice, right? So it goes back to your point. Dr. C, practice makes perfect or near perfect, we can't achieve perfection. Speaker 2 35:35 And I also think too that one of the reasons we're so comfortable talking about these is probably we've all made these mistakes at one point or another in my career, for sure, I've asked the patient, can you tell me something that we discussed today and the blank stare that I got back so you want me to tell you everything we talked about in 10 minutes? Right? And it was that light bulb that said, Okay, beginning to change the way that I approach these situations. But it was only through making those mistakes that I was able to become a better patient counselor. I think you could say that about everything we do in our career, all of those errors, mistakes are things that we take with us and help impart on future generation. Dr. Sean Kane 36:15 So you know, we've we've covered a lot today about patient counseling and for the listeners, if you want to kind of go through some of the key points that we've covered, we're we have show notes. So if you go to HelixTalk com episode 116 we're going to outline all of the key points that we've talked about today, so you can kind of go through, maybe identify a couple areas of opportunity for how you can improve your own patient counseling in the future, kind of again, plan it out and then start practicing, and you'll get better as you continue to move forward with that. We're on Twitter at HelixTalk, and we love for people to follow us and tweet at us with episode ideas and topics and things like that. And finally, we love the five star reviews that helps us climb the rankings in iTunes, and have other like minded practitioners find us as well in the iTunes podcast directory. So with that, I'm Dr. Kane. Dr. Khyati Patel 37:09 I'm Dr. Patel, and it was lovely to have you Dr. Srivastava and Dr. Candelario to partner with this episode. Thank you. And with that, I'm also going to say, study hard. Narrator - Dr. Abel 37:22 If you enjoyed the show, please help us climb the iTunes rankings for medical podcasts by giving us a five star review in the iTunes Store. Search for HelixTalk and place your review there Narrator - ? 37:33 to suggest an episode or contact us. We're online at HelixTalk.com thank you for listening to this episode of HelixTalk. This is an educational production copyright Rosalind Franklin University of Medicine and Science.