Amanda Seeto – Community Pharmacist and Owner; Branch Committee Member and Professional Practice Pharmacist, The Pharmacy Guild of Australia, Queensland Branch with Glenn Guilfoyle – Principal, The Next Level

Seamlessly linking the supply of advice to the supply of a medication

A common presentation to my pharmacy is a customer holding a wad of prescriptions, representing treatment for a range of co-morbidities, the number of which may be reduced with some in-depth conversations about medication management, good nutrition and healthy lifestyle choices. This patient is typically male, aged 40 years or more, overweight, diabetic, and often disinterested in what he can do to improve and extend his quality of life, because in his opinion, ‘Yeah, nah, she’ll be right, mate’.

At a glance, he would benefit from a MedsCheck, a blood glucose monitor upgrade (offered for free from some manufacturers) and three days of intensive monitoring to track his blood sugar levels. How much physical activity does he engage in daily? Does he regularly check his feet? There are more than 4,400 limb amputations every year in Australia as a result of diabetes, and 10,000 hospital admissions for diabetes-related foot ulcers. Diabetic foot disease is estimated to cost around $875 million every year How is his vision? Diabetes is the leading cause of blindness in Australia, with the total indirect cost of vision loss associated with diabetic macular oedema estimated at $28,000 per person. And the list goes on.  (ref. )

How do I engage Mr “She’ll Be Right” in a conversation that will set him on the path to good health? Introducing Glenn Guilfoyle, Principal of The Next Level, and industry thought leader on the conversation skills required in pharmacy for the provision of a complete customer solution.

Glenn says that the polypharmacy diabetic is a super opportunity to shine and create your forward pharmacy service template, making the powerful linkage between product, service and advice. With the continued growth of the big box discounters, the spectre of Amazon, and the inexorable rise of the self-educated customer via plethora manifestations of Dr Google, the industry is fast approaching the inevitability that the only thing left that these “sinister forces” will not be able to match is a personable and confident pharmacist, uniquely tailoring product, service and advice for each specific customer visit.

This requires a particular mindset of the pharmacist. A mindset that includes:

• I am time poor like every pharmacist, but I can deliver much value in a relatively short sharp conversation, and that is my top priority amongst the myriad of things I need to get done;
• I have knowledge and passion and therefore, even the time poor customer will want to listen to me once I begin to engage;
• I have an obligation to teach the customer things they don’t know about their health, condition and medication;
• I have a conviction to take a long term view to recalibrate my customer’s expectation of what is going to happen (differently) when they come into our pharmacy; and if the customer only wants their medication dispensed, I am happy to let them know which alternative pharmacies they can go to for that; and
• My raison d’etre is measured by the customer valuing my words of wisdom ringing in their ears more than the pills in their hand or service I have administered when they finish their visit.

So back to the focus on the polypharmacy diabetic. How do you pick your mark? Which such customers do you take a complete solution conversation to? Every one of them, Glenn says! They will all benefit, and they all deserve the attention. If you have the “luxury” of commencing this conversation at script-in, all the better. In reality, mostly this consultation would occur at script out. Too often our best intentions and advice will fall short on a Mr “She’ll be Right”.. True, at a glance, we have formulated a list of interventions and recommendations that we know our patient will benefit from. Sadly, Mr “She’ll be Right” only hears us telling him all this good advice. He is not truly engaged in a conversational consultation, which might sound something like this:

Pharmacist: Hi Mr “She’ll be Right”, I’ve got your Metformin ready for you. How has your diabetes been since last time you were in?

Mr She’ll be Right: Alright I suppose. I just keep taking my Metformin, and that takes care of it, right?

Pharmacist: Well let’s have a look at that for you. Firstly, let’s check that you are taking your Metformin correctly. The dose is one tablet daily. When do you take it?

Mr She’ll be Right: My missus puts a tablet next my dinner plate each night, so I have it after tea.

Pharmacist: Great! Metformin can sometimes give you an upset stomach so having it with a meal helps to prevent this. It’s also important to try and take it at the same time each day to help maintain control of your sugar levels.

Mr She’ll be Right: So, I’m on the right track, huh?
Pharmacist: Well, let’s check for related symptoms. Are you experiencing any fatigue, weight gain, increased thirst, a need to frequently urinate which can disturb your sleep, or worsening eyesight?
Mr She’ll be Right: Well I do often feel tired and worn out, and now that you mention it, I am finding that I am squinting more just to read things.
Pharmacist: How are those things affecting you at work and during the days?
Mr She’ll be Right: Well I am falling behind on lots of stuff, and sometimes I get headaches.
Pharmacist: How does that make you feel when you are falling behind?
Mr She’ll be Right: Not too flash… Just feel like I never seem to get on top of things.
Pharmacist: What if we had a look at something to relieve your lethargy and eyesight problem?
Mr She’ll be Right: Well ok then.
Pharmacist: I think we should look into a blood glucose monitor upgrade for you and three days of intensive monitoring to track your blood sugar levels. This company is currently offering blood glucose monitor upgrades for free and it wirelessly connects to your mobile phone or tablet so you can keep track of your readings, and this monitoring chart connects your readings to what you’ve eaten. By looking at the graph it produces, you’ll be able to easily identify any peaks and troughs in your blood glucose readings throughout the day. If you can pinpoint foods that are linked to the highs and add in a snack if you have lows, your energy levels should improve. You can also mark on this chart any exercise that you do, so you can see the direct effect it has on lowering your blood sugar levels. Also, I think we should send you off to your optometrist for an eye check. In addition to a basic vision test, an optometrist will examine the back of your eye for any possible damage that might have begun to occur as a result of your diabetes. They may prescribe glasses for you so that you can read without difficulty, but this will make it easier to get your work done and hopefully get rid of those headaches.
Mr She’ll be Right: So I should be right then with all that done, huh?
Pharmacist: Let’s just quickly check that the Metformin is not causing you any side effects. Are you suffering any diarrhoea?
Mr She’ll be Right: Nah!
Pharmacist: Good. Well, Metformin makes your body utilise the sugar in your diet more effectively and works best to keep your diabetes under control in conjunction with a diet that is low in refined sugar and with some regular exercise. Now, just before I let you go, what are you doing about lifestyle and prevention?
Mr She’ll be Right: I know I am meant to exercise more and get my weight down, but I have tried eating less and it doesn’t work for me.
Pharmacist: Well, given what we have discussed that sugary foods cause your blood sugar levels to spike up, and the benefit that some regular exercise can have on your diabetes, would you be motivated to try looking at what you are eating and a simple exercise regime that you can manage? I would really like to help you.
Mr She’ll be Right: Oh well, I s’pose I should say yes.
Pharmacist: Great. Seeing as you said you have tried eating less and it hasn’t worked, let’s just start with doing 30 minutes of exercise, five days a week. Is there any exercise that you enjoy doing?
Mr She’ll be Right: Well I don’t mind walking, and my missus is always nagging me to take the dog out, so I ‘spose I could do that each day.
Pharmacist: Good idea! You will notice that your blood sugar levels are not as high in the hours following this exercise and you will actually feel like you have more energy through the day. (Since you have given me a commitment to have a go at some exercise, I think we should give you the very best chance of success by booking you in for another consultation to review your other medications, to make sure they are working well together and not causing any side effects. I want to ensure there’s nothing else there that may be causing those headaches or preventing you from getting your weight down.
What a “wow” experience for Mr “She’ll be Right” – all in just five minutes This example also shows how we can say things like “losing weight, improving exercise and eating better is good for you”, without offending customers. The skill of good questioning is a technique that connects with the patient at an emotional level, rather than the dry approach of talking about signs, symptoms and side effects.

We all have customers like Mr ‘She’ll be Right”. We can connect with them on an emotional level by asking questions like “what are you doing about diet/lifestyle/prevention”, with compassionate meaning. The key is to then shut up for three seconds. Give the customer back control of what they do/do not want to tell you. If, as we saw in the above example, the conversation elevates from signs, symptoms and side effects to work, rest and play lifestyle implications, you will have very likely made an emotional connection with your patient.

When you then get to the point in the conversation where you need to ask a potentially invasive question like “what are you doing about diet?”, make sure your tone is open and non-judgmental. The “credits” you have earned due to your emotional connection will more likely get the patient to trust you and answer those otherwise prickly questions. And with the answer you can really spread your wings, and give great value and a wow customer experience.

Next issue in Part Two of this article we will delve further into how to change conversations with your customers from the topic of illness to one of wellness. How can a pharmacist use the tools of motivational interviewing to change the behaviour and mindset of customers like Mr She’ll be Right that led them to become inactive and overweight? If you can do this, then no longer does your customer suffer from diseases borne of bad behaviour, such as Type II diabetes. The pharmacist’s potential is huge.