Patient counseling in pharmacy: Through the looking glass

An article written by Lam et al. in this issue of JAPhA focuses on a needsbased, interactive patient counseling technique developed by the Indian Health Service (IHS) pharmacy program in 1980. It is the first published article demonstrating the effectiveness of the IHS technique over the traditional “read the label” lecture-style approach.1 This 35-year interval warrants a look back at the development of patient counseling activities in the pharmacy profession. Table 1 lists important benchmarks in the evolution of pharmacist–patient counseling on prescription medications. The 1952 American Pharmacists Association (APhA) Code of Ethics prohibited pharmacist counseling.2 However, in the early 1960s, IHS pharmacists, led by RADM Allen J. Brands, saw the need for pharmacists to counsel patients and implemented pharmacist–patient counseling about prescription medication systemwide, including the use of private consultation rooms.1,3 By the mid-1970s, the extensive implementation of pharmacist counseling in IHS revealed problems with effectiveness due to language, health literacy, and limitations of traditional counseling approaches. The IHS pharmacy program decided that a consistent, effective approach to patient counseling was needed. After conducting much research and consulting experts in the field of patient education, IHS decided to use its 17 years of experience to develop an internal program that could be taught to all IHS pharmacists. Initially, senior pharmacy managers were asked to identify their “best counselors.” Next, multiple counseling sessions by the 20 nominated pharmacists were recorded for both new and refill prescriptions. The results, when compiled by a small team of IHS pharmacists, were surprisingly similar. Most of the pharmacists used open-ended questions to create a dialogue to identify knowledge deficiencies about the prescribed medication before educating patients on what they didn’t know. Further investigation revealed that most of the pharmacists whose work was used had been trained as pharmacist practitioners4 and had adapted the open-ended question approach, learned in obtaining chief complaint histories, to counsel patients about prescription medication. Also, most of the pharmacists attempted to verify that patients understood the proper use of their medications before leaving the pharmacy. Using pieces from many pharmacists’ recordings, IHS finalized two standardized approaches: one for new prescriptions and one for refills, later named the prime questions and show-and-tell, respectively. The technique was piloted by several of the pharmacist participants, and from their experiences, the specifics of the technique were refined. Simultaneously, patient education authorities were again asked for input, and several pilot approaches to training new IHS pharmacists were conducted. The responses from the technique’s initial use and training were universally positive. The experts noted that multiple educational principles, which improved retention, had been incorporated into the technique, including use of the “teach-back” approach. Under the leadership of Bill Boyce, a coauthor of the Lam et al. study, in-house evaluations validated the technique’s effectiveness over traditional lecture-style approaches, and in the early 1980s, the IHS pharmacy program began teaching the technique to all IHS pharmacists. The Omnibus Budget Reconciliation Act of 1990 (OBRA '90), which required counseling about new prescription medication, increased the demand for training in patient counseling. The IHS pharmacy program partnered with Pfizer to develop a training program, complete with booklet and video.4 Originally distributed to all U.S. colleges of