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A MedList clinic: perspectives of a pharmacist and a student pharmacist
By David Jacobson / Tue Mar 4, 2014
A joint effort between the nation’s largest drug store chain, UCSF School of Pharmacy, and the UCSF Medical Center, the new retail facility features private consultation areas where UCSF and Walgreens pharmacists will routinely provide comprehensive medication review. The new pharmacy will also serve as a training facility for the School’s student pharmacists during the experiential portion of their doctoral degree program.
During last week’s official grand opening ceremonies, School pharmacist faculty members and student pharmacists offered a preview of the retail pharmacy as a center for medication management. They provided a free “MedList” clinic, inviting members of the public to come to the nearby Millberry Union Conference Center with all their medicines for counseling and the creation of complete, accurate, portable, and personalized medication lists—a card-size one for their wallets, a chart for their refrigerator doors, and an electronic thumb-drive version—to take with them to other health care providers.
More: Reimagining Pharmacy Care.
Patients were seen by teams of two student pharmacists and an experienced faculty pharmacist. Here we sample their perspectives on the event:
Every time I go to the doctor, there’s another pill they add. From the time I get up to the time I go to bed, I take pills. The bin is just overflowing with pill bottles.
—Helen, a patient served at the MedList clinic who asked that her real name not be used. Faculty and student pharmacists suggested ways she could reduce her pill burden by 30 percent while improving pain management.
A pharmacist’s perspective: Jennifer Cocohoba, PharmD
The man with the sad eyes and hilarious dry wit hefts a large bag carrying his medications to our table for review. As a practicing pharmacist, the duty of carefully reviewing medications with a patient is not new to me. I regularly help organize medications for my patients in the UCSF Women’s HIV Program who have multiple chronic diseases treated with multiple pills, who sometimes have limited health literacy, and who often come from marginalized populations.
Volunteering for the MedList Clinic feels a bit different. Patients here have proactively made appointments to have their medications reviewed, know the names of all their pills and when to take them, and are eager to learn even more about how to manage their health.
Yet no matter the clinic location or the patient being served, I am always astounded at the sheer number of bottles that keep coming out of the bags, and the common challenges that patients face in managing their medications. This man removes a fat packet of drug information leaflets he has collected from the pharmacy. It’s how he keeps track of all his pills. I shake my head in amazement and realize that he does it because he has to.
We go through his medications one by one, briefly discussing the indication for each and assessing for common side effects. In consultation with me, the student pharmacists are able to give our patient more precise information about what each of his medicines is being taken for. For example, letting him know that a medication he believes is for his stomach really acts by lowering his blood pressure, which, in turn may be beneficial for his stomach condition.
We provide details on how to take each drug properly. Like examining just one note in a song, the act of going through each medication might not seem that impressive. However, within a song each note must be played properly to create harmony. Reviewing medications is one small but very important way that a pharmacist can assist the conductor—the patient.
Being that conductor is not easy. Our patient shows us a tiny weekly medicine box that he is using, and asks if there is a bigger size available because he plans to travel on vacation for a month and can’t imagine bringing 10 bottles of medicine. He also worries about getting all of his medicines in time for the trip because they are ready for pick up on different weeks during the month. It feels a bit overwhelming, but he is determined not to let his medicines get the best of him or stop him from enjoying life.
Having practiced for a decade, I know how to encourage him to ask for services which may help him adhere to his medications better—like asking his pharmacy for monthly adherence packaging in punch-cards to bring with him on his trip, or asking the pharmacist to help him synchronize his medication pick up dates so that he doesn’t have to go to the pharmacy every week, and asking his insurance company to approve a vacation supply so that he won’t run out of medicine while he is away.
The student pharmacists run a drug-drug interaction screen and find that several of his medications can predispose his heart to an abnormal rhythm. The patient appears concerned about this ominous-sounding interaction, but my clinical experience allows me to reassure him that many medications carry this risk. I also remind him that he’s had an EKG [electrocardiogram] recently to monitor for this side effect. I promise to write a small reminder to his physician regarding the interaction on the medication list we are collaboratively creating.
Despite the students’ protests that they will copy this all down for him, our patient still takes out his pen and carefully takes notes. I smile. At the end of the day, this is the most important thing that the pharmacy team can provide: Encouragement and support for patients to actively take charge of their medicines and their overall health.
A student pharmacist’s perspective: Maher Abdel-Sattar, Class of 2014
Being a 4th-year student pharmacist nearing graduation, I have led patient interviews on many occasions in the hospital, ambulatory care, and community pharmacy settings. I’ve had ample practice in leading a mutually beneficial conversation with patients, framing open-ended questions in a tactful way, actively listening to what they have to share, and displaying empathy towards their challenges and concerns.
In most of my rotation experiences, I have either shadowed a professor who is a pharmacist, or done work independently, then presented it to a preceptor. What I loved about this experience in the MedList Clinic was getting to interview a patient alongside one of my peers and a preceptor at the same time. This collaboration allowed my relationship with my professor to quickly transform into a true partnership.
At the beginning of their appointments, many of my clinic patients did not necessarily appreciate the full value of having an updated, accurate, actionable, comprehensive yet concise, portable medication list. But by the end, they were thrilled to have a list that they can share with their health care providers along with any suggestions or recommendations from the pharmacist. This service empowered them to address some of their concerns about their current medications and encouraged them to revisit their physicians and have an educated conversation about their regimen.
Each patient I saw in the clinic had over 10 different medications and this type of review is essential in finding potential drug-drug interactions. We also verified that each of the medications had an appropriate indication. This helps eliminate duplication in therapy and minimize medication errors.
My patients were adherent to their medications, but one was taking three gabapentin capsules three times a day for neuropathic pain. She was delighted to hear that the medication came in higher strengths that would reduce her pill burden from nine pills per day to only three per day. At the bottom of her MedList, I added a detailed note to her primary care provider including the available formulations of gabapentin that they could consider switching to in an effort to maximize adherence.
My last patient came in with one bag of prescription medications and two full bags of herbals and supplements. He’d purchased all these non-prescription products based on advertisements and word-of-mouth. More importantly, he’d never shared this information with his physician, who he considered a "non-believer" in alternative medicine. The patient took them sporadically in addition to his scheduled prescription medications.
Based on this patient’s wishes, we repurposed our visit to go through each of the 25 herbals and supplements, discussing each of their potential benefits, highlighting those that have some clinical evidence, if any [supporting their use], checking for any interactions with currently prescribed medications, and eliminating products that have overlapping ingredients or serve the same purposes.
This task was especially difficult because there is very limited data on herbals and supplements. Also, these products come in thousands of different formulations and dosages. The patient was very impressed with our thorough review. We were able to help him choose five herbal products to take consistently, as that would be much safer and more efficacious than taking all 25 sporadically. Moreover, we were able to integrate these five into his portable MedList that he promised to share with his physician provider. We also gave the patient large printouts of his MedList to help him remember which of these [alternative] products he had chosen to take and how he should be taking them in addition to his prescribed medications.
It was refreshing to be in a setting where I could dedicate a whole hour to serve a patient to the best of my abilities. In the community pharmacy setting, patient interactions are often brief and sometimes impersonal. It’s nice to see that UCSF and Walgreens are collaborating to make pharmacists available as a resource for patients in the community: Very few recognize the full potential, level of knowledge, and scope of practice of pharmacists.
About the School: The UCSF School of Pharmacy aims to solve the most pressing health care problems and strives to ensure that each patient receives the safest, most effective treatments. Our discoveries seed the development of novel therapies, and our researchers consistently lead the nation in NIH funding. The School’s doctor of pharmacy (PharmD) degree program, with its unique emphasis on scientific thinking, prepares students to be critical thinkers and leaders in their field.