Out From Behind the Bench: Quick and Effective OTC Counseling

One of a pharmacist's greatest responsibilities is helping patients understand ways to treat themselves. Most of the time, patients initiate conversation with pharmacists. An increasing number of pharmacists, however, are now greeting patients in the pharmacy and initiating an assessment of the patient's self-care concerns and drug-related needs.

Pharmacists can increase self-care and nonprescription counseling by taking the following steps: acquire a full working knowledge of OTC drugs; gather information from patients through the interview process; analyze information by considering all product- related and patient-related factors; and counsel patients about problems presented.

Previous articles have addressed barriers to OTC counseling. Once those barriers are recognized, pharmacists can more effectively communicate with patients. Pharmacy school teaches us to ask open-ended questions when counseling patients about prescription medications, because doing so allows us to gather the greatest amount of information. These questions usually start with the words who, what, how, why, or where. Close-ended questions, which start with the words will, can, do, or did, are to be used only if the open-ended questions do not get the response the pharmacist is trying to elicit, and are not as effective because they can be usually be answered with a simple "yes" or "no." The Indian Health Services method uses the "Three Prime Questions" (Table 1) for all new prescriptions.

Counseling patients about self-care and nonprescription drugs cannot follow the same format as for prescription drugs. This counseling requires much more detail and probing questions on the part of the pharmacist. When counseling patients about self-treatment, it is necessary to find a balance between open- and close-ended questions. Close-ended questions are useful to clarify information gathered through open-ended questions.

A process developed by the American Pharmacists Association (APhA) to help community pharmacists to counsel patients about nonprescription medications is the QuEST communication process. The QuEST process helps the pharmacist to Quickly and accurately assess the patient, Establish that the patient is an appropriate self-care candidate, Suggest appropriate selfcare strategies to the patient, and Talk with the patient about those strategies (Table 2).

This systematic process helps the pharmacist elicit information from patients and make decisions and recommendations about self-treatment. The first step is to make a quick assessment of the patient's current problem, medications, and coexisting conditions or disease states. This assessment should not be an exhaustive history; we do not have time for that in community practice. Establishing a 1- to 2- minute limit is helpful. In order to do this, APhA offers another mnemonic device, SCHOLAR (Table 3), to help you recall the types of questions you should ask to assess the patient's current complaint.

You may not need to ask the patient about every element outlined. This is where your clinical judgment should guide the situation. The "S" in SCHOLAR stands for Symptoms. So, the pharmacist should find out what is bothering the patient and then assess the "C," or Characteristics, of the problem. The "O" stands for Onset, or when the patient started experiencing the problem. The "L" stands for Location of the problem, and the "A" stands for factors that may Aggravate or make the problem worse. Finally, the "R" stands for Remitting factors that might alleviate the problem.

The last 2 parts of the assessment process deal with current medications and coexisting conditions. The pharmacist should ask patients specifically about the nonprescription medications, herbal products, and supplements they are taking. See Table 4 for examples of questions to ask the patient regarding current medications and coexisting conditions. It is important to assess whether the patient has any underlying conditions, so as to avoid any drug-disease interactions.

The next part of the QuEST process is to establish that the patient is an appropriate self-care candidate. The information that you gathered during the assessment step helps you determine this. Patients who are not appropriate self-care candidates will need to be referred to a physician. Generally, patients should be referred if the symptoms are severe, if the symptoms have persisted beyond the usual treatment window, or if the pharmacist suspects that the patient is self-treating to avoid formal medical care.

The next part of the QuEST process is to suggest or select appropriate selfcare strategies to the patient. The pharmacist should help the patient select the medication with the suitable dosing regimen. The treatment regimen can extend beyond medication use. It can also include alternative therapies and general care measures such as getting rest or drinking more fluids. In some cases, no medications will be indicated, but general care measures will be indicated.

The last step of the QuEST process is talking with the patient. Important information about self-treatment should be explained to the patient during this step. You should explain what the medications or other therapies are, how they will help the patient, and what the patient should do as followup. Clearly explain how, and for how long, to take the medication. It will also be necessary to describe common adverse effects and how to manage them. When speaking with the patient, it is also important to tell him or her what to expect from treatment. In other words, explain how the patient can benefit from the treatment you are recommending. Finally, discuss what the patient needs to know about follow-up. It is important for patients to know how to recognize when their condition might be worsening and when they should seek a physician's advice.

Throughout the counseling process with the patient, the pharmacist should be formulating a clinical decision- making hypothesis, based on identifying actual or potential drug-therapy problems. This QuEST process will help you remember the steps in this process.

Dr. Ferreri is a clinical assistant professor at the University of South Carolina School of Pharmacy.