Proactive practice

Proactive: adjective. Of a person, action, policy, etc.: creating or controlling a situation by taking the initiative and anticipating events or problems, rather than just reacting to them after they have occurred; (hence, more generally) innovative, tending to make things happen.¹

Case: Mr. XY arrives to pick up his first refill of metformin 500 mg twice daily. The pharmacist notes that he is on time for the refill, then asks the patient, “How’s it going?” When Mr. XY replies “OK, thanks,” the pharmacist processes the refill.

Pharmacy has evolved to be transactional. Patient arrives with a prescription. Prescription is filled. Counselling on medication use and adverse effects given. End of transaction. This works reasonably well for distribution of medications, but modern pharmacy practice is meant to be much more than that.

Back to our case: The pharmacist processed the request from the patient—nothing wrong was done. But what was missing is: Was this the correct dose of metformin? Has the patient had any side effects? What is the A1c? Since the patient has diabetes, has diet been addressed? What about his blood pressure? Cholesterol? This is the kind of holistic care that patients like Mr. XY need but don’t necessarily know to ask for. He is dependent on his pharmacist to take the initiative.

Our problem is that pharmacists can be passive providers. We tend to wait for someone to ask for something, rather than being proactive to determine their health needs. I’m not saying that pharmacists are idly twiddling their thumbs, but many health problems are not very amenable to such a passive approach. For example,

• Hypertension: As a largely asymptomatic disease, many people do not know they have it, and even if they do, they do not know whether it is controlled. They will not know to ask you for help.

• Dyslipidemia: Ditto

• Diabetes: Ditto

• Asthma: Many patients have poor control. They might accept their symptoms as “the disease.” Alternatively, a large proportion (about half) of patients labeled as having asthma do not.²

• Chronic obstructive pulmonary disease: Ditto

• Arthritis: Many patients are poorly managed. Patients with rheumatoid arthritis may not receive a disease-modifying agent. In addition, all arthritis patients are at high cardiovascular risk, which is usually ignored as well.

• Vaccination: While many patients will ask for an influenza vaccination, what about your patient with diabetes who does not know to ask for a shingles or pneumococcal vaccine?

• Opioids: Many patients do not know about take-home naloxone kits or do not realize that they are at risk for opioid-induced respiratory depression. The stigma of opioid use may also prevent them from asking.

• Depression: Patients may not recognize their symptoms as depression. Again, stigma is a barrier to them asking for help.

• Deprescribing: While some patients might ask to reduce their medication burden, most will not know that some of their medications are unnecessary.

You see the pattern here: patients may not recognize the problem or may be afraid to ask. A passive, transactional approach in which we act only if asked to misses many patients’ problems. And that is incomplete patient care. Being passive holds us back—we cannot achieve our potential and our patients miss out.

A proactive practice model uses case finding³ and systematic assessment approaches to determine patients’ needs. Some workflow models actually put the pharmacist out front to assess patients at the beginning of the visit (watch this journal for an upcoming report on that). To stay relevant, meet our duty of care and combat Amazonization, this is the direction that pharmacy practice must take. ■