Health Literacy and Increasing Patient's Decision Making

Health literacy has been a buzz word in health care for several years now. It is an obvious idea when one thinks about it, but may not be overly apparent. Often we take our intrinsic knowledge for granted, and do not consider that a patient may not have basic reading skills yet alone basic science knowledge.

Because of this in class we talk about open ended questions, talk-back guidelines and reading level of materials. All very valid points, but they all underline a common theme. There is way too much unfiltered information out there for patients now.

Think about it, with the internet and sites like Google, the average patient has ready access to nearly the same medical material that health professionals have. This post does not even consider the large amount of misinformation present. I'm more concerned with the sheer amount of correct and pertinent information related to a patient's health.

Think about it, what if you had immediate access to, say, the building plans of your workplace.  The next day you come in and talk to the owner telling them you think this wall should be moved back another five feet or so to give us more room. In looking at the plans, you say it doesn't appear to be doing anything other than partitioning the floor space.

You know what would happen? The owner would laugh his ass off and walk away as you unknowingly want to move a load bearing structure.

Yet this is what we are forced to deal with in health care each day. Patients log on to WebMD or watch Dr. Phil, are presented with information that they do not have the neccessary background to fully understand. They then take this information, come to us and decide to make decisions about their health care without considering our own expertise.

At best it is ludicrous. At worst it is deadly.

I know, I know, you are all screaming. "But a patient has a right to know this information and participate in the management of their health!" And this is true... to a point.

Consider when the negative press about Avandia came to light. One particular patient of ours immediately stopped taking to the medication due to fear of "heart problems." Never mind the fact that the liklihood of this problem was not all that great, we cry wolf far too much in protocols now but that's another discussion, she did not want to die from a heart attack.

The pharmacist looked her straight in the eye and said, "Well you can possibly die from a heart attack or for sure die from diabetes. Your call."

Good for him.

As much as we do not wish to think of our profession in this way, pharmacy is really the management of poisons for positive health purposes. There are side effect whether we like them or not almost solely for this reason.

Many people simply do not understand this part. Life is full of risks, you speed on the freeway to make an appointment or start smoking to look cool with your friends. But when a drug can benefit a patient, but they don't want to take it due to a minor chance of a severe reaction that's okay?


Solutions to this problem can be insanely simple. For instance, when we hand out drug monographs, or when they are posted online, side effects are often listed under categories like 'common' or 'severe'. Dizziness is often listed in the same breath as heart palpitations... but does that mean that the probablity of both are equal? Actually, how often do these side effects occur?

As pharmacists, we know these answers. Patients do not.

So why not add odds of occurrences to all side effect listing? Or perhaps list them in the order of occurrence? I'm sure a few more patients will panic by seeing the exact numbers, but I'm sure many more will have their minds put at ease when they see how rare these 'common' side effects are.

A simple change like that mitigates one of the problems with health literacy and compliance. We have made information a little more digestible and give them a stronger base to make a decision about their health.

We talk about white space and reading level, but not how to relate the information to patients. Honestly, that should be the primary goal of health literacy. It doesn't matter if the material is at a fifth grade level if there is no way for the patient to relate the information in order to make a decision.

And that's ultimately what this is all about, making sure the patient is properly informed so they can make decisions about them selves. We cannot rid the world of WebMD or Oprah, as much as we may want to try, but we can certainly organize the information we give out in a better manner.

Seems simple enough, right?

The 'Nevers'

Fewer singular words are more difficult to comprehend than the word never. We live our daily lives looking towards the future and under the assumption that we can do whatever we set our minds to.

There is no 'never' in this mindset.

We teach our children that they can grow up to be a world famous scientist or the president or a star football player. As we enter young adulthood, we are told we can be the next great business person or a well respected health professional.

There's always more in life to attain and time appears to be limitless.

But the truth is, the older you get the more 'nevers' become apparent.

For instance, I will never be an astronaut. Surely this was a fantasy in the most literal sense, but I am now officially beyond the most basic requirements. Even if I were to set every ounce of energy towards attaining this goal, I can no longer attain it.

As the number of 'nevers' increases over the years some choose to ignore them while others choose to embrace them.

Namely because when you start thinking about the 'nevers' a wave of sadness floods over one's self. We do not like the term because never is ultimately connected with one of our most feared words... death.

For instance, I will never talk to my good friend again. Never again will we meet up yearly in my hometown for a local event, drink beers on the deck of my home and laugh at those who doubted us in high school. It's a difficult and bitter pill to swallow, and it is intrinsically laced with the word 'never.

I will never recapture the sheer amount of unbridled fun of the first year in college. There were minimal stresses in life and when all of your friends live on the same wing of your dorm you ultimately form daily unforgettable experiences. Today, we're lucky if we can all gather but one time a year.

Not all 'nevers' are negative in nature.

Never again will I not know what it's like to be a father. Who knew someone so small could brighten even the darkest days?

Never again will I have to worried about being loved in the last few years I have found more people who care for me than in all previous years combined. For someone who has found the deepest of depths of despair, it is reassuring to know this fact.

These are 'nevers' that I can live with. And they make the less enjoyable 'nevers' a bit more barable.

So on days like today, remember what we may never be able to change the past. We may never be able to change how we feel. We may never be able to get over our own personal pain.

But that's okay. It makes us stronger, more resilient and ultimately a better person.

And in the end, that is what truly matters.

No iPhone For You!

"I was wondering if you could possibly spot me enough of my meds for a week cause I won't have the money for my co-pays until I get paid next week."

An innocuous question, no?

I'm sure most of you are thinking that it is a completely unreasonable request and, as pharmacists, we should see no issue with heeding her request.

Which would be true... unless you had a bit more information.

First, the total amount on her seven medication was $1. I'm pretty sure there is enough change in my couch to total a buck.

Second, she asked this while her blinged-out iPhone 4 sat on our counter. A quick glance at said phone showed numerous pages of apps and, from what I could see on the page showing, numerous paid apps.

Knowing this, does your answer change?

Apparently this person, and many others, can fork over money for a pointless app which makes a farting nose for their phone, but they don't have the dollar for the medications which help keep them alive?

Does anyone else see the issue with this?

Look, I know what it's like not to have money, I live with it every day. I put off buying new shoes for over year until I could not glue or tape them anymore. Why? Because we needed that money for bills, diapers and other necessities.

It was not absolutely required to live, so I did not purchase it. Being able to provide basic needs should supersede any other frivolous spending at all times.

I don't care if someone splurges on themselves every once in a while and, in fact, it can be a good thing. But when you do so at the expense of your basic needs which may harm you, or others, what the hell is the point?

The better question is how we can let low-income individuals, whom for various reasons the public is supporting, be allowed to sign expensive phone contracts or fill said phones of paid apps? How is that fiscally responsible? They can't pay more than a dollar for their medications, but they can pay over $100/month for their iPhone.

Too often in today we rely on others to fix our own problems. We "pass the buck" far far too often and do not take responsibility for our actions.

And it's sad to see.

Ultimately the pharmacist decided not to spot her any of her medications partially for the reasons I mentioned and partially because this is a regular occurrence with said patient. There is only so much charity and hand holding we can do before the patient needs to stand up for themselves.

Cruel? Perhaps. Unprofessional? Maybe. Except for when she came back an hour later and paid with a crisp $20 bill.

Funny how that works.

Who Am I?

For various reasons I decided it would be best to take the summer off from using my brain. This is the first thing I have written in over two months and, for the most part, I have remained as distanced from pharmacy as I can be right now.

After the last year, I felt a need to simply relax and spend time with the family. And as I look ahead to second year starting in a little over the week, I find myself asking, "Who Am I?"

One year ago I was overly ambitious, hell bent on changing the pharmacy world upon graduation. I felt as if I was here to right so many of the injustices we all live with every day in the profession.

Then class started... and work become overbearing... and the baby came.... essentially, reality set in. I'm still bitter towards my school and the profession after how the first year panned out. Honestly, I'm not sure if I'll ever get that taste out of my mouth, no matter how much I try.

And if it wasn't for the wife or Lil Man, I doubt I would have survived.

But who I am now? All I want right now is to finish school, have enough money to provide for my family and spend time with them. Whether that's as the director of pharmacy for a large hospital or as simply the RxM at Walgreen's, it truly does not matter to me at the moment.

I would love to be able to find enjoyment in pharmacy again, to find that fire that used to burn so strongly inside of me.

And to find out just precisely who I am now... because I really have no idea.

The Pharmacy School Depression

You slave through several years of undergrad, study for hours and hours for the PCAT and finally earn your pharmacy school acceptance letter. To yourself you think, "I know pharmacy school will be hard, but at last my stress will be reduced because I've finally made it, I'm a pharmacy student!"

Alas this is not the case.

Sure, for the first few weeks of class you ride the wave of accomplishment, taking pride in earning admittance to a school few others enjoy. It's a wonderful feeling and ultimately you feel pretty damn good about yourself.

Only it will not last.

By December that stretch of unbridled joy will seem but a distant memory. Replacing it will be stress-induced insomnia coated with a bitter taste of self doubt.

One of the things that your school will not tell you, nor your friends, is how emotionally and mentally taxing pharmacy school is. If not for the material, than for the expectations of the school or the manner in which courses are taught.

You find yourself sitting next to a dual Ph.D. on one side and on the other sits the wiz kid who powered into pharmacy school riding a 4.0 after two years of undergrad. Suddenly you are no longer a big fish in a small pond... and you come to the realization that there are individuals, perhaps several, in your class who could mentally wipe the floor with you.

The first round of exams come and... they're not what you expect. Maybe you do well, maybe you do not, but you quickly realize these are not the same type of exams from semesters past.

Dozens of hours of studying and sleepless nights may yield a mere sixty percent on an exam. Material you thought you knew like the back of your hand vanishes under the complexity of exam questions.

Doubt sets in.

"Do I belong here?" you begin to wonder. "Did they make a mistake? Maybe I shouldn't do this... maybe I can't do this."

You moods became more variable as your patience wains. It's not common for you to suddenly snap at someone under even mild stress. Self-doubt clouds your mind from exam to exam as you scrape together the will to continue.

At times you do not think it will get any better. Friends speak of struggling during studying and exam taking, yet they proclaim earning an "A" while you quietly mumble about your "C". Socially you distance yourself as you internally chastise your inability to maintain pace with your friends.

You have the Pharmacy School Depression. Mentally you have been broken... perhaps you are merely a shell of who you once where.

The semester draws to a close and you feel as if you are on your last bits of sanity. Suddenly the tough facade that everyone else has erected begins to crumble.

The dual Ph.D. you sat next to? Barely scraping together Cs in a class... and wondering if pharmacy is for him.

The wiz kid? Can memorize the material, yet cannot figure out how to apply it in several courses.

One friend mentions how they almost withdrew from school towards the start of a spring semester. The other mentions that they scored well below you in some exams... only never mentioned it.

You come to realization that you are not alone. No matter what someone's intellectual pedigree may be, no matter how enthusiastic or how cocky someone will be, at some point they will have to face this bout of Pharmacy School Depression.

There is no escaping it. There is no denying it. For some it becomes encompassing and they do drop out. For others it becomes even more serious requiring hospitalization.

Yes, it does happen.

For those who survive, it is almost as big of an accomplishment as being accepted into pharmacy school. And as you walk out of an exam room for the last time, you look back on what this year has brought upon you.

Are you the same person? Are you better off? Or worse off? Can you still do this?

The last question is an easy answer... Yes. For you are not alone, and actually never were alone. We all suffer for with it, but few speak out.

So upcoming first year students, when you are in the greatest depths of self-doubt and despair remember that you are truly not alone.

We've all been there... whether we want to admit it or not.

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