When counseling goes awry?

[GreyFox2002]

Anyone here ever experience a situation where you counseled a patient on a medication and warned on a particular side effect, only to have it blow up in your face?

A couple weeks ago I had a patient's parent come in to fill a prescription for Tamiflu. I'm a go-getter and idealistic, so I like to counsel. I informed the patient how the drug can reduce flu symptom duration by around 24 hours or so. Told them the most common side effects we're nausea/vomiting. Then told him in very rare instances there have been reports of "mental status changes" in adolescents, so just watch the child during therapy and report anything unusual or different to the doctor.

I get a call 2 hours later from her frantic mother, demanding to speak to the person who told her this. I told her it was me. She then tells me that I told her that the drug can "make people crazy" and that she spoke with the doctor who told her I had no idea what I was talking about. After trying to calm her down for 5 minutes, I tell her that A: I did not tell her that Tamiflu will make her kid crazy, and B: She's more then welcome to pick up the information regarding the adverse effect from me anytime if she'd like.

It's so frustrating to actually try to do your job and do what's best for the patient and get thrown under the bus by a prescriber who wasn't fully aware of the effects of the drug (or didn't want to tell the patient). I worded my words carefully to try not to scare the patient but it didn't work anyways. It's also really unprofessional of the physician to tell the patient I was clueless.

What would you do in this situation? I feel it's the duty/responsibility of the pharmacist to warn a patient on potential severe adverse effects of new scripts their getting (angioedema with ACEIs, hypertensive crisis with clonidine cessation, suicidal thoughts with SSRIs, tendinitis with quinolones, for example). The information is available for them anyways, so why let them know what to watch out for so they can respond? I'm not going to go through every adverse effect with the patient, just the most common or important ones. I'd like the advice of individuals from the Medical side of the forums to respond as well.

Also, I know most cases of oseltamivir-induced psychosis has been reported from Japan, but this is likely due to increased utilization of the drug in that population. It has been reported elsewhere.

---

Members don't see this ad.

 

[All4MyDaughter]

I don't think I would have told the patient's parent about mental status changes b/c it's very rare and just from case reports. Additionally, it's not known whether the drug actually caused the reported events b/c influenza itself could also have been the cause...

I had to clean up a situation the other day when a patient came back to our pulmonary clinic furious and refusing to take his isoniazid b/c the pharmacist told him he could not eat cheese or fish during the duration of his therapy, which will be 9 months long. Now that counseling point has SOME basis in reality b/c isoniazid inhibits tyramine metabolism to a degree so patients can get some flushing with certain cheeses and patients can have allergic-type reactions to fish with high histamine content. But it's rare and it's from case reports. Our attending was furious and I agreed it was handled badly.

I generally do not tell patients about the "zebras" but focus on the most common adverse effects. Others may have different approaches.

 

[PharmDstudent]

I think counseling about Coumadin is the worst, since everything interacts with it.

 

[GreyFox2002]

I don't think I would have told the patient's parent about mental status changes b/c it's very rare and just from case reports. Additionally, it's not known whether the drug actually caused the reported events b/c influenza itself could also have been the cause...

I had to clean up a situation the other day when a patient came back to our pulmonary clinic furious and refusing to take his isoniazid b/c the pharmacist told him he could not eat cheese or fish during the duration of his therapy, which will be 9 months long. Now that counseling point has SOME basis in reality b/c isoniazid inhibits tyramine metabolism to a degree so patients can get some flushing with certain cheeses and patients can have allergic-type reactions to fish with high histamine content. But it's rare and it's from case reports. Our attending was furious and I agreed it was handled badly.

I generally do not tell patients about the "zebras" but focus on the most common adverse effects. Others may have different approaches.

I can see your point, but the situation you used is a little different. For one thing, isoniazid inhibition of tyramine metabolism is no where near as significant as a MAO-I, so telling a patient that they need to avoid all tyramine-containing foods for 9 months sounds ridiculous.

That being said, there is evidence supporting that Tamiflu can cause psychosis in adolescents. The FDA knowledges that post-marketing data exists supporting this adverse effect, and is currently investigating it further. This I feel is significant, as its potentially a very severe adverse effect. I'm not telling the patients their kid is going to go nuts, I'm telling them to just keep an eye out for any changes in behavior, and also reassuring them that is very rare but it's good to be aware of. On the flip side, if the child takes Tamiflu and does experience a psychotic episode while on it, is the pharmacist at fault for not telling them?

 

[naus]

"Very rare" is kind of imprecise. Would you tell the mother that she has a "very rare" chance of dying in a car accident on her way home from the pharmacy?

 

[All4MyDaughter]

I can see your point, but the situation you used is a little different. For one thing, isoniazid inhibition of tyramine metabolism is no where near as significant as a MAO-I, so telling a patient that they need to avoid all tyramine-containing foods for 9 months sounds ridiculous.

That being said, there is evidence supporting that Tamiflu can cause psychosis in adolescents. The FDA knowledges that post-marketing data exists supporting this adverse effect, and is currently investigating it further. This I feel is significant, as its potentially a very severe adverse effect. I'm not telling the patients their kid is going to go nuts, I'm telling them to just keep an eye out for any changes in behavior, and also reassuring them that is very rare but it's good to be aware of. On the flip side, if the child takes Tamiflu and does experience a psychotic episode while on it, is the pharmacist at fault for not telling them?

I can't find any statistics on the incidence of Tamiflu induced behaviorial changes, but it's based on case reports, similar to the reports about isoniazid and cheese/fish. I'm sticking with "very rare" and in the case of Tamiflu there is unclear causation.

Whether these rare adverse events occur is independent of whether the prescriber or pharmacist tells the patient about them. I'm not sure that there is any benefit to scaring patients with excess information about things that MIGHT happen but are statistically unlikely. Particularly when doing so might disrupt therapy.

You have to consider risk vs. benefit. It's not likely that the child is going to have a psychiatric reaction to Tamiflu and if he or she does, the parent will notice anyway and get appropriate treatment. But if the parent is frightened and decides not to give the child Tamiflu serious consequences could result. We *think* Tamiflu might cause psych reactions. We *know* influenza can be fatal in children.

 

[GreyFox2002]

We know that atherosclerotic disease can be fatal, that's for sure. We also that statin-induced rhabdomyolysis or hepatotoxicity can be severe and fatal as well. So when a patient gets started on a statin after being diagnosed with unstable angina and you tell them the benefits of the medication, are you not going to explain the potential side effects?

Counseling goes both ways. 1. Explain the benefits of the med. I didn't mention this in my post but I did say that Tamiflu can reduce symptom severity as well as the duration of illness. 2. Explain potential consequences and what to watch out for so you can report it to the physician.

I'll admit that no it's not clear why psychosis occurs with Tamiflu, and there isn't any hard data. It's out there thought....I don't think I used the worst judgement.

 

[naus]

I'll admit that no it's not clear why psychosis occurs with Tamiflu, and there isn't any hard data. It's out there thought....I don't think I used the worst judgement.

According to your logic, you'll tell the mother that vaccinating her baby might lead to a "very rare" risk of developing autism. "It's out there" too. Case studies are not rigorous, they're anecdotal.

And it's judgment.

 

[rxlea]

Sounds like an issue with "health literacy". You have to know not only WHAT to convey but HOW to convey it.... you say "changes in mental status", she interprets "kid is going to go crazy". I remember when I worked retail in the ghetto, I had to be very careful about what I said to patients because they didn't always know what I was talking about, especially when I was translating in Spanish between patient/pharmacist.

 

[Old Timer]

I don't know that I would counsel on that based on the information we currently have. There is NO proof that Tamiflu causes this effect. Almost ALL cases that have been reported have come from Japan. Japan is the largest consumer of Tamiflu in the world. There are many possible reasons:

• The Japanese use more Tamiflu than us, in fact more than anybody else.
• The Japanese may metabolize Tamiflu differently.
• The particular strain of virus may play a role.

In other words the number of reported cases in the US is minuscule and I would review the common side effects and refer the parent to the PI that comes with the drug for a comprehensive list of side effects....

As to your question, what to do when something goes wrong. Apologize for frightening them. Explain the effect is rare, but you wanted to inform them so they would know what to look for if their child exhibited these effects. Reiterate again your sorrow for alarming them, but you would rather err on the side of caution and give them extra information.

 

[LiveLoveFartRepeat]

One word you'll never, ever hear me use again in my life when counselling is " antipsychotic"

I was a brand new grad, proud of my counselling skills; when I counselled a patient pick up a new rx for Zyprexa. I opened the conversation by stating that "Zyprexa is an antipsychotic med...." She went balistic!! started yelling that I was saying that she was crazy, that her doctor told her this was a sleeping pill to help her sleep better at night. A private counselling session became a spectacle at my counter. I was speechless for few seconds and then I told yer that yes Zyprexa will calm her mind at night and help her sleep better and I called it quit...Boy, I'll never forget that.

last week a patient called and asked what his new rx of seroquel we had ready was for? eheheh ,my new official answer is " this medication will help calm your mind" I learned my lesson.

 

[genesis09]

You have to be very gentle with counseling for the anti-psychotics. So many kids are on risperidone/abilify, and the parents have no idea of all the side effects associated with it.

We have to attach the drug guides to certain medications. I once got a freak out call from someone with a rx for Avelox. Apparently, they actually read it and got worried about the tendonitis/ruptured tendons. I tried to tell them it was very rare, but he did not listen.

 

[MountainPharmD]

Anyone here ever experience a situation where you counseled a patient on a medication and warned on a particular side effect, only to have it blow up in your face?

A couple weeks ago I had a patient's parent come in to fill a prescription for Tamiflu. I'm a go-getter and idealistic, so I like to counsel. I informed the patient how the drug can reduce flu symptom duration by around 24 hours or so. Told them the most common side effects we're nausea/vomiting. Then told him in very rare instances there have been reports of "mental status changes" in adolescents, so just watch the child during therapy and report anything unusual or different to the doctor.

I get a call 2 hours later from her frantic mother, demanding to speak to the person who told her this. I told her it was me. She then tells me that I told her that the drug can "make people crazy" and that she spoke with the doctor who told her I had no idea what I was talking about. After trying to calm her down for 5 minutes, I tell her that A: I did not tell her that Tamiflu will make her kid crazy, and B: She's more then welcome to pick up the information regarding the adverse effect from me anytime if she'd like.

It's so frustrating to actually try to do your job and do what's best for the patient and get thrown under the bus by a prescriber who wasn't fully aware of the effects of the drug (or didn't want to tell the patient). I worded my words carefully to try not to scare the patient but it didn't work anyways. It's also really unprofessional of the physician to tell the patient I was clueless.

What would you do in this situation? I feel it's the duty/responsibility of the pharmacist to warn a patient on potential severe adverse effects of new scripts their getting (angioedema with ACEIs, hypertensive crisis with clonidine cessation, suicidal thoughts with SSRIs, tendinitis with quinolones, for example). The information is available for them anyways, so why let them know what to watch out for so they can respond? I'm not going to go through every adverse effect with the patient, just the most common or important ones. I'd like the advice of individuals from the Medical side of the forums to respond as well.

Also, I know most cases of oseltamivir-induced psychosis has been reported from Japan, but this is likely due to increased utilization of the drug in that population. It has been reported elsewhere.

That is what we call TMI or to much information. Counseling is supposed to get the basic information across to the patient. It is not meant to be an all incompassing cover every side effect session.

 

[MountainPharmD]

One word you'll never, ever hear me use again in my life when counselling is " antipsychotic"

I was a brand new grad, proud of my counselling skills; when I counselled a patient pick up a new rx for Zyprexa. I opened the conversation by stating that "Zyprexa is an antipsychotic med...." She went balistic!! started yelling that I was saying that she was crazy, that her doctor told her this was a sleeping pill to help her sleep better at night. A private counselling session became a spectacle at my counter. I was speechless for few seconds and then I told yer that yes Zyprexa will calm her mind at night and help her sleep better and I called it quit...Boy, I'll never forget that.

last week a patient called and asked what his new rx of seroquel we had ready was for? eheheh ,my new official answer is " this medication will help calm your mind" I learned my lesson.

I think we have all learned that lesson the hard way! When it comes to antidepressants and antipsycotics I always start the conversation off with "Why did your Doctor prescribe this medication?".

 

[MountainPharmD]

You have to be very gentle with counseling for the anti-psychotics. So many kids are on risperidone/abilify, and the parents have no idea of all the side effects associated with it.

We have to attach the drug guides to certain medications. I once got a freak out call from someone with a rx for Avelox. Apparently, they actually read it and got worried about the tendonitis/ruptured tendons. I tried to tell them it was very rare, but he did not listen.

I think if you do some reading it is not as rare as the manufacturer would like us to believe.

 

[All4MyDaughter]

That is what we call TMI or to much information. Counseling is supposed to get the basic information across to the patient. It is not meant to be an all incompassing cover every side effect session.

Part of the problem is how counseling is being taught in schools today. The counseling "check off" sheets have WAY too many items on them. You just cannot get all of that info across to the patient in the real world. It's not possible. Patients would get bored and leave and the pharmacist would never get any other work done.

I usually just tell the patient most important one or two things. Like if they are getting Augmentin I tell them to take it with food because it can be hard on the stomach and to make sure they finish all of it. Then I ask if they have any questions and call it good.

 

[All4MyDaughter]

One word you'll never, ever hear me use again in my life when counselling is " antipsychotic"

I was a brand new grad, proud of my counselling skills; when I counselled a patient pick up a new rx for Zyprexa. I opened the conversation by stating that "Zyprexa is an antipsychotic med...." She went balistic!! started yelling that I was saying that she was crazy, that her doctor told her this was a sleeping pill to help her sleep better at night. A private counselling session became a spectacle at my counter. I was speechless for few seconds and then I told yer that yes Zyprexa will calm her mind at night and help her sleep better and I called it quit...Boy, I'll never forget that.

last week a patient called and asked what his new rx of seroquel we had ready was for? eheheh ,my new official answer is " this medication will help calm your mind" I learned my lesson.

Sometimes Seroquel is prescribed as a sleep aid. This is questionably appropriate, but it happens. The patient may not even have a psych diagnosis.

If a patient asks me what a psych med is for I usually ask what they've seen the doctor for and then approach with caution. I might say "It's for your mood" or "this is for your nerves" or something similar.

A tough one is gabapentin b/c it can be used for so many things. If the patient doesn't know what they are getting it for, it may be impossible for the pharmacist to figure it out by talking to the patient. I usually say, "It can be used for mood, or for pain, or for seizures or other things. Without knowing exactly what's going on with you, I can't be sure why your doctor has prescribed it." Then I offer to check with the doctor or give them the doctor's number so they can call themselves. Usually works.

 

[rxlea]

1. What did the doctor tell you this medication was for?
2. How did the doctor tell you to take it?
3. What did the doctor tell you to expect?

Let them answer, then fill in the blanks for the most important stuff.....like appropriate directions if they didn't already know (like shaking augmentin, for example). Or, if there is a discrepancy between what they tell you and what the doctor prescribed it for (or there is some issue), then investigate it.

At least that is how they are teaching us.

 

[owlegrad]

1. What did the doctor tell you this medication was for?
2. How did the doctor tell you to take it?
3. What did the doctor tell you to expect?

Let them answer, then fill in the blanks for the most important stuff.....like appropriate directions if they didn't already know (like shaking augmentin, for example). Or, if there is a discrepancy between what they tell you and what the doctor prescribed it for (or there is some issue), then investigate it.

At least that is how they are teaching us.

You are talking about the liquid preparation aren't you? I didn't remember the liquid dosage form at first. I was racking my brain trying to figure out why you would council to shake augmentin tablets.

 

[PharmDstudent]

And be sure to ask them their name, as stupid as that sounds. It will save your butt if the ER or a large clinic gives your patient someone else's prescription.

 

[Sparda29]

Twice:

Once it was on Ibuprofen 800 mg, and I was mentioning risk of GI disturbances and risk of ulceration/perforation. Patient went, wtf I don't want this.

Another time, the patient asked me what class of medication he was getting. I told him it was an anti-depressant, and he got insulted because he was taking it for sleep disorder.

 

[All4MyDaughter]

1. What did the doctor tell you this medication was for?
2. How did the doctor tell you to take it?
3. What did the doctor tell you to expect?

Let them answer, then fill in the blanks for the most important stuff.....like appropriate directions if they didn't already know (like shaking augmentin, for example). Or, if there is a discrepancy between what they tell you and what the doctor prescribed it for (or there is some issue), then investigate it.

At least that is how they are teaching us.

That's pretty much the way I've been taught too, although we add a final component where we ask the patient to repeat everything back to us to assess their understanding. IMO it doesn't translate well to the real world. Our standardized patient counseling exercises and evaluations are 10 minutes long! In reality, you have about 30 seconds with most patients, assuming they even want counseling. I've even seen patients get mad at the "open ended question" model b/c they feel like they are being grilled. On the few occasions I've had patients who actually wanted and needed in depth counseling, it's worked better for me to give the patient they information they needed, both verbally and by highlighting the pertinent stuff from the printed drug information sheet and then letting them ask questions.

 

[rph3664]

You have to be very gentle with counseling for the anti-psychotics. So many kids are on risperidone/abilify, and the parents have no idea of all the side effects associated with it.

We have to attach the drug guides to certain medications. I once got a freak out call from someone with a rx for Avelox. Apparently, they actually read it and got worried about the tendonitis/ruptured tendons. I tried to tell them it was very rare, but he did not listen.

My dad refused to take a 5-day course of prednisone because the information sheet said it could cause osteoporosis and diabetes! I told him that if he was on it for 5 YEARS, it could do this, but 5 days? C'mon, just take those little white pills.

 

[rxlea]

That's pretty much the way I've been taught too, although we add a final component where we ask the patient to repeat everything back to us to assess their understanding. IMO it doesn't translate well to the real world. Our standardized patient counseling exercises and evaluations are 10 minutes long! In reality, you have about 30 seconds with most patients, assuming they even want counseling. I've even seen patients get mad at the "open ended question" model b/c they feel like they are being grilled. On the few occasions I've had patients who actually wanted and needed in depth counseling, it's worked better for me to give the patient they information they needed, both verbally and by highlighting the pertinent stuff from the printed drug information sheet and then letting them ask questions.

We are supposed to do it in a few minutes. If it's a refill, 1 minute unless they have questions. Some of my classmates said they used it and patients were receptive. We aren't supposed to take a long time unless we are taking a chief complaint, too.. Or doing medication history. But for new script/refill, they want it to be quick while meeting the "individual needs of the patient". For example, if a patient comes in who has like 5 children and already knows the drill for the amoxicillin or whatever, 30 seconds tops. The repeating back thing was sorta silly at first but I think I might try it when I go on my IPPE this summer. We will see how it goes.

 

[ucrx]

1. What did the doctor tell you this medication was for?
2. How did the doctor tell you to take it?
3. What did the doctor tell you to expect?

Let them answer, then fill in the blanks for the most important stuff.....like appropriate directions if they didn't already know (like shaking augmentin, for example). Or, if there is a discrepancy between what they tell you and what the doctor prescribed it for (or there is some issue), then investigate it.

At least that is how they are teaching us.

Do they require reflective responses also? "It seems like you're upset..." I always felt ridiculous during our counseling sessions. Our professor would use it in normal conversations and lectures and it always felt slightly insulting.

We also had to have our counseling sessions last no longer than 5 minutes, but had to get all of the little points in (with the repeat back at the end).

 

[rxlea]

Yeah but reflective responses do really work... And not just in pharmacy.

 

[Ackj]

Reflective stuff works great, I use it all the time (including outside of the pharmacy). The 3 Indian Health System probing questions are pretty good, until you get the "I dunno, you tell me" patient. The teach-back method is embarrassing, insulting, and an awful idea.

 

[crazybob]

Twice:

Once it was on Ibuprofen 800 mg, and I was mentioning risk of GI disturbances and risk of ulceration/perforation. Patient went, wtf I don't want this.

Another time, the patient asked me what class of medication he was getting. I told him it was an anti-depressant, and he got insulted because he was taking it for sleep disorder.

Did you say what it could be used for after you told him it was an anti-depressant?

 

[Sparda29]

Did you say what it could be used for after you told him it was an anti-depressant?

I was going to but he interrupted me right after I said the word anti-depressant.

 

[npage148]

Am I the only one that gets attacked when I ask why the doctor gave you the medicine for. I typically get 2 response, "what, you don't know what this is for, what kind of pharmacist are you?" and "I don't know, they didn't tell me" SO now i just take my chances and tell them it's an antipsychotic etc and clean up the pieces after the occasional flip-out

 

[rxlea]

You need to consider cultural factors, too.

 

[PharmDstudent]

Am I the only one that gets attacked when I ask why the doctor gave you the medicine for. I typically get 2 response, "what, you don't know what this is for, what kind of pharmacist are you?" and "I don't know, they didn't tell me" SO now i just take my chances and tell them it's an antipsychotic etc and clean up the pieces after the occasional flip-out

I always ask, "What did they diagnose you with? Or what was your diagnosis?", which usually follows with: "Yes. It can be used for that."

 

[eeyore spice]

So what I'm hearing in this thread is that 99% of patients are histrionic idiots and retail is for suckers.



*goes back to compiling my regulatory binder*

 

[PharmDstudent]

So what I'm hearing in this thread is that 99% of patients are histrionic idiots and retail is for suckers.



*goes back to compiling my regulatory binder*

Retail is for anyone who wants to practice pharmacy. Don't knock it until you try it! The problem is that academia is out of touch.

You see, I never, EVER give the drug class unless it's an antibiotic. For some reason, unbeknownst to me, people know what that drug class is. They have no idea what a potassium sparing diuretic is, an H2 antagonist, etc.

 

[crazybob]

Retail is for anyone who wants to practice pharmacy. Don't knock it until you try it! The problem is that academia is out of touch.

You see, I never, EVER give the drug class unless it's an antibiotic. For some reason, unbeknownst to me, people know what that drug class is. They have no idea what a potassium sparing diuretic is, an H2 antagonist, etc.

When you said "drug class" I thought you meant you tell them it's a quinolone or a 3rd gen cephalosporin

 

[PharmDstudent]

When you said "drug class" I thought you meant you tell them it's a quinolone or a 3rd gen cephalosporin

ROFL! Right. I should say "drug category". To the public, antibiotics are either penicillin or not penicillin. Lol

 

[spacecowgirl]

I always ask, "What did they diagnose you with? Or what was your diagnosis?", which usually follows with: "Yes. It can be used for that."

That's what I do as well. We have all had those situations and despite our best intentions will continue to have some along the way. What I worry about is someone taking what I say, hearing something totally different and repeating it to their doctor about why they won't take XYZ because the pharmacist said it could make their liver fall out.

 

[ucrx]

Yeah but reflective responses do really work... And not just in pharmacy.

I guess the problem was how many times they wanted us to use them and how obvious we had to make it sound to get credit. I get that they could be helpful if done properly, I just don't think our 5 minute lecture on them taught us how. And I don't think our professor knew how to use them either, considering how insulting it felt when he used them in conversations.

 

[All4MyDaughter]

I guess the problem was how many times they wanted us to use them and how obvious we had to make it sound to get credit. I get that they could be helpful if done properly, I just don't think our 5 minute lecture on them taught us how. And I don't think our professor knew how to use them either, considering how insulting it felt when he used them in conversations.

With the patient population I am accustomed to, using reflective responses might get you told to "**** Off."

I also agree that they can come off very patronizing and condescending. I rarely use them, and I think I'm pretty good at dealing with people and defusing conflict.

 

[gambit78]

Thanks for everyone's insight. I recall doing a lab in school about counseling and we did address "if we covered everything in the patient will get scared and not take it." When I did my rotations, it was sufficient to keep it succinct and then tell them to look over the med info sheet.