Home' Australian Pharmacist : Australian Pharmacist August 2013 Contents 26 Australian Pharmacist August 2013 I ©Pharmaceutical Society of Australia Ltd.
Ten years on and what have I
By Alan Freedman
I have been accredited to conduct medication reviews for 10 years and have
dutifully retained all documentation of my Home Medicines Reviews (HMR)
for more than seven years. Recently I started shredding some old records and
paused to read some of my early reports.
It is fair to say that my early work was a
relatively rudimentary attempt at advising
doctors on drug use for the management of
their patients. So 10 years on, here are some
reflections, tips and comments.
1. Learn how to 'think like a doctor'
One of the most important skills when
doing this work is learning what information
will be useful to the doctor. To do this you
need to develop an understanding of how
they think. There is no point discussing a
potential drug interaction and suggesting
that one of the drugs be ceased, without
offering alternative options to manage the
A way to gain an insight into the workings
of the general practitioner's (GP's) mind is
to read the publications on offer to them.
We need to know what they need to know.
Publications like the monthly Medicine
Today or the bi-weekly Medical Observer
or Australian Doctor all contain this sort of
2. Approach each medication review
with an open mind
You never know what might emerge in a
medication review. I conducted an RMMR on
a resident who took only one medication: a
vitamin D tablet daily. My first reaction was
whether to even proceed with this service
but after speaking with the nursing staff,
it transpired that this resident was often
refusing this one tablet. My solution was
simply to recommend a once weekly dose
of vitamin D drops which was commenced
with great success. This solution did not
require any great clinical expertise on my
part but nobody else had thought of it.
It is easy to look at a drug regime and
expect few surprises -- keeping an open
mind is essential for uncovering drug
3. Making assumptions is a recipe for
A trap accredited pharmacists sometimes
fall into is making assumptions about a
patient's medical conditions and then
launching into a discussion on medications.
Remember that the doctor will have a much
more detailed knowledge of a patient's
medical history. There may be background
issues, such as relationship tensions and
financial considerations that might impact
on medication use.
What would you think if you saw a diagnosis
of heart failure without the expected ACE
inhibitor, spironolactone and possibly
frusemide? Thinking you have spotted
a gap in treatment, perhaps you would
outline the current treatment guidelines.
But how do you know the patient has
systolic heart failure rather than diastolic?
Many older people have diastolic heart
failure where the treatment protocols are
not as clearly defined and often just involve
Making assumptions is likely to lead you
astray which in turn will devalue the quality
of the report you have written.
4. Take a universal approach to
disease state management
Consider a person with diabetes with a GFR
of 25 mL/min who is on metformin and who
has failed with other oral hypoglycaemics.
To optimise treatment, would you launch
into a discussion on switching to insulin?
This might seem the most appropriate
approach, but what if you knew that
the patient has a long history of poor
compliance and is unlikely to be able to
manage the insulin properly? In such a case,
the doctor might conclude that a once
daily tablet is preferable than attempting to
initiate a whole new management regime.
Doctors always keep the 'big picture' in
mind, and we must do this also.
5. Take advantage of the time spent
with the patient
An advantage we have in the medication
review process is the amount of time there
is to listen to the patient. Doctors typically
have around 10 minutes per consultation
which often limits the quantity and quality
of the information they receive. We have
more time at our disposal to explore issues
in greater depth which can uncover issues
that the doctor is unaware of.
6. Discuss proposals with the patient
Take advantage of the opportunity to have
a full discussion with the patient on an
issue before making a suggestion to the
doctor. For example, a patient has been
taking allopurinol for years without a gout
attack so you suggest that a trial cessation
be considered. However, doing so without
a discussion with the patient is unlikely
to result in the doctor taking your advice.
Doctors know that gout attacks can be
extremely painful and many patients will
not want to stop the allopurinol for fear of
a return attack. If you explain to the patient
all aspects of the issue, gain their consent to
proceed and then present this 'fait accompli'
to the doctor, your recommendation
will likely be acted upon and your
To conclude, completing a successful
medication review is much more than
having the best academic knowledge.
It requires the development of skills that
come with experience. If doctors are ringing
you occasionally for an opinion on some
aspect of drug use, you are probably on
the right path but if not, then I suggest
that there may be areas for improvement.
The best way to do this is by interacting
with both the doctors and your peers at
Alan Freedman has been intimately involved in
all aspects of the medication review program,
as well as training and mentoring pharmacists
undergoing accreditation. He now works full
time conducting HMRs and RMMRs.
ACCREDITED PHARMACIST SPECIAL INTEREST GROUP
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