Rural Home Health Pharmacy – What You Don’t Learn In Pharmacy School

I have been a pharmacist for over thirty-five years in a variety of positions.  The most challenging and rewarding has been my present position: working as a preceptor and clinical pharmacist for a rural home based primary care group.  As a preceptor, I have always been impressed with the clinical expertise of students and residents on rotation. However, there are many unique challenges and opportunities that accompany this job that cannot be taught in the academic setting. My humble advice to all who have the unique opportunity to enter this field is as follows:

1) Arriving at Your Patient’s House

Your clinical expertise is of little value unless you actually see the patient. I highly recommend that you invest in a good GPS system and always have a cell phone.  In a rural setting, the addresses are often on rural road where the houses are not numbered.  My territory is northeast Texas and southern Oklahoma.  In Oklahoma, the roads or houses often don’t have numbers. Calling the patient when (notice I did not say if) you get lost is usually helpful, but not always.  The following are directions either my colleagues or I have received:

a)      “Turn east where the Smith’s barn used to be before it burned down”

b)      “Head north until you see some black cows, then head immediately south”

c)      “Turn left where the Wal-Mart used to be before it moved a few years ago”

d)      “Go about a mile across the bridge that got washed out last spring.”

e)      “Oh hell, everyone knows where I live”

Hence, the value of a good GPS system. 

The best system to find patient’s houses is to ride out with a nurse or other co-worker who has already gotten lost and, hopefully, now knows the way.

2) Big Dogs and Guns:

Assuming you have finally arrived at your patient’s house, you may and probably will be greeted by a big dog.  Our policy states that animals must be secured before we arrive at the home, but if the patient has to choose between their dog and us…inevitability they will choose “man’s best friend” over a pharmacist.  The big dog(s) will almost always be friendly, but if you are not familiar with dog language, please heed the following

a)      Wagging tails are good.  You may approach dog with high pitched, soft “dog-ese” voice…(same as “mother-ese” when you talk to a baby). When you approach the dog throw in a few “good dog” and “please don’t bite me” comments.  Put your hand out slowly and let the dog lick the back of your hand. (ALWAYS carry the germicidal of your choice for later use).

b)      If the dog’s teeth are bared and he is growling and looks like he wants to eat you, stay in the car and call the owner.  Do not leave the car until the dog is put up and make an entry as such in your progress notes at your earliest convenience.

We also have a policy where guns must be secured.  To some of our patients, secure may be defined as having the safety on.  Again, my territory is northeast Texas and southwest Oklahoma where guns are “man’s second best friend” and everyone has several.  Although witnessing the presence of firearms may be a little disconcerting at first, do not be alarmed.  The guns are a working tool to kill rattlesnakes and coyotes, not pharmacists (at least very often). 

3) Greeting the Patient and First Impressions

a)  First and most importantly—ALWAYS show respect and courtesy to the patient, family and caregivers.  You are a guest in their home and are there by their invitation and their invitation only. 

b) To quote “Judge not that ye be not judged”-Some of their houses will be beautiful and immaculately cared for, some will be roach infested one room shacks.  Do not assume anything based on where or how they live.  Some of the worst houses are inhabited by the most educated and wisest who are merely down on their luck (often due to medical expenses) or simply choose to live in a non-materialistic setting.

4) Interviewing the Patient

a) Never appear (or be) judgmental.

If the patient feels you are going to judge or reprimand them, most will only tell you what they think you want to hear.  (eg. “I only have one or two drinks a week” when the reality is they drink a twelve pack nightly.)   My approach is to tell them up front that I am not there to judge them or jump on them, but I need them to be honest with me so I can help them better.  I generally leave my white lab coat in the vehicle.   White coats can be intimidating to some and they may be less likely to tell you the truth.  The same applies to wearing a tie.  Ties are often the uniform of those who have foreclosed on their houses or laid them off work. Regardless, the traditional clinical “uniform” may be interpreted by some as a display of superiority. These suggestions are merely suggestions. Some of my colleagues choose to wear the traditional uniform and do very well.  Leave your laptop in the car.  Many patients will feel that it is disrespectful to be entering data and paying attention to your computer when you should be talking to and focusing on them.

b)      Never appear (or be) condescending

There have been many articles written regarding barriers to communication.  Almost all that I have read list the first barrier as education (referring to patient’s lack thereof).  My perspective is that if you feel education is a barrier, it is your education that is the barrier.    Few patients may speak “pharmacy talk.”  They may have never heard the term “autonomic nervous system,” but they all know and have experienced “fight or flight.”  You can get a feel if the patient is following what you are saying by their body and facial language.  Using a vocabulary that isn’t understood makes your and your patient’s time useless and results in an uncomfortable and unproductive visit.  You may have to choose your words more carefully, but don’t ever talk “down” to anyone.  (e.g. Almost everyone knows what urination is; don’t use the word “pee” or “pee-pee” or ask “how their poops are”).  Very few of our patients (or people in general) are stupid.  They may be simple or “folksy,” but not stupid.   Always treat people with respect

c) Always realize you are treating a person.

I have often found the more clinical we become, the more likely we are to treat a disease state, lab value, or a specific medication rather than treating the patient.  At the risk of sounding new age-y, there really is a mind- body-spirit connection that can not be separated.  Research has shown the profound effect of physical and mental stress on blood glucose levels, blood pressure, heart rate, and various other disease states.  Patient’s who are isolated have a poorer prognosis of recovery from any number of illnesses.  Depression and PTSD certainly may hinder recovery and general well being of our patients. Take time to get to know them.  Ask about their families, their hobbies, what their passions are.  You are far more likely to find valuable information from the patients with whom you truly know and develop a rapport.  Develop a relationship of mutual respect and trust.  This can not happen with an austere approach to patient care.  Always treat the patient as a person.  On numerous occasions, I have heard medical personnel standing over a comatose patient, especially hospice patients, and acting like the patient was merely an object.  Hearing is the last sense to leave us.  There have been numerous cases where patients have come out of a coma and said they could hear every word said to them.  The words you speak in this situation may well be the last words on earth this person will hear.  Let them be words of kindness.

4) Play Well With Others

You have to work with other professionals.  Few pharmacists have prescribing privileges.  You may be the best clinician in the world and have tremendous knowledge and advice, but if you come across as arrogant or rude, a wall will go up and your advice, no matter how valuable, is likely to go unheeded.  Be knowledgeable and speak your truths quietly, but firmly. Nurses and nurse’s aids are an extremely valuable part of the team as are dieticians, PT, OT, and whoever schedules visits and appointments. You don’t have to be liked, but it is important not to be hated. The person you alienate today may be the person you need a favor from tomorrow.

Always say a kind word to the caregivers when you leave.  They are often a very valuable source of information.  I took care of my own Mom in home hospice for seven months until she died.  Care giving, especially for a loved one, is an honor that the sick grant you, but often results with the caregiver being sleep deprived, isolated, and depressed.  Please let them know how much you appreciate what they are doing for the patient.

5) The Payoff

Pharmacy is a very rewarding and worthwhile profession.  Pharmacy schools are becoming harder and harder to gain entrance. The caliber of students and their intelligence as well as their clinical knowledge increases yearly. However, the most rewarding experiences I have had have been the one on one interaction that I have had with patients on a personal level.  When I graduated in 1975, there were still the “mom and pop” drug stores with the soda fountains.  Filling sixty prescriptions a day was the norm and you were on a first name basis with most of your patients.  Home based primary care has made this sort of personal interaction possible again, and I strongly urge any and all of my colleagues to participate in programs like this if they are available.  It is good to come full circle (at least in this case).