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Check-In-The-Box Medicine: Can the Blunt Instrument of Policy Shape Our Communication with Clinicians?


I sat in a dingy pharmacy near the Seattle airport over the holidays, waiting for an emergency prescription.  For over two hours I watched a slow-moving line of people sign a book, pay and receive their prescription(s). The cashier told each customer picking up more than one prescription or a child's prescription to wait on the side.  In minutes, the harried white-haired pharmacist came over to ask the person if they were familiar with these medications, described how to take them, identified the side effects to look out for and demonstrated the size of a teaspoon for pediatric medications.  Then he asked the person to repeat back often in broken, heavily accented English ' what he or she had heard and patiently went over the parts they didn't understand.

I was impressed. This is what every pharmacy should be like except, of course, for the dinginess, the creeping line and the fact that it was so crowded I could overhear these conversations.  Maybe if we got federal legislation enacted requiring pharmacists to offer counseling with each prescription filled, this kind of attention would be the norm, adherence to medication regimens would improve and drug-related injuries would be reduced.

Wait a minute.  Someone already had that good idea.  It was the pharmacists themselves, concerned about the proliferation of pharmaceuticals and the unintended negative consequences it produced, who joined together to back federal legislation that went into effect in 1993.  And today when you pick up a prescription at your pharmacy, you sign the book or screen at the register, right?  Do you know what you are signing?

Probably not.  When you sign you are affirming that you have been offered personal counseling by the pharmacist and are documenting that you do not want his or her guidance about how to take your drug, possible side effects and contraindications.

Pharmacists, who face time constraints, lack financial incentives to meet this demand (the bill included no provisions for reimbursement for counseling) and a public unaware of its need for counseling and uninterested in hearing more about maintenance drugs, find their original wise intention undermined. This benefit they envisioned has been transformed into the time-saving strategy of asking us to check the box and sign the book or screen pad that says in tiny print that by signing we are declining assistance. Perhaps there was a time when that offer was given verbally (and in some places it still is), but the vast majority of us now add our signature, pay the bill and walk away, oblivious to the substantial benefit we have rejected.

Here's another example of an important interaction that's been reduced to checking the box: advance directives.  There is consensus that we are more likely to receive care resonant with our values and preferences when we are unable to make our wishes known if we have completed an advance directive.  The Patient Self-Determination Act, passed by Congress in 1991, requires most health institutions to inform all adult patients about their rights to accept or refuse medical or surgical treatment and the right to execute an advance directive.  Theoretically this inquiry, delivered at a strategically relevant point for us, should remind us to clarify our wishes with our loved ones, offer guidance about how to do so and then encourage us to distribute the documentation to our clinicians.  Notably, similar to pharmacists' medication counseling, patients' discussions about advance directives with health professionals are not reimbursed by public or private insurance.

And so this prompt has become another important interaction between us and our clinicians that has been reduced to a check-mark.  Try this next time you are asked whether you have an advance directive as part of a hospital intake procedure: Ask a) if someone can give you guidance about creating an advance directive; b) if they can provide blank forms for you to complete; and c) whether the facility has the capacity to keep those documents on file so that they can be part of your medical record and thus available if you are admitted through the ER. My bet is you'll come up empty on all counts.

Yet another example of potential check-in-the-box medicine in-the-making: Advocates for shared decision making, eager to disseminate this approach to collaborative health care, spent considerable energy getting legislation passed in the State of Washington in 2007 that informed consent for treatment should include specific elements of shared decision making.'  Such a dramatic change in the culture of both patients and professionals is a heavy lift for legislation that includes neither financial incentives nor effective penalties to encourage adoption of new behaviors.

Each of these examples describes a situation for which there is evidence that our actions have a significant impact on how and whether we benefit from specific health care interventions. Not one of these situations can be wholly out-sourced to a Web-based tool or pamphlet: the interaction that takes place between us and our health professional is critical to ensure that our needs, preferences, motivations and capacities are addressed in the care we receive going forward. ' In no instance are provisions made to compensate the health professional for the time and skills required to initiate the discussion.'  The significance of each of these interactions is such that clinical, patient and scientific advocates have joined together to get legislation and regulation passed and private policies implemented to make sure they take place. And regrettably, the unintended consequence of the policies requiring these interactions is that two of the three have become so routinized that they have been reduced to a check-mark.

As a long-time advocate whose aim is to ensure that everyone has the opportunity to talk with their clinician about these and other personal health concerns, I am puzzled by the optimism that drives advocates to believe that the blunt instrument of policy is sufficient to ensure that health professionals will change the way they interact with us about specific concerns. I'm still looking for evidence showing that such policies work: fewer medication injuries; more advance directives; greater satisfaction with care.

Legislation and regulation are seductively simple levers for social change that add legitimacy to the advocates cause.  The unintended consequence check-the-box health care should make us wary about when and how we use it.

Physician counseling for tobacco use cessation had the potential to become yet another check-in-the-box intervention, but for the persistence of advocates, scientists and clinicians and the financial investment of foundations and state and Federal governments led to a different outcome.  Plan- and institution-level policies requiring clinicians to Ask, Advise, Assist and Arrange for cessation support are supplemented by 1) considerable research support demonstrating the efficacy and value of clinician-initiated counseling for different subgroups; 2) clinician compensation for counseling; 3) insurance coverage for pharmaceutical cessation aids; 4) performance measures of counseling delivery via patient surveys; 5) readily available professional training for a variety of health professionals; 6) free national telephone counseling and 7) clean indoor air policies and powerful media messages that reinforce quitting.  Productive interactions between clinicians and patients with regard to tobacco use is, over the past two decades, slowly becoming the norm.

That harried white-haired pharmacist near the Seattle airport patiently counseling his clients is an exception. What additional measures what will and what resources must be taken to ensure that all pharmacists and other health professionals can confidently and gladly engage with us about how to make the best possible use of our health care?


More Blog Posts by Jessie Gruman

author bio

Jessie C. Gruman, PhD, was founder and president of the Center for Advancing Health from 1992 until her death in July 2014. Her experiences as a patient — having been diagnosed with five life-threatening illnesses — informed her perspective as an author, advocate and lead contributor to the Prepared Patient Blog. Her book, AfterShock, helps patients and caregivers navigate their way through the health care system following a serious or life-threatening diagnosis. The free app, AfterShock: Facing a Serious Diagnosis, offers a pocket guide based on the book. | More about Jessie Gruman

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MightyCasey says
June 16, 2011 at 12:13 PM

Given the tsunami of tasks presented to most clinicians - including pharmacists - I'm amazed we aren't seeing more literal drive-thru medicine: don't get out of your car, just speak your symptoms into the kiosk, drive to the window for your diagnosis (or scrip), and off you go.

I'm mostly kidding.

Pharmacogenomics has a lot of potential for medication-related issues for some common drugs like Coumadin, Wellbutrin, and others. I look forward to the day when genetic testing is ubiquitous and affordable, offering us a pathway to better early detection and control of a host of health conditions.

Right now, tho, we're stuck in check-the-box land.

June 2011 Health Wonk Review: Hockey, hoodlums and hot rod angels « Boston Health News says
June 23, 2011 at 11:41 AM

[...] Gruman asks: Check-In-The-Box Medicine: Can the Blunt Instrument of Policy Shape Our Communication with Clinician... posted at Prepared Patient Forum: What It Takes Blog. One example: counseling at the pharmacy, [...]

Chris Langston says
June 23, 2011 at 9:53 PM

This is a very interesting example of some of our system problems in health care. In many ways we have a very good policies in place (like pharmaceutical counseling and end of life planning requirements) but in the name of cost or time or something we don't abide by them - neither providers nor patients.

And the habit of box checking is pervasive. I'm 100% certain that the payments that pharmacists and hospitals do get say in the fine print that in return for the money they will provide the medication or end of life counseling along with the products and services for which patients have learned to settle. They too have automatically "checked the box" without seriously considering how much time in a day the work they are committing to will take, what it would mean for the economics of their businesses, etc.

Other examples are states that set medicaid payments so low that they must know they are fostering an apartheid medical system, preventative service recommendations that are so extensive that there is not time in the day for them all to be met with the workforce we have, and health professions that keep their numbers low and resist sharing work with others to keep their wages high.

Hodge Podge | The Hospitalist Leader says
June 26, 2011 at 8:30 PM

[...] is a notable post, and it affirms again, that regardless of existing statutes, if the work force or funding is not [...]

pharmaceutical delivery says
March 6, 2013 at 1:17 PM

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