Differential diagnosis in pharmacy practice: Time to adopt clinical reasoning and decision making.

The delivery of healthcare in most developed countries is under increasing pressure. Ageing populations with increasingly complex needs, coupled with financial constraints and imbalances in workforce, mean that healthcare policies look to contain cost and utilise resource as effectively as possible. Self-care is now widely advocated as a mechanism to manage acute presentations with pharmacy identified as a key resource to support such policy. Pharmacy teams are ideally positioned to facilitate the management of patients who present with acute illness. However, current evidence suggests that patient assessment and establishing a differential diagnosis could be better. It appears that how pharmacists are taught at Schools of Pharmacy adopts a protocol driven approach, which assumes presentation of low acuity conditions, and we argue that this method must be replaced with a curriculum that adopts clinical reasoning. This paper sets out the process of clinical reasoning and how the profession could embrace this as a better model in establishing a diagnosis.

Over-the-counter medicines: their place in self-care.

Over the last 20 years, there has been a shift in Western countries' healthcare policy to empower patients to exercise self-care by taking greater control in managing their own health, especially in cases where their conditions are deemed minor and self-limiting. In the UK, this has been facilitated by the Department of Health in making more medicines available to the public without the need for a prescription. This article highlights how policy is affecting practice, what attitudes the public and health professionals have toward greater medicine availability, and considers their place in patient management.

Enquiry analysis and user opinion of the Drugs in Breastmilk Helpline: a prospective study.

BACKGROUND: Since breastfeeding is universally recognised as the ideal way to feed infants, it is understandable, and at times inevitable, that breastfeeding mothers will want, or be required, to take medication. To meet the information demands of breastfeeding mothers and healthcare professionals, a UK charity, The Breastfeeding Network, established a free telephone helpline to answer queries on medicines in breastmilk. This study reports on the enquiries received by the Drugs in Breastmilk Helpline and user opinion of the service. METHODS: All enquirers to the Helpline between December 2010 and January 2011 were asked if they could be contacted in 2 to 4 weeks to provide more information on their experience of using the service. A combination of telephone semi-structured interviews and email surveys were used depending on whether the enquiry originated via telephone or email. RESULTS: Information was gained from 101 participants; 77 women and 24 healthcare professionals. Women reported high levels of service satisfaction (94%, n = 72/77) and healthcare professionals found the information provided useful (92%, n = 22/24). Women used the service for reassurance or because they had received conflicting information or distrusted healthcare professional advice. Healthcare professionals often could not answer questions or took a cautious approach to recommendation (i.e. advised avoidance of medicines whilst breastfeeding); this was often at odds to advice given by staff from the Helpline. Healthcare professionals did not routinely access resources to answer questions, but when they did, showed a lack of confidence in data interpretation. CONCLUSIONS: The Breastfeeding Networks' Drugs in Breastmilk Helpline provides an important service to breastfeeding women and healthcare staff to make informed decisions on medicine taking whilst breastfeeding. Healthcare professional uncertainty and incorrect advice given to breastfeeding women suggests that healthcare professional education needs improving and that greater use of specialist services should be encouraged.

Numeracy skills of undergraduate entry level nurse, midwife and pharmacy students.

BACKGROUND: The ability of healthcare professionals to perform basic numeracy and therefore dose calculations competently is without question. Research has primarily focused on nurses, and to a lesser extent doctors, ability to perform this function with findings highlighting poor aptitude. Studies involving pharmacists are few but findings are more positive than other healthcare staff. AIMS: To determine first year nursing, midwifery and pharmacy students ability to perform basic numeracy calculations. METHOD: All new undergraduate entrants to nursing, midwifery and pharmacy sat a formative numeracy test within the first two weeks of their first year of study. RESULTS: Test results showed that pharmacy students significantly outperformed midwifery and nursing students on all questions. In turn midwifery students outperformed nurses, although this did not achieve significance. When looking at each cohorts general attitude towards mathematics, pharmacy students were more positive and confident compared to midwifery and nursing students. CONCLUSION: Pharmacy students expressed greater levels of enjoyment and confidence in performing mathematics and correspondingly showed the greatest proficiency. In contrast nurse, and to a lesser extent midwifery students showed poor performance and low confidence levels.

Pharmacy professionalism and the digital age.

OBJECTIVES: To explore how the use of digital media could affect how people view professional behaviour. KEY FINDINGS: The growth in social networking sites has been phenomenal and they are now an extremely popular medium for interacting with others both commercially and privately. This as-yet-uncontrolled digital media provides ample opportunities for public and professional scrutiny for the unwary. Instances of employer screening and employee dismissal are already documented. All pharmacists who use digital media now need to be conscious that their virtual presence could be subject to regulator investigation. CONCLUSIONS: It is important that individuals are aware of the risks associated with using digital media and that pharmacy organisations begin to provide clear leadership to help pharmacists know what is and is not acceptable.

Potential adverse reactions to herbal medicines in patients attending a nephrology clinic in Abu Dhabi, United Arab Emirates.

OBJECTIVE: To provide data on herbal medicine (HM) use and safety in patients attending a nephrology clinic at Sheikh Khalifa Medical City (SKMC), Abu Dhabi, United Arab Emirates (UAE). METHODS: A prospective, 3-month study between June and September 2007, investigated all patients presenting to the Nephrology Clinic of the Sheikh Khalifa Medical center (SKMC) in Abu Dhabi, UAE. A structured questionnaire determined previous and current HM use, and descriptions of associated adverse reactions. Corroborating evidence was sought from the patient's medical records. Causality was assessed by consensus from an expert panel using the Naranjo algorithm. RESULTS: The HM use was widespread (468 of 688; 68%). Over two-thirds (69%) reported currently taking 3 or more herbal preparations. Patients reported using over 100 different HMs, many of them compounded mixtures; 35% could not identify a single ingredient of these mixtures, and 70% had not informed the clinic doctors that they were taking HMs. Just 2 patients had HM use recorded in their medical record. Twenty-eight HM-related adverse reactions were identified in 26 (5.6%) patients; 12 probably and 16 possibly related to HMs. Seven involved HMs alone and 21, a HM/prescription medication (PM) interaction. CONCLUSION: The use of HMs in patients with underlying kidney problems was extensive and contributed additional pathology to the underlying renal disease, either alone or in combination with PMs. The reluctance of patients to inform their healthcare providers of concurrent use highlights a need to take a thorough drug history on clinic registration.

Utility and value of a medicines information service provided by pharmacists: a survey of health professionals.

OBJECTIVES: many health professionals lack the time and skills to search for and appraise information on medicines. A solution might be to use others skilled in evidence appraisal, who make recommendations or provide information tailored to patients' needs. The objectives of this study were to assess how advice provided to health professionals by the northwest of England regional medicines information centre is used, whether it is useful for patient care and to measure satisfaction with the service. METHODS: a questionnaire was designed and sent to health professionals who contacted the centre between September 2008 and March 2009. Enquirers contacting the centre more than once were sent a questionnaire only in response to their first enquiry during the study period. Non-responders were sent a reminder. KEY FINDINGS: questionnaires were sent to 672 enquirers; 68% were returned. Nearly all respondents used the advice provided. Of the 430 respondents who provided data on how they used the information, 81% used it to manage a current patient and 29% to plan the care of future patients; nearly all considered it useful. Where data were given (n = 366), half used it to check if current or proposed management was appropriate, 45% to make changes to therapy and 35% to advise another health professional. In addition to patient care, one-quarter (n = 105/430) of respondents used the information for continuing professional development and 16% (n = 69/430) for training or teaching. CONCLUSIONS: health professionals value the enquiry-answering service and use the advice provided for patient care, continuing professional development and educating patients and other health professionals. The service is responsive, supporting the care of patients needing immediate and future management.

Can professionalism be measured?: evidence from the pharmacy literature / ¿Puede medirse la profesionalidad?: evidencia de la literatura farmacéutica

The need to ensure the future pharmacy workforce demonstrates professionalism has become important to both pharmacy educators and professional bodies. Objective: To determine the extent to which Schools of Pharmacy have taught or measured student professionalism. Methods: Review of the healthcare literature on teaching of professionalism at an undergraduate level. Results: Two-hundred and thirty one papers were retrieved but only 45 papers related specifically to pharmacy. Of these a further 25 were narrative in nature and did not report any findings. Nineteen papers were reviewed (one was excluded as it reported the same data). Papers could be broadly categorised in to those that have tried to create a tool to measure professionalism, those that are in effect pedagogical evaluations of new initiatives or longitudinal studies on student perceptions toward aspects of professionalism. Conclusion: A growing body of literature exists on pharmacy and professionalism. However, to date, very few Schools of Pharmacy appear to formally teach it let alone assess students' acquisition of professionalism (AU)

La necesidad de asegurar el futuro de los trabajadores de la farmacia demuestra que la profesionalidad se ha convertido en importante tanto para educadores de farmacia como para entidades profesionales. Objetivo: Determinar el grado en que las Facultades de Farmacia han enseñado o medido la profesionalidad de los estudiantes. Métodos: Revisión de la literatura sanitaria sobre enseñanza de profesionalidad a nivel de pregrado. Resultados: Se encontraron 230 artículos pero sólo 44 trataban específicamente de farmacia. De estos, 25 eran narrativos por naturaleza y no comunicaban ningún resultado. Se revisaron 18 artículos (uno fue excluido porque comunicaba los mismos datos). Podría clasificarse los artículos en los que habían intentado crear un instrumento para medir la profesionalidad, los que son realmente evaluaciones pedagógicas de nuevas iniciativas y los de estudios longitudinales sobre las percepciones de los estudiantes hacia aspectos de la profesionalidad. Conclusión: Existe un cuerpo de publicaciones creciente sobre farmacia y profesionalidad. Sin embargo, hasta la fecha muy pocas Facultades de Farmacia parecen enseñarla formalmente y dejan que los alumnos evalúen su adquisición de profesionalidad (AU)

Can professionalism be measured?: evidence from the pharmacy literature.

UNLABELLED: The need to ensure the future pharmacy workforce demonstrates professionalism has become important to both pharmacy educators and professional bodies. OBJECTIVE: To determine the extent to which Schools of Pharmacy have taught or measured student professionalism. METHODS: Review of the healthcare literature on teaching of professionalism at an undergraduate level. RESULTS: Two-hundred and thirty one papers were retrieved but only 45 papers related specifically to pharmacy. Of these a further 25 were narrative in nature and did not report any findings. Nineteen papers were reviewed (one was excluded as it reported the same data). Papers could be broadly categorised in to those that have tried to create a tool to measure professionalism, those that are in effect pedagogical evaluations of new initiatives or longitudinal studies on student perceptions toward aspects of professionalism. CONCLUSION: A growing body of literature exists on pharmacy and professionalism. However, to date, very few Schools of Pharmacy appear to formally teach it let alone assess students' acquisition of professionalism.

Medicine-related questions handled by community pharmacists: an exploratory study.

OBJECTIVES: The objectives of this study were to determine what type of medicine-related questions community pharmacists were asked and to ascertain whether responses given were appropriate. METHODS: All community pharmacists from three Primary Care Trusts were invited to participate in a week-long exploratory study. Piloted data-collection forms were self-completed. Data were analysed descriptively using Microsoft Excel and statistical tests conducted with Minitab. KEY FINDINGS: Sixty-six medicines-related questions were answered by participating pharmacists. The type of questions asked were varied and asked by patients, the general public and health care professionals. Most answers (over 80%) were assessed as being appropriate; only four questions raised concern with assessors that possible patient harm may have resulted. Almost half (42%) of the questions were answered without consultation to any reference source. CONCLUSIONS: Despite the small-scale nature of the study the findings show that community pharmacists provide a good-quality service that is easily accessible to all people. However, the failure to use reference sources may impact on pharmacists' ability to answer medicine-related questions fully.

A computer literacy skills profile of pharmacists residing in two counties of England.

BACKGROUND: Pharmacy is an information intensive profession and a pharmacist has to be proficient in health care information management. The advance in information technology and the use of computers to access, retrieve and analyse this information is increasingly important. Yet little is known about pharmacists' computer literacy or information technology skills. OBJECTIVES: To gain a better understanding of pharmacists' basic computer skills and their ability to use standard software. METHODS: Self-administered postal survey to 747 registered pharmacists residing in two counties of England. RESULTS: A total of 386 (52%) pharmacists responded after two mailings. Most responding pharmacists used computers at work and at home. They believed their basic computing skills to be high, although acknowledged that they were skill deficient in using certain software packages. Internet use at work was low (43%) as too was awareness and use of online medical databases; this was reflected in online medical database training being identified as of greatest need. CONCLUSIONS: Pharmacists were confident in operating computer systems but identified a training need for particular software applications. Of concern is the limited knowledge they possessed and access they had on medical databases.

A cross-sectional survey of herbal remedy taking by United Arab Emirate (UAE) citizens in Abu Dhabi.

PURPOSE: To determine patterns of United Arab Emirates (UAE) citizen herbal medicine taking. METHODS: Questionnaire survey of UAE citizens attending a primary healthcare clinic in Abu Dhabi. RESULTS: Three hundred and thirty surveys were analysed. Seventy-six per cent (250/330) had previously used herbal products, and of these 38% (94/248) were currently taking at least one herb. In total, 65 different herbs were being taken to treat 48 conditions. Respondents overwhelmingly felt herbal medicines were safe, yet 27 people reported experiencing an adverse drug reaction. Causality was not established because of multiple herbal use and a propensity for concurrent herbal and Western medicine taking. Respondents relied heavily on family and friends for advice and bought herbs from a 'condimental shop' (local herbal seller/healer). Despite high herbal use, respondents still preferred Western medicine to treat chronic diseases. CONCLUSIONS: This study has shown that UAE nationals have faith and confidence in herbal medicines and are consequently high users of them despite the country's progressive adoption of Western approaches to health care.

Evaluation of community pharmacists' recommendations to standardized patient scenarios.

BACKGROUND: Recent trends in the global nonprescription drug market show a massive increase in medicine availability to the general public. This places greater responsibility on community pharmacists to ensure that patients exercise self-care appropriately. This small study examined pharmacist performance in facilitating patient self-care. OBJECTIVE: To determine whether an appropriate course of action was taken by UK community pharmacists practicing in one geographic area when presented with 1 of 2 case scenarios: headache or abdominal pain. METHODS: A covert researcher, posing as a patient, spoke with the pharmacist on duty at each of 30 pharmacies, asking for advice on one of the scenarios. The pharmacist was interviewed and their responses were examined by an expert panel. RESULTS: Thirty pharmacies were visited resulting in 28 consultations, 14 each for both scenarios. Pharmacists performed better when counseling the "patient" with abdominal pain than headache. The majority of questions asked were categorized as being relevant by the panel (66% for headache, 89% for abdominal pain), although in both scenarios, the expected outcome of referral was observed only in 7 of the consultations for headache and in 8 cases for abdominal pain. Questioning centered on quantification and clarification of the presenting problem and rarely on questions related to history taking. CONCLUSIONS: Performance levels of the community pharmacists varied considerably. For all pharmacists to perform well, greater emphasis should be placed on eliciting information from the patient to ensure that the appropriate course of action is taken.