I have been thinking about this blog for some time. I am going to a meeting with the GPhC where they will discuss the recent Which report. I do want to say that sometimes I am put in the most invidious position when I am confronted by patients who expect me to be honest, particularly when they won’t like it – and to be honest, neither do I.
I met a lady with IBS – nothing unusual about this because there are lots of them out there. It was over lunch and her behaviour was somewhat bizarre – well a very picky eater and some pills popped before the meal – we pharmacists notice that sort of thing. She saw me looking and said – I have IBS. Usual symptoms, pain, discomfort, a strange feeling of bloating, but no obvious distension, although it felt a little rude of me checking and I could not really see, but she said that she could ‘blow up like a balloon any minute and that was why she avoided certain foods and didn’t like eating out. It is always a little difficult approaching the subject of bowel habit, but to my surprise the story flowed. Actually I was fascinated – one a week without help – three times a week with a suppository or enema and hardly ever feeling satisfied – how awful, but no red flag signs there.
The impact on he life was significant – seemed to interrupt most functions – and it was clear that she missed work at least a couple of days a month. But then she had been to her doctor in the morning and happily tipped out the bag of medicines and the questions flowed…….
Two laxatives – fibre and an osmotic great – yes they will help – take them like this – fine. Yes you can still use the suppositories if you want.
Mebeverine – will this help with the pain – ahh – well probably not, but it is worth a try. Actually I don’t believe that there is any evidence that suggests that it works on pain and bloating. I tried Colofac and Buscopan before and they didn’t work, but this is different. Hmmmm
Paracetamol – will this help with the pain – ahh – visceral pain – well probably no. but it is worth a try. Is it stronger than tramadol – the last doctor gave me that – well I don’t think that either will work in visceral pain and the tramadol may make the bowels worse so I would definitely avoid that one.
He wanted to give me an antidepressant called nortriptyline – would that be a good idea?
Do you get that sinking feeling – when things are not going well. Change tack….
Lets talk about soluble fibre as part of the laxative regimen, lets talk a little about lifestyle and exercise. Always a little tough with most people. Relax a little, eat better, be less stressed, take regular exercise – I should talk – and she is feeling that she is working harder and more stress as the pain and discomfort is interrupting her work and social life.
Then the big question – is there something that would be better for me? Scrambling in the handbag, followed by a newspaper article – the doctor said that he couldn’t prescribe this one for me on the NHS.
Well………. Now what do I say!
The whole point here is that giving the information that patients want is not easy and often the pharmacist who wants to be open and honest can fall into a most invidious position. How can I say that the doctor is prescribing to current guidelines, but there is little (actually no) evidence that they work. What do I say about Colofac and mebeverine? I can probably explain the antidepressant with a little care, but the new drug on the crumpled bit of paper? The GP could have prescribed it, but the CCG has probably told him not to, but how am I to know this. They might not have even considered it – most CCGs are likely to sit back and wait for a consultant to bring up the question about new medicines. I know no more than I have read about it in journals.
At the end of the day, I wish I had not noticed the pills, not started the discussion – even moved tables. But that is not me – I am a pharmacist – to boldly enter into conversations with patients about their condition and their medicines – to advise – to support – to help – to make a difference. Even if some times it is like walking through treacle.
So when you talk about pharmacists and information – recognise that sometimes it’s not easy.