Sunday, August 30, 2009

When a patient brings you flowers…

Posted by Kendra Yum at Sunday, August 30, 2009

The patient poked his head into the doorway, hesitant to enter when he saw the clinical pharmacist in conversation about antihypertensive treatments with this Michigan PharmD student. The pharmacist was my preceptor, Gloria, employed at Detroit’s Veterans Affairs Medical Center. The patient had arrived for a follow-up visit at the VA's Hypertension and Risk Reduction Clinic (HRRC).

“Come on in," Gloria said, rising from her seat to greet the patient at the door.

He smiled. But instead of walking in, he turned the opposite way, returning a second later with a bouquet of pink and white carnations. He spoke with a gentle voice. “These are for you, Gloria," he explained. "I really do appreciate all the help you've given me.” I was struck by the sincerity of his gesture.

Gloria started each patient appointment with blood pressure and weight measurements. She also checked for ankle edema (swelling) if the patient was on a calcium channel blocker. Then, she would ask the patient if he had completed his “homework”: recording his blood pressure twice a day at home in order to review this data with his pharmacist. (
HRRC provides an automatic blood pressure machine free to its VA patients.) Next, the pharmacist asked about unusual symptoms, tolerance to medication, and compliance with the prescribed medication regimen. A large portion of the session was devoted to lifestyle assessment, wherein the pharmacist extensively reviewed the patient’s dietary consumption, smoking habits, and exercise levels. She would then offer advice on how to make lifestyle changes to improve blood pressure.

Between patient appointments, Gloria explained to me how to develop a patient-specific drug therapy tailored to the patient’s biology, disease complexity, and pattern of compliance. She also identified what symptoms and lab values should be monitored.

"Although this is a hypertension and risk reduction clinic, I spend two minutes modifying the medication regimen and explaining how to take the medications,"Gloria
explained. "The rest of the time, I advise on lifestyle changes that can help reduce the risk factors contributing to hypertension.”

I learned from Gloria that clinicians often minimize the importance of patient participation in their care. She has achieved success by equipping patients with practical disease management tools, and by helping patients establish reasonable lifestyle modification goals.

Evidence shows… When we increase the dose of an antihypertensive drug, or add a drug to the regimen, we aim for a decrease in blood pressure of 10-15mmHg. Regular physical activity reduces systolic blood pressure by 4-9 mmHg. A weight loss of 10kg correlates to reduction in diastolic blood pressure by 15mmHg. A similar reduction is achieved by lowering salt consumption. Thus, multiple lifestyle changes can reduce blood pressure by 30mmHg: two to three times more than what medications achieve, and without ANY harmful side effects.

The patient who brought Gloria flowers had an excellent blood pressure measurement while at the clinic.
“Your blood pressure looks great today," Gloria smiled. The patient offered an explanation, “Well, maybe the clinic has something to do with that," he replied. "When I'm here, I feel comforted.”

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