Samantha Catanzano, PharmD, BCPP
Clinical Assistant Professor/Psychiatric Pharmacist
The University of Texas at Austin College of Pharmacy/UT Health Austin
As a pharmacist, navigating conversations about sensitive topics is a key part of delivering patient care. In the field of psychiatric pharmacy, such topics are encountered frequently and are an important component of patient interviewing and assessment. While some argue that attaching the word “sensitive” or “uncomfortable” to topics such as substance use or suicide further perpetuates stigma or discomfort, it cannot be ignored that these issues are stigmatized and often make patients and health care providers uncomfortable.
Student pharmacists are likely to feel uncomfortable in these conversations for a variety of reasons. For example, stigma, ambiguity regarding the role of a pharmacist, and lack of experience and/or knowledge have been identified as barriers to student pharmacists providing suicide care.1,2 Additionally, studies looking at student pharmacists’ baseline comfort level for the topic of suicide indicate the majority do not feel confident they could help a patient or would know what to say.3 By fostering strong communication skills and increasing exposure to these types of conversations, preceptors can help students increase their confidence in talking to patients and building a therapeutic alliance.
Know Where Your Student is Coming From
It may be helpful to identify if a student received prior training or has previous experience with discussing suicide or substance use. If a student has participated in Mental Health First Aid or gatekeeper training programs, this is an opportunity to revisit previously learned skills and practice applying those skills. It is equally important to encourage students to assess their own feelings or beliefs about a subject. Validate that cultural views and societal/political relations to certain topics can influence emotions experienced during patient encounters.
Model Communication Skills
Utilizing a “See One, Do One” teaching model can be useful to display archetype verbal and nonverbal communication skills. Key demonstrable skills include first-person language (e.g., utilizing substance use/misuse versus abuse, avoiding the term “addict”), culturally appropriate body language, and incorporating key interviewing questions (e.g., asking directly about suicide or how to utilize a substance use screening tool). Consider developing resources, or use existing ones, with tips and tricks to help students develop their authentic voices. Modeling also offers an opportunity to explore the gray areas of communication, such as cross-cultural effects or being present with a patient’s emotions during an encounter. While there is no “cheat sheet” for the best approach in these situations, this is an opportunity to discuss with students how and why a conversation went the way it did.
Use Role-Play or Case-Based Preparation
Providing a platform for students to practice conversations before sitting in front of a patient can help develop confidence and explore levels of discomfort. Role-playing can provide a safe space for students to practice verbalizing questions, as well as responding extemporaneously to varying patient responses. Using personally-oriented patient cases can help students develop empathy and identify challenges of transcultural health care. A preceptor can help students move past sticking points by prompting questions such as “How would you ask this patient about suicide if they do not show any overt warning signs?” or “How would you transition to asking about substance use?”
Debriefing is an important strategy for students to learn about individual performance. It can serve as an educational tool and therapeutic intervention by allowing space for students to reflect on their emotions. The hardest part is setting aside dedicated time. Utilizing the PEARLS debriefing tool can help organize a debriefing session.4 A productive analysis enables preceptors and students to identify where objectives were hit or missed and identify key takeaways and changes to implement next time.
In summary, we must equip student pharmacists with skills and experience to start these conversations with patients. Helping students understand why pharmacists are an essential piece of the dialogue is equally important. When making the argument for having these conversations with patients, I often quote a blog I read one year ago: “The trouble with silence is that we do not know what, if anything, we are missing.” I remind students that, for many patients, we may be the only one having these important conversations with them. Even if the interaction feels uncomfortable, an awkward conversation can be the difference between life and death for someone in our care.