“They ask me: why consult with a pharmacist?”-Patients’ experiences with a comprehensive medication management service

This study aims to reveal the patients’ experiences with a comprehensive medication management (CMM) service delivered in a specialty pharmacy in Brazil. This is a qualitative study performed from September 2015 to February 2016. In-depth semi-structured interviews were conducted with 10 patients followed-up in a CMM service in a specialty pharmacy located in Minas Gerais state. The interviews were recorded, transcribed and analyzed with the assistance of the NVivo11® software. According to the participants, they did not know what to expect from CMM at first. They showed difficulties on establishing a solid concept for CMM, however, they pointed some key aspects of pharmaceutical care philosophy based on their experience with the service. The interviewees identified the CMM pharmacist, seen as a care professional, as a different professional compared to the traditional pharmacist, mainly identified by them as a salesman. The ability to listen and the time that the CMM professional dedicated in the consultations were highlighted as primordial in the process of building a therapeutic relationship with the patient. The difficulties the patients have for establishing a solid concept for CMM might be due to the lack of pharmacists exerting this function, considering CMM is still a new service in Brazil. The results of this work can guide efforts to build a better interaction between patients and pharmacists, in a constant search for offering the best care possible.


Introduction
A high level of drug-related morbidity and mortality has been identified worldwide by various authors in the past few decades (Souza et al., 2014;Saha et al., 2008;Gurwitz et al., 2003;Ernst & Grizzle, 2001). Furthermore, the prevalence of multiple chronic non-communicable diseases is continuously growing and demanding the use of a high number of medications.
These changes make it even more urgent to have a professional that is capable of taking the responsibility for the optimization of drug use (Ramalho-de-Oliveira, 2011).
Pharmaceutical care is a person-centered practice that was developed in this context with the primary objective of identifying, preventing and solving drug therapy problems (DTP) to ensure that all the medications in use by the patient are necessary, effective, safe, and that the patient is able to adhere to the therapy. In this practice, the professional assumes the responsibility of being co-responsible for the best results of drug use. The philosophy and the methodological principles of pharmaceutical care guide the provision of a clinical service called comprehensive medication management (CMM) (Cipolle et al., 2012;Hepler & Strand, 1990).
National and international literature highlights the importance of CMM by demonstrating positive clinical, economic and humanistic results (Amaral et al., 2018;Hui et al., 2014;Ramalho-de-Oliveira et al., 2010;Planas et al., 2009). In Brazil, Detoni et al. (2017) showed positive impact of CMM service on clinical outcomes of patients with COPD, followed up in the same specialty pharmacy. Neves et al. (2019) and Santos et al. (2021) showed statistically significant reduction in the values of glycated hemoglobin, systolic blood pressure, low-density cholesterol, and total cholesterol in Brazilian patients that received CMM in primary health care.
As CMM is guided by a patient-centered care, it is important to understand patient experience with the service (Lyra Júnior et al., 2005). Although there are studies that describe in deep the pharmacist-patient relationship (Bissel et al., 2008;Guerreiro et al., 2010;Renberg et al., 2006), little is known about how patients perceive this relationship within a CMM Research, Society andDevelopment, v. 10, n. 6, e55610616147, 2021 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v10i6.16147 3 service, and how the change in the care paradigm affects their perception and clinical results. Most of the studies conducted with this aim used satisfaction and health quality surveys (D'andrea et al., 2012;Amarante et al., 2010;Montgomery et al., 2009;Lyra Júnior et al., 2005). Such study designs have the advantage of reaching a great number of participants simultaneously, but they are not able to provide a deep understanding of the meaning of the investigated phenomena for the individuals. Only by a more comprehensive approach one will be able to capture, with all the inherent complexity, patients' feelings and experiences. Thus, the objective of this study was to comprehend patients' perceptions about a CMM service in a Brazilian specialty pharmacy.

Setting
The study was performed in a specialty pharmacy in the state of Minas Gerais, Brazil. The specialty pharmacy (called in Brazil Farmácia do Componente Especializado da Assistência Farmacêutica) is a national program of the public health care system, which goal is to guarantee access to medications for the treatment of complex diseases in the outpatient level. In order to achieve its goals, the program counts with several dispensing units widespread over the country (Brasil, 2013). The specialty pharmacy provides medicines for more than 80 pathologies, including chronic obstructive pulmonary disease (COPD). The research setting is one of the dispensing pharmacies, with private rooms where the CMM consultations take place. The CMM service is offered by three pharmacists, aimed at patients who receive medicines for the treatment of COPD.

Study design
This qualitative study was performed from September 2015 to February 2016, having as reference Minayo (2010). Indepth semi-structured interviews were carried out with patients followed up in the CMM service. To be eligible, the respondent should have at least three CMM consultations and demonstrate good cognitive ability to answer to the interviewer's questions.
Four main topics were addressed for the semi-structured interview guides: (1) patients' initial perceptions about the service; (2) how they perceive CMM; (3) the role of the pharmacist in CMM service; (4) how the subjects perceive the clinical benefits of the service. Ten patients were interviewed and this number was considered sufficient by the researcher to reach data saturation and to meet the aim of this work.

Data Collection and Data Analysis
The interviews were recorded, transcribed verbatim and re-read while listening to the audio records to check for possible mistakes and misunderstandings. The analysis was performed using an iterative coding process, which consists in reading the transcriptions and comparing each new piece of data with the previous findings to identify repetitive themes. The individual sentences receive labels according to the meaning they carry and are grouped into nodes with the help of the software NVivo11®.

Ethical Considerations
This study was approved by the Ethics Committee of the Federal University of Minas Gerais and by the Ethics Committee of the Municipal Health Secretary of Minas Gerais, under the same approval number (CAAE number: 25780314.4.0000.5149). The identity of participants was preserved and the confidentiality of the information was guaranteed.
All participants signed the free and informed consent form prior to the interview. All the names are fictive.

Results
The interviews took on average 28 minutes. The data were grouped into five major categories as a result of the thematic analysis of the transcripts.

Estrangement about pharmaceutical care
None of the interviewees referred having previous contact with such type of service. In general, they all felt an "estrangement" regarding the offering of care in a dispensing pharmacy.
I've been getting my medicines in this pharmacy for a while now, but they had never invited me for anything like that before. I thought it was strange. But since they had set an appointment, I said: 'here we go'. (Caetano) Nevertheless, as they normally get their medications in this unit, they easily associated the CMM service to aspects concerning their drug therapy.

I thought that you [the pharmacist] might want to know whether I am satisfied or not, whether my medication is
working or not. (Gilberto)

The disparity between the traditional pharmacist and the CMM pharmacist
Participants demonstrated to have difficulties in talking about the role of the pharmacist in CMM service, since none of them have had clinical appointments with this professional before. They identified the pharmacist mainly as someone who works in drugstores, linked to sales of pharmaceutical products, and described their lack of interaction with this professional in this environment.
The pharmacist from the drugstore, the salesman, he just wants to sell you things. He is a seller in the drugstore.
What does the pharmacist do in a drugstore? I never had direct contact with the pharmacist in a drugstore, just with you here. (Belchior) When comparing the role of the CMM pharmacist with the drugstore pharmacist, the interviewees pointed out as differential the comprehensive approach used to identify their pharmacotherapeutic needs.  Research, Society and Development, v. 10, n. 6, e55610616147, 2021 (CC BY 4.
The importance of an individualized and shared decision-making process was highlighted and these aspects were considered by the participants as part of the CMM pharmacist approach.

She [CMM pharmacist] talks, but she also clears out my doubts, asks me if I still have any doubts and whether I agree
or not with what she said. I mean, she doesn't want to impose anything, she divides the problem with us. (Caetano) Also, participants' demonstrated to understand that, although they were included on the CMM service initially because of the COPD treatment, the pharmacist assessment has a comprehensive approach and the CMM care process is not directed only to the management of this single health problem.

She [the CMM pharmacist] solves many of my doubts and helps me a lot. Not only about the inhalers, but also about
all of my other medications. About blood pressure, thyroid. She always asks me about how I am feeling, this is pretty important, right? (Elis)

Recognizing an unfilled space on the patient care process
In the excerpts below, the participants talk about how they perceive a need for a professional that is able to evaluate patients' drug use. In their speeches, it is also pointed how the pharmacist could be the adequate professional for exerting this function.

The role of the pharmacist on CMM
The participants described the interventions made by the pharmacist on their drug therapy, demonstrating how they perceive the role of the pharmacist when offering a CMM service. It is important to point that, since there were no other health professionals in the specialty pharmacy, when necessary the contact with the physician was made by letters, containing all the pharmacist recommendations.
Well, I was taking a drug that was making me ill. It was suspended. There were some other medicines I had to use that I was not using. She asked me to do some blood tests; I went to the doctor and did it. Then I started taking another drug that I needed. (…) I was taking a pill and she asked me to stop. I stopped taking it and got better.

(…) I also had this pain on my knees… a terrible pain on my legs. Then she told me to buy a medicine. I bought it and now I feel better. (Belchior)
Although the interviewees showed difficulties on establishing a solid concept for CMM, they seemed to be able to exemplify actions performed by the pharmacists on the consultations and connect those in order to build an empirical concept that approaches the real function of the CMM service.

Perception about the clinical benefits
Also, participants highlighted the clinical benefits and the importance of being followed up in the CMM service.

The pharmacists' limitations in patient care
The absence of autonomy for the pharmacist to order exams was pointed as a barrier for establishing an effective care process. Nevertheless, the interviewees demonstrated to understand the value of consulting with the pharmacist even though he has to deal with these difficulties: Having to send me to the doctor for me to be able to do the exams delays a little the progress of the treatment, but it's helpful because otherwise, without the pharmacist's referral, I wouldn't even initiate the process. So it's a good start for me as a patient. I know I'm being taken care of. (Belchior)

Discussion
The results presented above through the patients' speeches enable a better understanding of the patients' experiences with a comprehensive medication management service delivered in a specialty pharmacy in Brazil. To ensure that the patient knows what to expect from the professional and from the service is critical when working in a person-centered approach. This way, the pharmacist can prioritize decisions by understanding patients' own demands (Ramalho-de-Oliveira, 2011).
The participants did not know what to expect from CMM at first since they have never had contact with the pharmacist offering this service. This fact was expectable, considering this is still a new service in Brazil. Because of that, respondents recognized the major function of the pharmacist as usually related to sales, since they formerly only had contact with this professional on commercial environments such as drugstores. Although drugstores constitute a connection between the production chain and the drug use by the patient, they transformed themselves more into a commercial establishment than into health establishment (De Barros, 2004). In a study conducted by Olsson et al. (2002), most of the interviewees mentioned that the main function of the pharmacist is to serve the customer as a "businessman" that earns money by selling medicines and whose professional motivation is to sell the most in the shortest possible time.
However, after some appointments, the interviewees demonstrated to understand how the CMM pharmacist has different responsibilities compared to the traditional pharmacist in drugstore. They perceive the CCM pharmacist as a healthcare provider and pointed out as differential the comprehensive approach used to identify their pharmacotherapeutic needs. This is a major point in pharmaceutical care's philosophy of practice: even when CMM is offered only to specific patients who have specific diseases, the pharmacist must work in a holistic manner, assessing all of the patients' pharmacoterapeutic needs.
In Brazil, the university reform that happened during the military dictatorship was strongly influenced by the Flexner Report (1910). The Flexnerian reform occurred in the United States in 1910, contributing to an educational process that privileges the high-level scientific training and stimulating the professional specialization, characteristics of the biomedical model of care . This educational pattern leads, in clinical practice, to an impersonal and fragmented care, mentioned by the interviewees as a concern. In accordance with this idea, Ismael (2005) presents Ivan Illich's observations that "it is more important for the doctor to auscultate the patient than to listen to him, abrogating the human face of medicine".
Moreover, the short time available for the professionals to evaluate the patient's situation make it hard for empathy to take part on the process, turning it into a "mere search for symptoms as a way of prescribing the adequate medicines for the complaints presented by the patients" (Pereira & Azevedo, 2005).
The lack of attention and time devoted for listening to the patients was a recurrent theme for all the interviewees, evidencing that the patients want to be heard and to co-participate on their own care process. They also described how the CMM pharmacist payed attention to their demands. This is a key point of a person-centered approach, one of pharmaceutical care's philosophical principles: the professional must consider that when the patient searches for her/his help, she/he brings her/his own experiences, expectations, feelings and social values. The practitioner must take all of these into consideration for choosing the best alternative to solve the patient's problem. Good communication between professionals and patients leading to the establishment of a therapeutic relationship is unequivocally connected to better results on what concerns not only patient satisfaction, but also about his/her clinical course (Sandhu et al., 2015;Sweeney et al., 2014;Pereira & Azevedo, 2005). [28][29][30] As Greenhalgh et al. (2004) stress, clinical decisions should not be merely based on clinical trials. Not only physiological, but also psychological and sociocultural factors can influence the drug treatment for a given patient and should be taken into consideration. Furthermore, Ryan et al. (2006) talk about the clinical benefits achieved when clinicians share decisions about the treatment with the patient. They criticize the traditional and vertical method where the health professional does not considered the value of the narratives and motivations of the patient. In contrast, the interviewees recognized the CMM pharmacist's effort to listen to their needs and to share responsibilities and decisions.
All of the points mentioned above were also highlighted by Ramalho-de-Oliveira et al. (2012) in a study that aimed at providing and discussing strategies for pharmacists to broaden their view of patients' experiences with drug use and how these influence the therapeutic outcomes achieved. The authors point out, among other strategies, 1) the importance of actively listening to the patients and developing a therapeutic relationship, acknowledging their experiences, feelings and concerns, and 2) the importance of negotiating with the patient the goals for her/his therapy and involving him on the decision-making process.
The absence of autonomy for the pharmacist in the CMM service was pointed as a barrier for establishing an effective care process. In fact, as the pharmacist cannot legally alter a prescription or prescribe medications (except for those that require no prescription), it takes a lot more time to solve some of the patients' problems. In some places, such as in Fairview Health Services in the United States, where CMM service has already gained more recognition, pharmacists already have autonomy and the "decision-making power" to prescribe or change prescriptions for patients (Maracle et al., 2012). In fact, this is still a very important limitation for the pharmacists in Brazil to be able to make their interventions in a more effective manner.
However, despite these difficulties, the interviewed patients seem to understand the value of being attended by a pharmacist.
Although the participants showed difficulties on establishing a solid concept for CMM, they were able to exemplify actions performed by the pharmacists on the consultations and connect those in order to build an empirical concept that approaches the function of the CMM service. Furthermore they demonstrate to perceive how they benefit from the service.
One of the interviewee points out a very important issue regarding his prescriptions: he was just getting the same prescriptions from the doctors, without doing any monitoring exams to check if his treatment was working. This seems to be a very recurrent problem on the healthcare system (Filardi et al., 2017;Price et al., 2017;Lilis & Lord, 2011). The authors discuss that this prescription behavior might increase convenience for patients and avoid clinicians' burden; nevertheless, it is very important to attempt to the safety of this practice, because it can generate many avoidable risks and harms for the patients.
As discussed by Lillis and Lord (2011), in order to improve safety in repeat prescribing, the communication with the pharmacist should be enhanced to reduce potential errors and harms. CMM pharmacists have a very important role on solving this as in her/his work, she/he will evaluate the effectiveness and safety of the drug treatment and then suggest modifications if he considers it is not appropriate.
As Cipolle et al. (2012) observe, within the context of pharmaceutical care, the focus of the pharmacist change from the product (the drug) to the person (the patient). This change of focus is clear in Cipolle's (1986) quote "drugs don't have doses -people have doses".

Final Considerations
This study enables a better understanding of the patients' experiences with a comprehensive medication management service delivered in a specialty pharmacy in Brazil. The interviewed patients have difficulties for establishing a solid concept for CMM since none of them had previous knowledge about the service or previous contact with another pharmacist offering a care service. Despite that, on their speeches they talk about aspects they consider pivotal on a consultation: the time dedicated by the professional to listen to their demands, how the practitioner respects their decisions and experiences, the holism and the open dialogue disconnected from the paternalism present on the traditional medical consultations. This way they identify some major cornerstones of the patient-centered care previewed by pharmaceutical care that must be incorporated by the practitioners offering a CMM service.