Health Communication

ISSN: 1041-0236 (Print) 1532-7027 (Online) Journal homepage: http://www.tandfonline.com/loi/hhth20

“How Dare You Question What I Use to Treat This Patient?”: Student Pharmacists’ Reflections on the Challenges of Communicating Recommendations to Physicians in Interdisciplinary Health Care Settings Paul Denvir & Jeffrey Brewer To cite this article: Paul Denvir & Jeffrey Brewer (2015) “How Dare You Question What I Use to Treat This Patient?”: Student Pharmacists’ Reflections on the Challenges of Communicating Recommendations to Physicians in Interdisciplinary Health Care Settings, Health Communication, 30:5, 504-512, DOI: 10.1080/10410236.2013.868858 To link to this article: http://dx.doi.org/10.1080/10410236.2013.868858

Published online: 27 Jun 2014.

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Date: 09 October 2015, At: 04:33

Health Communication, 30: 504–512, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1041-0236 print / 1532-7027 online DOI: 10.1080/10410236.2013.868858

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“How Dare You Question What I Use to Treat This Patient?”: Student Pharmacists’ Reflections on the Challenges of Communicating Recommendations to Physicians in Interdisciplinary Health Care Settings Paul Denvir Department of Humanities & Communication Albany College of Pharmacy & Health Sciences

Jeffrey Brewer Department of Pharmacy Practice Albany College of Pharmacy & Health Sciences

A growing number of pharmacists practice within interdisciplinary health care teams, leading pharmacy educators to place increased emphasis on the development of interprofessional collaboration skills. In the pharmacist–physician relationship, pharmacists’ medication therapy recommendations (MTRs) are a recurrent and significant interprofessional activity, one that can be challenging for both seasoned and student pharmacists. Drawing on in-depth ethnographic interviews with pharmacy preceptors and advanced student pharmacists, we identify and describe an important distinction between pharmacist-initiated MTRs and physician-initiated MTRs as contexts for interprofessional collaboration. We describe and illustrate a range of social, professional, and communication challenges that students experience in each context, as well as some strategies they use to navigate these challenges. Using the theoretical framework of dialectic tensions, we argue that the pharmacist–physician relationship is characterized by a tension between assertiveness and deference. We also offer recommendations to pharmacy preceptors, who can use this article to enhance the experiential education of pharmacists.

The pharmacy profession has undergone a dramatic transformation over the last 30 years, significantly expanding its role in the modern health care system. In the past, pharmacy was associated primarily with medication distribution, but this product-centered model is being supplanted by more patientcentered models (Giberson, Yoder, & Lee, 2011; Indritz & Artz, 1999). These models are visible in the range of medical services that pharmacists offer to patients, including immunizations (Blake, Blair, & Couchenour, 2003), medication therapy management (Garcia, Snyder, McGrath, Smith, & Somma McGivney, 2009), diabetes management (Sisson & Kuhn, 2009) and alcohol and tobacco counseling (Fitzgerald, Watson, McCaig, & Stewart, 2009). Pharmacists are also Correspondence should be addressed to Paul Denvir, PhD, Department of Humanities & Communication, Albany College of Pharmacy & Health Sciences, 106 New Scotland Ave, Albany, NY 12208. E-mail: paul. [email protected]

playing a larger clinical role in interdisciplinary health care settings (Lundquist & Moye, 2009). Although the majority of pharmacists continue to practice in community or retail pharmacies, a growing number practice in inpatient and ambulatory care settings (e.g., internal medicine, family medicine, dialysis clinic), providing direct patient care and collaborating with other providers as part of a health care team. The challenges of interdisciplinary collaboration have led researchers and medical practitioners to place increasing emphasis on the development of interprofessional competence, or “interprofessionality” (Interprofessional Education Collaborative Expert Panel [IECEP], 2011).

RESEARCH PROBLEM This article focuses on a specific interprofessional activity in the pharmacist–physician relationship, one that is both

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recurrent and potentially difficult: pharmacists communicating medication therapy recommendations (MTRs) to physicians. Pharmacists offer various kinds of recommendations, including initiating or discontinuing medications, adjusting dosage, initiating monitoring of labs, and identifying costsaving opportunities, such as shifts to generic versions of medications. These types of recommendations reflect the core expertise of pharmacists in optimizing medicationrelated outcomes. In order to develop a practical, datadriven “toolbox” of communication strategies for pharmacists, additional research is needed on the social and professional complexities that bear on communicating MTRs. This article contributes to that effort by (a) identifying an important distinction between physician-initiated MTRs and pharmacist-initiated MTRs, (b) identifying specific interpersonal and interprofessional communication challenges associated with each type, and (c) identifying potentially useful communication strategies for navigating each type.

LITERATURE REVIEW The aim of interprofessional collaboration is to synergize the interdependent knowledge and abilities of health professionals from different disciplines in order to provide an integrated and cohesive patient care experience (Jones et al., 2012). The success of these integrated approaches to care depends on effective communication among providers, who often have different training, experiences, roles, statuses, and attitudes about interprofessionality. A widely cited paper sponsored by the Interprofessional Education Collaborative (IECEP, 2011) outlines a range of principles and competencies required for effective interprofessional collaboration, including guidance on role clarity and communication skills. Similarly, a paper sponsored by the Institute of Medicine identifies a range of core principles and values for effective team-based care (Mitchell et al., 2012). They include values such as honesty and humility and principles such as shared goals and clear roles. These types of papers provide useful philosophical frameworks for approaching interprofessional collaboration, but are not necessarily intended to provide concrete guidance on the moment-to-moment particulars of everyday medical practice. Part of the issue is that the term “collaboration” subsumes—and thus tends to gloss over—a wide range of specific communicative activities that occur between members of different medical disciplines. Additional research is needed to connect the kinds of macro-level principles laid out by the Interprofessional Education Collaborative and others with the micro-level communicative activities through which interprofessional collaboration is ultimately constituted. Existing research in the pharmacy practice literature indicates that pharmacists’ recommendations play an important role in patient care, but can also introduce complex interprofessional tensions between physicians and

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pharmacists. The clinical benefit of pharmacists’ MTRs has been established both objectively, in terms of patient care outcomes (Abdelhalim, Mohundro, & Evans, 2012; Gillespie, Mörlin, Hammarlund-Udenaes, & Hedström, 2012), and subjectively, through other providers’ positive assessments of pharmacists’ contributions (Kozminski et al., 2012). However, there is also evidence that pharmacists’ MTRs represent a potentially sensitive activity in the pharmacist–physician relationship. Lambert (1995) found that pharmacists tend to employ deferential communication strategies in their interactions with physicians. He attributes this in part to the fact that pharmacists, by virtue of their role in the treatment process, are routinely in a position to clarify, question, or correct physicians’ treatment plans. In many instances, pharmacists initiate MTRs after discovering medication-related problems, such as drug interactions or redundant medications (Berger, 2009). In almost all cases, resolving these issues requires consultation with the physician, who typically has the final prescribing authority. Both parties may experience these consultations as “facethreatening” (Goffman, 1959). Physicians may feel that their medical knowledge, judgment, and autonomy are tacitly called into question when pharmacists assert themselves in treatment decisions. When physicians reject recommendations or treat them as unwelcome and unnecessary, pharmacists may feel that their specialized expertise and value to the team are not fully respected (Gillespie et al., 2012). To address these kinds of concerns, pharmacy educators have placed increased emphasis on interprofessional collaboration skills, shaping future pharmacists to be effective and collegial members of health care teams. One way this has been assessed is through the acceptance/rejection rates of their recommendations. The data are mixed, but generally indicate that students are able to make useful contributions to the team. Lundquist and Moye (2009) found that medical residents accepted 88% of student pharmacists’ recommendations during a 10-month, hospital-based Advanced Pharmacy Practice Experience (APPE), essentially an educational rotation for pharmacists. They found significant differences in the acceptance rates of written recommendations (84%) and verbal recommendations (98%), suggesting that direct verbal interaction plays an important role in the collaborative process. At the other end of the spectrum, McCollum, Nuffer, Ellis, and Turner (2009) found that physicians accepted just 32% of student pharmacists’ recommendations in a rural, community pharmacy-based diabetes management clinic. Studies like these help to identify factors that may impact physicians’ acceptance rates (e.g., written vs. verbal, physician status, setting), but tend not to closely examine the actual communication processes and practices involved. We know little about the specific communication challenges student pharmacists encounter in their interactions with physicians, and the strategies they employ to address them. This article builds upon preliminary research from this project (Denvir, 2012a, 2012b), in which we argue that a

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great deal of pharmacists’ communication with physicians is informed by a dialectic tension between assertiveness and deference. The theoretical framework of relational dialectics (Baxter, 1988) proposes that individuals in relationships are often motivated by competing or contradictory needs and impulses, sometimes called dialectic tensions. From this perspective, relational behaviors and patterns can be understood as adaptive resources for navigating these competing and sometimes irreconcilable desires. Initially developed to describe interpersonal relationships, the theory offered a small number of recurrent tensions in that context, such as the competing impulses for predictability and novelty in romantic relationships. Subsequent research has expanded the theory to address relationship dynamics in more formal institutional settings and has prompted researchers to identify setting-specific dialectic tensions. This approach has been productively applied to interprofessional communication in health care settings, such as Apker, Propp, and Zabava Ford’s (2005) research on dialectic tensions in the enactment of the nurse role. They emphasize tensions around issues of power and hierarchy in modern health care teams, showing how nurses struggle to find the appropriate balance between collaboration and subordination in their interaction with physicians. Along similar lines, we argue that pharmacists experience a dilemma or dialectic tension when making recommendations to physicians. On one hand, pharmacists display a concern with respecting physicians’ expertise and decision-making authority in matters of patient care (deference). On the other hand, pharmacists display a concern with proactively demonstrating their own competence and value in the setting (assertiveness). This concern with demonstrating value is tied to larger trends in the profession to expand the scope and perceived benefit of pharmacy (Giberson et al., 2011). These concerns around assertiveness and deference are not fully contradictory, but do require a sense of balance. Pharmacists who do not display an appropriate measure of deference may be seen as pushy, presumptuous, or intrusive. Those who don’t display appropriate assertiveness may not be taken seriously as a professional, which has consequences not just for that individual but also for the larger project of expanding the role of pharmacy in health care. In various places in this analysis, we make connections between the assertiveness-deference dialectic and the grounded experiential realities of participating in a health care team as a student pharmacist.

supervisors). Four student pharmacists completed two separate interviews. Although the emphasis of this article is on student pharmacists’ perspectives, the preceptor interviews also provided important information and context. The mean length of the interviews is 93 minutes; they range from 38 to 175 minutes. All interviews were transcribed verbatim by an outside contractor and all identifying information was removed or converted to pseudonyms. The fully transcribed data set translates to approximately 1,400 pages of single-spaced text. Participants At the time of data collection, all participants were associated with one fully accredited college of pharmacy in the northeastern United States. There were different recruitment procedures for preceptors and students. We solicited participation from preceptors by e-mailing all members of the college’s Department of Pharmacy Practice, sending regular updates near the start of each 6-week Advanced Pharmacy Practice Experience (APPE) module. These modules are analogous to medical-student rotations, exposing student pharmacists to a range of health care settings and experiences. Of the 38 eligible preceptors in the department, 14 volunteered to participate, resulting in a participation rate of 37%. Participating preceptors also consented to our soliciting their current APPE students by e-mail. Of the 51 students we solicited, 26 agreed to participate, resulting in a participation rate of 51%. No incentives were offered for participation. All participants completed an institutional review board (IRB)-approved informed consent process. Setting All participating preceptors maintained practice sites at a variety of regional medical settings, which also served as rotation sites for APPEs. The college structures its APPE curriculum to encourage exposure to a wide range of medical settings (e.g., inpatient, ambulatory, community/retail, industry, etc.) and specializations (e.g., general practice, family practice, nephrology, rheumatology, infectious disease, cardiovascular, psychiatry, medication therapy management, etc.). In the vast majority of APPE settings included in this study, student pharmacists worked closely with physicians as part of an integrated health care team. Data Collection

METHODS Data This analysis is based on audio-recordings of 44 indepth interviews with 26 advanced student pharmacists and 14 pharmacy preceptors (experiential education

Data were collected over the course of 1 year, from May 2011 through May 2012, in order to capture a complete 1-year cycle of APPE rotations. All student interviews were conducted either during or just after the completion of a 6-week APPE module, so their recollections are likely to be “fresh” and comparatively reliable. The first author conducted semistructured interviews covering a

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wide range of topics, including direct patient care experiences, interprofessional communication and relationships, pharmacy education, and the meaning of professionalism. Consistent with the general aim of qualitative research to gain a nuanced and complex understanding of focal phenomena, participants were encouraged to reflect on and evaluate their experiences, with the interviewer providing conversational prompts, probes, and nudges rather than closed-ended questions. For example, one question from the interview guide was, “Can you tell me about any memorable experiences you had communicating with physicians?” Follow-up questions would depend on the nature of the experience, but might include prompts about the student’s internal experience of it (“Can you describe what you were feeling/thinking when this was happening?”) or selfevaluative prompts (“How would you rate how well you handled that?”). Data Analysis All transcripts were imported into NVivo 9, a qualitative analysis software tool that enables more efficient data processing and sorting. Data were analyzed inductively, using a Grounded Theory framework (Glaser & Strauss, 1967), as well as coding processes and thematic analysis described by Lofland and Lofland (1995). The first author completed initial coding on all transcripts to identify provisional analytic topics/themes and to build collections of similar instances. One such collection contained all instances of discussion about pharmacist–physician communication and relationships (N = 308). Both authors then completed focused coding of that collection to produce a number of subcollections, many of which focused on a specific collaborative activity (e.g., drug information questions, recommendations, patient education requests). The subcollection on recommendations included 97 instances; both authors independently completed analytic memoing of this subcollection for intersubjective validation of interpretations. We then discussed our memos extensively, employed the constant comparative method to compare/contrast instances within the collection and across other collections, and identified deviant cases.

ANALYSIS Our data revealed two different contexts in which student pharmacists communicated MTRs to physicians. Previous research on pharmacists’ recommendations has not been sufficiently sensitive to the differences between these contexts. One context was when a physician had sought a recommendation from a student pharmacist or from the pharmacy team, which we refer to as a physician-initiated MTR. The other context was when a student pharmacist volunteered a recommendation without prompting by the physician, which we refer to as a pharmacist-initiated MTR. These two contexts

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differ significantly in terms of the social and professional footing from which the recommendation is communicated. Physician-initiated MTRs may be experienced as responsive and supportive (i.e., “helping out), whereas pharmacistinitiated MTRs may be experienced as presumptuous or corrective (i.e., “butting in”). Although our data led us to conclude that pharmacist-initiated MTRs were significantly more sensitive and difficult for students, both contexts presented unique social and professional challenges. Physician-Initiated Medication Therapy Recommendations We observed two primary challenges for student pharmacists when making physician-initiated MTRs. One basic challenge was to recognize when and how physicians actually make MTR requests, which can require listening skills and attention to subtle social cues. As we show, not all requests for an MTR are done directly or explicitly. A more complex challenge was to “answer the right question,” a phrase that one preceptor and several of her students used to describe situations in which a physician’s question to the pharmacy team is actually not the best question to address a patient care issue. Recognizing an MTR request: Indirectness and social cues. In many instances, physicians’ requests for MTRs are explicit and direct. For example, one student described an encounter in which a physician approached the pharmacy team and asked whether or not a patient who was on the “borderline” of developing osteoporosis should receive medication therapy for it. This rather straightforward MTR request can be contrasted with more subtle and indirect openings for pharmacy input. In the following quotation from a student pharmacist on a specialty inpatient APPE, a physician had invited the student to sit in on a patient consultation. Although the physician had not yet asked the student any direct questions on this rotation, the student felt there were instances in which the physician was indirectly nudging him to weigh in on a treatment decision: The doctor will look at the medication list and see if he wants to make any changes. “How are you tolerating this if we increase that?” And you know I’ll be sitting there and very rarely will the doctor—I [haven’t had] any questions yet. But the doctor will say something like, “I want to increase the dose of a drug that helps the swelling” and look at me like you know, do you agree?

This student pharmacist suspected that the physician was using indirect social cues to invite him to offer his perspective. One very broad social cue was inviting the student pharmacist to sit in on the consultation in the first place, which obviously does not amount to an MTR request, but does imply an open, collaborative relationship. When the

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physician would make eye contact with him after proposing a possible medication change, the student inferred that the physician was indirectly asking if he agreed with that change (“look at me like you know, do you agree?”). The student later indicated that he had not yet spoken up in these moments, but sensed it would be welcome. We found similar comments in student pharmacists’ discussions of participating in rounds/meetings with health care teams. In some cases, physicians would directly request input from the pharmacy team; in other cases, students sensed that they had an unspoken invitation to weigh in on drug management issues, but struggled to assert themselves at appropriate moments in the flow of discussion. It is possible that some physicians avoid a direct approach so students will not feel put on the spot, which is a thoughtful approach in experiential education. At the same time, using unspoken arrangements or subtle nonverbal social cues such as eye contact can present a challenge for students who are still negotiating the right balance of assertiveness and deference. If a student were to misread a social cue and offer a recommendation presumptuously (especially in front of a patient), the relationship might be damaged. At the other end of the spectrum, if a student consistently fails to respond to these subtle openings, physicians may begin to doubt the student’s expertise or willingness to get involved. Answering the right question. Both preceptors and student pharmacists reported instances in which physicians’ requests for an MTR led pharmacists to discover deeper patient care issues than the initial request might have suggested. In these instances, rather than simply answering the question as asked, student pharmacists are encouraged to look for the “right question,” meaning that they should seek to understand and address the underlying therapeutic issues. One student from a general outpatient APPE explained this approach: My preceptor actually has said before that physicians will come to you with a question but sometimes the question really isn’t the question. You have to ask questions to kind of narrow down what they’re actually asking. I mean yeah, someone can say, “Oh if this drug doesn’t work then what’s the next drug?” “Well in what patient? What meds are they taking? Do they have risk factors?” You have to take all of that information and then optimize their whole therapy.

One potential difficulty in this approach is that physicians may feel that their initial question has been disregarded or that the pharmacist is tacitly exposing a lack of sophistication in the way the physician is approaching therapeutic options. The same student shared a story in which her attempt to answer the right question was, in her words, “very frustrating.” The story began with a physician bringing a fairly specific drug information question to the pharmacy team: She was a new patient to the clinic. So the doctor—it was a resident—brought it to us and was like, “Hey, here is the

patient case and she’s using Calcitonin for her osteoporosis and it’s not agreeing with her so what other drug can we give her?” So [my preceptor] gave that one to me and then I went through pretty much her whole profile and picked out the big problems. . . . After looking into the patient and bringing all the problems together, I thought that they were overlooking one major issue called hyperparathyroidism, which could contribute to anxiety, depression, loss of appetite, diarrhea and constipation, unsteady gait, all of these symptoms she had. Since she was going to multiple specific doctors there wasn’t one person to look at the whole big picture. So I kind of mentioned this to [the physician] and she was—and I felt like it was because I was a student—she didn’t really take it into consideration and kind of put it to the side.

Several aspects of this story help to illustrate the challenges of answering the right question. Note that the physician’s MTR request was focused and closed-ended (“what other drug can we give her”). It is designed for a very specific type of help from the pharmacy team, an alternative medication for osteoporosis. While this is certainly a legitimate MTR request, the student pharmacist came to believe that it was not exactly the “right” question for this patient. Rather than recommending a single medication change to manage side effects, which is what the physician requested, she suspected that the patient might have developed hyperparathyroidism and needed someone to consider “the whole big picture.” This put into motion a complex interprofessional dynamic for the student, who felt she should actually address a different question than the physician had originally asked. In this case, the student felt that her hyperparathyroidism theory was essentially dismissed by the physician. The student pharmacist acknowledged that she struggled with how to present her theory to the physicians. She recognized that answering the right question sometimes runs the risk of alienating the very colleagues with whom she was trying to establish positive interprofessional relationships. She explained: I mean you don’t want to tell the doctors, “You’re doing your job incorrectly.” I mean that is kind of standoffish and that’s why I didn’t know how to present it to the doctors. Like maybe they thought, “Oh, well why didn’t I think of that? And she is just a student.” Like, I don’t know, I never like to overstep my boundaries and maybe piss off doctors.

This instance of attempting to “answer the right question” could be considered especially assertive in that the student was wading into diagnostic waters, the traditional domain of the physician. Her commentary clearly reflects some ambivalence about engaging in this activity, even though it appears that her motivations were fully patientcentered. When “answering the right question” involves reconsidering previous diagnostic conclusions, deference in communication tactics may be especially important.

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Pharmacist-Initiated Medication Therapy Recommendations Pharmacist-initiated MTRs appear to create more friction around professional boundaries, in part because they represent a form of unsolicited advice. Social scientific research on advice-giving in interpersonal relationships has shown that solicited advice is received much more positively than unsolicited advice, which can feel intrusive or presumptuous (Goldsmith & Fitch, 1997). It can also imply that the advisee has mishandled a situation or that she or he cannot solve her or his own problems. Student pharmacists were concerned that their unsolicited recommendations could be perceived as “butting in” or as tacit criticisms of the physician’s treatment approach. These concerns are certainly not baseless; many students shared stories in which their recommendations to physicians were met not just with resistance, but with hostility and territoriality. One student shared a story about a difficult experience with a physician in a hospital setting. The pharmacy team had access to labs, including sensitivity reports that showed which antibiotics would be most appropriate for a specific bacterial infection: So I had a doctor that put a patient on let’s say penicillin. I don’t know what it was but it was something very general that treats most things, and it came back resistant and that there was another medication that would’ve treated it better. And then the [precepting] pharmacist says to me, “Oh, why don’t you page him and let him know that he’s got to change it?” because, I mean, we can’t change the medication, we can only say like, “Hey, we noticed this” and it’s sort of uh, we’re helping them out. Like, they’re so busy rounding, they might not get a chance to look at that report until the next day and now they’ve been on antibiotics for two days that aren’t doing anything for them. So I paged him and he called back the pharmacy and I answered. The physician was very upset and he said, “How dare you question what I use to treat this patient?” I said, “You know, we just got the sensitivity reports back and it’s saying that it’s resistant” and he said, “Well isn’t that funny. I mean, my patient is getting better. I know what I’m doing, don’t ever question me again.”

This story clearly illustrates how pharmacists’ recommendations can engender concerns about professional competence. From the student’s perspective, the physician had an emotional reaction (“very upset”) and appeared to not only reject the specific recommendation, but also strongly rebuke the student for even making the recommendation (“How dare you”). The physician also perceived the recommendation as “questioning” his judgment. Although this was probably not the student’s intent, recommendations can be perceived as a tacit criticism of the physician’s previous and current therapeutic decision making. In explicitly asserting his professional competence (“my patient is getting better. I know what I’m doing”), the physician oriented to the student’s recommendation as a challenge to that competence. The student’s story had a surprising conclusion:

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The next day, during morning rounds, the student noticed that the physician had in fact changed the antibiotic to the one the student had recommended, but did so without ever acknowledging the student’s contribution or apologizing for his reaction. The student found this confusing and upsetting, even expressing reticence about making recommendations in the future. Setting aside questions of professional ethics and collegiality, we would emphasize that a student pharmacist can get the therapeutics right, but still end up in rather complex and discouraging interprofessional terrain. In this section, we describe three key challenges that student pharmacists encountered when learning how to make pharmacist-initiated MTRs, all of which involve striking a balance between assertiveness and deference. First, we show how students bring potential medication-related problems to physicians’ attention, which is often part of the larger package of making a pharmacist-initiated MTR. Second, we show how students recommend medication changes while minimizing the appearance of correcting the physician. Finally, we show how students emphasize the physician’s final decision-making authority when they offer recommendations. Bringing medication-related problems to physicians’ attention. While on rotation, student pharmacists learned not to make hasty assumptions about information in patients’ charts. Even when they discovered something seemingly problematic, most recognized that it was important to ask questions before jumping to the conclusion that a mistake had been made. One approach in these situations is to embrace the student aspect of their role and position the physician as a teacher, helping to explain his or her therapeutic approach. As one student explained: I’ve noticed problems with patients where I’ve come to [physicians] and said, “I can’t figure this out. I don’t know enough about this. Can you help me explain this, why you put them on medication X? I don’t see why this would be best for them. Can you explain to me why you got here or what you were thinking?” And hopefully in a non-confrontational way, where I’m not saying, [with aggressive tone] “Why did you do this?” But hopefully, in a collaborative way, where it’s like, “Okay, I see you did this. Can you explain to me why? Maybe it is the right answer. Maybe I’m just missing it.”

With this approach, the student pharmacist raised the possibility that there was a problem to be addressed, but gave the physician a chance to explain the reasoning behind the choice. She embraced the student aspect of her role, openly acknowledging her limitations and framing the conversation as a learning experience (“I don’t know enough about this” and “Maybe I’m just missing it”). This is a strategically deferent way to perform the assertive action of questioning a treatment decision. Depending on the physician’s reasoning, the student pharmacist could then abort the MTR, alter the

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MTR, or, if the reasoning is not sound, press ahead with the MTR. Minimizing the appearance of correction: Framing “bad” choices as “suboptimal”. Even when student pharmacists were fairly certain that a physician’s treatment decisions were problematic, they still communicated in ways that minimized the appearance of correcting a mistake. One student from a nephrology setting shared a story in which a physician had prescribed Symlin, a diabetes medication, even though there were three separate contraindications for that patient. Although the student was not directly responsible for that patient, he worked closely with the student who was responsible. We chose this extract for presentation, in part, because of the marked contrast between the pharmacy team’s view of the physician’s decision and the way the student actually chose to communicate the team’s recommendation. This extract also illustrates a language strategy that was commonplace in our data. In essence, student pharmacists tended to speak in term of optimal therapies, rather than “good” and “bad” therapies. As we show, this can function as a face-saving strategy when pharmacists recommend a change in patient medication. This patient had all three conditions, so [the other student] was kind of explaining to me how outrageous it was, again, going back to how the doctor can make a mistake. We then call the doctor and we got the patient off that drug right away, because it was a very, very bad choice. [The other student] was on the phone, the preceptor is kind of just listening in. It’s a newer drug but the contraindications are if you have any type of gastrointestinal disease; this guy had short bowel syndrome so they removed half of his small intestine. If you’re not compliant with your medication you shouldn’t be on it; this guy didn’t take anything. And then if you’re A1C level is higher than 9 you shouldn’t take it; he was like 10. So he had all three contraindications and by all means shouldn’t be taking this medication. And this guy has been on it for a while and that to me was outrageous for the doctor to do something like that.

Although the pharmacy team regarded the Symlin prescription as “outrageous” and “very, very bad,” the student who actually communicated with the prescribing physician took a much more measured tone: She wasn’t rude about it. She was explaining to him, “There are contraindications out there and then warnings that are out there and this patient did in fact present with these three and we feel like it’d be a better option if we change them to regular insulin.” When she was talking to us obviously it was more, this doctor is an idiot, but she wasn’t going to use that same tone with the doctor; she’s got to show respect to the doctors. So when she was talking to him, it was, “You know we do feel like, from what we’ve seen, we feel like it’d be a better recommendation.” She can’t call him up and say, “You’re an idiot. You should know better.” But for us obviously we’re joking around, you know, I can’t believe he’d write something like this, this is not right, this is very stupid,

to be honest this is not a good recommendation. But when she’s calling him obviously she had to show a bit of respect and you know, “We do feel that it’s a better decision to stop it.”

In three places, the student used the adjective “better” (“better option,” “better recommendation,” and “better decision”). This language choice has important implications for how a recommendation might be perceived. “Better” implies that the Symlin choice was “good,” just not optimal. We know from the other commentary that the student pharmacists viewed this medication choice as “very stupid.” The student took the opportunity to educate the physician about Symlin, which she may have regarded as her professional obligation at that point, but did not expose just how poor a decision the physician had made. In fact, “better” gave the physician much more credit than was due. As the student noted, “she’s got to show respect to the doctors.” It appears that even when a medication-related problem would seem to call for highly assertive, even corrective types of communication, student pharmacists maintain a deferent orientation toward physicians. Emphasizing the physician’s final decision-making authority. Some student pharmacists were concerned that their recommendations could seem pushy and were careful not to presume too large a role in final therapeutic decisions. They developed some communication strategies to help achieve the right balance of assertiveness and deference. One such strategy was using a version of the preface, “If it were me, I would . . . ” Students spoke this way in order to acknowledge the limits of their role and to foreground the physician’s decision-making authority. One student from a general outpatient setting explained his approach: Student: And I said, “Based on the patient’s history and I went over the pain scale with [the patient] and when it affects them, I think they’d really benefit from NSAIDs [nonsteroidal anti-inflammatory drugs]. If it were me, I would give him Naproxen 500 twice a day.” And [the physician] was like, “Okay” and went in to give him Naproxen 500 twice a day. Interviewer: I’m curious, why do you say, “If it were me I would?” S: I mean just because I don’t want to make it seem like I am telling them what they have to do. Like, it’s still their patient. It’s still their choice but this is what I would do if I were in your shoes. So I’m not like taking their place. They’re where they are. I am on the outside giving a recommendation. I am not telling you what you have to do. You can feel free to disagree with me. I guess that’s kind of why I do it.

The preface, “If it were me, I would . . . ” allows a student to assert the full weight of his or her expertise behind the idea, while still recognizing that it is not actually his or her decision (“I am on the outside giving a recommendation”). This is a subtle language choice, but one that can help

HOW DARE YOU QUESTION?

students frame their recommendations in ways that display appropriate respect for the hierarchy of the medical team.

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DISCUSSION AND RECOMMENDATIONS Health communication scholars are in an excellent position to complement broad philosophical frameworks on interprofessional collaboration (e.g., IECEP, 2011) with research that digs in empirically on the specific communicative activities through which collaboration is actually realized. This analysis demonstrates that medication therapy recommendations represent a significant and potentially challenging interprofessional activity between student pharmacists and physicians. We have identified a range of complexities that bear on student pharmacists’ development of competence in this area, as well as potentially promising strategies for navigating those complexities. We believe these findings would be especially useful for experiential educators in pharmacy (i.e., preceptors), who can use this as a resource for designing empirically based didactic instruction at the start of APPE rotations, facilitating student reflection and self-analysis throughout their rotations, or constructing data-based assessment instruments for evaluating interprofessional communication skill development. From a theoretical perspective, this article also represents a fruitful application of the assertiveness–deference dialectic tension (Denvir, 2012a, 2012b) that informs a great deal of contemporary pharmacist–physician collaboration. We would argue that pharmacists’ MTRs are inherently assertive social actions, in that they are designed to bring pharmaceutical expertise to bear on decisions that are ultimately the responsibility of physicians. Many of the strategies we identify in this article can be understood as attempts to perform this assertive action in ways that display an appropriate measure of deference for the physician’s role as the health care team leader. For example, the challenge of “answering the right question” potentially involves a range of assertive or even aggressive social actions, such as disagreeing with the physician’s treatment approach, correcting the errant assumptions built into the physician’s question, or disregarding the substance of the original question in order to address the “right” question. These sorts of social actions are recurrently disjunctive and face-threatening. The assertiveness–deference dialectic draws our analytic attention to the ways in which deferent communication strategies, such as enacting the role of learner, can be used as a more collegial package for performing actions that might otherwise appear too assertive for those in the role of the student pharmacist. Future research on interprofessional collaboration may benefit by making similar distinctions between the underlying social actions that co-professionals are sometimes asked to engage in (disagreeing, correcting, refusing, etc.) and the “surface level” of language through which these actions are performed. While we cannot change the fact that

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teamwork sometimes requires disjunctive types of actions, a measure of deference at the level of language can at least demonstrate to recipients that care was taken to acknowledge and soften the disjunction. We stress that this type of strategic deference is not necessarily an expression of powerlessness; rather, it is a form of situationally adaptive communication within a hierarchical structure. The pharmacists we interviewed—both students and preceptors—felt that it was quite appropriate for physicians to function as health care team leaders and did not view themselves as vying for control over therapeutic decisions. Rather, they emphasized the primacy of the physician–patient relationship and saw themselves as supporting team members. One pharmacy preceptor routinely told his patients (and his students) that the physician should be regarded as the “captain” and the pharmacist as the “first mate,” a simple and effective metaphor that captures the sense of legitimate hierarchy while also emphasizing the value of the pharmacist. We are sympathetic to recent research that has taken a more critical stance toward the prospects of democratic or egalitarian team-based health care (e.g., Finn, Learmonth, & Reedy, 2010), especially the acknowledgment of competing agendas that are built into any institutional structure. We see efforts to balance assertiveness and deference as a productive starting point for discursively negotiating those agendas without undermining the collegiality that is necessary for patient-centered interprofessional collaboration. Limitations and Directions for Future Research This analysis was based on data from a single college of pharmacy in the northeastern United States. Findings may reflect the culture of that institution rather than the entire profession of pharmacy. Readers should be cautious in overgeneralizing what we observed to other institutions or geographic regions. Several other voices should be emphasized more fully in subsequent research. This research design did not include the physician voice, the other half of this interprofessional dyad. Previous research (e.g., Apker et al., 2005) has shown that physicians experience complementary power dilemmas from their hierarchical position relative to nurses, and it could be important to examine this dynamic in the context of pharmacist–physician relationships. Pharmacists are currently expanding their professional territory and could be seen as more proximate to physicians in terms of education, training, power, or status within the health care team. We know very little about how physicians actually process interpersonal encounters with collaborating pharmacists. It would be useful to know whether physicians are attentive to the assertiveness and/or deference expressed in pharmacists’ recommendations. Future research should also examine pharmacy preceptors’ perspectives on MTRs. As more seasoned and respected representatives of the

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pharmacy profession, they may orient to the assertiveness– deference dialectic differently or may have developed more polished strategies for navigating the underlying tensions. Future quantitative research on acceptance/rejection rates of student MTRs may benefit by factoring in whether the recommendation was initiated by the physician or pharmacist. We regard this as a potentially significant factor in how the recommendation is both offered and received, one that has received virtually no research attention to date. Although we do not yet know enough to offer formal hypotheses, we suspect that there may be differences in the acceptance rates or practitioner satisfaction rates between these two conditions. Finally, the communication challenges and strategies we identified in this article should be developed into explicit educational initiatives in pharmacy education, with an eye toward evaluating the relationships between the use of such strategies and other outcomes of interest.

FUNDING This research project was supported by a Scholarship of Discovery grant awarded by Albany College of Pharmacy & Health Sciences.

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