I. !
Put Yourself into the OIC
Professional
Picture-Professionally
Management
Last year, Americans bought almost $5 billion worth of over-thecounter (aTC) medications. An ever increasing share (now 40%) of this market has been going to nonpharmacy outlets such as food supermarkets, discounters, department stores, and convenience outlets. 1 Ignoring or adopting the sales promotion tactics of nonpharmacy .competitors can only be detrimental to the pharmacist's professional image. To reverse the trend, pharmacists need to assert themselves professionall y . The aTC drug department is unique in the pharmacy because of the opportunity it gives pharmacists to act in a primary care capacity while maintaining a competitive stance in the market place. In the prescription department, pharmacists are constrained by a web of regulations and the complexities of physician/pharmacist/patient interrelationships. Frequently, much more latitude for professional judgment exists in the aTe drug department. Here, if they so choose, pharmacists can actively help people self-medicate wisely. In this department as in perhaps no other, the pharmacist's dual role as merchant and health professional is evident. It is too easy to think of OTC drugs as being similar to other products such as greeting cards, flash bulbs, and shoelaces. In fact, a casual inspection of pharmacies in any urban area provides evidence that many pharmacists have adopted this attitude, at least implicitly. Nonprescription drugs are displayed on self-service counters
David A. Knapp, PhD, is professor and Robert S. Beardsley, PhD, is assistant professor, department of pharmacy practice and administrative science, University of Maryland School of Pharmacy, Baltimore, MD 21201.
By DAVID A. KNAPP and ROBERT S. BEARDSLEY
sideration: • Selection of products for inventory; • Accessibility of products; • Promotion and advertising policy; • Role of professional and nonprofessional staff; • When and how pharmacists should deal with patients . Selection of Products
and merchandised in the same manner as in nonpharmacy outlets. Some pharmacists eagerly and uncritically embrace the point-ofpurchase displays and cooperative advertising efforts of over-thecounter manufacturers without considered professional judgment. Someti!lles it is impossible to tell the difference between the aTe drug departments in pharmacy and nonpharmacy outlets, even to the total absence of a supervising pharmacist. Most pharmacists, of course, have not adopted this extremely commercial model. Although aTe drug products may be displayed on selfservice, pharmacists are at least accessible for consultation if patrons seek them out. However, pharmacists could improve their aTe drug department performance, both professionally and economically, if they were to ass~rt themselves more aggressively and differentiate their practice from nonpharmacy sources of drugs. How can this be done? There are several areas that need serious con-
American Pharmacy Vol. NS19. No. 10. September 1979/549
There is no reliable count of how many over-the-counter products are on the market; HEW has estimated that there may be more than 300,000. Obviously, no pharmacy can handle them all. Many productstocking decisions are obvious, based on widespread consumer demand. Pharmacists should examine the ingredients, formulation, and claims of all products carefully, however, before deciding to stock them. Fulfilling a professional role involves assessing what patients need as well as what they demand. Thus some widely promoted products may be sought by patients but judged unworthy by pharmacists. Examples include many products promoted for weight reduction and "fad" substances such as "vitamin B I5 ·" Pharmacists should make technical decisions on drugs of choice in a variety of therapeutic categories in order to stock products that they can recommend with confidence. These decisions require an examination of the scientific and professional literature. The Handbook of Nonprescription Drugs 2 is of great value in this area. As a general guideline for aTe . drug product selection, it helps to ask these questions: • Has the product class been reviewed by the appropriate FDA aTe pan~l, and if so, does the spe·· 37
cific product meet the standards recommended by the panel? • Is there physical evidence of good product formulation and packaging? • Is the manufacturer known and reputable? • Are the advertising and promotion misleading? • Are the cost, selling price, and other marketing factors reasonable? Accessibility of Products Professional judgment is also required in determining how and where products are to be displayed or kept in the pharmacy. Some products may require more personal consultation than others. Many pharmacists (and APhA) advocate a third class of drugs, available to the public only through pharmacists. It follows, then, that there are some products such as ophthalmics, otic preparations, reducing aids, sleep aids, and certain cough and cold preparations which should not be available on self-service but should be stocked such that a pharmacist is required to obtain them. It is certainly not necessary or advisable to completely eliminate selfservice for OTCs. Many purchases for nonprescription items are made from habit, and there is generally little need for personal consultation except in unusual cases. Pharmacists should be alert for situations that do call for consultation. For example, there may be a need to break a patient's habit of purchasing a particular product if formulation or patient variables change. With the implementation of the OTC review, many products are undergoing formula modifications, which under certain circumstances can be crucial. Pharmacists should develop methods of calling these changes to the patient's attention (since manufacturers often do not), perhaps by posting a suitable placard adjacent to the product under considera tion. Promotion and Advertising One of the most difficult dilemmas facing thoughtful pharmacists
38
is the type and extent of OTC sales promotion in the pharmacy. Shelf facings, point-of-purchase displays, and advertising allowances from manufacturers undoubtedly can increase sales, but pharmacists should not let the pursuit of profits compromise professional judgments. In September 1976 the Journal of
• Any time symptoms are discussed; • When the patient is under two years of age; • When the clerk feels unsure of the nature of the complaint or appropriateness of the remedy.
the American Pharmaceutical Association devoted an entire issue to the
Before the pharmacist undertakes to intervene in an OTC transaction, the criteria for effective interaction should be understood: • The patient's perception of the need for and the value of more information; • The patient's perception of the pharmacist as a capable provider of the information; • The pharmacist's knowledge and ability to supply the information; • The pharmacist's self-confidence in this professional role; • An environment that provides uninterrupted communication between patient and pharmacist. Often, patients feel that they have neither the time nor the need to learn about OTC medication. Pharmacists feel too busy to answer patients' questions completely, or they may sense patient uninterest. These impressions seem to be unfounded, however. An FDA study revealed that 45% of persons interviewed thought that more information concerning OTC products should be made available. 3 In addition, an in-depth study of selfmedication decision making fou nd that the most important factor reported in influencing someone to buy an OTC drug for the first time was the pharmacist. 4 To provide the right information at the right time, pharmacists m ust determine what patients need to know about the selection and use of a particular product and what they already know about the product. Deciding what patients need to know is based on the pharmacist's professional judgment about what is relevant, given the patient's individual needs and characteristics. Evaluating what they know already is critical, since patients may have
topic of OTC drug advertising. Many of the articles were highly critical of some of the techniques used to promote OTC drugs. Pharmacists who embrace the content and techniques of truthful but subtly deceptive promotion throw a cloak of professional respectability over such attempts and tarnish their own efforts to be objective in product recommendations. Pharmacists must retain and exert control over all promotion and display activities in the OTC drug department and should not allow them to be delegated to nonpharmacist personnel, including the merchandising specialists of corporate pharmacies, manufacturer's or distributor's representatives, or clerks. Certain types of promotion, such as offering commissions on the sale of some products, are never acceptable in the OTC drug department, since they foster inappropriate selection and overuse of OTC products. It is also not accepfable to promote or distribute house brands unless they represent rational therapy and are of appropriate quality. Role of Staff Product category distinctions should be clear to both professional and nonprofessional staff so that all are aware of their responsibilities. Even if a system has been established by the managing pharmacist, it will not operate effectively unless staff pharmacists and supportive personnel understand it and carry it out. In general, a transaction requires the pharmacist: • When the patient returns in a short period of time to purchase the same or similar product;
Dealing with Patients
American Pharmacy Vol. NS19, No. 10, September 1979/550
misinformation that could result in inappropriate use. The level of patient knowledge can be assessed by asking nonthreatening, probing questions and obtaining feedback. The Handbook of Nonprescription Drugs provides examples of questions. Patients may already know all the important information about the product. In this case, further education is not necessary and may be resisted or resented. However, reinforce ment by pharmacists is always appropriate to assure that patients retain correct information. Pharmacists also must decide how information should be presented. Educational research has foun d that verbal communication is more effective for retention over short to medium time periods, while written is more effective over long periods, since people have a chance to refer to the information periodically.5 Combining both verbal and written information is more effective than using either separately. Pharmacists should develop or obtain pamphlets or information sheets on appropriate products and should provide verbal reinforcemen t as necessary. Informal questioning can help assure that patients have a clear understanding of the proper use of the product. A tactic used by some pharmacists is to place signs or posters next to any OTC products with potential difficulties; thus patients with certain diseases or problems would be alerted to the dangers and would be advised to speak with the pharmacist before selecting an arc drug. For example, since many cough preparations contain large amounts of sugar, diabetics may be warned to select these preparations carefully. Recommended products may be listed on the sign, or the patient can be directed to the pharmacist. These in-pharmacy tactics can be reinforced by conducting out-ofpharmacy educational efforts, such as speaking to community groups about OTC medications, writing columns in local newspapers, or distributing educational materials to
'The only thing that differentiates the OTe department in a pharmacy from that in a food store is the pharmacist.'
the general public. Well-executed efforts such as these could remove many patient misconceptions and myths about OTC medications, help make patients aware of the need for additional information before selecting and using drugs, and reveal the availability of a knowledgeable and underused resource, the pharmacist. Patient education efforts sometimes fail because of barriers to effective pharmacist/patient interactions. For example, the pharmacy's environment might not be conducive to private discussion, since the pharmacist typically is found behind a prescription counter or a glass partition. Some patients do not perceive the pharmacist as a source of accurate, unbiased information about aTe drugs. Economic factors and the amount of time available for counseling also limit counseling opportunities. If pharmacists decide to assert themselves by educating patients, they must identify existing barriers and remove them.
American Pharmacy Vol. NS19, No. 10, September 1979/551
Key to OTe Professionalism Pharmacists should assert themselves by counseling patients on the appropriate selection and use of OTC medications. Many patients select and use according to misperceptions or myths perpetuated by OTC drug advertising and promotion. In addition, certain products are inappropriate in particular disease conditions or when taken concomitantly with other drug products. It is well documented that many patients do not read the labels of arc drugs and thus may miss even the most prominent written warning statements. Reinforcement with oral warning is often necessary and always appropriate. It is important to understand that the active intervention advocated is selective. It is not necessary to attempt to give advice to every patient on every purchase. Patients do not want to have to ward off eager pharmacists .seeking to establish a complete drug and medication history to replenish the family stock of aspirin tablets. On the other hand, most patients will appreciate the judicious intervention of pharmacists who have the health of the patient in mind. To ask the right kinds of questions and to offer the right kind of advice requires more than just appropriate technical knowledge. It requires a concern for the patient as an individual and the development of interpersonal skills which will facilitate good communications. Remember: the only thing that differentiates the OTC drug department in a pharmacy from a similar department in a food store is the pharmacist. Appropriate · assertiveness as a practicing health professional is the key to retaining and enlarging a satisfied clientele. References 1. Drug Topics, 123(11), 27 (1979). 2. "Handbook of Nonprescription Drugs," 6th ed ., APhA, Washington, D.C., 1979. 3. D.E. Knapp, et ai., Apothecary, 88, 8 Ouly-Aug. 1976). 4 . D.E. Knapp, et ai., Med. Marketing Media, 10(11), 29 (1975) . 5. J.e. Clinite and H.F. Kabat, ,. Am . Pharm . Assoc., NS16, 74 (1976).
39
Put Yourself into the OIC
Professional
Picture-Professionally
Management
Last year, Americans bought almost $5 billion worth of over-thecounter (aTC) medications. An ever increasing share (now 40%) of this market has been going to nonpharmacy outlets such as food supermarkets, discounters, department stores, and convenience outlets. 1 Ignoring or adopting the sales promotion tactics of nonpharmacy .competitors can only be detrimental to the pharmacist's professional image. To reverse the trend, pharmacists need to assert themselves professionall y . The aTC drug department is unique in the pharmacy because of the opportunity it gives pharmacists to act in a primary care capacity while maintaining a competitive stance in the market place. In the prescription department, pharmacists are constrained by a web of regulations and the complexities of physician/pharmacist/patient interrelationships. Frequently, much more latitude for professional judgment exists in the aTe drug department. Here, if they so choose, pharmacists can actively help people self-medicate wisely. In this department as in perhaps no other, the pharmacist's dual role as merchant and health professional is evident. It is too easy to think of OTC drugs as being similar to other products such as greeting cards, flash bulbs, and shoelaces. In fact, a casual inspection of pharmacies in any urban area provides evidence that many pharmacists have adopted this attitude, at least implicitly. Nonprescription drugs are displayed on self-service counters
David A. Knapp, PhD, is professor and Robert S. Beardsley, PhD, is assistant professor, department of pharmacy practice and administrative science, University of Maryland School of Pharmacy, Baltimore, MD 21201.
By DAVID A. KNAPP and ROBERT S. BEARDSLEY
sideration: • Selection of products for inventory; • Accessibility of products; • Promotion and advertising policy; • Role of professional and nonprofessional staff; • When and how pharmacists should deal with patients . Selection of Products
and merchandised in the same manner as in nonpharmacy outlets. Some pharmacists eagerly and uncritically embrace the point-ofpurchase displays and cooperative advertising efforts of over-thecounter manufacturers without considered professional judgment. Someti!lles it is impossible to tell the difference between the aTe drug departments in pharmacy and nonpharmacy outlets, even to the total absence of a supervising pharmacist. Most pharmacists, of course, have not adopted this extremely commercial model. Although aTe drug products may be displayed on selfservice, pharmacists are at least accessible for consultation if patrons seek them out. However, pharmacists could improve their aTe drug department performance, both professionally and economically, if they were to ass~rt themselves more aggressively and differentiate their practice from nonpharmacy sources of drugs. How can this be done? There are several areas that need serious con-
American Pharmacy Vol. NS19. No. 10. September 1979/549
There is no reliable count of how many over-the-counter products are on the market; HEW has estimated that there may be more than 300,000. Obviously, no pharmacy can handle them all. Many productstocking decisions are obvious, based on widespread consumer demand. Pharmacists should examine the ingredients, formulation, and claims of all products carefully, however, before deciding to stock them. Fulfilling a professional role involves assessing what patients need as well as what they demand. Thus some widely promoted products may be sought by patients but judged unworthy by pharmacists. Examples include many products promoted for weight reduction and "fad" substances such as "vitamin B I5 ·" Pharmacists should make technical decisions on drugs of choice in a variety of therapeutic categories in order to stock products that they can recommend with confidence. These decisions require an examination of the scientific and professional literature. The Handbook of Nonprescription Drugs 2 is of great value in this area. As a general guideline for aTe . drug product selection, it helps to ask these questions: • Has the product class been reviewed by the appropriate FDA aTe pan~l, and if so, does the spe·· 37
cific product meet the standards recommended by the panel? • Is there physical evidence of good product formulation and packaging? • Is the manufacturer known and reputable? • Are the advertising and promotion misleading? • Are the cost, selling price, and other marketing factors reasonable? Accessibility of Products Professional judgment is also required in determining how and where products are to be displayed or kept in the pharmacy. Some products may require more personal consultation than others. Many pharmacists (and APhA) advocate a third class of drugs, available to the public only through pharmacists. It follows, then, that there are some products such as ophthalmics, otic preparations, reducing aids, sleep aids, and certain cough and cold preparations which should not be available on self-service but should be stocked such that a pharmacist is required to obtain them. It is certainly not necessary or advisable to completely eliminate selfservice for OTCs. Many purchases for nonprescription items are made from habit, and there is generally little need for personal consultation except in unusual cases. Pharmacists should be alert for situations that do call for consultation. For example, there may be a need to break a patient's habit of purchasing a particular product if formulation or patient variables change. With the implementation of the OTC review, many products are undergoing formula modifications, which under certain circumstances can be crucial. Pharmacists should develop methods of calling these changes to the patient's attention (since manufacturers often do not), perhaps by posting a suitable placard adjacent to the product under considera tion. Promotion and Advertising One of the most difficult dilemmas facing thoughtful pharmacists
38
is the type and extent of OTC sales promotion in the pharmacy. Shelf facings, point-of-purchase displays, and advertising allowances from manufacturers undoubtedly can increase sales, but pharmacists should not let the pursuit of profits compromise professional judgments. In September 1976 the Journal of
• Any time symptoms are discussed; • When the patient is under two years of age; • When the clerk feels unsure of the nature of the complaint or appropriateness of the remedy.
the American Pharmaceutical Association devoted an entire issue to the
Before the pharmacist undertakes to intervene in an OTC transaction, the criteria for effective interaction should be understood: • The patient's perception of the need for and the value of more information; • The patient's perception of the pharmacist as a capable provider of the information; • The pharmacist's knowledge and ability to supply the information; • The pharmacist's self-confidence in this professional role; • An environment that provides uninterrupted communication between patient and pharmacist. Often, patients feel that they have neither the time nor the need to learn about OTC medication. Pharmacists feel too busy to answer patients' questions completely, or they may sense patient uninterest. These impressions seem to be unfounded, however. An FDA study revealed that 45% of persons interviewed thought that more information concerning OTC products should be made available. 3 In addition, an in-depth study of selfmedication decision making fou nd that the most important factor reported in influencing someone to buy an OTC drug for the first time was the pharmacist. 4 To provide the right information at the right time, pharmacists m ust determine what patients need to know about the selection and use of a particular product and what they already know about the product. Deciding what patients need to know is based on the pharmacist's professional judgment about what is relevant, given the patient's individual needs and characteristics. Evaluating what they know already is critical, since patients may have
topic of OTC drug advertising. Many of the articles were highly critical of some of the techniques used to promote OTC drugs. Pharmacists who embrace the content and techniques of truthful but subtly deceptive promotion throw a cloak of professional respectability over such attempts and tarnish their own efforts to be objective in product recommendations. Pharmacists must retain and exert control over all promotion and display activities in the OTC drug department and should not allow them to be delegated to nonpharmacist personnel, including the merchandising specialists of corporate pharmacies, manufacturer's or distributor's representatives, or clerks. Certain types of promotion, such as offering commissions on the sale of some products, are never acceptable in the OTC drug department, since they foster inappropriate selection and overuse of OTC products. It is also not accepfable to promote or distribute house brands unless they represent rational therapy and are of appropriate quality. Role of Staff Product category distinctions should be clear to both professional and nonprofessional staff so that all are aware of their responsibilities. Even if a system has been established by the managing pharmacist, it will not operate effectively unless staff pharmacists and supportive personnel understand it and carry it out. In general, a transaction requires the pharmacist: • When the patient returns in a short period of time to purchase the same or similar product;
Dealing with Patients
American Pharmacy Vol. NS19, No. 10, September 1979/550
misinformation that could result in inappropriate use. The level of patient knowledge can be assessed by asking nonthreatening, probing questions and obtaining feedback. The Handbook of Nonprescription Drugs provides examples of questions. Patients may already know all the important information about the product. In this case, further education is not necessary and may be resisted or resented. However, reinforce ment by pharmacists is always appropriate to assure that patients retain correct information. Pharmacists also must decide how information should be presented. Educational research has foun d that verbal communication is more effective for retention over short to medium time periods, while written is more effective over long periods, since people have a chance to refer to the information periodically.5 Combining both verbal and written information is more effective than using either separately. Pharmacists should develop or obtain pamphlets or information sheets on appropriate products and should provide verbal reinforcemen t as necessary. Informal questioning can help assure that patients have a clear understanding of the proper use of the product. A tactic used by some pharmacists is to place signs or posters next to any OTC products with potential difficulties; thus patients with certain diseases or problems would be alerted to the dangers and would be advised to speak with the pharmacist before selecting an arc drug. For example, since many cough preparations contain large amounts of sugar, diabetics may be warned to select these preparations carefully. Recommended products may be listed on the sign, or the patient can be directed to the pharmacist. These in-pharmacy tactics can be reinforced by conducting out-ofpharmacy educational efforts, such as speaking to community groups about OTC medications, writing columns in local newspapers, or distributing educational materials to
'The only thing that differentiates the OTe department in a pharmacy from that in a food store is the pharmacist.'
the general public. Well-executed efforts such as these could remove many patient misconceptions and myths about OTC medications, help make patients aware of the need for additional information before selecting and using drugs, and reveal the availability of a knowledgeable and underused resource, the pharmacist. Patient education efforts sometimes fail because of barriers to effective pharmacist/patient interactions. For example, the pharmacy's environment might not be conducive to private discussion, since the pharmacist typically is found behind a prescription counter or a glass partition. Some patients do not perceive the pharmacist as a source of accurate, unbiased information about aTe drugs. Economic factors and the amount of time available for counseling also limit counseling opportunities. If pharmacists decide to assert themselves by educating patients, they must identify existing barriers and remove them.
American Pharmacy Vol. NS19, No. 10, September 1979/551
Key to OTe Professionalism Pharmacists should assert themselves by counseling patients on the appropriate selection and use of OTC medications. Many patients select and use according to misperceptions or myths perpetuated by OTC drug advertising and promotion. In addition, certain products are inappropriate in particular disease conditions or when taken concomitantly with other drug products. It is well documented that many patients do not read the labels of arc drugs and thus may miss even the most prominent written warning statements. Reinforcement with oral warning is often necessary and always appropriate. It is important to understand that the active intervention advocated is selective. It is not necessary to attempt to give advice to every patient on every purchase. Patients do not want to have to ward off eager pharmacists .seeking to establish a complete drug and medication history to replenish the family stock of aspirin tablets. On the other hand, most patients will appreciate the judicious intervention of pharmacists who have the health of the patient in mind. To ask the right kinds of questions and to offer the right kind of advice requires more than just appropriate technical knowledge. It requires a concern for the patient as an individual and the development of interpersonal skills which will facilitate good communications. Remember: the only thing that differentiates the OTC drug department in a pharmacy from a similar department in a food store is the pharmacist. Appropriate · assertiveness as a practicing health professional is the key to retaining and enlarging a satisfied clientele. References 1. Drug Topics, 123(11), 27 (1979). 2. "Handbook of Nonprescription Drugs," 6th ed ., APhA, Washington, D.C., 1979. 3. D.E. Knapp, et ai., Apothecary, 88, 8 Ouly-Aug. 1976). 4 . D.E. Knapp, et ai., Med. Marketing Media, 10(11), 29 (1975) . 5. J.e. Clinite and H.F. Kabat, ,. Am . Pharm . Assoc., NS16, 74 (1976).
39
