Hello, deprescribers! Today we are excited to have another interview post with clinical pharmacist Pam Howell (Ontario, Canada), telling us about her (deprescribing) experiences working as part of the telemedicine initiative GeriMedRisk.
Q: You are part of the GeriMedRisk initiative. First off, can you tell us a little bit about GeriMedRisk and how the consultation service works?
Pam: GeriMedRisk is an interdisciplinary telemedicine consultation and education service for doctors, nurse practitioners, specialists, and other allied health professionals in Ontario, Canada. A referral means the clinician gets easy and timely access to a team of geriatric specialists including psychiatry, pharmacy, clinical pharmacology, and geriatric medicine. This is especially important in rural areas where geriatric services are limited or an in-person assessment is not possible. We often are asked for suggestions to optimize medications, address mental health concerns and or help manage complex comorbidities. Clinicians receive a coordinated response – a single comprehensive plan with suggestions for drug and non-drug options, for investigations to make a diagnosis, and tools to support making health decisions.
Q: What attracted you to joining GeriMedRisk?
Pam: In Ontario, there are other virtual consultation and assessment services available and this has definitely grown with COVID, but GeriMedRisk is different. The interdisciplinary approach is a novel concept. Usually, referrals to specialists focus on their area of expertise and may not address other areas outside of their scope. For instance, a psychiatrist may address mood issues but not pain as they might see this outside their scope. The prescriber is left to tease through these issues alone or wait for multiple consults. With a team-based approach, we are not providing our recommendations in seclusion and we work through these issues for the prescriber. Everyone provides input based on their specialty, we debate the pros and cons and finally come to a consensus with our recommendations. Ultimately, we present solutions that are practical and not contradictory.
Q: Which kind of patients do you typically receive requests about in GeriMedRisk?
Pam: The founders of GeriMedRisk, Dr. Ho and Dr. Benjamin, are believers in supporting clinicians and building capacity wherever they can. That can look different depending on each referral and I have been involved in a wide range of assessments. The clinical questions can be as targeted as, “I want to use drug X, but am worried about their chronic renal failure”. It can also be as broad and complex as, “Please provide a full medication review and management options in this patient with polypharmacy, chronic pain, and depression”. In all cases, we involve the right mix of specialists, gather and sift through all the available information, perform a medication history where possible with the patient/caregiver and then provide one cohesive set of recommendations.
Q: Can you share some of your experiences with deprescribing in these patients?
Pam: My most challenging case so far has been a patient reporting the use of 58 different medications. I empathize with patients and clinicians trying to piece together a coherent plan. Where do you even start? For this case, our team encouraged the clinician to approach deprescribing in stages, focusing first on patient-reported priorities – things affecting her overall well-being, like pill burden, mouth pain, and constipation. There were high-risk medications that needed deprescribing, but previous failed attempts made the patient wary of changes. I felt we needed to build confidence in the process before tackling those more challenging drugs. My work with the Buryѐre Deprescribing Guidelines team has also made me aware of the barriers to deprescribing and has given me an appreciation as to why there is a hesitancy to make changes. Lack of time and uncertainty in how to deprescribe are quite common. As a consultant, I have the opportunity to fill this gap. There is no one size fits all and so, sometimes, it is the “art” of how you pull it all together. My assessments provide stepwise recommendations tailored to the patient and cognizant of potential challenges.
Q: From your point of view as a pharmacist, what are some of the key areas of focus for deprescribing in this patient population?
Pam: Ultimately, I want clinicians and patients to feel empowered to deprescribe. To overcome the inertia. There are three key areas I try to include in my consults. The first is confirming not just what and how a patient is taking medications, but also their experiences with them. Are they working? Are they causing side effects? What symptoms are of most concern? Answers to these questions help guide how to prioritize medication changes for the prescriber and keeps the patient’s goals in mind. A thorough review of medication combinations is also important. I believe medication changes have a “trickle effect”. If you change or add a medication, how will that affect all the others? Being aware of the fine balance can identify and prevent problems. It is a unique skill pharmacists bring to the table as medication experts. Lastly, I see deprescribing as a team approach – it takes a village to care for our complex and frail older adults. Community pharmacists and allied health colleagues like social workers, occupational therapists, physiotherapists, and nurses can provide prescribers a wealth of tools, interventions, and support throughout the process, whether that be in offering non-drug alternatives or helping with monitoring.
Q: Last but not least: What do you find most satisfying when making deprescribing recommendations in your GeriMedRisk consults?
Pam: Encouraging the clinician to engage in shared decision-making conversations with their patient and providing them with ways to do so. The “personal” part of medication optimization is often overlooked and yet, can be so powerful. Deprescribing is not always a smooth road, but being transparent about the process and having the patient help direct the course can make all the difference to its success. In the end, our purpose as clinicians is to help our patients navigate towards better health, whatever that may look like for them.
If you have any questions for Pam, you can reach her via email (firstname.lastname@example.org) or on Twitter (@PamHowell1975). You can also find more information about GeriMedRisk on Twitter (@GeriMedRisk) or on their webpage: https://www.gerimedrisk.com/