Currents in Pharmacy Teaching and Learning 10 (2018) 185–194

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Currents in Pharmacy Teaching and Learning

journal homepage: www.elsevier.com/locate/cptl

Experiences in Teaching and Learning

“How do I say that?”: Using communication principles to enhance

T
medication therapy management instruction
⁎
Paul M. Denvira, Katie E. Cardoneb, , Wendy M. Parkera, Jennifer Cerullib
a
Department of Population Health Sciences, Albany College of Pharmacy and Health Sciences, 106 New Scotland Ave, Albany, NY 12208, United
States
b
Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, 106 New Scotland Ave, Albany, NY 12208, United States

AR TI CLE I NF O AB S T R A CT

Keywords: Background and purpose: Medication therapy management (MTM) is a comprehensive, patient-
Medication therapy management centered approach to improving medication use, reducing the risk of adverse events and im-
Communication proving medication adherence. Given the service delivery model and required outputs of MTM
Advanced pharmacy practice experience services, communication skills are of utmost importance. The objectives of this study were to
identify and describe communication principles and instructional practices to enhance MTM
training.
Educational activity and setting: Drawing on formative assessment data from interviews of both
pharmacy educators and alumni, this article identifies and describes communication principles
and instructional practices that pharmacy educators can use to enhance MTM training initiatives
to develop student communication strategies.
Findings: Analysis revealed five key communication challenges of MTM service delivery, two
communication principles that pharmacy teachers and learners can use to address those chal-
lenges, and a range of specific strategies, derived from communication principles, that students
can use when challenges emerge. Implications of the analysis for pharmacy educators and re-
searchers are described.
Summary: Proactive communication training provided during MTM advanced pharmacy practice
experiences enabled students to apply the principles and instructional strategies to specific pa-
tient interactions during the advanced pharmacy practice experiences and in their post-gradua-
tion practice settings.

Background and purpose

The Medicare Modernization Act of 2003 included a mandate for the provision of medication therapy management (MTM)
services to high-risk Medicare beneficiaries with Part D prescription drug coverage.1 MTM is a patient-centric and comprehensive
approach to improve medication use, reduce the risk of adverse events and improve medication adherence.1,2 The cornerstone of
MTM is the comprehensive medication review (CMR), defined as an interactive, person-to-person or telehealth medication review
(including prescriptions, over-the-counter medications, herbal therapies, and dietary supplements) performed in real-time by a
pharmacist or other qualified provider.2,3 A written summary of the medication review is provided to the patient in the form of a
personal medication list and a medication action plan (MAP). Following the CMR, pertinent findings are communicated to

⁎
Corresponding author.
E-mail addresses: paul.denvir@acphs.edu (P.M. Denvir), Katie.cardone@acphs.edu (K.E. Cardone), Wendy.parker@acphs.edu (W.M. Parker),
cerullij@gmail.com (J. Cerulli).

https://doi.org/10.1016/j.cptl.2017.10.014

1877-1297/ © 2017 Elsevier Inc. All rights reserved.

P.M. Denvir et al. Currents in Pharmacy Teaching and Learning 10 (2018) 185–194

prescribers, often in written form.2,3

Given the service delivery model and required outputs of MTM services, communication skills are of utmost importance. Not only
must the MTM provider effectively communicate with patients and/or caregivers, but also with prescribers, other health professionals
and colleagues. Both the Accreditation Council for Pharmacy Education Standards 20164 and the American Association of Colleges of
Pharmacy's Center for the Advancement of Pharmacy Education (CAPE) Educational Outcomes5 cite the importance of effective
communication. Communication skills, health literacy assessment, interprofessional teamwork, audience-adapted communication
and cultural sensitivity are identified as necessary skills to meet these competences, which are foundational to the delivery of MTM
services.4,5

Rationale and objectives

The MyMedZ Medication Management Service at Albany College of Pharmacy and Health Sciences began in April 2011 when
opportunities for provision of MTM services began to emerge in the region. At that time, students, preceptors, and faculty were not
routinely providing MTM, leading to MTM payers having unmet needs for providers in the region. Thus, the MyMedZ Service
emerged to meet both the unmet provider need and unmet training need, serving as an on campus “laboratory” for the training of
future practitioners. In the clinic, students shadowed the preceptors for several encounters (recruitment, comprehensive medication
reviews CMR), then engaged in provision of MTM services with direct pharmacist supervision. Patients were referred by third party
payers via electronic MTM platforms that were used to provide, document and bill for services. Patients were not familiar with the
college service at the outset. Approximately 95% of services were provided telephonically. From 2011 to 2015, the service grew from
providing 120 CMRs and 170 targeted medication reviews (TMRs) to almost 200 CMRs and 324 TMRs annually, with a patient CMR
acceptance rate of over 30%.
The MyMedZ service promotes MTM services through patient care, teaching, service, and scholarship. A goal of the practice is to
provide quality MTM services while educating student pharmacists to deliver patient care using the MTM framework. Two years after
establishing MTM-focused advanced pharmacy practice experiences (APPEs) within the service, two pharmacy practice faculty
sought to conduct a formative assessment of the MTM training experience. Whereas summative assessment emphasizes measurement
of learning outcomes to determine the effectiveness of an educational intervention, formative assessment is typically used to explore
teachers’ and learners’ emerging understandings and perspectives and to inform future interventions.6
In standard course evaluations of our MTM experiences, students’ Likert scale and open-ended responses indicated that the APPEs
were seen as valuable and professionally satisfying (data available upon request). Open-ended comments specifically highlighted the
value of communication skills training, with particular emphasis on opportunities for patient interaction. The pharmacy practice
faculty preceptors believed that the standard APPE evaluation tools did not adequately address oral and written communication-
based competencies that were present in eleven of the experience's sixteen educational objectives (Table 1) and wished to further
explore the teaching and learning of MTM communication skills. Previous literature of MTM service delivery during APPEs has not
specifically focused on communication skills and used student survey methods to assess their perceived achievement of educational
outcomes.7,8 This pilot study assesses communication skill development in a different way. An interdisciplinary collaboration
emerged between the pharmacy practice faculty, a health communication scholar, and a medical sociologist to complete this for-
mative assessment. Institutional review board approval was obtained.
The primary purpose of this article is to identify and describe communication concepts and instructional approaches that may be
used to enhance MTM training initiatives. The specific objectives of this article are to draw on both faculty and student perspectives
to describe the following: (1) communication challenges encountered during MTM service delivery; (2) communication principles

Table 1
Medication therapy management (MTM) APPE communication-focused course objectives.

1. Identify and describe the components of a comprehensive medication review (CMR) as defined by Centers for Medicare and Medicaid Services (CMS) and the
Core Elements of MTM Version 2.0. (Rememberinga)
2. Describe the features and benefits of MTM services to various stakeholders (e.g., patients, prescribers). (Understanding)
3. Prepare for a CMR with a patient by conducting a preliminary review of prescription medication claims and diagnoses to identify potential medication-related
problems. (Applying)
4. Collect patient specific information during a CMR with a patient (either live or telephonically) including identifying the patient chief compliant, conducting a
medical history and gathering medication information. (Understanding)
5. Assess medication therapies to identify and prioritize medication related problems (MRPs) utilizing primary literature and print/electronic references.
(Analyzing)
6. Improve patients’ knowledge of their prescriptions, over-the-counter medications, herbal therapies and dietary supplements, identify and address problems or
concerns that patients may have, and empower patients to self-manage their medications and their health condition. (Understanding)
7. Effectively verbally communicate the potential MRPs and recommendations to the patient. (Applying)
8. Create a personal medication record for the patient using either the web-based MTM platforms. (Applying)
9. Effectively communicate in writing to the patient via a Medication Action Plan a plan to resolve MRPs and address patient concerns using patient friendly
language. (Applying)
10. Verbally communicate potential MRP and recommendations to the physician office as needed. (Applying)
11. Prioritize and communicate the potential MRPs and recommendations to the physician via a written SOAP note. (Evaluating, Creating)

CMR (comprehensive medication review); CMS (Centers for Medicare & Medicaid Services); MTM (Medication Therapy Management); MRP (medication-related
problem); SOAP (subjective, objective, assessment, plan).
a
Bloom's taxonomy level.

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that are central to MTM service delivery; (3) ways of adapting established instructional practices in APPEs to develop students’ MTM
communication skills; and (4) examples of communication strategies, derived from broader communication principles, that students
used to address the unique communication challenges of MTM service delivery. Our overall intent with this article is to provide an
accessible and empirically-grounded educational resource that pharmacy educators can use to develop the novice MTM practitioner.

Educational activity and setting

Setting

The educational objectives of the MTM-focused APPEs expose students to various aspects of MTM service delivery, including
therapeutics, compensation mechanisms, practice management, literature evaluation and professional certificate training (Table 1).
These six-week APPEs occurred in both a campus-based, stand-alone MTM clinic and in an ambulatory dialysis setting. The ex-
periences began with an orientation to MTM, including payer requirements, plan service descriptions, overview of MTM platforms,
overview of patient recruitment process, and CMR provision and documentation. Students prepared for CMRs by conducting a pre-
review using a preliminary medication list (from claims data, prescriber records, patient-provided medication lists, and/or previous
medication reviews) to identify potential medication-related problems. The patient population included MTM-eligible Part D ben-
eficiaries, including a cohort of patients receiving dialysis. The practice received compensation for the services provided.
Throughout the experiences, faculty utilized several commonly used instructional practices, including group discussion, role-
modeling, shadowing, and collaborative editing of written documentation to meet the educational objectives in a two-to-one student-
to-faculty ratio. Faculty preceptors modeled the patient recruitment process and demonstrated how to conduct a CMR. After sha-
dowing the faculty member, APPE students led CMRs under faculty supervision via telephone or in person. Discussions with pre-
ceptors and peers before and following encounters encouraged dialogue regarding how to gather needed information from patients
and to review anticipated or encountered challenges. Students were provided with sample scripts and templates for patient re-
cruitment, completing the pre-review and conducting the CMR.9 Faculty and students collaboratively wrote, shared, and critiqued
written communication to be sent to patients and their physicians.

Data and participants

A health communication scholar and qualitative researcher conducted a joint interview with the two MTM faculty preceptors. An
interview guide was developed to explore the underlying communication challenges and principles at work in MTM as well as the
instructional strategies used to develop students’ communication skills (see Appendix for sample questions). While the interview
guide provided an overarching framework for discussion, qualitative approaches to in-depth interviewing also require active listening
and improvisation, pursuing novel or unanticipated topics that emerge from interviewees’ responses. The interview was conducted
over two sessions, each about two hours in duration, with the interviewer taking notes. While the interviews provided a teaching
perspective on MTM communication skills, we also sought to include learners’ perspectives. We did so by contacting alumni.
For the alumni interviews, we solicited all former MTM service APPE students by email (n=36). A total of five alumni responded
to the solicitation, all of whom completed an informed consent process. This sample includes representation from two preceptors’
experiences and from two different academic years (2011–2012 and 2012–2013). Among the five alumni, three were currently
providing MTM services in their places of employment (and had played a role in its adoption by the employer), one had been
advocating for the current employer to adopt MTM services, and one was not currently providing MTM services. The development of
the alumni interview guide (see Appendix for sample questions) was informed by the previous faculty interviews. For example,
because faculty preceptors had indicated that students often struggled communicatively with patients when addressing potentially
sensitive topics (e.g., adherence difficulties or lifestyle modifications), the alumni interview guide included open-ended questions
about those matters. The alumni interviews sought primarily to explore their views of the communication challenges they experi-
enced and to identify the specific strategies they used to navigate these challenges. This provided a way to assess the extent to which
students could apply communication principles and instructional strategies to concrete moments of patient interaction. All interviews
were audio-recorded and transcribed verbatim by an outside contractor, with identifying information replaced by pseudonyms. The
mean length of the interviews was 86 min, yielding a total of approximately 150 pages of single-spaced interview text.

Data analysis

Faculty and alumni interview data were analyzed inductively using thematic analysis,10 an approach that builds on the core
methodological strength of Grounded Theory,11 the constant comparative method. The overall approach was to develop various
thematic collections of data that share common features (e.g., “language that could offend patients” or “definitions of MTM”), but to
remain flexible about the name, meaning, or analytic value of the collection until all data have been considered. That is, each new
piece of data considered for a provisional collection is constantly compared to previous entries in that collection, as well as other
collections. As new data are added, the analyst may re-conceptualize the collection, combine it with other collections that initially
seemed dissimilar, decompose the collection into more suitable sub-collections, or develop a new collection. Throughout this process,
the “fit” between the data and the emerging analytic themes is refined, with the goal of giving authentic voice to the participants,
rather than imposing pre-existing concepts on the data.
Four waves of qualitative coding were used to analyze the interviews. First, NVivo (qualitative analysis software) was used to

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complete initial coding of all transcriptions, breaking the data into broad topical collections (e.g., “oral communication”). Second,
focused coding of these initial collections was completed, resulting in additional sub-collections (e.g., “oral communication” was
decomposed into more useful sub-collections, such as “conversations about adherence” and “conversations about patient lifestyle”).
Third, analytic memoing (sometimes called “open coding”) of each sub-collection was completed. Analytic memoing is a process of
writing emerging ideas, concepts, connections, or reactions in the margins of the collection. For example, analytic memoing of the
sub-collection “conversations about adherence” yielded a number of specific language strategies for avoiding offense when exploring
reasons for non-adherence, which also revealed connections with other themes that addressed patient-centered communication. This
wave yielded a wide range of themes and sub-themes that were shared with the research team, along with examples of data from each
theme. For the fourth and final wave of coding, the research team discussed the current themes and data together, sought out
negative cases, and resolved differing interpretations. As a pilot study with a relatively small sample size (two preceptors and five
alumni), it is difficult to confidently assess saturation; additional interviews may have yielded a more exhaustive and diverse set of
responses.

Findings

Describe the unique communication challenges encountered during MTM service delivery

Pharmacists encounter unique communication challenges when learning to provide MTM services. The service delivery model
requires a degree of interpersonal and interprofessional competence that may not be called upon in other pharmacy settings. These
challenges informed the communication-based teaching/learning practices developed within this MTM service. Five key challenges
that emerged in faculty and student interviews are summarized below (though not exhaustive, these do represent recurrent issues for
MTM learners).

Persuading stakeholders of the value of MTM

As a prerequisite for providing MTM services, pharmacists must first explain and advocate for MTM services with various sta-
keholders, including patients, providers, pharmacy owners, and insurance companies. The Centers for Medicare and Medicaid
Services (CMS) will use the CMR completion rate as a Medicare Part D Star Rating quality measure, placing a special emphasis on
effective patient recruitment skills for MTM practitioners.12 Alumni reported encountering different kinds of obstacles during patient
recruitment. A basic difficulty that appeared across all interviews was patients’ unfamiliarity with the term “medication therapy
management.” Alumni indicated that recruitment often included an introduction of the service, though many patients did not seem to
fully understand it. Several pointed out that patients seemed more accustomed to physicians providing this type of care, and that
elderly patients especially might be reluctant to engage in a different model.13,14 Relatedly, some alumni described what might be
called medical interaction fatigue, a sense that most qualifying MTM patients already had to talk to so many health professionals that
MTM could feel like “too many cooks in the kitchen.” Some obstacles are unique to telephonic recruitment. Several alumni com-
mented that this can feel like cold calling, and advocated against communication approaches that were overtly “sales-y,” as this might
make patients skeptical. Establishing credibility over the telephone can be difficult; alumni who had completed their MTM APPE in a
dialysis setting commented that it was easier to recruit within that setting, as it provided a broad context of credibility for the MTM
service. Although this analysis focuses on persuading patient stakeholders, it is worth stressing that successful implementation of
MTM is enhanced by broader institutional buy-in from executive leadership, administrative staff, nurses, and other providers.

Minimizing judgment when addressing patient problems

Although traditional pharmacy counseling can help to surface patient problems, it is an explicit goal of the CMR to systematically
identify and address such problems. This can be a sensitive matter for both patient and pharmacist, as these problems and their
remedies can bring to light highly personal issues, such as economic hardships, sexual side-effects, or the life stressors that can inhibit
medication effectiveness. MTM providers must learn to formulate questions without the subtle language biases that can silence or
offend patients. They must learn to collaboratively nudge patients toward potential behavior changes without appearing judgmental
or controlling. In short, they must use patient-centered communication in their pursuit of medication-related problems.

Balancing quality and quantity of patient interaction

To be financially sustainable, MTM services need to provide an adequate return on investment, which can create tensions between
the quality and quantity of patient interaction. In terms of quality, it is important that pharmacists develop trust and rapport with
patients, not only to provide a positive, personalized healthcare experience, but to create an open, welcoming interpersonal dynamic
that will ultimately yield better patient information. Achieving this dynamic with a patient takes time, and this presents a challenge
for meeting the necessary quantities of patient contact. Although academic pharmacists are typically compensated independent of
revenue generated from MTM, faculty members recognize that the service must be cost-effective in the “real world” and educate
students accordingly. From a communication perspective, achieving a balance between quality and quantity of patient contact
requires careful management of topics and concerns during a CMR. Pharmacists must guide and prioritize topics, while also creating
opportunities for patients to express their concerns. To create rapport, pharmacists should allow time for “small talk,” while also
developing strategies for politely redirecting conversation back to the medication review.

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Writing a patient-centered medication action plan

To encourage patients’ engagement in their own health care, best practice is to provide a written MAP to the patient after
completing a person-to-person CMR; this is also a CMS mandate for services delivered on behalf of a Medicare Part D plan. A MAP is
an itemized list of self-management recommendations that a patient can use to help reach his/her health goals. It provides a shared
resource for patients and MTM providers to record and track progress toward these goals. The MAP might include instructions or
education, problem-solving strategies, reminders to follow-up with physicians, and prioritized recommendations for further action.
The MAP is distinct from other kinds of writing that pharmacists might enter into progress notes or patient charts. Unlike notes to
medical professionals, the patient-directed MAP must be adapted to a patient's needs, concerns, and literacy level. Our data suggest
two key challenges in this regard: balancing the use of accurate and complete medical terminology with plain, accessible language;
and striking a tone that is supportive and empowering, not dictatorial (e.g., “I suggest…” versus, “You should…”).

Collaborating with other providers through written documentation

MTM service requires communication with other healthcare providers, typically in the form of written documentation. Following
each CMR, pharmacists provide prescribers with a reconciled medication list and a prioritized list of recommendations. These
documents are intended to keep the healthcare team apprised of the patient's medication status and to offer recommendations to
resolve problems. The style, tone, and word choices in the documentation are shaped by several factors unique to the MTM model.
There is a degree of anonymity, as the prescribers and pharmacists may be unfamiliar with each other and must write in ways that
display collegiality and earn trust. Because prescribers are often pressed for time, MTM providers must learn to write with a balance
of conciseness and completeness. Another consideration is the paucity of objective data (e.g., laboratory data, diagnoses) needed to
complete an accurate assessment of medication therapies. In this circumstance, pharmacists must learn to frame their re-
commendations in conditional terms (“If X is true, please consider Y”) without undermining their own credibility.

Describe communication principles (adaptation to audience and adaptation to medium) that are central to MTM service delivery

Analysis of faculty and student interviews revealed the salience of two key principles, both well-established in the discipline of
communication, that could be used as a framework for future MTM training. They serve as reflective tools when students understand
the therapeutic content to be communicated, but wonder, “How do I say that?”

Adaptation to audience
Consistent with the audience-adapted theme embedded within the CAPE outcomes, health communication research has amply
demonstrated that health-related messages are more effective when they take their intended audiences into consideration.15 MTM
service delivery requires students to develop sensitivity to the needs of two primary audiences, patients, and physicians, and to
develop a repertoire of communication strategies for adapting their messages to these audiences. The experiences offered by this
MTM service emphasized both sensitivity to the knowledge-base of the recipient and to tonal issues. With respect to knowledge-base,
students were trained to adapt their communication to the different kinds of knowledge that patients and physicians bring to
healthcare encounters. For example, while patients may prefer detailed, accessible, jargon-free explanations for recommended
medication changes, prescribers may prefer crisp, evidence-based, terminologically well-informed explanations of those same
changes. With respect to tonal issues, faculty encouraged students to adopt oral and written language strategies that conveyed
warmth, patient-centeredness. and collegiality, while avoiding language that could inadvertently cause offense or distress.

Adaptation to medium (oral vs. written)

Faculty also strived to develop student sensitivity and adaptability regarding two modes of communication, oral and written. In
this service delivery model, oral communication was almost exclusively with patients, and infrequent with prescribers. Whereas oral
communication with patients is immediate and interactive, requiring active listening and improvisation, written communication
requires more planning and sculpting of the final message, which serves as a formal record of the patient's medication list, MAP, and
physician communication. One of the constraints of written communication is that the participants cannot easily send or receive the
subtle nonverbal cues (i.e., intonation, timing, gesture, facial expressions) that help to create meaning in face-to-face interaction.
Language choices, particularly their precision and connotations, are at a premium in written communication. Oral and written
communication are also uniquely interconnected in MTM services; well-written documentation should be sensitive to the informa-
tion, concerns, and recommendations that emerged in the verbal interaction between pharmacist and patient. For example, a patient
having trouble remembering to take alendronate weekly may be verbally counseled to use a calendar and link administration to a
weekly event that is significant to the patient, such as a religious service. The corresponding MAP should be written in a way that
reinforces this verbal discussion, using the terms and/or events that emerged as relevant or useful to the patient. For example, an item
in the MAP might read: “Mark your calendar to take your alendronate before leaving for Sunday mass.”

Describe how established instructional practices in advanced pharmacy practice experiences can be adapted to develop students’ MTM
communication skills

Faculty utilized a variety of instructional practices to enhance students’ MTM-based communication skills, all of which involve
personalized, collaborative contact among faculty and students. Although the basic practices are well-establish in pharmacy edu-
cation, they were delivered in ways that emphasized application of the two communication principles (adaptation to audience and

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Table 2
Summary of communication challenges and instructional practices.

Instructional Practice Strategy COM Challenge(s) Addressed COM Principle(s) Example of use of instructional practice in MTM service
Implemented delivery

Collaborative Discussion
Role Modeling during patient
recruitment and medication
reviews CMR)
Student-led Patient Interaction with
Preceptor “Jump In”
Peer-to-Peer Feedback
Faculty-Student Collaborative
Documentation
Balancing quality and quantity
of patient interaction
Minimizing judgment when
addressing patient problems
Persuading stakeholders of the
value of MTM
Balancing quality and quantity
of patient interaction
Minimizing judgment when
addressing patient problems
Balancing quality and quantity
of patient interaction
Minimizing judgment when
addressing patient problems
Writing a patient-centered
medication action plan
Collaborating with other
providers through written
documentation
Writing a patient-centered
medication action plan
Collaborating with other
providers through written
documentation
Adaptation to Development of patient question formats, discussing
Audience question phrasing (i.e., How do I say…?)
“Why aren’t you filling your prescriptions on time?” vs.
“What barriers are you having to taking your medications?”
Adaptation to Students observe preceptors’ techniques for gently steering
Audience conversation back to focal topics
Adaptation to Sensing the patient does not understand, preceptor “jumps
Audience in” to translate student's medical jargon
Preceptor “jumps in” to collect more information which the
student omitted
Adaptation to Students proofread one another's documentation and make
Audience textual suggestions to soften recommendations that sound
Adaptation to Medium like commands
Adaptation to Preceptor uses track changes to show which words/phrases
Audience can be trimmed from an unnecessarily detailed note or
Adaptation to Medium modify wording choice such as removal of “should” from a
physician correspondence

COM (communication); MTM (medication therapy management); CMR (comprehensive medication review).

medium) to overcome the five unique communication challenges encountered in MTM service delivery. For example, role-modeling is
a fairly standard instructional practice, and the faculty would model both recruitment and CMR activities, but this was followed by
group discussion about any communication challenges or strategies the students observed (e.g., techniques for gently steering the
conversation, thus balancing quality and quantity of patient interaction). Across the spectrum of instructional activities, faculty
encouraged a focus on communication, and collaborative reflection before and after oral and written communication experiences (see
Table 2). This approach allowed students to think critically and adaptively about patient-centered communication, and arrive at their
own solutions in a less didactic fashion, rather than seeking to mimic particular scripts.

Describe examples of communication strategies, derived from broader communication principles, students used to address the unique MTM
communication challenges

One of the aims of the alumni interviews was to identify and evaluate the specific communication strategies former students
developed to address the unique communication challenges of MTM service delivery. While it is useful to be aware of the challenges,
the critical next step in learning is for the student to develop a repertoire of communication strategies to draw on when these
challenges emerge. The strategies that emerged in the alumni interviews confirm that adaptation to audience and medium can serve
as a concise and accessible MTM communication framework, while also providing an initial practical toolbox of communication
strategies for MTM learners. We organize and present these strategies as responses to the five communication challenges described
earlier in the article.

Student strategies for persuading stakeholders of the value of MTM

For patient recruitment activities, students indicated that they took patients’ lack of familiarity with MTM into consideration.
They framed MTM in accessible, patient-friendly terms, emphasizing that the point was to help the patient feel better, not just update
administrative records: “I’d walk up to them and be like, ‘Hello, my name is Jane. I'm a pharmacy intern and I'm on rotation here in
the clinic. If you have a couple minutes, would you be willing to discuss your medications with me? I'd like to see how you're feeling
and see if there is anything we can do to make you feel any better.” In many cases, students refrained from using the phrase
“medication therapy management” because it might sound bureaucratic or intimidating to some patients. One student was concerned
that the word “therapy” has strong connotations with psychological counseling and did not want patients to decline the service for
fear of being psychoanalyzed. This finding is consistent with previous focus group data by Garcia et al.16 indicating that using
language other than “MTM” or “medication therapy management” may be preferred by patients. The profession continues to work
hard to educate patients about the benefits and role of MTM services and ensure consistency in both terminology and the services
provided.17 Educators should ensure students are familiar with both the profession and CMS definitions of MTM services in addition
to emerging work to define services for consistency.1–3
The following series of quotations from a former student illustrates how she adapted definitions of MTM for different audiences

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when working as a professional. The student captures many of the aforementioned features of MTM, while also clearly illustrating the
principle of audience adaptation:
“It depends on who I'm targeting…. If I'm looking at my definition for a patient, I would say it's a basic review of your medication, reviewing
basic things like side effects, drug interactions, but also looking at things like your cough and your priorities that will help you manage your
medications and achieve your health goals. And then my description for pharmacists will be a little bit different, trying to encourage them to
take up MTM more and encourage them that it's just your basic activities that you've been doing every single day since you graduated from
pharmacy school. You know, taking that knowledge that you had about each individual medication and actually applying it to a patient
and addressing them holistically, so you have a more encompassing intervention which looks at the patient more holistically rather than just
individual medications.”
“I was involved with at least one managed care organization that was requesting more information about MTM services. For them, I found
out that it's all about the dollars. You need them to buy the fact that MTM decreases costs, but you need to provide concrete examples…. I
found that the most impactful way to describe MTM to a managed care organization is to basically give them specific examples of a patient
where you change their medication to something less expensive, so say this amount of dollars over this many years.”
This quote shows the ability to adapt the message to a managed care audience. It was the alumnus's perception that the managed
care organization with which s/he was working was concerned with the financial implications of offering an MTM program. Although
MTM services are mandated by Medicare Part D, they are not reimbursed separately by Medicare. Thus, the managed care organi-
zation must provide the service within the confines of the existing payment from Medicare part D plan. Therefore, generating an
“efficient” MTM program is important to the prescription drug plan, as they must be able to achieve the quality outcomes sought by
the program with judicious use of resources.

Student strategies for minimizing judgment when addressing patient problems

Former students used the word “judgment(al)” extensively to describe the wrong tone for MTM patient interaction. This came up
often when discussing strategies for inviting patients to discuss medication-related concerns or confusion. Interviewees understood
patients might be reluctant to acknowledge confusion when speaking with highly trained professionals: “I think they're a little
intimidated to say, ‘Well, I don't understand.’ because they're talking to a pharmacist or a doctor and they must be really, really smart.
They think, ‘If I don't understand, well it's my fault.’ And that's not the case. I mean that's what doctors and pharmacists are there for,
to explain and make sure that patients understand why they take the medication and how to take the medication and find a med-
ication that they can afford and that works with their lifestyle and their schedules.” While it is true that some patients may be hesitant
to engage or ask questions because they feel they lack knowledge or confidence, this is not the case for all. Some patients do not wish
to engage in MTM services because they feel they are very knowledgeable about their medications and conditions and don't want to
make any changes.14 In any pharmacy encounter, there is wide variability in patients’ levels of health literacy and practitioners
should be prepared to assess and adjust accordingly. When orienting students to a university MTM call center, faculty suggest
practitioners consider that they may be talking to a broad range of patients such as someone with a sixth-grade education or perhaps a
retired physician. The authors encourage MTM practitioners to respect the knowledge of the patient, talking on their level and use
every day “living-room language” to be easily understood and reduce potential intimidation.7
One of the strengths of the MTM model is identifying and addressing adherence challenges in personalized ways, but students
recognized that the discussion needs to be framed with some sensitivity. Students displayed empathy for the patient's perspective
when speaking with a pharmacist about non-adherence: “Well as a pharmacist they probably expect that we will expect them to take
their medication each and every day and if we don't communicate to them that it's very common to miss your meds they may feel that
we're passing judgment on them.” Students approached adherence discussions in terms of collaborative, patient-centered problem-
solving, rather than patient blaming. In terms of specific communication techniques, students reported that they learned a great deal
during their APPE about how to phrase questions about adherence in patient-centered, judgment-free ways. Open-ended question
formats were seen as especially useful in this regard, as they invite more elaborated patient perspectives and agendas: “When you get
into the rotation, the first couple times the professor would lead a little more, but they would ask you for some questions to ask the
patient. If they saw some that were yes/no, that could lead a patient in a particular direction, or would be easy for the patient to just
say yes or no to, that would sort of end the conversation. They'd be like, ‘Okay, well how can we change this question a little bit to
have the patient give a more active response to it?’” Another student provided an especially sharp contrast between open and closed-
ended ways of asking about adherence issues. The closed-ended version was, “Are you taking [the medication] as prescribed?” and
the open-ended version was, “How do you feel [the medication] is working for you?” The open-ended version invites a more ela-
borate patient response, with the broad phrase “working for you” welcoming a wide range of medication-related concerns, from
symptom management, to side-effects, to lifestyle implications. The closed-ended version implies a posture of authoritarian oversight
in which patients may have “failed” in their obligations.

Student strategies for balancing quality and quantity of patient interactions

Students generally spoke to the importance of building rapport through informal “chit chat,” but several reported they had been
particularly impressed by the subtle and tactful ways that their former preceptors steered the conversation toward focal medication
issues, maintaining efficient progress through the CMR. They viewed this as a high-level communication skill, and acknowledged that
this was still a learning process for them: “Sometimes you ask patients a simple, innocuous question - how are you doing? - and they'll
just launch right into it and they're having some issue. They're willing to share a lot of their personal history with you. And it was

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always interesting for me to see how the professors are able to take that information on the fly, roll with it, and still work it into
leading to the medication question (laughs). Taking a little detour if they had to but always bringing it back in a gentle way. Never
being like, ‘Okay enough of that; let's get back to this,’ but leading the patient back: ‘Okay, well are you on any medications for this?
And what do you take and how do you take it?’ Bringing it back that way.”

Student strategies for writing a patient-centered medication action plan

Students reported three main challenges for writing MAPs: using patient-friendly terminology, balancing conciseness with
completeness, and phrasing recommendations supportively. Each of these challenges requires adaptation to audience and written
medium.
Students’ emphasis on patient-friendly terminology reflected their adaptation to patients’ knowledge-base and overall health
literacy. Although there are opportunities to enhance health literacy through MTM services, students believed that MAPs should be
written in accessible, layperson's language, essentially meeting patients where they currently are. One student would think about
different family members as a reference point in planning her MAPs: “I always think, if I were explaining this to my parents, how
would I do it? And if that's not something that works for the student, say you have a cousin who's about ten and you wanted to counsel
them on their medications, how would you explain it to them? You don't want to talk down to the patient, but you want to make it
simple and clear. Most patients, they're not going to know what a sphygmomanometer is. Call it a blood pressure cuff, call it the lay
term for it. It's high blood pressure. You don't want to write hypertension because patients see these big words and it can intimidate
them.”
Students recognized MAPs should be concise, meaning they shouldn’t overwhelm patients with long paragraphs to read about
every condition or medication. Students were concerned that long, complicated MAPs could cause patients to simply ignore them. At
the same time, they recognized that MAPs served as an important self-management resource and their notes should be complete
enough to give patients all of the necessary information to implement the plan. This ultimately involves striking a balance com-
municatively and learning to prioritize some things over others: “I think the biggest thing that I try to do with that is reinforce the
most important pieces. You don't want to overwhelm a patient by sending them this huge list of all these things that you expect them
to do or expect them to remember. I try to pick out no more than five of the most important things that we talked about.” By limiting
her MAPs to the five most important issues and by reinforcing topics that came up in the discussion, this student worked to strike a
balance between empowering and burdening her patients with self-management actions.
For those parts of the MAP that involve recommendations for the patient, students were taught to avoid language that could sound
demanding or dictatorial in favor of language that sounds more supportive and respectful of patients’ decision-making authority.
Rather than terse, “do this and do that” language, students learned phrases that could mitigate the appearance of commands. For
example, students offered the following phrases as potentially useful: “Try to avoid…,” “Consider…,” and “Remember to…”. These
phrases still identify helpful actions to take, but sound like friendly advice and support rather than “pharmacist's orders.”

Student strategies for collaborating with other providers through written documentation
Although there were few opportunities for face-to-face collaboration with physicians on these experiences, students reported that
learning the style and tone of the physician documentation helped them understand some of the dynamics of interprofessional
collaboration. In terms of adapting written communication for the physician audience, students emphasized many of the same issues
as with the patient MAP, but with very different implications. They emphasized the balance between conciseness and completeness,
as well as the importance of communicating recommendations with credibility and respect.
In terms of balancing conciseness and completeness, students indicated that they initially tended to err on the side of com-
pleteness, providing far more information than the physician needed (or would have time to read). Through intensive, one-on-one
editing of documentation with their preceptors, students developed a sense of physicians’ practical needs, as well as their working
knowledge of pharmacotherapy. In their zeal to demonstrate competence to another medical professional, students tended to over
explain things that physicians would either already know or would not need to know. For example, one student recounted an editing
session in which her preceptor pointed out that, while she had provided an accurate description of the pharmacokinetics of a
medication, the level of detail was not necessary for the physician's management of the patient. Students indicated that their pre-
ceptors emphasized conciseness even in grammar and format, favoring crisp sentence fragments over long paragraphs. The emphasis
on conciseness was clearly audience-sensitive, rooted in a realistic understanding of the time constraints under which physicians are
typically operating.
Students were well-versed in the nuances of phrasing their recommendations to physicians. Previous research has indicated that
pharmacists’ recommendations to physicians can be difficult interprofessional terrain, especially because recommendations may
come across as tacit criticisms of the physician's past or current treatment decisions.18 Students reported a wide range of commu-
nication strategies for managing these issues with a physician audience. One strategy that every student reported was appropriate use
of published clinical evidence. Students indicated that evidence bolstered the credibility of their recommendations and allowed
physicians to investigate and come to their own conclusions: “If you're going to make a recommendation, you need to have it very
thoroughly supported by literature. Even if it seems like common knowledge, everything needs to be in accordance with current
consensus guidelines X, Y, and Z to make sure everything is supported. Because, as much as you're building a relationship with the
patient, you're also building a relationship with the prescriber. They need to trust you because their thought is, and I've heard this
feedback a lot, there are concerns about taking the recommendations of a practitioner who has not actually seen the patient.”
As with patient MAPs, students used language that sounded collaborative rather than dictatorial. In addition to specific mitigated
phrases (e.g., “consider…” and “…might be appropriate”), students indicated that their overall approach was to present their

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recommendations as “options” for the physician, rather than clear-cut, obvious next steps. One student reported a particularly
respectful and audience-sensitive strategy for framing recommendations. The key principle is to write with the assumption that the
physician may have already considered the recommended action, thereby giving credit to the physician: “So there was a patient who
is probably a candidate for an oral diabetes medication, but they have poor renal function. So in your comment you want to address
any potential oversight. You might phrase it, I'm not going verbatim here, but basically ‘The patient may not be a candidate for
Metformin due to impaired renal function.’ So you're showing them that you acknowledge the fact that they've probably already
considered that and they're aware of it but you’re bringing that up as well, pointing out that you understand that there are reasons
why this would not be appropriate and acknowledging the fact that the doctor is probably already aware of this.”

Discussion

This pilot study fills an important gap in the literature by identifying specific communication principles and instructional ap-
proaches that pharmacy educators can use to enhance MTM training. Formative assessment of the APPE activities from both in-
structor and student perspectives revealed five unique communication challenges in MTM service delivery, two communication
principles that can be productively applied to those challenges, and a range of student-reported strategies that draw on these
principles to address the challenges. The article also shows how established instructional practices in APPEs can be modified to
promote reflective thinking and strategic communication in a collaborative learning environment with a small faculty-to-student
ratio. As the title suggests, even when students understand the content of what is to be communicated from a medical or therapeutic
perspective, the question, “How do I say that?” remains a potent issue for students, one that highlights the interpersonal and in-
terprofessional sensitivity required in MTM. It underscores that how something is communicated can be as important as what is
communicated.
This work has several implications for MTM training. First, it reveals specific, empirically derived communication concepts that
can be used to supplement standard course evaluations in MTM-focused APPEs. For example, students could be asked how well the
experience prepared them to navigate each of the five challenges. This would provide valuable feedback for instructors, who can
adapt pedagogical materials to address areas where students seem to struggle. Second, these materials could be used to assess
individual student progress in the experience. For example, students could be quizzed to provide audience-adapted strategies for
navigating a particular challenge (e.g., “Describe some non-judgmental ways to ask patients about their difficulties with adherence”).
Finally, this work reveals that when preceptors make time in APPEs for collaborative reflection about communication choices,
students prove resourceful. This kind of reflection and group feedback can be incorporated into familiar instructional practices in
APPEs to emphasize the importance of communication choices in MTM service delivery. It also engages critical thinking about
audience, a key feature of empathy. Rather than memorizing scripted actions and reactions, this approach encourages students to
apply principles in situationally sensitive ways.
A limitation of the current study is its relatively small sample size; however, the detailed qualitative analysis reveals important
themes and concepts to enhance future curricular innovations and self-assessment methods. Based on this formative pilot study,
future work will aim to apply and test this framework in a more structured and summative way, building in pre- and post-experience
measures for MTM communication skill development. We would be cautious in generalizing from a relatively small sample size, but
we are confident that these data provided rich, detailed informant perspectives on a wide range of topics, including communication
challenges encountered, oral and written communication strategies utilized, commonly encountered communication principles
central to MTM service delivery, instructional practices to teach MTM communication skills and examples of communication stra-
tegies. An additional limitation is that we did not assess, from the student perspective, which instructional practices were most useful.
This was assessed from a faculty perspective only.

Summary

MTM provides significant opportunities for pharmacists to expand their roles in patient care and interprofessional healthcare
teamwork, but this role requires excellent communication skills training. Faculty and preceptors working with students to develop
their MTM communication skills can use the instructional practices such as collaborative writing and critical reflection to aid student
development. When armed with knowledge of the unique communication challenges in MTM service delivery and communication
principles that can be productively applied to those challenges, pharmacists will be better able to mobilize stakeholders and deliver
high quality MTM services.

Disclosures/Conflicts

None to report.

Appendix A. Supplementary material

Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j.cptl.2017.10.
014.

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