Pharmacist: Hello, Mrs. Jones. How are you today?

Mrs. Jones: Just fine. Couldn’t be better.

Pharmacist: Great! I’ll go refill your prescription.

Pharmacist: (a few moments later) Mrs. Jones, I noticed that your blood pressure medicine should have run out several weeks ago. Are you taking your medicine the way you’re supposed to take it?

Mrs. Jones: Oh sure, every time I get a headache.

Pharmacist: That doesn’t make any sense. How often is that?

Mrs. Jones: Oh, maybe once a week.

Pharmacist: Mrs. Jones, that’s not how you’re supposed to take it at all. Where did you get such an idea? Didn’t you read the label instructions? It says take it every day.

Mrs. Jones: What’s your problem? Just give me my medicine! (grabs the bag) Put it on my account. (exits the pharmacy)

Pharmacist: But you’re not taking it the right way.

The pharmacist is in no position to have influence here because of the approach he takes. He will probably have to call Mrs. Jones later and get this situation straightened out. Rather than taking a calm approach, he berates Mrs. Jones. She is unwilling to listen and leaves without finding out what the problem is. Let’s see how this might have been approached:

Pharmacist: Hello, Mrs. Jones. How are you today?

Mrs. Jones: Just fine. Couldn’t be better.

Pharmacist: Great! I’ll go refill your prescription.

Pharmacist: (a few moments later) Mrs. Jones, I noticed that your blood pressure medicine should have run out several weeks ago. Can you tell me how you’re taking it?

Mrs. Jones: Oh sure, every time I get a headache.

Pharmacist (calmly): So you take it when you get a headache because you believe that you have headaches when your blood pressure is up?

Mrs. Jones: Exactly!

Pharmacist: That makes sense. However, we should have done a better job of explaining to you how to take this medicine.

Mrs. Jones: What do you mean?

Pharmacist: It is certainly true that people with high blood pressure sometimes get headaches. But it is usually stress, not your high blood pressure, that is causing them. It is really very difficult, if not impossible, to tell when your blood pressure is up without measuring it. The medicine should be taken once a day for you to get the most benefit from it.

Mrs. Jones: Once a day? I didn’t know that.

Pharmacist: Well, let’s have you start taking it once a day from now on, even if you don’t have a headache. I want to make sure your blood pressure stays controlled.

Mrs. Jones: So do I. I never knew.

Pharmacist: I know. Again, I sure can understand the confusion.

This pharmacist took responsibility, and, because he did not blame or berate the patient, she was willing to listen. She was able to be influenced because she felt understood. The pharmacist’s communication was directed toward solving a problem, not ascribing blame. Even though he knew the label directions were not being followed, he felt no need to point this out and risk embarrassing her.

There is a great deal of literature indicating that men and women use different persuasive strategies. However, the literature is inconsistent about exactly what those differences in persuasive communication strategies are and whether they result from gender differences or differences in roles. For example, some literature reports that women use a more democratic and participative leadership style to have influence, whereas men tend to be more autocratic and directive.³ Other research attributes these differences more to role in the organization than to gender. That is, as women move higher in the organization, their communication tends to be more autocratic and directive.

Regardless, Gilligan and Attanucci⁴ found that “men employ a ‘justice’ orientation in reasoning about moral choices by emphasizing the importance of rights, respect, and impartiality, whereas women employ a ‘care’ orientation in their moral reasoning by emphasizing mutual participation, cooperation, and attention to individuals’ feelings and needs.” Men are most likely to influence by focusing on rights and responsibilities, and women are likely to influence by emphasizing issues relating to feelings and caring.⁵ These influence focuses are not right or wrong, they are simply the way many men and women attempt to influence others. These strategies do work, but only for individuals who orient in the same way. Both men and women need to be flexible enough to realize that appeals to justice also work for many women and appeals to emotions and caring also work for many men. A flexible set of influence strategies is needed.

Believability of the message. The believability of the message is related not only to the credibility of the message source but also to whether the message fits the patient’s belief system. Some patients may find it very hard to believe (and understand) concepts that we take for granted. For example, potency is often a difficult concept for patients. A patient may have been taking a tablet for pain relief. This tablet was taken twice a day and was quite large, but the patient got no relief despite the fact that he was taking it properly. The physician then prescribed another medication that is more potent, is taken less often, and comes in much smaller tablets. It may be difficult for some patients to accept that this smaller tablet is going to help if the larger one taken twice as often did not help. As a result, the patient may not even try the new medicine unless he is persuaded by the pharmacist. To be persuasive, the pharmacist will first have to acknowledge and objectively reflect back an understanding of the patient’s beliefs. Then, factual information about potency will have to be given that makes sense to the patient. Analogies may need to be used to allow the patient to understand the concept of potency. One analogy that might make sense to a patient is that of black pepper versus cayenne pepper, the idea being that smaller amounts of cayenne pepper have more potent effects in the mouth than larger amounts of black pepper.

Another issue that may be difficult to grasp is that many drugs have multiple indications at various dosing schedules. For example, diazepam can be used for anxiety, epilepsy, and muscle relaxation. It is often very difficult for patients to understand how this can occur. Therefore, when a patient asks, “What’s this medicine for?” the best answer is, “Could you tell me what caused you to see the doctor?” rather than, “It’s for numerous things, like anxiety, epilepsy, and muscle relaxation.”

Environmental factors. Environmental factors in a pharmacy include privacy, noise, interruptions, and distractions that can affect whether a message is heard and understood. It is important that persuasive messages be delivered in an environment that, to the extent possible, is free from noise, distractions, and interruptions. Each time these things occur, the likelihood of message comprehension and retention decreases. The pharmacist should do as much as possible to create private areas for talking with patients. If this is not possible, then attempts should be made to pull patients away from sources of noise, interruptions, and distractions.

Comprehension and retention. Obviously, for a persuasive message to be effective it must be understood and recalled. We have already discussed the effects of environmental factors on comprehension and recall. In addition, as one might suspect, the credibility of the message source is a critical variable in comprehension and recall. I probably won’t listen to the message if I don’t believe that you are a credible source or if I question the believability of the message.

Another key factor that affects comprehension is the language level of the message. Is the message conveyed in language that is understood by the receiver? Too often in health care, providers use jargon that is common to medicine and pharmacy but not to patients. For example, a 67-year-old woman came into a pharmacy and asked a pharmacist how her methyldopa lowered her blood pressure. She was told that it was a dopa decarboxylase inhibitor. (I wish I could say that I made this up, but it is a true story.) The woman looked confused, but she said, “Oh, OK,” and then left the pharmacy. I’m sure that she found the message believable. I’m not so sure she understood a word the pharmacist said. It is vitally important to use language the patient can understand. It is better to say “high blood pressure” than “hypertension.”

Another comprehension problem has to do with the receiver’s interpretation of the message. Sometimes, our communication with patients seems clear to us but is open to interpretation by the patient. For example, we know that when we tell patients to “take one tablet twice a day” we mean that we want them to take a tablet approximately every 12 hours. But if this meaning is not made explicit, problems may occur. How is the direction to “take one tablet after meals and at bedtime” interpreted? It depends on how many meals you eat a day. A patient with diabetes may eat six or seven small meals each day and take seven or eight tablets. I eat two meals a day, so I would take three tablets. If neither of these responses is correct, then we need to be much more explicit in our directions.

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