Introducing pharmacy students to patient pathographies

American Journal of Pharmaceutical Education, Fall 2000 by Diggs, Amanda M, Anderson-Harper, Heidi M, Janer, Ann L

The traditional disease-centered approaches of the practitioner-patient relationship have historically neglected the impact of the patient in treatment. More contemporary, patient-centered approaches have recognized the important role that patients play in their therapeutic regimen. In this article, the authors advocate the use of the patient pathography as an additional or alternative teaching tool for the medical history record. The patient pathography is seen as a way of restoring the patient; to patient care. In order to begin to teach students the concepts of patient caring as well as empathy, the pathography represents an effective tool.

INTRODUCTION

This article describes two pharmacy courses that have incorporated patient experiences in the first quarter of the first professional year. The patient pathography is included as an integral part of the patient assignment for these courses. Pathographies, as defined by Hawkins(l), are a personal account of illness written by the patient, a friend or relative. In addition, the pathography is described as an extended narrative documenting the author's experience of illness as it relates to the meaning of his or her life. This article will contrast the patient pathography with the biomedical record and then describe the use of the patient pathography in these courses. According to Gurwich(2), the medication history has been discussed as a clinical pharmacy practice activity since the late 1960s. "The taking of a drug history is an accepted part of clinical pharmacy practice," states Badowski, Rosenbloom, and Dawson(3). The medication history is a useful tool because it serves multiple purposes. The medication history as described by Ranelli, Svarstad, and Boh(4) involves an interaction between a health care professional, usually a pharmacist, nurse, or physician, with a patient concerning his or her past and current therapeutic regimen. The researchers explain the various purposes of the medication history as follows: "to acquire information about the patient's medication-taking experiences; to assess the patient's understanding of past and current medication-taking experiences; to assess the patient's motivation for complying with the medication regimen; and to evaluate possible changes in the regimen if the information gathered warrants such an action"(5).

The medication history serves important functions. According to Badowski, et al., it serves as a "crucial source of information" for pharmacists(6). The researchers further explain that the information obtained from the medication history can be incorporated into subsequent therapeutic interaction to affect beneficial outcomes for the patient(6). The medication history provides benefits for the pharmacist beyond therapeutic outcomes. Prosser, Burke, and Hobson(7) state that the medication history has implications for the practice of pharmaceutical care. The researchers state, "to practice pharmaceutical care, pharmacists will need to communicate and document their recommendations in the medical record"(8). Badowski, et al. state, "Medication history interviews frequently provide pharmacists with the opportunity to begin professional relationships with patients"(9). In this regard, Prosser, et al., suggest that pharmacy students should be taught how to write in the medical record(8).

Despite the various functions and potential benefits that the medication history provides within the medical arena, it has been criticized. The current use of the medication history has been punctuated by an emphasis on the clinical elements of treatment steeped in the biomedical approach to health care. Churchill and Churchill(10) offer the following assessment: "Medical histories are stories about patients or their diseases constructed by physicians with the taxonomy of the biological sciences." Health care providers historically have focused on the "disease" rather than the patient. "In order to know the truth of the pathological fact, the doctor must abstract the patient...," states Foucault(11). The traditional disease-centered approaches of the practitioner-patient relationship tend to subtract the patient from health care. These models neglect the impact of the patient in treatment. Hawkins(12) explains that the medical history fails to convey any "genuine sense" of the patient's experience. Donnelly(13) surmises, "Astonishingly, the voluminous records of previous hospitalizations, clinic visits, and the like usually contain little or no information about what these patients understand and feel about their major diagnoses and how they are coping with the effects of chronic disease and disability, the treatment, and, in some cases, their impending death." Flood and Soricelli(14) sum the criticisms of the medical history. The researchers state, "The case history, for all its striving to present a clinically accurate picture of the patient, is incomplete in terms not just of the patient's humanity but the physician's as well. . ."