Comparative analysis of clinical reasoning and decision-making of community pharmacists during dispensing in Malta and the Philippines

Abstract

Pharmacist’s clinical reasoning and decision-making are critical competency areas that should be investigated due to the increasing clinical involvement of the profession. Clinical reasoning in pharmacy is a complex process that hinges on the pharmacist’s capacity to integrate and apply accumulated knowledge, use and weigh evidence, evaluate all available arguments, and reflect upon the process to arrive to a clinical therapeutic decision. The aim of this study was to investigate clinical reasoning process adopted by community pharmacists in Malta and Philippines when dealing with patients presenting with acute minor ailment concerns. The main outcome of this research was to provide recommendations based on implications in pharmacy education, practice, and research to effectively develop clinical reasoning and decision making competencies among pharmacists and future pharmacists. A comparative qualitative ethnomethodology study was conducted, particularly using a retrospective think aloud technique to examine the patterns of clinical reasoning and decision making processes of community pharmacists. Community pharmacists in the Philippines (10) and in Malta (5) with at least 3-year work experience were observed in the workplace for an entire shift, and were subsequently interviewed. Interactions with adult patients concerning minor ailments, namely, headache, cold and flu, muscle pain, and cough, were documented. All verbal reports were audio/video recorded, transcribed and analyzed using protocol analysis. This study was approved by Faculty of Research Ethics Committee of University of Malta and University of the Philippines Research and Ethics Board. During the observation, 30 and 16 cases of pharmacists responding to minor ailments were observed in The Philippines and in Malta, respectively. Patient requests were classified into two: seeking specific medicine (n=33) or advice (n=13). Pharmacists performed clinical reasoning by collecting contextual patient information and analyze these using objective pharmaceutical knowledge and clinical experience leading to clinical actions to improve patient outcomes or maintain quality of life. Five predominant cognitive strategies when conducting clinical reasoning were identified: collect, assume, infer, act, and explain. When patients seek specific medicines, the pharmacists conducted reasoning only in 29% (Philippines) and 63% (Malta) of the cases, mostly through if/then and hypothetico-deductive approach, respectively. Majority of the specific active ingredients and brands requested by patients were dispensed as is, and about less than 33% were given a pharmaceutical equivalent, alternative or were reassessed. When patients sought for advice, pharmacists reasoned 100% of the time in which Filipino pharmacist utilized if/then approach (83%), whereas Maltese pharmacists tend to assess and decide medications by forward-chaining (50%). Pharmacist’s clinical reasoning approach mostly followed the analytical decision making, which critically varied according to patient’s request at the onset of the interaction.