How much should we expect from patients?

A couple of letters and an op-ed in today's USA Today got me thinking, just how much should we expect patients to take responsibility for?A series of letters addressed an earlier article on fill errors at retail pharmacy. Such errors are actually very rare, but they can have serious consequences and are easier for patients to document than errors that occur in a physician's office or hospital. Two of the letters suggested reasonable roles for patients.Steve Giroux, president of the National Community Pharmacists Association wrote:

...[A]s patients, we must insist on a relationship with our pharmacist, as well as with our physician...As health care continues to evolve, the only way we can be assured high quality care is by asking questions and remaining informed. Don't let a busy pharmacy discourage you. Wait to speak directly to the pharmacist or come back later. As a pharmacist, I do my best to counsel my patients, and I encourage all my colleagues to insist upon the same standard.

Giroux's group represents community pharmacists, i.e., those not in the big chains. Traditionally those pharmacists pride themselves on doing more counseling than their chain store equivalents. However in recent years the distinction has become more blurred as the larger chains have realized the importance of counseling. The automation they've put in place (ironically cited as a driver of medication errors in the original article) actually allows the pharmacist to spend more time with patients.I agreed only partially with Dr. Vicki Rackner, who wrote:

If you went to a drugstore and the clerk grabbed the wrong developed photos or gave you the wrong change, you would recognize the error and speak up. Why do we not invite the same customer contribution when it comes to prescription medication? After all, the patient has the most to lose with medication errors.

Rackner goes on to describe the importance of inviting the patient into the practice of medicine, and I think that's generally right, but there are some problems with the example above. It's easy to recognize when pictures are not of your family, and counting change is something that's an everyday experience and taught in school. Photo clerks and cashiers don't have major educational requirements. Meanwhile, patients are unaware of the names of prescription drugs --many of which are confusing, similar sounding, come in different formulations, and are referred to by both their brand and generic names-- and pharmacists usually have six years of post-secondary training and are highly regulated.Robert Lipsyte, in an op-ed piece on practical concerns for patients, repeats the now-common suggestion that patients ask their physicians if they've washed their hands. He acknowledges that it's hard to do:

I think the toughest question to ask a health care provider about to touch your body is, "Did you wash you hands?"...It is well-known that thousands of Americans die every year from diseases contracted in hospitals. But most patients don't ask the toughest question because they are not comfortable enough with their doctors or the medical environment to do it in a friendly, non-challenging way, and they are afraid of causing antagonism. We need to be made equal partners in the system so we can talk freely.

I agree with Lipsyte that it's hard to do this. I personally have a hard time asking a doctor if he's washed his hands and generally don't. It probably is worth doing --just because of the dangers potentially avoided-- but I also think it's completely outrageous to think it's a reasonable responsibility for the patient.As I've said before (Where's defensive medicine when we need it?), we don't ask our pilot if the plan has fuel, if he's closed the door, or if the runway's long enough. We don't remind fire dispatchers to send trucks that have ladders if we're on the 3rd floor, to put air in the tanks, or to make sure to write down our address. We don't ask lawyers if their advice is based on the law, and so on. We shouldn't have to remind physicians of the most basic safety issues.