- Email: [email protected]
Visibility for your Pharmacy How to stand out in a Crowd
How to Stand Out in a Crowd
, ' ViSibility is the key word when promoting your pharmacy in the community," says Linda Garrelts, a pharmacist from Spokane, W A, who's been practicing since 1978. Garrelts' carefully coordinated efforts to make her practice stand out from the crowd surely represent innovation, in the best sense of the word . Many of the activities routinely done to promote community health at Jones' Low-Priced Pharmacy in Spokane, of which she is a co-owner, "are excellent ways of educating the public, while at the same time presenting the pharmacist as a valuable
46
health professional," she says . In addition, these endeavors work to increase general sales and prescription volume, as well as lay the groundwork for continued loyalty among patrons. Garrelts' ongoing programs include holding blood pressure clinics (and maintaining patient records of blood pressure readings), offering pediatric information folders to pregnant women and new parents, displaying an assortment of healthrelated reading materials and conducting counseling based on this material, and distributing a pharmacy public relations pamphlet. She
also performs a number of outreach activities, such as on-site blood pressure checks and presentations of APhA's National Medica tion Awareness Test (NMAT).
BlOOd Pressure Screening To date, more than 60 million Americans have been identified as having high blood pressure (2::1401 90 mm Hg), or have reported that their physician has told them they
American Pharmacy Vol. NS24, No. 10, October 19841674
have this condition. In its May 1984 report, the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure noted that" control of this widespread problem begins with detection and requires subsequent surveillance." Yet, for many people, the high cost of a physician office visit makes it difficult for them to comply with this recommendation. Another recent government document, "Aging and Health Promotion: Market Research for Public Education," funded by the Department of Health and Human Services, reports that elderly participants in particular lament the high price tag on monitoring blood pressure readings by a physician. However, the report 'observes, "a significant number of respondents mentioned using free screening programs."
• Patients using this service at a particular pharmacy are more likely to have prescriptions refilled at that pharmacy; • The whole process provides another setting for building the patient-pharmacist relationship.
Setting Up There are several things that have to be done before the clinic can open to the public, Garrelts says. A first step is to set up a rack of free literature on high blood pressure (see box, below). These materials should be organized in display racks for the pub-
Widespread Demand There is obviously a widespread demand for an inexpensive, but reliable, means of following blood pressure, particularly after the successful efforts of government public education programs like the High Blood Pressure Education Project have made so many Americans acquainted with the potentially dire consequences of this often symptom-free illness. Garrelts offers these additional reasons why pharmacists should become actively involved in blood pressure screening: • Both patient and physician interact frequently with the pharmacist; • The pharmacist is highly accessible to the public; • Pharmacists have up-to-date knowledge on blood pres·sure medications, side effects and contraindications; • Patients tend to feel more relaxed with their pharmacist-who is seen more often-than with their physician; • Patients may volunteer more information concerning how drugs affect them, and ask more questions of a pharmacist; • Elderly people often require repeat.ed instructions and reminders on medication and compliance;
American Pharmacy Vol. NS24, No. 10, October 1984/675
lic, and located adjacent to the area designated for blood pressure screening. The actual equipment for the screening can be obtained from medical equipment wholesalers, or you ·m ay be able to get what you need free of charge through the sales reps of the drug companies that sell an tih ypertension medications. Personnel that can be tapped for doing the blood pressure measurements might include interested patients who are registered nurses, pharmacy interns, or student nurses. It's also possible to train other peo-
Hyperten'sion Literature ' Booklets
• High Blood Pressure-Facts and Fiction • Questions About Weight, Salt, and High Blood Pressure The National High Blood Pressure EducationProgram,National Heart, Lung, and Blood Institute, 120/80 National Institutes of Health, Bethesda, MD 20205. • High Blood Pressure-Your Doctor's Advice Could Save Your Life • High Blood Pressure-Health Enemy #1 • Measuring Blood Pressure • Blood Pressure Record (wallet card) Health Information Services, Merck Sharp & Dohme, West Point, 'FA 19486. • Understanding High Blood Pressure Searle & Company, Box 5110, Chicago, IL60680. • Blood Pressure: What's Your Number? Public Relations Dept, Blue Cross of South€rn California, 4777 Sunset Blvd., Los Angeles, CA 90027.
• High Blood Pressure and Your Kidneys National Kidney Foundation, 2 Park Ave., Suite 908, New York, NY 10016. Catalogues
• How Many of Your Hypertensive Patients Stay on Treatment? High Blood Pressure Information Center, 120/80 National Institutes of Health, Bethesda, MD 20014. • The 1984 Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure • Directory of Community High Blood Pressure Control Activities • Handbook for Improving High Blood Pressure Control in the Community • Catalog of Audio-Visual Aids in Hypertension • Catalog of Audio-Visual Aids in Hypertension (Supplement) • Detection, Evaluation, and Treatment of High Blood Pressure National Heart, Lung and Blood Institute, National High Blood Pressure Education Program, 1201 80 National Institutes of Health, Bethesda, MD 20205.
47
pIe who express an interest in helping their community. Next, you have to advertise the availability of this service, emphasizing the date and time, through radio public service announcements, newspapers, store flyers or circulars, and signs placed out in front of the pharmacy. The area for taking the readings will need a few basics, too: seating for the patient and nurse (a school chair with a "writing" arm is ideal for the patient), and tables for the files. It's also a nice idea to display some examples of low-sodium products (obtained from detail representatives), such as antacids and salt substitutes.
Running the Clinic If the patient who comes for a blood pressure check has had his or her pressure measured at the pharmacy before, the patient index card can be pulled from the file and u pdated by queries like: "Are you still on antihypertensive medication?"; "If so, have there been any changes in dosages?"; "Are you feeling OK on the medication?"; "Have you noticed an y troublesome side effects?"; "Are you careful to limit your intake of sodium and caffeine?" If the patient doesn't already have a card, a new one will have to be filled out, noting: • Name and birthdate; • Medications and dosages; • Blood pressure or heart problems known to the patient; • Whether the patient's prescriptions are usually filled at the pharmacy. If not, this setting offers an excellent opportunity to explain that your pharmacy will be happy to provide this service, and will include a free patient profile to check on compliance and monitor for drug allergies or possible interactions. The patient can also be given a brief introduction on why your pharmacy has elected to furnish this service, relating the importance of public awareness about hypertension and its serious consequences. As part of this discussion, Garrelts advises that pharmacists inform new patients that their pharmacy "offers the best pharmacy care possible, and this is just one of the many services
48
Pharmacists are fortunate in that the information and programs they can provide can serve equally well as marketing tools and as genuine services to the community. your pharmacy has to offer." Then the patient's blood pressure is checked. The meaning of the reading is explained to the patient, and the numerical value recorded on both the file card and on a patient wallet card. The patient can also be given a brochure on blood pressure to take home and read. To keep up patient interest, it's wise to hand out a different brochure at each clinic visit. Finally, the patient needs to be told the date scheduled for the next blood pressure clinic.
Follow-up If a patient seems confused about medications or the issue of noncompliance, his or her physician ought to be informed about it. Also, those with highly elevated readings at their
first clinic check (diastolic pressure of 105 mm Hg or over, or systolic pressure of 200 mm Hg or more) should be advised to contact a physician as soon as possible. At the first recheck, those with diastolic pressures of 2::90 mm Hg, or systolic pressure of 2:: 140 mm Hg, also need further evaluation by a physician. (See American Pharmacy June 1984, p. 48, for a summary of the revised guidelines-as of May 1984-issued by the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure.) When new patients with prescriptions for antihypertensive dru gs come into the pharmacy, they should be informed about the store's free blood pressure service, too. Other customers at high risk for hypertension, such as blacks, smokers, the obese, and the elderly, might appreciate a special mention of your clinic as well.
Pediatric Information Handing out a pediatric information folder (see suggested contents of folder, below) to each pregnant woman who comes into the pharmacy for a
Pediatric Information Folder • Family Medical Record March of Dimes Birth Defects Foundation, 1275 Mamaroneck Ave., White Plains, NY 10605. • The Bond of Love-A Guide for the Nursing Mother Ortho Pharmaceutical Corporation, U.S. Route 202, Raritan, NJ 08869. • Parents Guide to Childhood Immunization (OHEW #05 7750058; $23.00 for package of 50). • Caring for Your Baby's Skin Westwood Pharmaceuticals, Inc.,
100 Forest NY 14213.
Ave.,
Buffalo ,
• First Aid for Poisoning • Poison Stickers (Mr. Yuk) Local poison control center. • Pediatric Medicine Chest-See list in box, p. 49. Print or photocopy this list for use by your pharmacy. Insert your pharmacy name, address, phone, etc. • Syrup of Ipecac Information SheetSee box, p. 49. Print or photocopy this list for use by your pharmacy.
American Pharmacy Vol. NS24, No. 10, October 1984/676
Pediatric Dosage Recommendations* Age group Weight (lbs)
0-3 months
12-23 months
2-3 years
4-5 years
6-8 years
9-10 years
11-12
months
6-11
12-17
IS-23
24-35
36-47
4S-59
60-71
72-95
40 1/2
SO
120
160
240
320
400
480
1
Ilj2
2
3
4
5
1/2
%
1
P/2
2
21/2
3
1%
2
3
4
5
6
Tylenol (mg) Drops (SO mg/O.S ml) dropperfuls
4-11
Elixir (160 mg/5 ml) teaspoonfuls Chewable tablets (80 mg each)
years
' Doses should be administered 4 or 5 times daily but not to exceed 5 doses in 24 hours.
prescription, or to new parents purchasing items such as liquid vitamins or antibiotics, can both promote the pharmacy and help new parents. The materials included-for the most part obtained free from various government agencies, private organizations, and businesses-can assist parents in learning about practical matters that may not be covered in more esoteric books on child development, such as drug dosing (see box, above), immunization schedules, and the basic components of a pediatric medicine chest (see box, below). Like the blood pressure screening program, the folder, says Garrelts, "makes the customer aware that the pharmacist is knowledgeable, reliable, and an easily accessible resource for pediatric information." Again, this sort of effort also works "to strengthen the loyalty and bond
between the customer and the pharmacist." To promote distribution of the folder, a sign can be placed near the brochure display which says, "Ask at the pharmacy about our Pediatric Information Folder." Garrelts advises that the folder be personally handed out by the pharmacist, who can then discuss the information in it and provide a quick education on syrup of ipecac (see box, below) and Pedialyte. At least on the outside of the folder-but perhaps also on any of the other materials included in it-
Pediatric Medicine Chest 1. Infant rectal
2. 3. 4. 5. 6. 7. 8. 9.
thermometer A & 0 Ointment Liquid Tylenol Pedialyte Petroleum jelly Disposable diapers Bandaids Syrup of Ipecac Accurate measuring device
American Pharmacy Vol. NS24, No. 10, October 1984/677
the name, address, and phone number of your pharmacy can be imprinted or rubber stamped to reinforce the identity and professional resourcefulness of your store.
Health Brochures Garrelts comments that "free health literature will help educate and inform the public on health matters that interest and affect them." On the other hand, patients may easily
Syrup of Ipecac What is Ipecac? Syrup of Ipecac is an emetic used to induce vomiting in overdose and in certain poisonings . When should Ipecac be given? When the poison center or your physician has instructed you to use it in a poisoning case. Always consult your physician or poison control center in case of an accidental poisoning. Try to be prepared with information on the product and the amount ingested. When should Ipecac never be used? It shouldn't be used in unconscious, semiconscious, or convulsing persons. It also should not be
used when certain poisons are ingested, such as petroleum distillates, strong alkali, acids, or strychnine. How much Syrup of Ipecac should be given? • For children under 1 year old: Give two (2) teaspoonfuls (10 ml) followed by % to 1 glass of water. • For children over 1 year old and adults: Give one (1) tablespoonful (15 ml) followed by 1 to 2 glasses of water. If vomiting does not occur within 10 minutes, the dose may be repeated once. If vomiting does not occur within 20 minutes after the second dose, call the poison control center again.
49
turn is likely to lead to individualized counseling. Counseling, in the eyes of the patient, is seen as a highly personalized service that sets the pharmacy that provides it apart from the others . All of the information should have the pharmacy's name, address, and phone number stamped on it to provide patients with a constant reminder of your pharmacy and the wide range of services it has to offer. The materials are best displayed close to the pharmacy, so that the pharmacist can get out and talk to people as they browse through the literature. Some ideas for health-related materials for display are listed in the boxes on pp. 50 and 51.
Pediatrics and Pregnancy Information • Epilepsy: You and Your Child-A ,Guide for Parents Epilepsy Foundation of America, 4351 Garden City Dr., Landover, MD 20781. • Be Good to Your Baby Before It Is Born • Birth Defects: Tragedy and Hope • Question & Answers About Down's Syndrome • Drugs, Alcohol, Tobacco Abuse
During Pregnancy • Pregnant? Before' Your Drink, Think .. March of Dimes, Birth Defects Foundation, 1275 Mamaroneck Avenue, White Plains, NY 10605. • A Guide to the Methods of Contraception O'r tho Pharmaceutical Corporation, U.S. Route 202, Raritan, NJ 08869.
Diabetes Information • Foot Notes for Better Diabetes Care • Dealing with Juvenile Onset Diabetes . ' Hyperglycemia Information (card) . ' I Have Diabetes (ID card) • Insulin Reaction Information (sheet) • Getting Started Series: i. Answers to Questions About Sick Days ii. Drawing and Injecting Insulin iii. Site Selection and Rotation Becton Dickinson Consumer Products, P.O. Box 5000, Rochelle Park, NJ 07662.
• Parent to Parent-Your Child Has Diabetes • Parent to Parent-Your Baby Has Diabetes Juvenile Diabetes Foundation, 60 Madison Ave., New York, NY 10010.
PubHc Relations,
• You Can Live with Diabetes If You Learn How American Diabetes Association, Inc., 2 Park Ave., New York, NY 10016.
Fi,rst Aid Inform,ation • Home Safe Home for Your Explorer The Soap and Detergent Association, 475 ' Park Avenue South, New York; NY 10016. • CPR Saves Lives, Who Teaches It? We Do (#ARC-2188) • First Aid for Poisoning (#320800;
become bored if the same materials are on display all the time, so she also advises: By having a variety of pamphlets on each health topic on hand, the pharmacist can continually rotate the information which is available to the
50
$10.00 for 100 copies) • First Aid for Snakebite (#ARC2189) • First Aid Training (#ARC-2150) • Whitewater in an Open Canoe (#ARC-2173.) Local American Red Cross Chapter.
Unfortuna.tely, to' many people in the United States, the profession of pharmacy remains something of a mystery. They simply don't know what. a pharmacist does; what kind of education, training, and testing pharmacists must complete; or what services they can offer. One way to get patients better acquainted with the background and functions of pharmacists-and the pharmacy in which they work-is through a brief brochure which can be given to each new patient when a prescription is filled. As the pharmacist takes the information for the patient profile, he or she can explain, says Garrelts, "that you also feel it is important for the patient to know a lot about the pharmacist and pharmacy. Emphasize that the choice of a pharmacy should be made carefully. The brochure can also be given to each person at the blood pressure screenings who is not a regular patron. Suggested contents for this kind of brochure include: • Address, phone number, hours of operation, days open, and where to call in an emergency; • A short history of the profession of pharmacy, and a synopsis of what fI
public at anyone time. This keeps up the interest of regular customers, and is an added reason for that person to patronize your pharmacy. Informational health brochures also serve to stimulate questions from patrons for the pharmacist, which in
American Pharmacy Vol. NS24, No , 10, October 1984/678
pharmacists do today; • Education and training pharmacists receive; • A short biography of each phar,macist; • Fee schedules, an explanation abou t generic drugs, and some information on how the pharmacy handles third-party prescriptions; • A description of what's in the patient profile and the ways it can help the patient. Garrelts summarizes: The public relations pamphlet will serve to increase the understanding of the patient on pharmacy, yours in particular. The patient will know what your philosophy is on the practice of pharmacy, how you price prescriptions, where you stand on generics, why you ~eed to phone the physician for refill okays, which third-party plans you participate in, as well as any other services you have to offer.
Drug Use & Abuse Information • The Medicines Your Doctor Prescribes • Signs of Use of Substances for Drugging Effects Pharmaceutical Manufacturers Association, 1100 Fifteenth St., NW, Washington, DC 20005. • Drugs of Abuse Drug Enforcement Administration, 1405 I St., NW, Washington, DC 20530.
Miscellaneous Information • Sickle Cell Anemia March of Dimes, 1275 Mamaronbeck Ave., White Plains, NY 10605. • "Flu" -What Is It? Who Gets It? What Can You Do About It? • Hay Fever Holiday-How to Escape The Ragweed Season • A Healthlf Lifestyle: One Key to
Community Services To increase the visibility of your pharmacy within the general community, there are other activities you can undertake outside the store that can help educate the public while at the same time enhancing the professional image of the pharmacist.
Using the NMA T Of course, not everyone feels instantly comfortable speaking before a large group. For this reason, APhA's National Medica tion Awareness Test (NMAT) provides a good way for pharmacists to begin their careers as public speakers on drugs and other health topics. The NMAT includes a set of slides, an audio tape, and a written script, which cover common sense aspects of taking medication correctly. Garrelts says a good audience for the NMAT is "junior and senior high school students, since they will be consumers of nonprescription and prescription medications for the next 50 years . Now is the time to ed uca te them on wise consumerism and who to turn to for sound medication counseling-their family pharma-
• Communities: What You Can Do About Drug and Alcohol Abuse • Drugs and Driving: Why Take the Risk? • Parents: What You Can Do About Drug Abuse • Peer Pressure: It's OK to Say No National Clearinghouse for Drug Abuse Information, P.O. Box 416, Kensington, MD 20795.
cist. " Other excellent targets for the NMAT are service groups and honorary sororities, community groups (like parent-teacher organizations and Boy and Girl Scouts), and senior citizen groups. Local professional groups such as municipal or state medical and dental societies may benefit from the program, too, she says. Presenting the NMAT (1) strengthens ties between professions and generates discussion between colleagues; (2) promotes the community pharmacist as a knowledgeable and integral member of the health care team; and (3) allows other professionals to recommend the pharmacist's NMAT to their contacts in the community.
Media Exposure Through media exposure, pharmacists can avail themselves of yet another channel for projecting themselves as va:luable sources of
American Pharmacy Vol. NS24, No. 10, October 1984/679
Lower Health-Care Costs • What You Should Know About Hepatitis: Everything From A to B • Legionnaires' Disease: The Mystery Malady Abbott Laboratories, Attn.: Public Affairs, 0-383, 14th & Sheridan Rd., North Chicago, IL 60064.
knowledge. As an expert on medications, the pharmacist should be the primary contact for any TV or radio news program dealing with medicines. If the pharmacist doesn't have the precise information the media needs, he or she at least knows where to find it. However, pharmacists themselves may have to take the initiative to remind the local media of their competence in the area of medications and their willingness to talk about drugs and health. To get started in becoming a media spokesman, pharmacists can contact: • TV and radio program directors; • News reporters and public affairs reporters; • Local newspaper medical editors. Garrelts encourages pharmacists to contact "all of the stations and newspapers-don't limit yourself to just one." Having reached the right people in the media, pharmacists should
51
explain their availability to be interviewed on a variety of specific topics dealing with medications. Garrelts adds: "Make sure that they understand that if it's wanted, you have complete packaged interviews available, complete with questions."
Media Topics Pharmacists can also invite news
personnel to come and see the NMAT whenever they present it to a community group. Another good opportunity for pharmacists who want to reach the media is offered by the multitude of national health observances that occur throughout the year (see box, p. 53). The pharmacist's discussion can explain why it is important to raise
public awareness on a given topic, and relate how his or her pharmacy educates the public on this topic (for instance, through counseling or brochures). Other packages for helping pharmacists gain media exposure are Burroughs Wellcome Company's "Suggested Drug-Related Program Topics with Interview Questions,"
APhA's Audiovisual Spotlights
A
ready-made way for pharmacists to spotlight themselves as a handy source of medication information is in the form of three audiovisual programs developed by APhA with the support of Lederle Laboratories. The three programs-the National Medication Awareness Test (NMAT), the Health Check Test (HCT), and the Self Medication Awareness Test (SMAT)-use a "test" format which presents information as well as asks questions that heighten the participant's awareness concerning medication. • NMAT focuses on important information patients need to know about their medications, how to take it, and how it works in the body. • HeT emphasizes the kinds of information patients need to take an active part in their own health care, and introduces a unique record-keeping system for prescription and nonprescription medications taken and other health care services received. • SMAT stresses that nonprescription medication must be selected and used with the same care that is exercised with prescription medications. The program provides information patients need to determine
52
Pharmacist Garrelts reviews the answers to the NMAT with a high school student. (Photo courtesy of Linda Garrelts.)
whether self medication is desirable and, if so, how to self medicate safely
and effectively. The programs can be presented to any group the pharmacist can assemble in his community. In addition to making patients and other consumers aware of their own individual responsibilities in medication, presentation of the program(s) will enhance the pharmacist's professional standing in the community. For more information on how you can present these programs, contact APhA's Academy of Pharmacy Practice, 2215 Constitution Avenue, NW, Washington, DC 20037.
American Pharmacy Vol. NS24, No. 10, October 1984/680
National Health Observances January: February: March:
April: May:
Birth Defects Month Smoking Education Week (2nd week) American Heart Month Children Dental Health Week (2nd week) Easter Seals National Nutrition Month Red Cross Month Save Your Vision Week (2nd week) Poison Prevention Week (3rd week) Community Health Week (3rd week) Cancer Control Month World Health Day (April 7th) Mental Health Month
which encompasses 26 topics with questions to be asked of a pharmacist by an interviewer, and the "Do It Yourself Radio Programs" (also from Burroughs Wellcome). The latter is a packet that explains everything from how to get on a program, to what to say and how to say it. Garrelts particularly recommends that pharmacists alert program directors about their ability to speak on the issue of drug abuse, because "this topic is always one the media is interested in." One resource for boning up on the topic is the "Drug Abuse Information Kit" from Eli Lilly &Co.
Extended Services Since many people can't-or don't choose to-take the time to get regular blood pressure checks, pharmacists can further assist the community by setting up and performing blood pressure measurements at job sites and senior citizen centers. Pharmacists should first contact the personnel manager (at job sites) and explain the value of blood pressure control to the employer, citing tangible gains like increased productivity and less absenteeism. A good time to suggest for screening might be the employee lunch hour. Then, the employees have to be notified (via company newsletters and posters for bulletin boards). After conducting the clinic and pursuing any necessary follow-up, the relative success of the venture should be discussed with the personnel manager, and suggestions for
October: November: December:
Arthritis Month High Blood Pressure Month Hearing and Speech Month Foot Health Week (2nd week) Immunization Month Drug Abuse Prevention (3rd week) Child Health Day (1st Monday) Diabetes Month Lung Disease Month (Christmas Seals) Mental Retardation Month Diabetes Month Lung Disease Month (Christmas Seals)
Pharmacists should take the initiative to remind the media of their competence in the area of medications and their willingness to talk about drugs and health. improvements made. Another screening date can then be scheduled for the future-usually 3-6 months later. Pretty much the same procedure can be followed when doing screenings for senior citizens. In this instance, the director of the seniors' group should be contacted, and the vital role of controlled blood pressure and compliance with medication regimens explained. Pharmacists should then set up a convenient, regular time for screenings, at a central location, such as the town library. Garrelts suggests that blood pressure measurements then be made available for about 2 hours on a particular day-for example, the first Tuesday of every month. The volume of traffic in this program can usually be easily handled by one pharmacist. Local monthly newsletters provide the best vehicle for telling senior citizen residents about this service. As each person's pressure is measured, he or she can be given a copy of the pharmacy's public relations
American Pharmacy Vol. NS24, No.1 0, October 1984/681
brochure, and also asked if the pharmacy currently fills the patient's prescriptions. If not, the pharmacist can note that the pharmacy would be happy to provide this service, along with a regularly updated patient profile. For this profile, Garrelts recommends a standard evaluation measure for any marketing endeavoran increase in the number of prescriptions filled in the area where the senior center is located after a screening program is begun.
Set for Success Pharmacist Garrelts' suggestions for expanding a pharmacy practice and making it more visible in the community prompt several interesting conclusions. First, pharmacists are fortunateand possibly unique-in that the informa tion and programs they can provide can serve equally well as marketing tools and as genuine (and sorely needed) services to the community. Second, it will admittedly take some self-motivation to get these programs in motion, but just as surely, the rewards will be there once they get underway. Finally, one can't help but notice the intelligence, creativity, and thoroughness with which Linda Garrelts approaches each one of the projects undertaken to promote her pharmacy. Such an attitude cannot assure complete success-nothing can do that-but it certainly sets up the preconditions that allow it to happen. -Dana Murphy
53
, ' ViSibility is the key word when promoting your pharmacy in the community," says Linda Garrelts, a pharmacist from Spokane, W A, who's been practicing since 1978. Garrelts' carefully coordinated efforts to make her practice stand out from the crowd surely represent innovation, in the best sense of the word . Many of the activities routinely done to promote community health at Jones' Low-Priced Pharmacy in Spokane, of which she is a co-owner, "are excellent ways of educating the public, while at the same time presenting the pharmacist as a valuable
46
health professional," she says . In addition, these endeavors work to increase general sales and prescription volume, as well as lay the groundwork for continued loyalty among patrons. Garrelts' ongoing programs include holding blood pressure clinics (and maintaining patient records of blood pressure readings), offering pediatric information folders to pregnant women and new parents, displaying an assortment of healthrelated reading materials and conducting counseling based on this material, and distributing a pharmacy public relations pamphlet. She
also performs a number of outreach activities, such as on-site blood pressure checks and presentations of APhA's National Medica tion Awareness Test (NMAT).
BlOOd Pressure Screening To date, more than 60 million Americans have been identified as having high blood pressure (2::1401 90 mm Hg), or have reported that their physician has told them they
American Pharmacy Vol. NS24, No. 10, October 19841674
have this condition. In its May 1984 report, the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure noted that" control of this widespread problem begins with detection and requires subsequent surveillance." Yet, for many people, the high cost of a physician office visit makes it difficult for them to comply with this recommendation. Another recent government document, "Aging and Health Promotion: Market Research for Public Education," funded by the Department of Health and Human Services, reports that elderly participants in particular lament the high price tag on monitoring blood pressure readings by a physician. However, the report 'observes, "a significant number of respondents mentioned using free screening programs."
• Patients using this service at a particular pharmacy are more likely to have prescriptions refilled at that pharmacy; • The whole process provides another setting for building the patient-pharmacist relationship.
Setting Up There are several things that have to be done before the clinic can open to the public, Garrelts says. A first step is to set up a rack of free literature on high blood pressure (see box, below). These materials should be organized in display racks for the pub-
Widespread Demand There is obviously a widespread demand for an inexpensive, but reliable, means of following blood pressure, particularly after the successful efforts of government public education programs like the High Blood Pressure Education Project have made so many Americans acquainted with the potentially dire consequences of this often symptom-free illness. Garrelts offers these additional reasons why pharmacists should become actively involved in blood pressure screening: • Both patient and physician interact frequently with the pharmacist; • The pharmacist is highly accessible to the public; • Pharmacists have up-to-date knowledge on blood pres·sure medications, side effects and contraindications; • Patients tend to feel more relaxed with their pharmacist-who is seen more often-than with their physician; • Patients may volunteer more information concerning how drugs affect them, and ask more questions of a pharmacist; • Elderly people often require repeat.ed instructions and reminders on medication and compliance;
American Pharmacy Vol. NS24, No. 10, October 1984/675
lic, and located adjacent to the area designated for blood pressure screening. The actual equipment for the screening can be obtained from medical equipment wholesalers, or you ·m ay be able to get what you need free of charge through the sales reps of the drug companies that sell an tih ypertension medications. Personnel that can be tapped for doing the blood pressure measurements might include interested patients who are registered nurses, pharmacy interns, or student nurses. It's also possible to train other peo-
Hyperten'sion Literature ' Booklets
• High Blood Pressure-Facts and Fiction • Questions About Weight, Salt, and High Blood Pressure The National High Blood Pressure EducationProgram,National Heart, Lung, and Blood Institute, 120/80 National Institutes of Health, Bethesda, MD 20205. • High Blood Pressure-Your Doctor's Advice Could Save Your Life • High Blood Pressure-Health Enemy #1 • Measuring Blood Pressure • Blood Pressure Record (wallet card) Health Information Services, Merck Sharp & Dohme, West Point, 'FA 19486. • Understanding High Blood Pressure Searle & Company, Box 5110, Chicago, IL60680. • Blood Pressure: What's Your Number? Public Relations Dept, Blue Cross of South€rn California, 4777 Sunset Blvd., Los Angeles, CA 90027.
• High Blood Pressure and Your Kidneys National Kidney Foundation, 2 Park Ave., Suite 908, New York, NY 10016. Catalogues
• How Many of Your Hypertensive Patients Stay on Treatment? High Blood Pressure Information Center, 120/80 National Institutes of Health, Bethesda, MD 20014. • The 1984 Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure • Directory of Community High Blood Pressure Control Activities • Handbook for Improving High Blood Pressure Control in the Community • Catalog of Audio-Visual Aids in Hypertension • Catalog of Audio-Visual Aids in Hypertension (Supplement) • Detection, Evaluation, and Treatment of High Blood Pressure National Heart, Lung and Blood Institute, National High Blood Pressure Education Program, 1201 80 National Institutes of Health, Bethesda, MD 20205.
47
pIe who express an interest in helping their community. Next, you have to advertise the availability of this service, emphasizing the date and time, through radio public service announcements, newspapers, store flyers or circulars, and signs placed out in front of the pharmacy. The area for taking the readings will need a few basics, too: seating for the patient and nurse (a school chair with a "writing" arm is ideal for the patient), and tables for the files. It's also a nice idea to display some examples of low-sodium products (obtained from detail representatives), such as antacids and salt substitutes.
Running the Clinic If the patient who comes for a blood pressure check has had his or her pressure measured at the pharmacy before, the patient index card can be pulled from the file and u pdated by queries like: "Are you still on antihypertensive medication?"; "If so, have there been any changes in dosages?"; "Are you feeling OK on the medication?"; "Have you noticed an y troublesome side effects?"; "Are you careful to limit your intake of sodium and caffeine?" If the patient doesn't already have a card, a new one will have to be filled out, noting: • Name and birthdate; • Medications and dosages; • Blood pressure or heart problems known to the patient; • Whether the patient's prescriptions are usually filled at the pharmacy. If not, this setting offers an excellent opportunity to explain that your pharmacy will be happy to provide this service, and will include a free patient profile to check on compliance and monitor for drug allergies or possible interactions. The patient can also be given a brief introduction on why your pharmacy has elected to furnish this service, relating the importance of public awareness about hypertension and its serious consequences. As part of this discussion, Garrelts advises that pharmacists inform new patients that their pharmacy "offers the best pharmacy care possible, and this is just one of the many services
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Pharmacists are fortunate in that the information and programs they can provide can serve equally well as marketing tools and as genuine services to the community. your pharmacy has to offer." Then the patient's blood pressure is checked. The meaning of the reading is explained to the patient, and the numerical value recorded on both the file card and on a patient wallet card. The patient can also be given a brochure on blood pressure to take home and read. To keep up patient interest, it's wise to hand out a different brochure at each clinic visit. Finally, the patient needs to be told the date scheduled for the next blood pressure clinic.
Follow-up If a patient seems confused about medications or the issue of noncompliance, his or her physician ought to be informed about it. Also, those with highly elevated readings at their
first clinic check (diastolic pressure of 105 mm Hg or over, or systolic pressure of 200 mm Hg or more) should be advised to contact a physician as soon as possible. At the first recheck, those with diastolic pressures of 2::90 mm Hg, or systolic pressure of 2:: 140 mm Hg, also need further evaluation by a physician. (See American Pharmacy June 1984, p. 48, for a summary of the revised guidelines-as of May 1984-issued by the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure.) When new patients with prescriptions for antihypertensive dru gs come into the pharmacy, they should be informed about the store's free blood pressure service, too. Other customers at high risk for hypertension, such as blacks, smokers, the obese, and the elderly, might appreciate a special mention of your clinic as well.
Pediatric Information Handing out a pediatric information folder (see suggested contents of folder, below) to each pregnant woman who comes into the pharmacy for a
Pediatric Information Folder • Family Medical Record March of Dimes Birth Defects Foundation, 1275 Mamaroneck Ave., White Plains, NY 10605. • The Bond of Love-A Guide for the Nursing Mother Ortho Pharmaceutical Corporation, U.S. Route 202, Raritan, NJ 08869. • Parents Guide to Childhood Immunization (OHEW #05 7750058; $23.00 for package of 50). • Caring for Your Baby's Skin Westwood Pharmaceuticals, Inc.,
100 Forest NY 14213.
Ave.,
Buffalo ,
• First Aid for Poisoning • Poison Stickers (Mr. Yuk) Local poison control center. • Pediatric Medicine Chest-See list in box, p. 49. Print or photocopy this list for use by your pharmacy. Insert your pharmacy name, address, phone, etc. • Syrup of Ipecac Information SheetSee box, p. 49. Print or photocopy this list for use by your pharmacy.
American Pharmacy Vol. NS24, No. 10, October 1984/676
Pediatric Dosage Recommendations* Age group Weight (lbs)
0-3 months
12-23 months
2-3 years
4-5 years
6-8 years
9-10 years
11-12
months
6-11
12-17
IS-23
24-35
36-47
4S-59
60-71
72-95
40 1/2
SO
120
160
240
320
400
480
1
Ilj2
2
3
4
5
1/2
%
1
P/2
2
21/2
3
1%
2
3
4
5
6
Tylenol (mg) Drops (SO mg/O.S ml) dropperfuls
4-11
Elixir (160 mg/5 ml) teaspoonfuls Chewable tablets (80 mg each)
years
' Doses should be administered 4 or 5 times daily but not to exceed 5 doses in 24 hours.
prescription, or to new parents purchasing items such as liquid vitamins or antibiotics, can both promote the pharmacy and help new parents. The materials included-for the most part obtained free from various government agencies, private organizations, and businesses-can assist parents in learning about practical matters that may not be covered in more esoteric books on child development, such as drug dosing (see box, above), immunization schedules, and the basic components of a pediatric medicine chest (see box, below). Like the blood pressure screening program, the folder, says Garrelts, "makes the customer aware that the pharmacist is knowledgeable, reliable, and an easily accessible resource for pediatric information." Again, this sort of effort also works "to strengthen the loyalty and bond
between the customer and the pharmacist." To promote distribution of the folder, a sign can be placed near the brochure display which says, "Ask at the pharmacy about our Pediatric Information Folder." Garrelts advises that the folder be personally handed out by the pharmacist, who can then discuss the information in it and provide a quick education on syrup of ipecac (see box, below) and Pedialyte. At least on the outside of the folder-but perhaps also on any of the other materials included in it-
Pediatric Medicine Chest 1. Infant rectal
2. 3. 4. 5. 6. 7. 8. 9.
thermometer A & 0 Ointment Liquid Tylenol Pedialyte Petroleum jelly Disposable diapers Bandaids Syrup of Ipecac Accurate measuring device
American Pharmacy Vol. NS24, No. 10, October 1984/677
the name, address, and phone number of your pharmacy can be imprinted or rubber stamped to reinforce the identity and professional resourcefulness of your store.
Health Brochures Garrelts comments that "free health literature will help educate and inform the public on health matters that interest and affect them." On the other hand, patients may easily
Syrup of Ipecac What is Ipecac? Syrup of Ipecac is an emetic used to induce vomiting in overdose and in certain poisonings . When should Ipecac be given? When the poison center or your physician has instructed you to use it in a poisoning case. Always consult your physician or poison control center in case of an accidental poisoning. Try to be prepared with information on the product and the amount ingested. When should Ipecac never be used? It shouldn't be used in unconscious, semiconscious, or convulsing persons. It also should not be
used when certain poisons are ingested, such as petroleum distillates, strong alkali, acids, or strychnine. How much Syrup of Ipecac should be given? • For children under 1 year old: Give two (2) teaspoonfuls (10 ml) followed by % to 1 glass of water. • For children over 1 year old and adults: Give one (1) tablespoonful (15 ml) followed by 1 to 2 glasses of water. If vomiting does not occur within 10 minutes, the dose may be repeated once. If vomiting does not occur within 20 minutes after the second dose, call the poison control center again.
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turn is likely to lead to individualized counseling. Counseling, in the eyes of the patient, is seen as a highly personalized service that sets the pharmacy that provides it apart from the others . All of the information should have the pharmacy's name, address, and phone number stamped on it to provide patients with a constant reminder of your pharmacy and the wide range of services it has to offer. The materials are best displayed close to the pharmacy, so that the pharmacist can get out and talk to people as they browse through the literature. Some ideas for health-related materials for display are listed in the boxes on pp. 50 and 51.
Pediatrics and Pregnancy Information • Epilepsy: You and Your Child-A ,Guide for Parents Epilepsy Foundation of America, 4351 Garden City Dr., Landover, MD 20781. • Be Good to Your Baby Before It Is Born • Birth Defects: Tragedy and Hope • Question & Answers About Down's Syndrome • Drugs, Alcohol, Tobacco Abuse
During Pregnancy • Pregnant? Before' Your Drink, Think .. March of Dimes, Birth Defects Foundation, 1275 Mamaroneck Avenue, White Plains, NY 10605. • A Guide to the Methods of Contraception O'r tho Pharmaceutical Corporation, U.S. Route 202, Raritan, NJ 08869.
Diabetes Information • Foot Notes for Better Diabetes Care • Dealing with Juvenile Onset Diabetes . ' Hyperglycemia Information (card) . ' I Have Diabetes (ID card) • Insulin Reaction Information (sheet) • Getting Started Series: i. Answers to Questions About Sick Days ii. Drawing and Injecting Insulin iii. Site Selection and Rotation Becton Dickinson Consumer Products, P.O. Box 5000, Rochelle Park, NJ 07662.
• Parent to Parent-Your Child Has Diabetes • Parent to Parent-Your Baby Has Diabetes Juvenile Diabetes Foundation, 60 Madison Ave., New York, NY 10010.
PubHc Relations,
• You Can Live with Diabetes If You Learn How American Diabetes Association, Inc., 2 Park Ave., New York, NY 10016.
Fi,rst Aid Inform,ation • Home Safe Home for Your Explorer The Soap and Detergent Association, 475 ' Park Avenue South, New York; NY 10016. • CPR Saves Lives, Who Teaches It? We Do (#ARC-2188) • First Aid for Poisoning (#320800;
become bored if the same materials are on display all the time, so she also advises: By having a variety of pamphlets on each health topic on hand, the pharmacist can continually rotate the information which is available to the
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$10.00 for 100 copies) • First Aid for Snakebite (#ARC2189) • First Aid Training (#ARC-2150) • Whitewater in an Open Canoe (#ARC-2173.) Local American Red Cross Chapter.
Unfortuna.tely, to' many people in the United States, the profession of pharmacy remains something of a mystery. They simply don't know what. a pharmacist does; what kind of education, training, and testing pharmacists must complete; or what services they can offer. One way to get patients better acquainted with the background and functions of pharmacists-and the pharmacy in which they work-is through a brief brochure which can be given to each new patient when a prescription is filled. As the pharmacist takes the information for the patient profile, he or she can explain, says Garrelts, "that you also feel it is important for the patient to know a lot about the pharmacist and pharmacy. Emphasize that the choice of a pharmacy should be made carefully. The brochure can also be given to each person at the blood pressure screenings who is not a regular patron. Suggested contents for this kind of brochure include: • Address, phone number, hours of operation, days open, and where to call in an emergency; • A short history of the profession of pharmacy, and a synopsis of what fI
public at anyone time. This keeps up the interest of regular customers, and is an added reason for that person to patronize your pharmacy. Informational health brochures also serve to stimulate questions from patrons for the pharmacist, which in
American Pharmacy Vol. NS24, No , 10, October 1984/678
pharmacists do today; • Education and training pharmacists receive; • A short biography of each phar,macist; • Fee schedules, an explanation abou t generic drugs, and some information on how the pharmacy handles third-party prescriptions; • A description of what's in the patient profile and the ways it can help the patient. Garrelts summarizes: The public relations pamphlet will serve to increase the understanding of the patient on pharmacy, yours in particular. The patient will know what your philosophy is on the practice of pharmacy, how you price prescriptions, where you stand on generics, why you ~eed to phone the physician for refill okays, which third-party plans you participate in, as well as any other services you have to offer.
Drug Use & Abuse Information • The Medicines Your Doctor Prescribes • Signs of Use of Substances for Drugging Effects Pharmaceutical Manufacturers Association, 1100 Fifteenth St., NW, Washington, DC 20005. • Drugs of Abuse Drug Enforcement Administration, 1405 I St., NW, Washington, DC 20530.
Miscellaneous Information • Sickle Cell Anemia March of Dimes, 1275 Mamaronbeck Ave., White Plains, NY 10605. • "Flu" -What Is It? Who Gets It? What Can You Do About It? • Hay Fever Holiday-How to Escape The Ragweed Season • A Healthlf Lifestyle: One Key to
Community Services To increase the visibility of your pharmacy within the general community, there are other activities you can undertake outside the store that can help educate the public while at the same time enhancing the professional image of the pharmacist.
Using the NMA T Of course, not everyone feels instantly comfortable speaking before a large group. For this reason, APhA's National Medica tion Awareness Test (NMAT) provides a good way for pharmacists to begin their careers as public speakers on drugs and other health topics. The NMAT includes a set of slides, an audio tape, and a written script, which cover common sense aspects of taking medication correctly. Garrelts says a good audience for the NMAT is "junior and senior high school students, since they will be consumers of nonprescription and prescription medications for the next 50 years . Now is the time to ed uca te them on wise consumerism and who to turn to for sound medication counseling-their family pharma-
• Communities: What You Can Do About Drug and Alcohol Abuse • Drugs and Driving: Why Take the Risk? • Parents: What You Can Do About Drug Abuse • Peer Pressure: It's OK to Say No National Clearinghouse for Drug Abuse Information, P.O. Box 416, Kensington, MD 20795.
cist. " Other excellent targets for the NMAT are service groups and honorary sororities, community groups (like parent-teacher organizations and Boy and Girl Scouts), and senior citizen groups. Local professional groups such as municipal or state medical and dental societies may benefit from the program, too, she says. Presenting the NMAT (1) strengthens ties between professions and generates discussion between colleagues; (2) promotes the community pharmacist as a knowledgeable and integral member of the health care team; and (3) allows other professionals to recommend the pharmacist's NMAT to their contacts in the community.
Media Exposure Through media exposure, pharmacists can avail themselves of yet another channel for projecting themselves as va:luable sources of
American Pharmacy Vol. NS24, No. 10, October 1984/679
Lower Health-Care Costs • What You Should Know About Hepatitis: Everything From A to B • Legionnaires' Disease: The Mystery Malady Abbott Laboratories, Attn.: Public Affairs, 0-383, 14th & Sheridan Rd., North Chicago, IL 60064.
knowledge. As an expert on medications, the pharmacist should be the primary contact for any TV or radio news program dealing with medicines. If the pharmacist doesn't have the precise information the media needs, he or she at least knows where to find it. However, pharmacists themselves may have to take the initiative to remind the local media of their competence in the area of medications and their willingness to talk about drugs and health. To get started in becoming a media spokesman, pharmacists can contact: • TV and radio program directors; • News reporters and public affairs reporters; • Local newspaper medical editors. Garrelts encourages pharmacists to contact "all of the stations and newspapers-don't limit yourself to just one." Having reached the right people in the media, pharmacists should
51
explain their availability to be interviewed on a variety of specific topics dealing with medications. Garrelts adds: "Make sure that they understand that if it's wanted, you have complete packaged interviews available, complete with questions."
Media Topics Pharmacists can also invite news
personnel to come and see the NMAT whenever they present it to a community group. Another good opportunity for pharmacists who want to reach the media is offered by the multitude of national health observances that occur throughout the year (see box, p. 53). The pharmacist's discussion can explain why it is important to raise
public awareness on a given topic, and relate how his or her pharmacy educates the public on this topic (for instance, through counseling or brochures). Other packages for helping pharmacists gain media exposure are Burroughs Wellcome Company's "Suggested Drug-Related Program Topics with Interview Questions,"
APhA's Audiovisual Spotlights
A
ready-made way for pharmacists to spotlight themselves as a handy source of medication information is in the form of three audiovisual programs developed by APhA with the support of Lederle Laboratories. The three programs-the National Medication Awareness Test (NMAT), the Health Check Test (HCT), and the Self Medication Awareness Test (SMAT)-use a "test" format which presents information as well as asks questions that heighten the participant's awareness concerning medication. • NMAT focuses on important information patients need to know about their medications, how to take it, and how it works in the body. • HeT emphasizes the kinds of information patients need to take an active part in their own health care, and introduces a unique record-keeping system for prescription and nonprescription medications taken and other health care services received. • SMAT stresses that nonprescription medication must be selected and used with the same care that is exercised with prescription medications. The program provides information patients need to determine
52
Pharmacist Garrelts reviews the answers to the NMAT with a high school student. (Photo courtesy of Linda Garrelts.)
whether self medication is desirable and, if so, how to self medicate safely
and effectively. The programs can be presented to any group the pharmacist can assemble in his community. In addition to making patients and other consumers aware of their own individual responsibilities in medication, presentation of the program(s) will enhance the pharmacist's professional standing in the community. For more information on how you can present these programs, contact APhA's Academy of Pharmacy Practice, 2215 Constitution Avenue, NW, Washington, DC 20037.
American Pharmacy Vol. NS24, No. 10, October 1984/680
National Health Observances January: February: March:
April: May:
Birth Defects Month Smoking Education Week (2nd week) American Heart Month Children Dental Health Week (2nd week) Easter Seals National Nutrition Month Red Cross Month Save Your Vision Week (2nd week) Poison Prevention Week (3rd week) Community Health Week (3rd week) Cancer Control Month World Health Day (April 7th) Mental Health Month
which encompasses 26 topics with questions to be asked of a pharmacist by an interviewer, and the "Do It Yourself Radio Programs" (also from Burroughs Wellcome). The latter is a packet that explains everything from how to get on a program, to what to say and how to say it. Garrelts particularly recommends that pharmacists alert program directors about their ability to speak on the issue of drug abuse, because "this topic is always one the media is interested in." One resource for boning up on the topic is the "Drug Abuse Information Kit" from Eli Lilly &Co.
Extended Services Since many people can't-or don't choose to-take the time to get regular blood pressure checks, pharmacists can further assist the community by setting up and performing blood pressure measurements at job sites and senior citizen centers. Pharmacists should first contact the personnel manager (at job sites) and explain the value of blood pressure control to the employer, citing tangible gains like increased productivity and less absenteeism. A good time to suggest for screening might be the employee lunch hour. Then, the employees have to be notified (via company newsletters and posters for bulletin boards). After conducting the clinic and pursuing any necessary follow-up, the relative success of the venture should be discussed with the personnel manager, and suggestions for
October: November: December:
Arthritis Month High Blood Pressure Month Hearing and Speech Month Foot Health Week (2nd week) Immunization Month Drug Abuse Prevention (3rd week) Child Health Day (1st Monday) Diabetes Month Lung Disease Month (Christmas Seals) Mental Retardation Month Diabetes Month Lung Disease Month (Christmas Seals)
Pharmacists should take the initiative to remind the media of their competence in the area of medications and their willingness to talk about drugs and health. improvements made. Another screening date can then be scheduled for the future-usually 3-6 months later. Pretty much the same procedure can be followed when doing screenings for senior citizens. In this instance, the director of the seniors' group should be contacted, and the vital role of controlled blood pressure and compliance with medication regimens explained. Pharmacists should then set up a convenient, regular time for screenings, at a central location, such as the town library. Garrelts suggests that blood pressure measurements then be made available for about 2 hours on a particular day-for example, the first Tuesday of every month. The volume of traffic in this program can usually be easily handled by one pharmacist. Local monthly newsletters provide the best vehicle for telling senior citizen residents about this service. As each person's pressure is measured, he or she can be given a copy of the pharmacy's public relations
American Pharmacy Vol. NS24, No.1 0, October 1984/681
brochure, and also asked if the pharmacy currently fills the patient's prescriptions. If not, the pharmacist can note that the pharmacy would be happy to provide this service, along with a regularly updated patient profile. For this profile, Garrelts recommends a standard evaluation measure for any marketing endeavoran increase in the number of prescriptions filled in the area where the senior center is located after a screening program is begun.
Set for Success Pharmacist Garrelts' suggestions for expanding a pharmacy practice and making it more visible in the community prompt several interesting conclusions. First, pharmacists are fortunateand possibly unique-in that the informa tion and programs they can provide can serve equally well as marketing tools and as genuine (and sorely needed) services to the community. Second, it will admittedly take some self-motivation to get these programs in motion, but just as surely, the rewards will be there once they get underway. Finally, one can't help but notice the intelligence, creativity, and thoroughness with which Linda Garrelts approaches each one of the projects undertaken to promote her pharmacy. Such an attitude cannot assure complete success-nothing can do that-but it certainly sets up the preconditions that allow it to happen. -Dana Murphy
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