Having long been a fan of early, and dumb, comedies, I am quite familiar with the "dope slap." It was perfected by Moe Howard but employed by many before and since. A Google-searched definition describes a dope slap as the physical equivalent of "Whatta you, a moron?!" Its purpose is to slap some sense into a person quickly (or if your technique is on par with Moe’s, several people at once) who can obviously use an instant jolt of common sense.
While I haven’t thought about the dope slap in quite some time, it came to mind recently when looking at some common "what were you thinking?" practices in health care. I’m just not sure who gets the slap. Here’s what triggered the thought. Several months ago, I had the opportunity to visit Taiwan, participating in a design event in Taipei. Over the weekend, I was shown around town by one of the Taipei-based designers. Walking through a market, I stopped into a Chinese medicine shop. It was a pharmacy of sorts—if you consider various exotic herbs and powdered animal parts to be pharmaceuticals. While the ingredients were fascinating, and just a little scary, the most interesting part may have been the 45-minute conversation I had with the "pharmacist." (We conversed through translation—save for a few poorly pronounced words, my Chinese is nonexistent).
Despite the completely foreign setting, most memorable was the fact that such an extended conversation took place. The pharmacist took the time to talk, listen, and explain. The Chinese medicine shop encounter was more extensive, holistic in scope, and more informative than any conversation I have had with a pharmacist in the United States, ever.
Revelation. I’m a designer. I’ve seen Chinese medicine shops before. But look at the design of that shop, and the display of the ingredients on the shelves! Look at all those interesting things in jars in the glass cases, scary as mentioned but at least somewhat identifiable! And stools at the counter! The whole place is set up to encourage conversation. Compare that with pharmacies I have been used to all my life. Why am I just making the connection now? The first dope slap goes to me.
How obvious is it that my pharmacy in the U.S. is so different and in many ways vastly inferior to that found in many ancient traditional cultures. For one thing, stools in the Chinese medicine shop mean I’m supposed to sit! The entire place is set up with the intention that conversation and consultation are part of the norm. In contrast, my local pharmacy experience is not radically different from a dreaded visit to the Department of Motor Vehicles, where extended interaction is not in anyone’s best interest.
For reasons I cannot explain, my pharmacist is stationed behind a glass partition. I often have to stand in line till it’s my turn at the booth. I stand while talking. Usually it’s the pharmacy’s less-professional assistant who I interact with. (Actually, I’m not sure what her background is—pharmacist-in-training, salesclerk, something else?) She’s my main contact unless I have a question. Then the pharmacist will come out from behind the glass and provide a usually abbreviated answer. That, or just holler the answer back.
The setting is, to say the least, not very conducive to conversation. Quite the opposite, it gives signals to just keep moving along—its real goal is speed. Yet we know from studies into medications and compliance that a good relationship with a pharmacist can greatly increase the chances of staying on a drug regimen.
Non-compliance with prescription medications is a serious problem. Compliance has been shown to drop as much as 40% within the first six months of a patient starting a regimen. Interaction with a pharmacist has been shown to significantly reduce that drop, keeping more patients on track. This not only means healthier patients. It results in more sales for the pharmacies. And more sales for pharmaceutical companies. And more overall measurable effectiveness for that drug. At stake are the health of the country and literally billions of dollars in transactions. There is no good reason to discourage one-on-one interaction at pharmacies. But look at the design. Dope slap number two goes to whoever was in charge of designing my chain-store pharmacy.
While apparent from my visit to the Chinese medicine shop, these thoughts really started to gel after a recent discussion I had with a group of undergraduate design students from Syracuse University. In their school project, they pointed out many additional and equally unfortunate differences between pharmacies and other common, more comfortable settings. Compare a pharmacy today to a pharmacy from the 1930s. Or to an Apple store. Or to a neighborhood bar.
For one thing, today a typical pharmacy displays rows and rows of pills in similar-looking white bottles on the pharmacist’s shelves. These different drugs are then transferred to identical-looking pill bottles. With the bottles being heavily tinted in an orange or Target-pharmacy red, the pills themselves—even when they look different in actuality (many don’t)—are difficult to see. (The Target pill bottle, circa 2005, with its flat sides and color-coded ring, helps, but it’s not a silver bullet.) The generically printed bottle labels look the same and bear drug names that are hard to differentiate and difficult, sometimes impossible, to pronounce.
Why do people on medications seem so confused and fail to comply as instructed? Dope slap number three goes to anyone asking this question. Who wouldn’t be confused?
By comparison, pharmacies in the 1930s were less sterile looking and more personable. The Apple store has a Genius Bar, complete with stools. The neighborhood bar, of course, has bar stools. It also has a busy-but-often-talkative bartender, and lots of different-looking bottles on the shelves that we all (or at least many of us) can readily identify. A recent redesign of Walgreens pharmacies by a team at Ideo addresses some of these issues. It stations a health care guide-person in the center of the space and features both an "Ask Your Pharmacist" booth and a more private consultation room. The result: better communications with pharmacists.
That’s a positive step in the face of this generally ignored opportunity to improve health care. The pharmacy system may have evolved to its current state for a reason, but that reason is not design or compliance. In an apparent attempt to create pharmacies that portray an appearance of being superficially efficient, hospital-like, and sterile, we may be missing a significant opportunity to help people. Pharmacies today are by no means designed to improve compliance. With an increasing number of people on more and more medications, shocking statistics on drug confusion and non-compliance, and the fact that the pharmacy is in a position to help, it’s tragic that design is not more widely enlisted to become part of the solution. Dope slap number four—a multiple one this time.