Friday, January 11, 2013

When doctors aren't needed

One of the cool things wandering around the spheres of thought about health care is that pharmacists should do more disease management, since we have a super shortage of primary healthcare providers.  Last spring the US Public Health Service released a report about all the "trial projects" and demonstration sites they've had where after a patient gets a diagnosis, they see a pharmacist for follow-up.  It works really well, better than when patients see a doctor for that follow-up.

Relatively recently the NY times wrote an article mentioning this, and it makes me happy that we're getting that level of recognition. 

Why should we send people to see a pharmacist after getting a diagnosis from their doctor, aside from pharmacists being awesome and available?

Availability is a great reason to see a pharmacist.  Work weird hours?  There's probably a pharmacy open even weirder hours than you, and you can get in to see a pharmacist at some strange time.  Depending on how the pharmacy is set up, you might be able to drop in, wait a while, and get a short visit in.

Better outcomes is a good deal too.  Not surprisingly, when you get the medication expert on the healthcare team to talk to people about the medications they take, you get better adjusting of the meds than when the diagnosing expert chats with the patient about it.  This is not to say that doctors do a bad job! I think they do amazing things, but enabling doctors to focus on treating/diagnosing rather than having to also focus on the nuances of which medication is best in which set of complex circumstances would probably benefit them. 

Example in current system: Patient with high blood pressure develops a cough after taking lisino.pril, so we're going to switch to the next choice of an ARB (another similar medicine for high blood pressure), which while discovered by the pharmacist when Patient was picking up a refill, so refers Patient to doctor to get a prescription for the new drug.  Doc picks one based on what absolutely works best.  Patient goes back to pharmacy to get the new med, and it costs $125 a month because it's a brand name only product.  There's a generic ARB that works almost as well as that brand name drug and Patient's insurance has it for a low copay.  So the pharmacist calls the doc, and within a day or two, that change gets made.

Example in new system where pharmacists can prescribe for continuing care: Patient with high blood pressure getting a refill of lisin.opril has a cough but no cold, so Pharmacist switches to an ARB after checking Patient's insurance to see which one is covered.  A copy of the progress note gets sent to the doctor(s) involved.

Look at that! It took a lot less time for everyone for the pharmacist to just make the change based on an adverse reaction rather than seeing the doctor and then having to have a second change made because the doctor doesn't know prescription insurance like the pharmacist.

It goes beyond the simple "you're having a bad reaction to medication x, so now we try y instead" sort of change, of course.  There's increasing or decreasing doses based on simple lab parameters or something like blood pressure that we can measure.  There's changing medication based on more complex lab results we get from a bigger "real lab" like elderly people with low kidney function needing some slightly different medication.  Pharmacists are already trained to make these changes, and in many settings are already doing so.  Patients benefit.  It saves money.

How do we make it happen?  First we need to give pharmacists status to bill as healthcare providers according to Medicare (and the rest of insurers will follow along).  It makes me giggle a lot that a PA, with 2 years postgraduate educations, is allowed to prescribe but a pharmacist with 4 or 5 years postgraduate education isn't.  Make sense? Nope.

Second, doctors need to realize that pharmacists aren't trying to take over their jobs.  I never want to diagnose.  It isn't my job, I'm not trained to do it, and I don't want to.  I just want to work at the top of my license and save everyone some time by using my skills to their fullest.  In several states, doctors' organizations are very busy stopping pharmacists from legally expanding into areas like giving shots (let alone into prescribing for patients with a diagnosis).  Nurses get worried about pharmacists taking their jobs too, to which I say, again, no.  I don't want your job, I want to do my job better so everyone avoids headaches and wasted time.

To the nurses and doctors who are all "MY TURF!" I say: didn't you read that article in the NYT or the report from the Public Health service?  There's a shortage of doctors and primary care providers (advance practice nurses with prescribing rights and physicians' assistants).  Pharmacists can help fill that gap, especially in rural areas where there's a bigger shortage of primary care providers.  Where I live, it takes at least 6 weeks to see a primary care person outside of urgent care (and urgent care isn't the same thing as seeing a primary doc at all).  It's more like 10 weeks if you want a longer visit like a new patient or well-child visit.  It isn't very rural here, which means that in more rural areas, the shortage is worse.  Couldn't we play nice and let the pharmacists save doctors time with those continuing medications folks who need a tweak?  We can't be a healthcare team if doctors and nurses want their own private teams.  Patients lose in that system.


  1. I think this is a fantastic idea, and I very much hope to see it put in to action sometime very soon!

  2. as a nurse I think this is a fabulous idea...I saw a blurb on Access Live with Dr Oz (who is only kind of a real doctor to me) talking about talk to your pharmacist, they're available and FREE! I loved this idea. I'm so grateful for my local pharmacist who went above and beyond multiple times with my fertility meds, and even a common cough syrup for my husband. My FIL is a pharmacist and I've seen first hand how hard he guys are a blessing to us!!