Can Pharmacists Help Reinvent Primary Care in the United States?

There's a shortage of primary care physicians in the United States. The Association of American Medical Colleges (AAMC) recently reported that by the year 2030, we may be short more than 104,000 doctors, making it difficult for patients to get the care they need.

Knowing this, medical schools are scrambling to steer students away from specialty care; health care systems and hospitals are on a recruitment binge, offering salary bonuses and other incentives to primary care physicians; and technologists are developing new and innovative ways for patients to connect with far-away doctors - for instance, through telemedicine and other video technologies.

All of these approaches have the potential to help ameliorate the problem. Nevertheless, we should not ignore the solutions right in front of our eyes - one of which is to make better and more effective use of pharmacists. Some may think of them as the behind-the-scenes at retail drug chains, but pharmacists are highly trained clinicians who can play a vital role in improving health outcomes while also increasing efficiencies - and it's time to unleash their potential.

Across healthcare, organizations are launching sustained initiatives that tap into pharmacists' wealth of knowledge as we seek to manage chronic diseases and complex health issues.

When I was a doctor at the Brigham and Women's Hospitals, pharmacists would huddle every morning with doctors, nurse practitioners, and medical assistants to preview the day's cases. The pharmacists flag patients who might be non-adherent to prescribed medications, offer insights into how dosages could be adjusted and educate their colleagues about the latest medications and guidelines for specific medications. Pharmacists at the Veteran's Administration often embed themselves within clinical teams and are responsible for reviewing all of the prescribed medicines all for inpatients.

Why are pharmacists uniquely helpful? Pharmacists spend three to four years studying medications. Many of them have completed specialized residencies in subjects like nephrology, geriatrics and ambulatory care. That training informs evidence-based practices and ensures that the medications we prescribe are appropriate for each patient - while also reducing what we call "treatment burdens," which often prevent patients from taking their medications. They are also critical stewards of patient safety.

Here's a real-life example: in a recent morning huddle in the outpatient clinic in which I do clinical work, the team discussed a patient I'll call Camille. Camille is 74 years old and has diabetes. Like many individuals with diabetes, she also suffers from depression and neuropathy, which caused an extremely painful stabbing sensation in her foot.

Camille's physician had recommended duloxetine for the neuropathy. The problem was that Camille was already taking escitalopram oxalate for her depression. Duloxetine is an ideal treatment option for neuropathy - but, like the escitalopram oxalate, it blocks the reuptake of the neurotransmitter, serotonin. Before any new prescriptions were written, the pharmacist reviewing Camille's electronic health record spoke up, noting that adding duloxetine to the escitalopram oxalate would make Camille "a walking serotonin syndrome waiting to happen" - a dangerous complex of side effects that could lead to seizures, muscle breakdown, and worse.

It was the pharmacist who was embedded on the care team who recommended switching Camille exclusively to duloxetine - and noted the dosage at which it would treat both her neuropathy and depression. Three months later, Camille is taking one pill a day - and that one pill has reduced both the pain of the neuropathy and the symptoms of her depression.

But the expertise of pharmacists isn't limited to individual prescriptions. My pharmacist colleagues a few years ago noticed that many diabetic patients were "non-adherent." That is, they were not taking their insulin on a regular basis. The pharmacist team not only flagged the problem, but also set out to find the cause and a solution. After speaking individually with the identified patients, the pharmacist team discovered that cost was the problem.

Almost all of the patients queried were taking what we call "analogue insulin" - a synthetic form of insulin that is the standard in diabetes care. The problem was that this form of insulin was expensive - and its price was going up - doubling in cost every few years. Not surprisingly, patients were quickly reaching their drug coverage limit and, unable to afford their insulin, they simply stopped taking it. This is no small thing - non-adherent diabetic patients eventually present at the emergency room due to hypoglycemia or hyperglycemia. Those visits are expensive and disruptive and no substitute for proper chronic disease management.

So the pharmacy team looked for a solution, and found it in "human insulin," an older form of the drug, which they discovered was extremely affordable-and delivered similar outcomes. The pharmacists began an ambitious program to transition patients to lower costs drugs. I want to stress that the pharmacists didn't just switch medicines. They also worked with the patients - on an ongoing and individualized basis - to educate them about adherence and create personalized regimens that reduced the number of injections each day. This is work that many would traditionally see as the domain of physicians and nurse practitioners-and it was managed expertly, arguably better, by pharmacists.

There's one last reason I personally want more pharmacists closely integrated into my team. It's simply that they're great team members. Pharmacists are not only trained in medication; they're also trained in how to engage people - including patients and doctors. This often translates into the kinds of influence skills needed to change patient and physician behaviors alike.

So, by all means, let's bring more bright minds into medicine. But let's not ignore the secret weapon that we already have: pharmacists. In many cases, we can offload time-intensive chronic disease management that currently lies in the hands of doctors and nurse practitioners to the capable hands of pharmacists-who have a mastery of medication management, as well, as behavior change. Much of care that has historically been delivered by physician primary care providers can be delivered by pharmacists.

By relying on them more and further integrating them our healthcare delivery models, we can provide better, more affordable and more effective care to everyone-and potentially alleviate the looming crisis in access to primary care.

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