July 9, 2014:
Elba Santos, 63, rolled up her black trousers so Ryan Gates could examine her shins and feet. Gates touched a beet-red area, asking if it hurt. Santos winced and nodded. “Even just from breathing, the pain hurts down here,” she said.
Gates noted unusual glucose levels in her daily blood sugar log, ordered a new medication to reduce water retention in her feet and legs and another for her blood pressure, and told her to return in a week.
Then he reminded her to visit her doctor for other health issues.
Gates, 40, is not a physician. He’s a clinical pharmacist and a reason that many poor and underinsured diabetic patients can get consistent treatment in Kern County – one of the most diabetes-prone counties in the state. Diabetes afflicts 9.2 percent of all Kern residents, compared to 8.4 percent statewide, and has the second-highest death rate from the disease.
Gates is also a leading example of how pharmacists practicing at a much higher level are helping to change the face of primary care medicine in California.
“Super pharmacists” like Gates who are assuming more responsibility are providing direct care in a number of locations in the state, including a clinic at San Francisco General Hospital, and at a group of low-income clinics in Los Angeles and Orange Counties.
And their importance will grow as millions of newly insured Californians crowd into the health care system because not all of those residents will be able to see a doctor on demand.
When Gates, a native of Kern County, returned from his pharmacy residency at Veterans Affairs in San Diego in 2005, only one endocrinologist at Kern Medical Center, Victor Ettinger, saw indigent and Medi-Cal covered diabetes patients, he said. The wait time for an appointment was at least six months.
Diabetes was epidemic among Latino families. Many of them were farmworkers who didn’t have the money, or a clear understanding of how to adhere to a diet that would help keep blood sugar under control. “The dichotomy was really striking,” Gates said. “The people who were suffering the greatest were the people picking the healthy food.”
At the time, there were no pharmacists seeing diabetes patients. But Gates had specialized in diabetes in school. Ettinger was desperate for help and started referring patients to Gates for dose adjustments.
By 2009, Gates and Ettinger, who recently retired, had created a pharmacist-led diabetes practice at Kern Medical Center.
Today, there are no endocrinologists in Kern County to serve the uninsured and there is an eight-month wait for people with diabetes on Medi-Cal, according to primary care providers. But the pharmacist-led clinic is open to them four half-days a week. It includes six clinical pharmacists and a host of pharmacy students in a residency program.
On a weekly basis, the clinic sees 116 patients. Gates and his colleagues regularly prescribe and change doses of medications, order lab work and counsel patients on diet and exercise.
Preliminary data show that pharmacists at the medical center are making a difference:
Between 2012 and 2014, resident pharmacy researchers compared 126 patients seen in the pharmacist-led diabetes clinic with 129 diabetic patients seen only by general practitioners. The clinic patients had 41.5 percent fewer emergency room visits than the comparison group, and on average had a blood sugar drop 41 percent greater than patients in the other group.
Before this year, Kern Medical Center saw the pharmacists as a cost-containment tool. Preventive care kept indigent diabetes patients from ending up in the emergency room or in a hospital admission, where the costs were born mostly by the hospital itself.
But with the dramatic expansion of Medi-Cal benefits as part of the Affordable Care Act, the vast majority of Gates’ patients this year will come in the door with their care covered, he said.
Lobbyists for pharmacists in Sacramento pointed to Gates and the clinic as they successfully argued last year for bumping up pharmacists’ authority. A California law that went into effect in January codified a new class of “advanced practice pharmacists” who can enter collaborative agreements with physicians to start, change or discontinue medications, and help manage chronic diseases.
In Bakersfield, some doctors were skeptical before they saw Gates and his pharmacist colleagues in action. Among them was Sevag Balikian, who arrived in Bakersfield for his residency in 2006. “I thought pharmacists should clear everything through doctors, and that we know better about managing blood sugar and medicine,” recalled Balikian, now a kidney specialist in Pasadena.
But Balikian said he was quickly disabused of that notion. “They (pharmacists) were so meticulous. Sometimes we were the backup, because they were the ones on the phones and constantly checking in with patients.”
Raul Gonzales, 41, was one of those patients. A year ago, soaring blood sugar levels had led to a stroke that robbed him of speech, the ability to walk on his own, and clouded his vision.
He went to Gates, who drew detailed drawings of what diabetes did to the body, taught him how to eat properly and count carbohydrates, and take his medication. Gates also gave him his cell phone number. Gonzales said it became a lifeline.
‘Like an angry woman’
“I’d call him up crying and tell him that I had shooting pains every 15 seconds in my legs,” Gonzales said. “He’d talk me through it saying that the nerves in my legs were like an angry woman. Both of them need time.”
Today, he’s not only able to walk, he climbs mountains.
Gates said much of his phone work is aimed at averting emergencies. On a recent day, he called several patients to check in. One has diabetes, HIV, hepatitis C among other diseases and takes 22 different medications to keep himself stable. Gates has changed 10 of his medications in the last year.
“With a patient on all those medications, things can go sideways really fast, especially if they have kidney problems,” Gates said.
Such phone calls also help patients who don’t have the means or transportation to get to the clinic. Many patients also are transient, and return after a year or more with their diabetes out of control again.
“At the 30,000-foot view, it could become very discouraging,” said Gates. “So one patient at a time keeps me encouraged.”