For diabetics, the best doctor may be a pharmacist

Senior clinical pharmacist Ryan Gates checks Raul Gonzales' leg for swelling at Kern Medical Center in Bakersfield.

This article first appeared in the San Francisco Chronicle

BAKERSFIELD --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, 40, had treated Santos before at Kern Medical Center’s diabetes clinic. On this day he noted unusual glucose levels in her daily blood sugar log, advised her to take another of her medications if she overindulged at family gatherings, ordered a new medication to reduce water retention in her feet and legs, 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.

That’s because Gates is not a physician. He’s a clinical pharmacist who is one of the reasons 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.  

When Gates, a native of McFarland, returned to Kern County from his pharmacy residency at Veterans Affairs in San Diego in 2005, only one endocrinologist at the county hospital 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. The lone endocrinologist who treated the poor at the county hospital in Kern, Victor 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 an 8-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 6 clinical pharmacists and a host of pharmacy students in a residency program. It sees 116 patients weekly.   Gates and his colleagues regularly prescribe and change doses of medications, order lab work and counsel patients on diet and exercise.

Preliminary data shows 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 to 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% greater than patients in the other group.

Ryan Gates writes prescriptions for diabetic patients Salwa Eltabee and her husband Mohamed Eltabee at the Kern Medical Center in Bakersfield.
Photo Credit: Anacleto Rapping

Prior to 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 this 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.

These "super pharmacists" are already providing direct care in a number of locations, including a clinic at San Francisco General Hospital, and at a group of low-income clinics in Los Angeles and Orange Counties.

Robert Beltran, the chief medical officer for Brand New Day, a Medicare specialty health plan, is planning to launch a pharmacist team program in Orange County and in the Inland Empire east of Los Angeles this summer.

The importance of pharmacists assuming more responsibility will grow as millions of newly insured Californians crowd into the healthcare system.  Not all of those residents will be able to see a doctor on demand because the supply of physicians will be stretched in many areas. But the newly insured may well be able to access personalized care, especially for chronic conditions, at their local pharmacy or at pharmacist-led clinics.

Student intern pharmacist Stephanie Tu consults with Ryan Gates over a patient's records at Kern Medical Center in Bakersfield.
Photo Credit: Anacleto Rapping

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 back-up, 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.

“I’d call him up crying and tell him that I had shooting pains every 15 seconds in my legs. 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.

On a recent day a resident told Gates that she was having trouble getting a patient to reduce his milk consumption, and imitated his fierce resistance: “‘Non mi leche!’” she said in a raised voice, shaking her fist.

Karla Zepeda, 31, and her mother Elba Santos , 63, are diabetes patients of pharmacist Ryan Gates in Bakersfield.
Photo Credit: Anacleto Rapping

Gates reviewed the patient’s chart and noted that his blood sugar was pretty well controlled. He decided to back off on the milk issue. “Getting small victories are important,” he said. “If [patients] tried to implement every change overnight, they’d be in a fetal position within a week.”

Physicians and other health providers often refer the most difficult diabetes cases to Gates’ clinic, both because of its expertise and the time it can devote to treatment.

 Mary Collignon, a nurse practitioner at Omni Family Health in Bakersfield, said she sends such patients to Gates because “I have 15 minutes, 20 minutes maximum,” per patient.  

Gates and the other pharmacists at the clinic spend a lot of time handholding patients through their scary first days of injecting insulin.  Time spent then can prevent emergencies later, Gates said. Improper dosages of insulin result in 98,000 emergency room visits annually in the United States, according to a recent article in the Journal of the American Medical Assn.

Elba Santos’ daughter Karla Zepeda, 31, recalled how frightened she was last Christmas not long after a hospitalization where she learned she, like her mother, had diabetes.

 “I was having trouble breathing, and so I called Dr. Gates around 5 times that day. I didn’t know if it was the insulin or that I’d eaten too many tamales.”  Gates helped her adjust her insulin.

Much of his phone work, Gates said, 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 him 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,” he said.  

Such phone calls also help patients who don’t have the means or transportation to the clinic. Many patients, too, 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,” says Gates pausing. “So one patient at a time keeps me encouraged.”

More Stories from This Project

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Jose Navarro regularly trekked to the drugstore after being diagnosed as a diabetic seven years ago. In a sign of transformation in the local fight against diabetes, the pharmacist is now coming to him.

Prescription for Success: Caring

When pharmacist Steve Chen first saw him, Mike Metcalfe was straight out of a hospital ward following an eight-day diabetic coma. He was 50, homeless, weighed 300 pounds, and his doctor had given up on him.

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