Test and treat – another thought

“…Pharmacists are experts at recognizing and preventing drug interactions.”

dr Jeffrey Singer

This is undoubtedly true, but they have no training in prescribing care – and Paxlovid is very effective, but only one option. Molnupiravir, as Dr. Bloom has pointed out isn’t as effective, but is flying off the shelves because it’s more readily available. There’s also bebtelovimab, a monoclonal antibody that’s approved against the Omicron variant but requires an infusion. Most importantly, with any infectious disease, that is, any disease, follow-up is critical to assess the effectiveness of therapy and the need for additional interventions. Pharmacists do not make follow-up appointments; They dispense drugs, they don’t care.

dr Singer is right that the AMA and other medical organizations were very concerned about the expansion of the practice of nurses and physician assistants — but that’s another concern. Both nurses and physician assistants are trained in the treatment of diseases; pharmacist does not. They also don’t currently have insurance coverage for the prescription. Pharmacists give vaccines because their states have allowed them to do so in certain circumstances.

There are other options to enable “test and treat,” but they all involve one of these people trained in disease care, not just dispensing medication. And unfortunately they all charge an additional fee. (Pharmacists would also like to get more than the $6 dispensing fee they get now).

The ecology of medicine

There is a structure in how we have organized the care. GPs take care of our everyday and chronic illnesses, helping us navigate the landscape to find specialists and hospital care when the need arises. In recent years, the “disruptors” have attempted to address the everyday needs of patients in what I would call “lump and bump care of walking” (sore throats, earaches, sprains), alternatively, more comfortable settings, and at lower prices.

The COVID-19 pandemic accelerated the adoption of telemedicine instead of office visits. A variety of online websites are now prescribing medications (birth control drugs, erectile dysfunction drugs) and medical devices (CPAP machines) that include online “exams” and prescriptions from licensed physicians. Emergency centers, both freestanding and within pharmacy walls, provide care and medication simultaneously under the direction of a physician, nurse, or physician assistant. Here is the result of that interruption.

Few of us have a family doctor like an OB/GYN, cardiologist, internist, or family doctor that we see regularly enough to build a relationship. And these doctors are our health Sherpas—they know the landscape of disease, with its pitfalls and nuances; and be aware of your skills and blind spots. You wouldn’t try to climb Everest without her. Since you are connected by a rope, you must ultimately trust them with your life. While this might be a somewhat dramatic analogy for a family doctor, that rope, that trust, is built from many smaller, lower-risk encounters. A consistent health Sherpa leads to better care.

The further shift of simple care to cheaper providers will lead to the end of family doctors in the ecology of medicine. We should be careful what we wish for, because as Joni Mitchell wrote: “You don’t know what you have until it’s gone.”

Other sources to consider when forming an opinion:

A successful test-to-treat program requires all hands on deck

Pharmacists are pushing for a stronger role in life after the pandemic

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