A Proposal

“Difficulties are meant to rouse, not discourage.”
-William Ellery Channing

The thought came to me when I was examining an elderly woman whose mobility was sharply reduced by a severe case of arthritis. Medicine and therapy had helped to decrease her pain, but she remained dependent on her daughter to bring her to our appointments. After I finished the exam, I explained to the daughter what tests needed to be done, and when our next visit was to take place.

The younger woman looked tired. Her face seemed to me to reflect a certain weariness of the soul that one learns to recognize from dealing with thousands of people who have too much on their plates.

“Is everything OK?”

She smiled and looked at the floor.

“Yes and no. I am grateful that you saw her on time, and that you explain things so well. But, as hard as her illnesses are on her, they are also hard on me.”
I think that I understand. Please tell me what it’s like to be her caregiver.

She looked at me with wonder. For sure I did not want to hear this; there is no way that I had the time. I encouraged her.

I have a few extra minutes. Go ahead; talk to me.

A long story short: Her mother saw four specialists and a primary care doctor besides me. She had to take off work for each of these visits, plus for any of the X Ray or lab appointments that the doctors made. Most of the time she had to wait a minimum of 45 minutes before her mother was called into the exam room. She was concerned: She had a career that was important to her, but she worried that her boss’s patience was running thin.
Access. Something that I was not taught in medical school. Not one thought devoted to how patients got to the doctor’s office; their pharmacies; their blood and X Ray test appointments. Very few whispers as to how these services got paid for. You can be a genius at recognizing and treating illnesses. If your patient has no way of getting to your office, your knowledge is useless.

Where do you buy your medicine?
“There is a Walgreens a block away from her apartment.”

It occurred to me that Walgreens, CVS, and all drugstores were wonderful places for people to get their medical care. They are everywhere. They encourage people to visit. Later on, when Walgreens and CVS began to sponsor primary care offices, someone told me that they did not make a profit on these offices. They make money on prescriptions sold, and on the sundry purchases that people just cannot leave a pharmacy without making.

I called one of the marketing officers for the health care organization that employed me.

“We have electronic medical records. We could share access with the primary care office at the neighborhood pharmacy. They employ a nurse to get vital signs and review prescribed medicines. We can connect by videoconference. There are “medical robots” available at reasonable cost that will record breath and heart sounds and transmit images of the eyes and throat, also recordable. We can make a disposition and order appropriate studies. No reason for this lady’s daughter to leave work.”

I was told that insurance would not pay enough for this kind of service. I was discouraged from looking into this matter. Once again, it was not about what was good for the patient. The medical center has to be fed.

Years passed. The covid-19 epidemic hit. All of a sudden, we have found a way to “see” patients remotely. Insurance companies are paying, although I do not know how much. I did some preliminary research. I hasten to add that I am not an expert on public health or delivery of care. These are just ideas.

There are 67,000 pharmacies in the US. In 2017, the most recent year that I could come up with, 880 million visits to the doctor were recorded. It seems likely that half of these were to deliver primary care. If we were to allow pharmacies to become the main locations for primary care practices, this translates to 7,000 visits per pharmacy per year. About 20 a day, if we keep them open seven days a week. That is easily doable.

Think about it. Primary care doctors would have no need to pay for office rental, or for employees. We could pay them half of what we pay them now, and they would still come out ahead. They would not be forced by local markets to be employed by a large organization. They could make a deal with their neighborhood pharmacy, where they could walk to that building daily. Or they could stay at home and work from home.

Expand on this. Provided that all electronic medical record systems are forced to easily communicate with each other, we could incorporate all of a patient’s medical appointments into one (albeit a lengthy one). There would be ways for specialists to discuss a patient’s care in real time, and for decisions to be made without needing to wait for letters to be typed and faxed or mailed.

Once the neighborhood store is recognized as THE place to go for medical matters, it would be easy to schedule group appointments for people who have a diagnosis in common. Ten people with Type II diabetes can meet with a nurse and a primary care provider for one hour. Plenty of time to share tips on diet and exercise; to commiserate; to lend support. A medical home.

The state or federal government would certify testing sites that will be forced to be in close proximity to the medical offices. Walking distance. Most patients would be done with their required care in one day. No more taking off work for most relatives or friends.

Adjustments to this model would have to be made in rural areas, where some form of transportation is still required for many people to access a pharmacy. We can afford that.

Most of the huge medical office buildings would vacate. The money saved in rent can be steered to use them as treatment and support centers for mental health, substance abuse, meditation training, yoga, and exercise. There would be no need for any doctor to have more than 200 square feet of space. If that; remember that they could choose to work from home. Appointments could be set up at the pharmacy centers if a patient needed a knee injection, a biopsy, or an infusion of medicine. More complicated procedures can be moved to a hospital outpatient area.

For too long we have treated patients as sources of income. Their convenience is not our first priority. Even in these days where we are careful to measure everything, we do not have an established set of criteria that determines what constitutes good medical care. Maybe we should start with providing what is good for the patients.