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Ruby Gifford has come to see Armon B.
Neel Jr. out of fear and perhaps desperation. Gifford, 86,
hasn’t been feeling well lately, and the list of symptoms that
have prompted her to come to Neel’s office in Griffin, Ga.,
might mark her as a hypochondriac in the eyes of many doctors. The
problems run from dizzy spells and falls to osteoarthritis and
back pain, from uncontrolled high blood pressure and erratic pulse
rates to anxiety and depression. Then there are the skin rashes,
hives and other allergic symptoms that seem to have come out of
nowhere.
Gifford’s 60-year-old daughter has
brought her to the Wednesday morning appointment, and the two wait
anxiously in Neel’s conference room, where he meets with
patients. Neel, however, isn’t a doctor. He’s a pharmacist
whose specialty is determining whether people are taking the right
medications—and in the right doses—for what ails them. Neel,
66, hasn’t worked behind a prescription counter since the early
1970s, when he gave up dispensing drugs for a career that would
often put him on a collision course with the doctors who prescribe
them.
"If I could find out what’s
causing all these allergies," Gifford begins. (Her name has
been changed in this story to protect her privacy.)
Neel asks to see the blood pressure log
she’s been keeping at his request, along with all the
medications she’s been taking. Gifford reaches down, produces a
freezer-size Ziploc bag that’s bulging with prescription drugs,
and places it on the table. Then comes another Ziploc bag, this
one full of over-the-counter medications.
Neel quizzes Gifford about the
prescription drugs, one by one. "What about that?" he
asks. "How did that one do?"
He then asks Gifford about Ultracet, a
pain medication that she’s taking. "I never have
headaches," she says. "My aches are all from
falls."
"Tell me about the falls," Neel
says. "Tell me how long it was after taking this pill that it
happened."
Neel gently guides Gifford through the
entire inventory. He explains that Aldactone, the blood pressure
medication she’s been taking, isn’t the drug of choice in her
case and may in fact be responsible for some of her other health
problems. As he looks through Gifford’s records, he sees that
her doctor, in attempts to control her hypertension, has tried
four different ACE inhibitors, two beta-blockers and two
alpha-blockers. Nothing has worked, and Gifford has had allergic
reactions to all of them. Neel seems stupefied.
"There wasn’t a need to go to the
second one after the first one did you harm," he says.
"They’re in the same family. You need a calcium channel
blocker instead."
Next, Neel zeroes in on Mobic, the NSAID
(nonsteroidal anti-inflammatory drug) that Gifford’s doctor has
prescribed for her osteoarthritis. "There are certain drugs
you just don’t give old people," he explains, and NSAIDs
are among them. It turns out that the doctor has ordered yet
another NSAID, in the form of Voltaren eye drops. "There’s
a newer product that’s better than this," Neel says.
Gifford seems relieved but at the same
time disturbed. "I don’t want to go back to this
doctor," she says. "She never checked anything before
she gave it to me."
Neel promises to put everything in a
written report by the end of the week. "Some of these
things," he says, pointing to all the medications spread out
on the table, "we might just chuck in the trash can."
Neel hits the road later in the day to
make his way to two nursing homes in rural Georgia, where he will
review the charts of dozens of residents and carry on his crusade
against the overmedication of geriatric residents in long-term
care facilities. Neel does this two or three days a week, nearly
every week, and has been doing it since 1968. He’s one of a few
thousand consultant pharmacists nationwide who specialize in
identifying, resolving and preventing medication-related problems
that affect, and afflict, older people.
"You see so many cookie-cutter
approaches to taking care of old people," Neel says.
"Almost 100 percent of the people I see as outpatients are
overmedicated, because the ones I see are the ones who are having
problems. If I go into a long-term care environment, it’s about
80 percent."
Typically, medication levels in nursing
homes can be cut in half or better. "If I can get the drug
therapy management correct," Neel says, "there are fewer
hospital stays, fewer hospital admissions, lower labor costs
involved in care and a better quality of life for residents."
Neel is a rebel with a cause—namely,
advancing the idea that pharmacists must serve and protect the
people who take the medications they dispense. "I get paid by
the patient," he says, "not the doc." The way he
sees it, pharmacists are often a patient’s last line of defense
in a nation of doctors who, more often than not, don’t know much
about the drugs they are prescribing and the geriatric population
they are treating.
The renegade streak goes way back. In
1963, just two years out of pharmacy school, Neel opened an
apothecary shop in Griffin that, just like a doctor’s office,
had a carpeted reception room and a separate consultation room. He
also set up prenatal counseling programs as well as hypertension
and diabetes clinics. Neel thought the new approach would earn
praise; instead it drew ridicule from many of his peers.
In the late 1960s, Neel, at the request
of a friend, started doing some clinical consulting in nursing
homes, and what he saw both shocked and transformed him.
"Here was a brand-new population of people, and nobody had
any earthly idea how to take care of them," he recalls.
"Back then you’d see Mellaril [a powerful antipsychotic
drug] brought in by the truckload. They used it as a chemical
restraint. Nursing homes back then didn’t have a lot of help, so
the best help they had was to drug the patients. I knew it
wasn’t humane, and I fought it from day one."
On Wednesday night Neel is driving to a
mom-and-pop motel in rural Georgia that he has stayed in many
times. It’s not far from a county-owned nursing home Neel counts
among his six institutional clients.
The next morning at 9, Neel is stationed
at a small desk near the nursing director’s office. He has
brought along a notebook computer, portable printer and a supply
of blank forms and printed materials. He knows just about
everyone, it seems, by name.
The doctor who serves as the nursing
home’s medical director doesn’t seem to care for Neel’s
approach to a job—mandated by federal law—that others see as
rubber-stamp work. The doctor doesn’t talk to Neel, choosing to
deal with him mostly through the nursing staff.
Throughout the day Neel will type his
medication-related suggestions on a form of his own design
(printed on a pink slip of paper so as to stand out in the
patient’s medical records) that directs the patient’s
physician to check a box that says "Accept" or
"Reject" before signing and dating it.
The medical director rejects, almost
without exception, Neel’s suggestions. He evidently takes
umbrage at being second-guessed by a pharmacist—something, Neel
says, that’s not at all unusual. Neel finds the lack of
engagement troubling. "He’s here once a month," he
says. "Maybe five minutes per patient. That’s all they’re
required to do."
Neel begins working his way through a
tall stack of blue loose-leaf binders that contain the patient
charts and other medical records. Today he’s reviewing the
charts of residents who are taking nine or more prescription
medications simultaneously.
It’s important on at least two counts
that Neel—or someone like him—review the medications these
people are receiving. First is safety. The risks of adverse
effects expand exponentially with the number of medications
"onboard," partly because they indicate the presence of
numerous diseases or other medical problems and provide an
opportunity for both drug-disease and drug-drug interactions.
Second is cost. "The rule of thumb," Neel says, "is
$100 a drug." That’s per patient, per month. Thus the cost
of having someone on, say, 15 different medications—many of
which may be unnecessary or even harmful—is $1,500 a month, or
$18,000 a year.
First up today is the chart for a
68-year-old man who is on many drugs, including Nitrofurantoin, an
antibacterial that’s prescribed for urinary tract infections.
Neel enters the man’s age, weight, height and information from
his blood work into a calculator programmed with certain formulas
he uses over and over. Neel explains that toxic levels of the drug
will build up in the man’s system because his kidneys aren’t
as efficient as they used to be.
Why would a doctor prescribe it?
"Because," Neel says, "it works in young
people." (A new study in the Archives of Internal Medicine
found that 20 percent of outpatients 65 and older were prescribed
"at least one drug that should generally be avoided in
elderly people.")
The next chart is for an 89-year-old
woman who’s on 13 different prescription medications, including
Zantac, which raises an immediate flag for Neel. There are no
blood chemistry tests in her charts, but Neel quickly computes her
probable renal clearance at 32.5 cubic centimeters a minute.
"This tells me right off the bat she shouldn’t be taking
it," he says. He then types his suggestion to the doctor:
"Zantac dose too high/could lead to ‘hepatic shutdown’
... resulting in serious patient adverse events."
Neel opens the next chart, that of an
82-year-old woman who’s on 17 different medications, including,
for type 2 diabetes, a prescription drug called metformin. He’s
dumbfounded at first, then angry. He reads the suggestion slip he
typed out a month and a half earlier: "patients with serum
creatinine clearance less than 60cc-m use of metformin is
contraindicated and places the patient at high risk for lactic
acidosis, which is fatal in most cases."
In a little while, Neel joins the staff
for lunch in the cafeteria and spends much of the time soaking up
details about residents that may prove useful in his work. On the
way back from lunch Neel stops to visit with them in their rooms
or in the hallway.
Neel rises early the next morning to
drive to another nursing home about 20 miles south. There, too, he
has a combative relationship with the facility’s medical
director.
As soon as Neel arrives at the facility,
he searches out a 73-year-old resident who’s been there since
February 1999. The man, who has advanced Parkinson’s, brightens
instantly. When Neel first looked at his chart, the man was on 20
milligrams of the antipsychotic medication Zyprexa, a daily dose
that by any measure is therapeutic overload; he’s down to 2.5
milligrams a day, and soon, Neel says, he may be off the drug
entirely. The man’s old symptoms, among them nonstop yelling,
have all disappeared, and now he sometimes comes to sit quietly
next to Neel as he works.
The physician overseeing the man’s
treatment told Neel and the nurses that he would never be able to
walk again. But walk he now does—and walk and walk. He visits
other residents in their rooms and likes to sit near the main
nursing station—the hub of activity. "I gave him his life
back," Neel says matter-of-factly.
One problem, as Neel sees it, is that few
of the 300 or so doctors who treat patients in the facilities he
visits have a specialty in geriatrics. How many do? "Maybe
two," he says. "They’re not up to date with the
physiology of the geriatric patient as it relates to the chemistry
of the drug. That’s the easiest way to put it."
Neel reviews a few more patient charts,
producing more small pink suggestion slips, each numbered
sequentially, as he goes. A little while back he passed the
300,000 mark.
At another nursing home, where Neel has
known the medical director for some 25 years, the success of a
collaborative approach is clear. "If I write up a suggestion
to paint the nose blue," Neel jokes, "when I go back the
next time, the nose is blue." The daily cost per patient for
drugs at the nursing home is down to $7.22, the lowest in Georgia
and just over half the statewide average.
Neel will be back in Griffin before
suppertime, where he’ll finish the written report that he
promised Ruby Gifford before leaving for a weeklong vacation with
his wife, children and grandchildren. He doesn’t yet know that
Gifford’s physician will be angered by her decision to seek out
his help and will refuse even to read Neel’s 17-page report.
So Armon Neel soon will help Gifford find
a new doctor. He isn’t one to pass the buck. "I’ve always
gotten along well with old people," he says. "They’ve
always been special to me." A mischievous smile breaks.
"And I really like ’em now, ’cause I’m one of ’em." |
