A Pharmacist-operated Travel Clinic in the U.S. - A Profile
Karl Neumann, MD, FAAP
Dennis Stanley's travel medicine office in suburban Richmond, Virginia, about 100 miles south of Washington DC, is about as unremarkable as most such offices, though, perhaps, a bit more sophisticated in appearance. In his consultation room there is ample space for his desk, four chairs for clients, a computer monitor open to a popular travel health information service, a refrigerator, a table with travel-related products and handouts, and a bookshelf holding familiar travel health manuals. On the walls, he has posters urging travelers to get vaccinated, a large world map, and a bulletin board with pictures and postcards, mostly of sub-Saharan Africa.
What is perhaps remarkable about Dennis and his office is that Dennis is a pharmacist and that his office is located in a super market. The consultation room, entirely private, is located next to the pharmacy counter, behind one of the walls of the store. Dennis also has a conference room, just as private and adjacent to his office. There he can comfortably seat fourteen people around a large table for travel medicine counseling. That is where he advises church groups going to volunteer in Africa, for example,
The supermarket itself is huge, about the size of a football field and very upscale and attractive, with high ceilings, unusually wide aisles, and good lighting. The lighting makes you feel that you are outdoors on a sunny, spring day. And there is an enormous variety of delectable produce, a comfortable, sit-down restaurant (delicious freshly-made sandwiches and salads, for sure), a branch office of a bank, a flower market and a surprisingly large health food section.
The best route to Dennis's office is to turn left after entering the store, pass the flowers, and then to make a right into the aisle between the ice cream freezers and the cereal shelves. There are possibly several hundred varieties and sizes of ice creams in those freezers - it is hard to imagine a bigger selection existing elsewhere. Ditto for the cereals. Dennis's office is opposite a display of incontinence product, and flanked by a dispenser of bottled water and a counter of sugarless wafers. This store itself is a marvelous place for browsing.
Dennis has been a pharmacist for about thirty years and has worked at independent, regional and large national pharmacy chain stores. His workplace for about the last 10 years has been a Ukrop's store, part of a chain of fashionable supermarkets, all located in the Richmond, Virginia area. His present store is in a rapidly growing area, an area changing from rural to suburban, with many of the new homes in the expensive category. Ukrop's has 29 stores and bear the name of the founder and the family that operates them.
Nearly all Ukrop's supermarkets have pharmacy departments and most of them have "wellness centers" attached to the pharmacy. It is the wellness center in Dennis's store that serves as his travel medicine office. The same facility is also used for regularly scheduled sessions, days and evenings, devoted to diabetes, cholesterol, blood pressure, osteoporosis, and other vagaries of health. Customers with such issues are encouraged to come in and listen to experts shed light on staying healthy. The experts may be pharmacists, nurses, dieticians, and other health professionals. When necessary screening tests for these conditions are recommended, and may be done on premise. Because of Dennis's interest in travel health his wellness center is known in this field. He gets travelers referred from physicians, health departments and pharmacists at the other stores. Dennis and his partner, Sharon Gatewood, PharmD see about 1,000 travelers a year, and the number is growing.
Dennis came to be a travel health practitioner in increments. "Earlier in my career I began to realize that there should be more to health than dispensing medications for individuals already ill. I became interested in `wellness', keeping people healthy so that they need fewer medications. As I became involved in wellness, I saw that many of my customers, especially adults, were not protected against vaccine-preventable diseases, influenza, for example. So I helped start a vaccination program which proved very popular. One day a group of people came in for vaccinations before traveling to Africa. I always had an interest in travel. So I decided to make myself knowledgeable in travel medicine."
In the United States, the parameter of what pharmacists may practice is mandated by the states and varies tremendously. In most states, pharmacists may give injections and may have limited permission to prescribe medications, sometimes under the aegis of a physician, through collaborative practice and sometimes on their own. Generally if a physician is involved, the physician's supervision is remote, with the physician occasionally checking logs and going over new procedures, but having little or no direct contact with the client of the pharmacy. All Ukrop's pharmacies notify the patient's primary care physician of any and all vaccines administered, maintaining the patient-physician-pharmacist relationship.
Presently few pharmacists administer vaccines or prescribe medications, even in states where they are permitted to do so. They are too busy with their other duties. But this may be changing. The economics and realities of retail pharmacy - people buying their more expensive and long term needs by mail, for example - may result in more pharmacists involving themselves in wellness.
"Pharmacists can operate wellness centers and, if they wish, travel clinics as competently as other health care professionals," says Dennis. Obviously, pharmacists have a strong background in pharmacology and increasingly, pharmacy school curriculum includes vaccinology. Dennis lectures about vaccines at the Virginia Commonwealth University, at the Medical College of Virginia School of Pharmacy and at pharmacy conferences around the country. He is a member of the ISTM, has a stamp to give yellow fever vaccine, is listed as a travel clinic on the CDC and ISTM websites, and has himself visited sub-Saharan Africa numerous times.
Dennis believes that supermarket pharmacies are ideal settings for wellness centers - and that travel clinics are merely specialized wellness centers. "The concept of wellness is still relatively new. The public needs to be reminded of the importance of this concept with educational outreach programs and convenient facilities where information and supplies are readily available. Supermarkets are ideal for this. They are accessible, non-threatening and consumer friendly, have convenient hours, carry the necessary supplies, and are staffed by experts who can answer most questions, truly one-stop shopping facilities for wellness."
But there are some limitations to a pharmacist-operated travel clinic. For example, in Virginia, Dennis cannot write prescriptions. He can and does make recommendations for medications that he believes are indicated for particular trips, for malaria prophylaxis and treating gastroenteritis for example. Clients are given written recommendations and/or Dennis and his staff contact the patient's physician by telephone for any needed prescriptions. Since Dennis's expertise in travel medicine is known in the area, virtually every recommendation he makes is followed.
Dennis stocks all vaccines except Japanese encephalitis. "We have very little demand for J.E," he says. "If someone needs it we order it and have it shipped overnight if necessary.
"We charge a consultation fee for pre-travel visits and add an administration fee for the vaccines we give. Insurance generally does not cover the costs for travel-related items or medications. We usually submit claims to the insurers, but only rarely do we receive payment."
The Ukrop's travel clinic operates pretty much like most travel clinics. Most visits are made by appointment via the telephone but walk-ins come in fairly frequently. If Dennis is available he sees the walk-ins; if not they are asked to make an appointment to come back. Clients are asked to bring their vaccination records and fill out health questionnaires. If a client has health issues that could be adversely affected by necessary immunizations and medications or by the trip itself they are referred to medical facilities.
The clinic publicizes itself by word-of-mouth, publicity releases, a listing on the web and discrete signs in the store. The clinic also receives some referrals from primary physicians, usually when the physician does not stock a vaccine or necessary supplies. Dennis says that his relationships with area physicians are quite good and that there is little sense of competition.
Do travelers come back to the pharmacy when they come home sick? Yes, occasionally. "If it is a run-of-the mill problem, gastroenteritis or too much sun, we will advise them and prescribe medications, as we would for any client," says Dennis. "Obviously, if the condition is more serious, we will refer them to physicians."
Karl is the Editor of ISTM NewsShare. He writes frequently about travel medicine for both health professionals and the public. He visited this super market/pharmacy/wellness center/travel clinic to report this article.
