Wednesday, September 17, 2008
3:22 AM ; We are a Team!
We are a TEAM! I cannot say that I’m not surprised when I saw the wave of reluctance, especially with doctors, with regards to the pilot project mentioned by our Director‐General of Health, Tan Sri Dr Ismail Merican, in attempt to separate dispensing and prescribing medications.
The system of prescribing in clinic, while dispensing in pharmacies has been long established in the United Kingdom and United States. This system offers many benefits above ours. The patient medications will be prescribed and then subsequently dispensed by two independent professionals whom will countercheck each other to ensure fewer mistakes in prescribing and dispensing. Many drugs used have multiple actions hence resulting in multiple contra‐indications. Thus the public should not compromise their own safety for the sake of convenience as some errors might be fatal or even cause life‐long complications. An asthmatic patient may be prescribed a drug for hypertension; however that drug itself may actually aggravate his asthmatic condition. It may have been a simple mistake which could have been easily prevented by having another professional in the system to countercheck. I have studied Pharmacy in the United Kingdom and have observed how important this system of counterchecking is. When a doctor writes a prescription, it is his responsibility to include the diagnosis of all the existing medical conditions of the patient, and hence the pharmacist would be able to countercheck for possible contra‐indications, drug‐drug interactions and dose or frequency errors. Being engaged as a pharmacist in a hospital which practices this system of separate prescribing and dispensing, the value of this system is reinforced in my opinion. The number of interventions in problematic prescriptions is significant. During practice, medication errors are often encountered; especially overdosed paediatric prescriptions. Doctors do make mistakes as there are times when they are not familiar with dosage requirements/adjustments for a specific group of patients. Even specialists encounter problems with certain drugs out of their specialised field of practice. Furthermore, given the long hours of practice every day (especially during their on‐calls or long clinic hours in 24‐hour clinics) as well as a huge number of patients to attend to, certain mistakes are indeed inevitable. Perhaps this is another reason why sometimes they really do not have time to explain the use of drugs or certain medical devices to patients. The biggest question now will be whether or not patient treatments were optimised all this while? Could their condition be better than they should have been now? All in all, the intention of putting forward this system is in fact not some petty personal war between pharmacists and doctors, nor is it plain fault‐finding or turf protection; rather it is to deliver a more wholesome and better healthcare service to patients where doctors and pharmacists work integrally as different parts of a grand team. Nevertheless, doctors should be saluted for their dedications in our healthcare system which demands their endless commitments.
I concede that logistics may be an issue especially with the shortages of pharmacists nationwide. This is why I can understand Tan Sri Dr Ismail’s rationale to pilot this project in major cities where pharmacies are readily available within close proximities of clinics. Also, pharmacies should be ready to provide 24-hour round‐the‐clock services in order to cater for acute cases even in the middle of the night. Areas which are still the acute lack of pharmacists should continue to have doctors dispensing until sufficient pharmacists are available. However, the issue of dispensing medications by pharmacy assistants is notwithstanding (Section 2(1) Poisons Act 1952)**. To dispense medications without the immediate
personal supervision or presence of a pharmacist in the pharmacy is blatantly offending the law (Section 18(1)(b) Poisons Act 1952)**. Refilling prescription‐only drugs without a doctor’s prescription is also a liability in court (Section 21(1)(c) Poisons Act 1952)**. Therefore patients requiring a refill are required to consult a doctor and obtain a prescription prior to getting their prescriptions refilled. The pharmacists‐in‐charge of these offending pharmacies would be charged in court and face penalties of up to RM5,000 fine or imprisonment not exceeding 2 years or both for EACH offence. In addition they may also face disciplinary actions from the Pharmacy Board. To reinforce such laws, pharmacies are routinely inspected and tested for such offences by the Pharmacy Enforcement Branch.
Doctors on the other hand are far too busy to handle the dispensing personally; therefore clinics usually employ non‐medical professionals to dispense medications. As a result, patients rarely receive any detailed instructions or in‐depth counseling upon receiving their medications which may greatly increase the risk of medication related untoward incidences. Bear in mind that improper medication counseling may also lead to therapeutic failure! Even branded medications, such as cholesterol‐lowering drugs, can be rendered completely useless just by taking it at the wrong time of the day.
Pharmacies currently carry very little of prescription drugs because rarely do any patients turn prescriptions in to be filled. This may be a problem for patients bringing prescriptions in to a pharmacy not carrying the drugs required. With the introduction of the pilot, I believe this situation should rectify itself (within the pilot test area) as pharmacies unable to cope with patients’ prescription would ultimately be phased out of competition.
The current medical service is good, but it does not mean that it does not hold room for improvements. The proposed system has been trialed and tested by many first‐world countries and proven itself to be both efficient and effective in delivering the optimal healthcare service to patients. I do not believe that we should dismiss this system as “inefficient” or “retrogressive” just because of negligible inconvenience or the simple lack of parking space. When a new system is being introduced, undoubtedly, there would be obstacles and difficulties, but once these hurdles are conquered, we would then be able to see through the fog and taste the fruits that it bears. From another perspective, it may be of convenience to quite a number of patients too, especially for those with chronic diseases whose conditions are stable to the medications currently prescribed. A doctor may choose to write a prescription for repeat dispensing where it can be filled in pharmacies for a period of time before the next follow up. This way, patients do not have to meet up with their doctors every time just to receive their medications. Won’t that be of greater convenience?
To a certain extent, generic drugs may not be as efficacious as original branded drugs, but this does not defeat the cost issue, which is very real for some patients. It may be a difference of meals for several days or weeks! Healthcare professionals should be sensitive to patient’s overall healthcare. Imagine a patient suffering from gastritis sacrificing lunch just so that he could buy branded drugs to treat gastritis. That would be counter‐productive! Hence the pharmacist may advice the patient in terms of cost‐effectiveness of the drugs. All drugs marketed legally in Malaysia have passed the Drug Control Authority's quality testing to ensure that they deliver at least a certain amount of efficacy and to cast these generic drugs as no better than flour pills is unreasonable. Many hospitals purchase generic products in order to cut costs so as to cater for the huge population it handles. Does that mean that these hospitals are serving them nothing more than flour?
Pharmacists now are currently well‐trained and experienced to cope with the identification of adverse events, contra‐indications or drug interactions. Undergoing the Pharmacy course in any university would require the student to undertake clinical attachment, and study practical pharmaceutical care. After which, a pharmacist would be required to undergo one year of housemanship and in the recent years, three years of mandatory service in hospitals. This gives them ample experience in indentifying many possible clinical problems and thus sending the patients back to their GP on such identification. A chronic dry cough may be due to an infection, it may also be due to a side effect of anti‐hypertensive drug. A pharmacist may not be capable in diagnosing the cough, but he may be able to keep an extra eye out for patients and refer them back to their GP when it is necessary.
If the proposed system proves to be better than the current one, I do not see the reason why patients should not be legally bound to obtain a prescription and their medications separately from doctors and pharmacists respectively. Patients may not foresee the pivotal benefits of the new system and, for the sake of some convenience forfeit these benefits. However as healthcare professionals, we are able to objectively analyze the result of the upcoming pilot and make a professional conclusion. If the conclusion is in favor of the proposed system, it would be logical to enforce it legally to ensure that as many patients may enjoy these benefits as possible.
In essence both doctors and pharmacists are both healthcare professionals working to provide maximal healthcare benefits to patients and I believe that it is this aim that drives them to take up the new challenge and work out a system that is best for patients.
By Gan Pou Wee, Co‐authored by John Tiong J.L.
Section 2(1) Poisons Act 1952
Dispensed medicine means a medicine supplied by a registered medical practitioner, registered dentist, veterinary surgeon or a licensed pharmacist on the premises specified in his license.
Section 18(1)(b) Poisons Act 1952
Part I Poison shall not be sold or supplied to any person except by retail sale effected by or under the immediate personal supervision of a licensed pharmacist.
Section 21(1)(c) Poisons Act 1952
Group B poison shall not be sold or supplied by retail to any person except by a licensed pharmacist, as a dispensed medicine on and in accordance with a prescription prescribed by a registered medical practitioner, registered dentist or veterinary officer.