Thursday, April 03, 2008

10 reasons why doctors should maintain the rights to dispense

I am surprised to find some GPs have Podophylline in their clinics, in view of the difficulty to obtain this chemical in the government clinics. Podophylline is used to treat anogenital warts.

This post has moved to Storyformydoctor 1.0

MMR: Doctors dispensing medicine II.

33 comments:

Chen said...

in the private sector, everything boils down to $$$

Anonymous said...

I really disagree with your prejudice statement about pharmacist. I'm an ex-med student from one of the developed countries that practices dispensing separation cuurently practicing on one of the gov hospital. what can i counter are;

1. There are not enough pharmacists.
when dispensing separation takes place, of course more 24 hours pharmacies can be opened, and more students now graduated as pharmacist in msia

do you know latest 2007 statistics state that know there are more than 5000 registered pharmacist in msia.



2. Not all pharmacies have certain medicine.
Come on, the med started to be introduced in msia in 2002 (differin), but i must say that retin-a(tretenoin) is always in the pharmacy whenever i go. if you are looking for only "retin-a", i suggest u go for generics product.

If you want to search for than class C poison for scabies, the pharmacist can always suggest alternative (that is what they are trained for, do you ever get it?)


3. Pharmacists offer alternative medicine when they don't have the prescribed item.
about primolut, it is also for menorrhagia and the pharmacist suggestion is right, what wrong is, the pharmacist does not call u for the suggestion.

4. Pharmacists did not follow instruction on prescription.
Hey, look for latest hospital formulary and moh treatment guideline. the pharmacists just did their thing.

5. Pharmacists try to overrule doctors instruction.
hei, u must not hv been in countries practicing dispensing medication, that is the responsibility of the pharmacist to make sure the treatment being as cost effective as it can be.

6. Pharmacists implementing unfair policy.
That is not their policy, refer back to your P&T commitee hospital.


7. Pharmacists conveying wrong information to patients.
The pharmacist is right about the indication, but tell the pharmacist to ask the patient what she is having.


8. Pharmacists (as human being) do dispense wrong medicine by mistake.
doctor also human being, do a lot of mistake. we shud not think that we are smarter than them and dint do mistakes.

9. Pharmacists who think they are smarter.
Do you know that pharmacist is responsible for patient compliance, and no problem to give enalapril 10mg OD for hypertension. but for HF, then it should be given in divided doses. (u think u r smarter? they actually are smarter than u)
Hey, pharmacists are trained to make sure that stock of medication shud be maintained. If the drugs dat hv the same indication available, why need waste buying another?
My pharmacist friend tell me that that is what they learn in the pharmacoeconomics subject. That is my first time i heard about that "pharmacoeconomics" word, do you too?



10. Pharmacist playing doctors.

One thing u should know, diabetes drugs are in group C poison, pharmacist can dispense as many time as they like if they have record on her previous prescription. as for hypertension drugs that most of it are group B poison, pharmacist can only dispense with prescription and renewed prescription(if the pharmacist have the records saying the prescription can be renewed.)

do you know that pharmacist test for glucose and cholesterol not to diagnose but to ensure patient's compliance.





p/s: do u think the pharmacist just like the nurse or dispensers that u can look downward to. exactly no, do u know that pharmacist and dentist is the second highest paid salary after physician in the hospital? Do u also know that in USA, BPharm and PharmD graduates are also legally qualified the title "Dr" in front of their name?

(i made this answers together with my pharmacist friend, lots of new thing i know about pharmacist after doing this)

Anonymous said...

why don't we try to separate dispensing and prescribing?? It is not wrong

Anonymous said...

I am a pharmacist currently serving the government. I just wanna ask Cystum, does doctors not make mistake?? The public would be all out for dispensing separation if the Pharmacy Intervention Record book are made public! I have doctors who prescribe amlodipine 10mg bd (when maximum is 10mg od) and when called up they don't even know thats the maximum dose. Mind you, these are not houseman doctors ok. These are medical doctors way past their training years. I also have doctors who apparently does not know that Augmentin and Amoxicillin are from the same penicillins group and thus both are prescribe at the same time. And when told about this, this doctor have the cheek to argue with me that i am wrong. There are many more "silly" type mistakes that doctors make but of whom i shall not write here. To give the pharmacists dispensing separation rights will make sure that all these silly mistakes does not happen.
Another thing i would like to point out, patients very often tell the doctors something and tell the pharmacists different thing. I have patients when the doctors prescribe ventolin for his shortness of breath, and when i told him this, he make a very big scene about how he does not have shortness of breath nor any coughing for that matter and he will not take the medication. So, as the pharmacist, i have to call up the doctor and explain the situation to him and he told me adamently that the patient is the one who said he has some trouble breathing. No examination, doctor?? In the end, the doctor said to strike off ventolin from the prescription.
My point is that if dispensing separation were to take place, a check and balance system will be in place. The doctors wins, the pharmacists win, the patients win. Win-win for all. Isn't that good? or does the doctors all have some ulterior motive as to why dispensing separation should not take place? I wonder, does it have something to do with money and not the patients afterall?

Cytusm said...

Thanks Anonymous 4.04AM for taking time to read my posting and shared your views.

I really disagree with your prejudice statement about pharmacist. I'm an ex-med student from one of the developed countries that practices dispensing separation cuurently practicing on one of the gov hospital. what can i counter are;

1. There are not enough pharmacists.
when dispensing separation takes place, of course more 24 hours pharmacies can be opened, and more students now graduated as pharmacist in msia

do you know latest 2007 statistics state that know there are more than 5000 registered pharmacist in msia.

Cytusm: The number of pharmacists is still way behind doctors.

2. Not all pharmacies have certain medicine.
Come on, the med started to be introduced in msia in 2002 (differin), but i must say that retin-a(tretenoin) is always in the pharmacy whenever i go. if you are looking for only "retin-a", i suggest u go for generics product.

If you want to search for than class C poison for scabies, the pharmacist can always suggest alternative (that is what they are trained for, do you ever get it?)

Cytusm: If pharmacists want to practice dispensing, they must ensure that most medicine is available easily. Differin and Pementhrin are commonly prescribed drugs (both are not available in the government hospitals). I usually ask patients to buy from private pharmacies. Can you imagine one’s frustration, after going to 4 pharmacies in your neighborhood, none of them had it? It is definitely more convenience if the doctors prescribe and dispense it on the spot.

3. Pharmacists offer alternative medicine when they don't have the prescribed item.
about primolut, it is also for menorrhagia and the pharmacist suggestion is right, what wrong is, the pharmacist does not call u for the suggestion.

Cytusm: It is absolutely wrong and DANGEROUS for pharmacists to suggest alternative, especially hormonal drug (Primolut) is not the first line of treatment for menorrhagia. It should be the doctors’ decision and not the pharmacists.

4. Pharmacists did not follow instruction on prescription.
Hey, look for latest hospital formulary and moh treatment guideline. the pharmacists just did their thing.

Cytusm: Guidelines are there to guide; it should not be followed strictly. Different patients have different clinical conditions. Doctors must have their own reasons to give certain duration for medicine and that should be followed exactly by the pharmacists who dispense. They have no rights to change what have been decided by the doctors.

5. Pharmacists try to overrule doctors instruction.
hei, u must not hv been in countries practicing dispensing medication, that is the responsibility of the pharmacist to make sure the treatment being as cost effective as it can be.

Cytusm: Again, pharmacists have no absolute rights to overrule doctors’ prescriptions. Very dangerous! Doctors know best because they see the patients! When one is dealing with somebody’s life, there is no such thing as ‘cost effective’ or not.

6. Pharmacists implementing unfair policy.
That is not their policy, refer back to your P&T committee hospital.

Cytusm: Some policies are made with strong input from the pharmacists. Some doctors who sit in the committee do not really care whether certain policies are convenient to patients or not. Some of them are not even practicing clinicians, they are administrators.

7. Pharmacists conveying wrong information to patients.
The pharmacist is right about the indication, but tell the pharmacist to ask the patient what she is having.

Cytusm: Certain medicine has many indications. If they do not know, always consult the doctors and clarify. Do not confuse patients.

8. Pharmacists (as human being) do dispense wrong medicine by mistake.
doctor also human being, do a lot of mistake. we shud not think that we are smarter than them and dint do mistakes.

Cytusm: Yes, everybody makes mistake. So, pharmacists should not think that they are only the best person to dispense.

9. Pharmacists who think they are smarter.
Do you know that pharmacist is responsible for patient compliance, and no problem to give enalapril 10mg OD for hypertension. but for HF, then it should be given in divided doses. (u think u r smarter? they actually are smarter than u)
Hey, pharmacists are trained to make sure that stock of medication shud be maintained. If the drugs dat hv the same indication available, why need waste buying another?
My pharmacist friend tell me that that is what they learn in the pharmacoeconomics subject. That is my first time i heard about that "pharmacoeconomics" word, do you too?

Cytusm: Again I want to stress; doctors must have their reasons why certain medicine are to be given certain way. It is insignificant whether OD is for HPT or BD for HF, it is just a recommendation. Patient’s clinical condition or profile matters more. Do you know why we ask dialysis patients to take Perindopril ON? When implementing policies, pharmacist should listen to doctors because doctors are the one seeing the patients. They know best. The example I gave, Stemetil works better for vomiting with CNS symptoms whereas Maxolon works when there is vomiting associated with GI symptoms. Again whatever ‘phamacoeconomics’ term is unimportant when one is dealing with life of patients. What we doctors care is to save LIFE. Doctors should have the freedom to prescribe variety of drugs and not restricted by pharmacists who control the dispensing.

10. Pharmacist playing doctors.

One thing u should know, diabetes drugs are in group C poison, pharmacist can dispense as many time as they like if they have record on her previous prescription. as for hypertension drugs that most of it are group B poison, pharmacist can only dispense with prescription and renewed prescription(if the pharmacist have the records saying the prescription can be renewed.)

do you know that pharmacist test for glucose and cholesterol not to diagnose but to ensure patient's compliance.

Cytusm: You are very wrong and misguided. Testing glucose and cholesterol are doctors’ roles. Doctors are the best persons to advice on patients’ clinical condition and progress.

p/s: do u think the pharmacist just like the nurse or dispensers that u can look downward to. exactly no, do u know that pharmacist and dentist is the second highest paid salary after physician in the hospital? Do u also know that in USA, BPharm and PharmD graduates are also legally qualified the title "Dr" in front of their name?

(i made this answers together with my pharmacist friend, lots of new thing i know about pharmacist after doing this)
4:04 AM

Cytusm: I am not looking down on pharmacists. They definitely have important roles, where ‘dispensing’ is only one of them. I am giving some example of inconveniences where there is separate dispensing. Not all system is perfect. Also, pharmacists should not be too smart to interfere with doctors’ decisions. Doctors know best because they deal directly with patients. I am defending the issue on why doctors should preserve their RIGHTS to continue dispensing, role that exists since ancient time. Prescribing and dispensing by doctors are convenient for patient, tailored to the needs of patients and definitely cost effective.

Thank you.

Cytusm said...

Anonymous 10.11AM:

It is not wrong to separate prescribing and dispensing. This system has been practiced in all government hospitals and clinics as well as all private hospitals.

The only doctors not practicing such system are private GPs and most individual specialist clinics.

In such individual small private practice, it is not feasible to have separate dispensing. Prescribing plus dispensing is done for patients' convenience and cost. Most of the GP cases are simple and straight forward. Doctors charge minimal fee, and gain from dispensing.

Take for example, simple URTI case with PCM, cough syrup and antibiotic, is charged RM20-30. If doctors are not allowed to dispense, they would charge RM30 for consultation and patients will have to pay more for medications dispensed from pharmacies.

Cytusm said...

Anonymous 1.01 PM:

My point here is not to blame anyone or look down on pharmacists. Everyone makes mistakes, doctors or pharmacists.

Like what I have said before, separate dispensing is already been practiced in all government and private hospitals.

Pharmacists are trained not only for dispensing role. They have other responsibilities such as patients counseling, education, research, drug preparation and formularies, TDM, etc. They also have role in assisting clinicians in the clinical care.

My point here is that, doctors should maintain their RIGHTS to DISPENSING.

Money is definitely an issue. Most GP cases are non complicated. Many GPs charge very minimal consultation fees and gain from dispensing. Most of them have no special skills, so they can't charge more on consultation fees.

So, if these doctors loose their rights to dispensing, they will need to charge to the maximum recommended fees.

Also, various factors need to be considered like the number of pharmacies and logistics. It may not be convenience to patients especially those from suburban and rural areas.

There is no one perfect system. I have some frustrations working in hospitals that practice separate dispensing. Doctors are limited by choices and freedom of prescribing. Certain policies are unfair and are made to the fancy of certain policy makers who do not understand how the system works. The variety, choices and availability of drugs are totally controlled by pharmacies. Some original drugs are replaced by generic to save cost with irregard to the efficacy and patients' tolerance.

As for check and balance, pharmacists are there to check on doctors's prescribtions, but who are there to check on whether pharmacists dispense the correct medicine or according to dosage and duration?

Therefore, I am in the opinion, and strongly support MMA President's call, that doctors should MAINTAIN their RIGHTS to dispensing medicine.

The patients should then be given the options whether to get the medicine from the clinics or from the pharmacies.

Anonymous said...

hai..
i am currently a pharmacist in the gov...
1)cystusm i guess u still suffer from the docs knows the best syndrom..where ur thinking is way back where docs have all the say in seeing patient,prescribe..the only thing u really feel is the job of the pharmacist is tdm counseling which u find u docs tedious or dunno how to do..in hosp setting u feel that pharmacist should be the store keeper ie no opinion in drug use..as for me i feel that is very very old thinking..we are train in medication use..if u were not to be too defensive u'll will see that though we sometimes appear as nuisance with our interventions...but we have made a impact in the medical world...our interventions have got many specialist's recognision that we can play a role.i know that because the medical specialist in my hosp ask for additional clinical pharmacist,,
2)i do admit to an extend the current retail pharmacy do lack certain clinical skills are also more money focus as they were not clinically trained..way back they are only trained 1 short years that is barely enough..but the new generations will have adquate training n clinical skills to cope

also u mention the frustration for patient to look for certain drug that the hosp do not keep,my friend the reason the hosp do not keep is because these drug are rarely use(u have problem of expiring drugs)wat more a small retail pharmacy...don GPs also just use the alternative they have..do u think they stack the rare drugs??

p/s: i just wonder did u fill in the column for diagnosis in the prescription when u prescribe carbamazepine??if not of course we'll mention the most common indications..

3)lastly the reason i feel dispensing rights should be given to pharmacist because there also many GP's that practice non ethical medication use..i have personally encounter GPs giving very strong antibiotics for simply flu n cough
steroids for sore throat also salbutamol tablet for asthma..
there are also GP's that refuse to tell patient the medications that were given,patient approached me with medications from GPs to ask wat is it for(turns out medication for depression)is it right for patients to be on antidepresant without them knowing???

let the pharmacist dispense so that the doctors can concentrate to diagnose..

Anonymous said...

I give Anonymous my support! I am a registered pharmacist with Australia and I have practised in Aust for a few years before I came back to Malaysia. If you know how the national health scheme in aust work you will know the dispensing separation is a right way if we want our country to move from developing country to developed country. I have encountered some unethical drs who refused to tell the name of the medications to the patients in malaysia, so that they can charge them a bomb when they go back to them. To be honest, how many drs in malaysia are willing to give out prescriptions? They are not even willing to tell the patients what they are taking!!

- k o R i - said...

why are all of you giving your comments anonymously? honestly, the arguments you made just made me think that you're trying to imply "pharmacists are better than doctors no matter what the doctors say".

I'm from the pharmaceutical industry, somewhere in between the doctor and the pharmacist. And I study medical science as a researcher who will one day help both doctors and pharmacists (since I will develop the drug and I will also diagnose the patient in labs).

From what I know, the bottom line is truly in understanding the patient. Yes, pharmacists know what medicine does what and can therefore come up with something for what the patient says. But honestly, other than what the patient says, can they really do more? What if, based on their own interpretation of the problem, they give medication to patients that cause them more detrimental problems than before? Drugs are drugs, lets face it. Dosage is everything that sets the limit when medicine becomes poison. Reasons for specific prescriptions are more important than blaming economics.

Doctors can prescribe medicine based on diagnosis done in a clinic and using the knowledge they know of both the patient's history and the symptoms of diseases. For them to have the right to dispense medication should be retained. The patients can always go back to the pharmacists for more if the doctor prescribes it.

The honesty factor and the trust factor is really important between the patient and the doctor. All the attacks and defences I've been reading from "anonymous" comments are personal attacks on specific "doctor"s and not what the doctor represents. The human being is not perfect but it is not what defines a doctor or a pharmacist. Ethics is important, yes, but using ethics to give dispensing rights to pharmacists is not the way to go.

Pharmacists, please don't take this personally and please, look at it from another angle. If you want dispensing rights, fine. Just, make your point more relevant instead of attacking the person and not the job. Is it because you can't think of reasons why any doctor in the whole wide world, regardless of their ethical value, is capable of dispensing?

Fat4 said...

Kori,

It is rather sad that if you are from the pharmaceutical industry, you seem to have a lack of understanding between PRESCRIBING and DISPENSING. To you it is the same. In actual fact it is not. The reason why I took the trouble to write three posts to refute cystum claims is because what he has written are "PERSONAL" experiences. Trust me there are by far and plenty of horror doctor stories.

Doctors should prescribe. Pharmacists should dispense. The reason why doctors are so particularly protective of this turf is money. That is the only ONE sole reason. Perhaps greed can be a better word. Doctors who had practiced in countries where there is a separation of duties work well and hand in hand with pharmacists. Problems as described by cystum will not exist once the separation of rights becomes a reality.

Unfortunately, the medical lobby group in Malaysia is a strong one. And as far as I can see, I am the only blogger who has so far attempt to bring the record straight. I have full medical training in a country which has separation of duties.

Please be fair to the public and provide ONLY accurate information and try not to get Prescribing and Dispensing mixed up.

Thank you. ;-)

Cytusm said...

Thanks Anonymous 3.16PM, 5.16PM and Kori for your comments. I appreciate feedbacks too.

For those pharmacists who are reading this, whether you accept it or not, my view is that, doctors as clinicians, definitely know their patients better.

Pharmacists can tell you hundred and one of side-effects of a drug, but doctors who see the patients know better which one are common. Take for example, doctors should know whether some skin rashes are due to drugs or any other causes because doctors see and examine the patients and not pharmacists.

When deal with patients' health care and decision, doctors are the primary team.

I don't want to indulge into argument on whether doctors are better than pharmacists or vice versa further.

All other supporting health care personnels are as important too, whether they are pharmacists, medical laboratory scientists, dietitians, physiotherapists, etc.

Doctors should not look down on them. They are professionals with degree too, some even have similar grades as doctors.

When treating patients, other supporting staffs can advise and offer their expert opinions, but the ultimate decision making shall be made by doctors after taking into consideration on various factors.

I also don't want to argue who made the most mistakes, whether doctors or pharmacists, as all human beings make mistakes.

Pharmacists should be made clear that nobody is denying their rights to dispense, but doctors should MAINTAIN their RIGHTS to dispense too.

If everyone is like what pharmacists are thinking, others like MLTs, physiotherapists, dietitians should then also exert their exclusive rights too. Then, doctor should really concentrate on diagnosis alone and say anything less.

Malaysia has got a very unique health care system, I believe no other country has. Malaysia is the only country where patients pay RM1 and have (or expect to have) everything done. The fact is, health care is seen as necessity, an issue not to be politicized or commercialized.

So, don't compare us with what other countries are doing. One can name me a list of countries practicing separate dispensing, but one can also name me countries that don't practice such separation. Why make a fuss?

The bottom line is, doctors are not against anyone doing what they are trained to practice, but doctors should maintain the roles they have been practicing.

Anonymous said...

I am supporting the practicing of dispensing separation.

This is a scenario i often seen:

GPs tend to prescribe and use the drugs that they kept in their clinics.
Very often, GPs tend to buy the drugs after persuation from the sales representatives.So, in order to clear those drugs, the GPs will try to presribe them.
And of course, those prescritions will be inappropriate.GPs presribe them just to clear off the stock.

Of course there are pro and cons for dispensing separation. But i do see there are more benefits for dispensing separation.

Anonymous said...

i am a pharmacist student. after reading all the comments and the posts, i come to a conclusion....
did doctors feel like pharmacists are taking over their job to PRESCRIBE drug? i think this will NEVER EVER happen. pharmacist's job is to DISPENSE...if dispensing separation is practise in msia, the only difference is that the patient need to bring the prescription to the pharmacist and buy their medication...doctor still PRESCRIBE the medication according to the patient's condition. that's all..and i believe that there will be specific authority to govern this practise to prevent mis-behave of
pharmacists..doctors and pharmacists and all other health care people should work hand in hand...
=( don fight against each other...
be mature!

Anonymous said...

Cytusm, it seems that you are very well implying that doctor has better clinical knowledge, pharmacology knowledge, everything.
This is something very subjective as each person knowledge depends on the training, exposure as well as studies. Generally, pharmacist are trained to dispense. They do have clinical knowledge and are expert in drugs. While doctors too have drug knowledge and are expert in clinical. And therefore expert should do what expert does, doctor diagnose and prescribe and pharmacist check and correct whatever necessary and review with doctor if necessary and finally dispense.

Yes, pharmacist are better than doctor in drug related issues. Period.

Anonymous said...

Dispensing is only one of the roles of pharmacists. If pharmarcists think they are only trained to dispense, then they are no different from any 'dispensor'. Go ask the authority to replace all the dispensors in the hospitals/clinics (who are sitting at the counter dispensing) first.

Cytusm said...

Anonymous 2.50PM:
Things you said about GPs' dispensing practice which you think are unethical, could also be practiced by pharmacists. No point comparing who is more unethical. The point I see when GPs do the dispensing is, they make sure that is what the patients get, at lower cost and more convenient (this applies to GPs only).

Anonymous 1.31AM (Pharmacy student):
To answer your question, it is 'no'. Doctors don't think pharmacists are taking over their job to PRESCRIBE drug. I never denied pharmacists are of great help especially on advise and dispensing. Pharmacists can go ahead and do the dispensing, but I feel that this rights should not be just EXCLUSIVE to pharmarcists. I have pointed out some inconveniences. Not all doctors are doing dispensing, only GPs do. I think in GPs set up, such practice may not be feasible. Doctors should maintain such role. I think it is just as appropriate that patients be given the choice to get the dispensing whether from the GP clinics or pharmacists else where.

Cytusm said...

Anonymous 3.55AM:

I did not imply that doctor has better clinical knowledge, pharmacology knowledge, everything. That is your own perception.

I don't want to go on to debate who is more knowledgeable.

My point is, pharmacists can go ahead with their role of dispensing, nobody is stopping them from doing so.

But doctors should maintain such role too.

Let say, a doctor sees a patient in the GP clinic who just complains of fever and cough. So, the doctor diagnose as URTI and just want to prescribe PCM and cough syrup.

Don't you think it is just ridiculous that the doctor just can't give the simple drugs because he has no rights to do so?
That is what I meant by a person with gun but without the bullets.

Pharmacists can go ahead and sell the 'bullets', what doctors want, is to continue to use the 'bullet'.

Simple.

Anonymous said...

hai i am the Anonymous 3.36 am
kori-sorry me left the massage as Anonymous cause its the easiest way i found..again it is just me not good with comp.

anyway after reading all the comments again,yes cytusm u have a point just pcm n cold product too troublesome..but these things can be iron out..probably simple items can be kept by all ..i think situation have shown that most GP keep the medication they give like 'secret' which is not right..also that is why continuing giving the GP right to dispense there will never be role of pharmacist in dispensing as u 'ideally painted'..pharmacist n doctors both do make mistakes and both also can be unethical in their own way..but i support dispensing right is because this way GP's practice can be like hosp where there can be counter-check..i'm sure for doctors in hosp you'll also come across case where u feel GP do need counter check..with dispensing right,gov should also buff up the regulation in pharmacies,drugs should be dispense by prescription..
if the dispensing right can work for hosp,i believe it can be modified to be implemented outside too..don straight away reject the idea..

Anonymous said...

haha, i doubt dispensing rights will be given to pharmacist, malaysia is a coutry which is very resistant to change for the better one, double standard , corruption, injustice and being stubborn of it is what malaysia is good at.

Though i personally feel that, being part of medical faculty is a noble proffession, and it's only noble for doctors to give back the dispensing rights to the pharmacist.

Cytusm said...

Anonymous 7.00PM:

Nowadays, more GPs have started labeling their drugs. A number of them use computerized system. A famous clinic chains in the northern states is one good example. Doctors hiding the name of drugs, not a problem. A lot of negative practices can be changed or modified without the doctors loosing the dispensing rights.

Anonymous 1.31AM:

Malaysia has an unique health care system which is heavily subsidized by government. The medical community has also been talking about the National Health Financing Scheme, many of what people used to compared with the one in the 'developed' countries. This scheme has received strong opposition by various parties.

The fact is many people still want the government to continue subsidizing the cost of health care.

Pharmacists used to think GPs are their main competitors, but unfortunately not true. GPs don't gain much from dispensing.

The truth is, more people (including some rich ones) are seeking treatment from the government hospitals and clinics because they only need to pay RM1 or RM5 for a whole goody bag of drugs dispensed there.

This is the main factor drawing away patients from getting their drug supplies from the private pharmacies.

Think.

Last thing I want to comment is, doctors have been dispensing medicine all this while (even before pharmacists exist), nobody has taken the rights from the pharmacists.

Anonymous said...

If i am not mistaken, pharmacist inherited the role of apothecary of formulating and dispensing medicines to the patient,physician or surgeon since 15th century.

Anonymous said...

Base on current studies comparing a dispensing doctors to a non- dispening doctors,

. Background factors:

dispensing doctors' patients are normally older, with a higher proportion of them being over 65 years old;

dispensing doctors have less years in practice;

dispensing doctors have a less positive attitude to pharmacists;

when the law allows dispensing by doctors in relation to rurality, more dispensing doctors will be situated in rural areas compared to non-dispensing doctors; if the laws do not relate dispensing doctors to rurality, this difference could not be found;

consultation time was found to be 1/3 for dispensing doctors in comparison to non-dispensing doctors. Also history taking was found to be less elaborate for dispensing doctors. Only 11% of dispensing doctors provided information to patients on their diagnosis, compared to 37% for non-dispensing doctors. In this study the dispensing doctors were paid through the sale of drugs, whereas non-dispensing doctors were pediatricians who were paid a consultation fee.

2. Rational drug use:

the number of drugs prescribed per patient annually and per encounter were found to be higher for dispensing doctors in two studies and the same in another;

use of injections by dispensing doctors per encounter was found to be higher for dispensing doctors than for non-dispensing pediatricians;

dispensing doctors were found to prescribe more antibacterials, anti-diarrhoeals, and home made mixtures of unknown composition than ND-pediatricians;

fewer dispensing doctors prescribe ORS compared to non-dispensing pediatricians;

generic prescribing in two studies was found to be lower for dispensing doctors; in spite of financial incentives (fundholding) it did not reach the level of non-dispensing doctors;

in two studies, the average number of visits per patient per year was found to be higher for dispensing doctors' patients, who were also issued 13% more prescriptions.

3. Economics:

annual cost per patient from dispensing doctors practices was, in several studies, found to be higher (10 -13%) than for non-dispensing doctors;

dispensing doctors were found to prescribe lower quantities per encounter;

dispensing doctors may be better informed on drug prices than non-dispensing doctors;

one study found dispensing doctors to have a lower income than non-dispensing doctors and another found dispensing doctors to have a higher income.

On evaluating good pharmacy practices by dispensing doctors and comparing their practices with those of pharmacies, the following conclusions can be drawn, taking into consideration the above mentioned reservations:

4. Interactions and compliance:

no significant differences were found between patients admitted to hospital by dispensing doctors and by pharmacies in regard to adverse events, non-compliance and mis-compliance, evaluating about 4500 admissions.

5. Dispensing and storage based on Ministry of Health inspections in South Africa:

52% of dispensing doctors practices dispensed medicines by inappropriately trained persons;

33% of dispensing doctors practices counted tablets by hand;

61% of dispensing doctors practices had unsuitable containers;

labeling was unsatisfactory in 27% of the dispensing doctors practices;

storage conditions were inappropriate in 46% of the dispensing doctors practices, with unsatisfactory cool storage facilities in 39%, no expiry monitoring system in 30% and medicines not clearly labeled in 20%.

6. Economic factors:

refunds for average prescription costs were found to be higher for dispensing doctors than for pharmacies;

comparisons of drug sales or procurement prices for prepackagers and pharmacies, in most studies, found that dispensing doctors' prices were more expensive for the majority of the drugs evaluated than those sold by pharmacies.

Cytusm said...

Anonymous 5.19AM:

Thanks for sharing your thoughts here. I am interested to look at the study papers. Any links?

I don't know where you quote this studies from, and I wonder if this are local studies.

I come to understand that (in this country), dispensing doctors are private GPs and non-dispensing doctors are the government doctors or consultants in private hospitals.

They all see different type of patients and at different level.

Here are some differences:

Dispensing doctors/GPs:
1. They see lesser volume of patients.
2. They are non-specialists.
3. They don't have procedural skills.
4. They are primary health care providers who see all range of cases from the simplest ones like viral fever to some complicated ones, where often that needed to be referred to specialist center.
5. They are the ones where most patients consult first.
6. They know patients well, some are family doctors.
7. They have control of what drugs to be dispensed to patients.
8. Patients get exactly what is prescribed.

Non-dispensing doctors/Government doctors:
1. They have fixed salary.
2. They see big volume of patients.
3. The specialists have special procedural skills.
4. They see patients with more complicated problems that need more time on diagnosis and investigation, less emphasis on drugs.
5. They don't usually concern with what drugs the patients get.
6. They have no control of what drugs to be given to patients.

Based on many differences between these groups, I wonder if some of the results were valid.

Obviously, there is a big difference between a GP clinic from a Paediatrician clinic that you mentioned.

baref00t said...

The crux of the argument is that the pharmacist's role is primarily to DISPENSE medicine; while one of the doctor's role is to PRESCRIBE medicine.

Hospitals in Malaysia, both government and private sectors, have always been practising such division of roles. After consultation with the doctor, the patient can conveniently obtain his prescription which is dispensed by the resident pharmacy. This system has proved beneficial in terms of patient care, convenience and pharmaco-economics by way of economies of scale. Pharmacists also play an important role in monitoring therapeutic drug levels (eg epilepsy medications, warfarin INR, immunosuppresants etc.)

The problems lie with the general practitioner/specialist clinics and the community pharmacies. Doctors and physicians in this setting traditionally have been SHARING dispensing rights mainly due to the inadequate number of community/retail pharmacists especially in the rural areas. Nevertheless, do not forget that patients have always had the ALTERNATIVE option of obtaining the medication prescribed by the doctor via any community/retail pharmacist.

Pharmacists are now demanding "EXCLUSIVE" rights to dispensing. Why? Primarily for MONETARY gains. Simple as that. There is no need to beat around the bush. Of course, there are the fringe benefits of improving patient compliance to medication, reducing "dispensing errors" and presumed overall cost reduction to the patient due to the economies of scale.... but these are all DEBATABLE.

It's all about the money. Period. It's the pot calling the kettle black.

Doctors may have to take a minor pay cut once this system is implemented; however I'm sure any self-respecting doctor worth his salt will agree to any system which does not compromise patient safety and improves overall patient health care.

But what is right for others may not be ready to be implemented in our country. The main problem in this system is that there is LACK OF REGULATION against renegade pharmacists in Malaysia who abuse the system. No doubt, Pharmacies in the hospital settings are self-regulated well. However, it's common knowledge in Malaysia that some pharmacists especially in the smaller retail practices outside are already "playing pseudo-doctor", encouraged to some extent by the ignorance of some Malaysian public (many of whom are in a perpetual "self-denial" stage and avoid clinic follow-ups like SARS!). Medications are "recommended", or "alternatives" offered in view of their self-proclaimed "extensive pharmaceutical knowledge" without consulting the primary doctor. Other infringements include the practice of indefinitely dispensing scripts which have already expired without informing the doctor concerned. Short term analgesics end up being dispensed continuously; diabetics/hypertensives are suboptimally controlled etc. Someone mentioned Blood sugar strips and BP checkup, the practice of which is already treading the fine line... they can be used to measure compliance in addition to good old pill-counting BUT many pharmacists extend their use to SCREENING patients (by law, screening tests require a doctor's request and interpretation; IMHO why use blood sugar strips/BP measurement in pharmacies when you are not qualified to interpret it anyway?)

As a consequence to the pseudo-quackery and compounded by the patients defaulting follow-ups, some patients end up with life-threatening complications such as DKA, hypoglycemia, GI bleeding, renal failure, Stevens-Johnsons etc for which many of our "pharmaceutical-knowledge deficient" doctors are very familiar with and have to manage and ultimately bear the responsibility.

Pharmacists do not have patients dying in their arms; they do not need to face angry/distraught relatives. Please do not exalt your superior knowledge when any doctor in Malaysia who has had a pharmacy intern tagging with him knows that the CLINICAL drug knowledge of the intern is only equal or worse than a medical intern!

In a nutshell, exclusive dispensing rights to the pharmacists only works in Malaysia if the regulations are up to par and other conditions are ideal. It will happen eventually but when it does, please do not overstep your boundaries. Stick to dispensing, leave the rest to the professionals.

Anonymous said...

Hmm, though it seem that discussion has swayed away to doctors accusing pharmacist with deficient knowledge, malpractice clinically while pharmacist is doing the same. I serious doubt that pharmacist, are in anywhere has insufficient knowledge in interpreting blood glucose or blood pressure. Perhaps its just they are not legally qualified to do so. Now i will try to summarize what both sides primary concern.

Pharmacist is in for separation dispensing and the main concern is definitely role recognition from public and especially from the doctors and of course increase in income. Pharmacist do not want to play second fiddle to the doctors.

Doctors is not into such separation dispensing due to, one striped of power and autonomy in the trade. Second would be a setback in the income. Doctors would want them to be self-sufficient and not go through a certain filter process as this is inconvenient to them as any inappropriateness can be brought to the light to the patient by the pharmacist.

These generally are the whole scenario, though i have encountered both pharmacist who is against separation dispensing and doctors who insist on dispensing separation with various reasons.

Now the situation, pharmacist has gain some trust from the public as they have have fill out what the doctors has missed out. Patient do not get much consultation time with the doctors due to lots of patient or perhaps doctor prefer patient not to be the wiser. While, majortiy of the public still feels that doctor knows the best. The regulation of pharmacist on prescription dispensing is very much unregulated due to regulation authorities does take pity on the pharmacist situation. The current system force pharmacist resort to dispensing without prescription to secure their rice bowl. Pharmacist as well are reluctant to refer to doctors, understandable right?


In developed countries such as UK, pharmacist can prescribe certain group of drugs after taking a duration of course and apply, Similarly, doctors can apply for dispensing depending on the condition such as rurality of the area, but of course medical affairs in those country are very well regulated. These were done to improve efficiency of the health system. My point is that prescribing does not necessary belongs to doctor and dispensing does not necessary belongs pharmacist solely. I strongly feel barefoot's strong prejudice. Historically there are not very well defined areas of pharmacist or physician in dispensing or prescribing. Medical system has evolved into dividing roles in patient healthcare.

Now i would want to address why separation dispensing. In the first place separation dispensing was adopted in other countries is to prevent exploitation of physician to the patient. Luckily, public awareness in malaysia is not too bright either, thus public outcry is low. I will not go on to how or how prevalent exploitation can occur. But, i would say current system promotes quality of prescription to decrease, quantity of prescription increases, inadequate counselling, lack of reinforcement of compliance and patient being taken advantage of.

By far, if separation dispensing were to be implemented, proper regulation of dispensing and prescribing is necessary.

baref00t said...

First and foremost, "Anonymous", let me reiterate that I agree fully on the gradual implementation of pharmacists dispensing medications exclusively, PROVIDED that the required regulatory and enforcement mechanisms are in place. Though I feel as a result, patients will suffer as health care cost will escalate.

However, I disagree with your views regarding "pharmacists having the right to prescribe medications". Just because it is practised elsewhere does not make it right!

Since you seem to have an affliation with the UK, you should know the National Health System (NHS) in the UK has been and is still in financial crisis, with a debt of a billion pounds or so. Health care in UK is not as rosy as Malaysians always assume. In line with cost cutting and after intense lobbying by certain parties, several radical and controversial measures were taken recently. One of which was to delegate prescription of medications and management of stable patients to a new category of "specialist" pharmacists and nurses. Yes, if you are not yet aware, nurses too have been upgraded to "nurse specialist in so-and-so" and "nurse consultants", and have been empowered to treat patients. As you mentioned, they can do so after taking part in a short course eg., diabetic glycemic management, hypertensive control etc.

Again, money makes the rules here.

Economic wise it makes sense to the embattled NHS... after all, this new breed of specialist nurses and pharmacists cost less to train and employ compared to an overpaid overhyped doctor. But is it ethical to the well-being of patients? After all, before you can prescribe, you need to take a full history, perform a comprehensive physical examination and ultimately come to a DIAGNOSIS... and does this fast-track way ensure that you are safe to do that??

I'm not degrading the competencies of nurses and pharmacists in any way, in fact I whole-heartedly respect and appreciate the important roles they play. Team work is essential and there should not be overlap of work/roles to prevent redundancy and complications. BUT, if a pharmacist/nurse still choose to prescribe, the system is open to abuse; IMHO, I strongly feel that he should enroll in medical school and complete his 5 years and housemanship, and get his MD/MBBS first.

To paraphrase an analogy by a Wise Man: If debt-ridden MAS suddenly decides to cut cost by upgrading senior air-stewardesses to "specialist air stewardesses", and empowers them to pilot planes after taking a short course, would YOU fly on such a plane???

Anonymous said...

Your analogy kinda make sense though air stewardest and pilot are very very different job.

Its only a small group of drugs they can prescribe, seriously, its within the competent range, ultimately prescribers are still physician. The diagnosis of hypertension is not something extremely hard to diagnose anyway. By heck, even optometrician can prescribe. Psychologist are fighting for it though. Medical system is evolving. There will be some small overlapping of roles in patient healthcare to promote efficiency. Of course its best not to step on each other area of expertise.

Yes, i definitely agree on the regulation and enforcement mechanism must be there if separation dispensing is to be implemented. That is something to really to be ponder about in Malaysia. One step at a time and someday Malaysia will reach developed status.

Vincent Bong said...

Wouldn't the split of task between doctors and pharmacists be a better way to improve both professionalism since they can concentrate more on their own duties? Besides, ppl, do u think a pharmacist will be tat stupid to dispense medication simply when they don't understand the patient's background?

Sharon said...

I'm a pharmacist currently serving the government. I feel we have done a lot with the dispensing right in the government sector.We've detected many prescription errors, dose of the medicine wrongly prescribed being corrected from paediatrics to geriatrics. In the infectious disease clinic where I'm currently attached in, doctors have given us the task to the counseling of medication which they feel less lot burden so they can concentrate on the diagnosis of patients. If any of you have noticed, many developed countries have been practicing the same thing. Patient goes to doctor, doctor prescribes the medicine & patient gets it from the pharmacy. So what if us the pharmacists make mistake? Don't you doctors so too? I have received many prescription errors which I always have been clarifying with the doctors. Imagine if the doctor prescribe & dispense at the same time. Those errors will be undetectable. Furthermore, with more pharmacists coming in to the compulsory service & more are furthering their studies in specific field, they are equally competent to dispense medication (not diagnosing as we are not trained to do so). We know how medicines work so let us do the job with the dispensing & counseling

Anonymous said...

Woo hoo i am in england yesh~ hahaha

Anonymous said...

hey please be fair.if the dispensing right is not given to the pharmacist will they have enough funding in open more pharmacy for the public?doctor can still survive on the consultation fees but pharmacist provide the services for free?And i have met a few doctors that criticize the pharmacy saying they are not ethical and simply give out false medication.In my opinion,in the future the doctor should only do the dianogsis while prescribing and dispensing should leave to the pharmacist as they know ALL the MECHANISM of drugs works which is not the professional field of doctors..thats all i want to say.

RPh said...

I found a contradicting point, what is your stand when it comes to human life? You mentioned cost effectiveness is not important as long as it save life, in the mean time you are trying to "help" the patient to reduce health care cost by opposing the idea of dispensing separation which is another (last) barrier in protecting patient's life by means of counter-checking of prescription by a pharmacist who study drugs for 4 year.

What say you?

p/s: (1)Dispensing separation does not certainly translate into high health care cost.
(2) In any business, that's including a pharmacy, there is a term called "competition" and "supply and demand". Having dispensing right doesn't mean pharmacist can earn more money
(3) I do agree sometimes a brand and a generic drug does have different effect on patient even though it claims to be bioequivalence etc, and if a doctor insist on giving branded drugs I would accept his/her decision.