Wednesday, December 17, 2014

Doctors Prescribe, Pharmacists Dispense, Patients Suffer .... by Product Of The System

Doctors Prescribe, Pharmacists Dispense, Patients Suffer


Real Life Scenario
Madam Ong is a 52-year-old lady with a twelve-year-history of hypertension and diabetes. She complained of generalised lethargy, lower limb weakness, swelling and pain. She brought along her cocktail of medications for my scrutiny. Her regular medications included the oral antidiabetics metformin and glicazide and the antihypertensives amlodipine and irbesatan. Madam Ong also had a few episodes of joint pains three months ago for which she had seen two other different doctors. The first doctor suspected rheumatoid arthritis and started her on a short course of the potent steroid prednisolone. Thereafter, she developed increasing lower limb swelling for which a third doctor prescribed the powerful diuretic frusemide. 
Madam Ong was not on regular follow-up for hypertension and diabetes. Additionally, she has been re-filling her supply of steroids and diuretics at a pharmacy nearby with the purpose of saving up on the consultation charges. 


I took a more complete medical history and performed a thorough physical examination. I concluded that this lady’s health was in a complete mess. 
She was under sound management by the family physician until the day she defaulted follow up and was started on prednisolone by a doctor who was unaware she was diabetic. The steroid probably helped in relieving her arthritic pains though the suspicion of rheumatoid arthritis was never proven serologically.
However, it also worsened her sugar and blood pressure control and weakened her immune system. 
Her legs swelled up because of the fluid retentive properties of the steroids. In addition, early signs of cellulitis were showing up around her legs due to a weakened immune function. The diuretic prescribed by the third doctor helped a little with the swollen limbs but she became weak from the side effects of diuretics. 
Madam Ong’s problems escalated when she decided to forgo her doctors’ opinion altogether and decided to self-medicate simply by collecting all her medications from the pharmacist who supplied them indiscriminately. Unknowingly, the pharmacist had added to the lady’s problems in spite of the wealth of knowledge the pharmacist must have possessed. 
The above scenario is a fairly common scene in the Malaysian healthcare. We see here an anthology of errors initiated by doctors, propagated by the patient’s health seeking behavior and perpetuated by a pharmacist.
Noteworthy but Untimely Move 
The Ministry of Health is set to draw a dividing line between the physician’s role and the pharmacist’s, restricting physicians to prescribing and according dispensing rights solely to the pharmacists. 
Such a move virtually has its effects only upon doctors in the private practice and particularly the general practitioner who relies on prescription sales for much of one’s revenue. 
Doctors prescribe and pharmacists dispense. It’s the international role of each profession and very much the standard practice in most developed countries. 
The Ministry of Health however, has failed to take into account the local circumstances in mooting this inaugural move in Malaysian healthcare. The logic and motive behind the Ministry of Health’s proposal is in fact laudable, but only if the Malaysian healthcare scenario is more organized and well-planned.
Spiraling Healthcare Costs
In the United Kingdom, all costs are borne by the National Healthcare Services. In the United States, despite all the negativity painted by Michael Moore’s Sicko, most fees are paid for by health insurance without which one cannot seek treatment. In these countries and many European nations, there is hardly any out-of-pocket monetary exchange between patients and their clinicians. 
This however is not the case for Malaysia. Most patients who visit a private clinic are self-paying clients. The costs of consultation and medications are real and immediately tangible to patients. A visit to the general clinic for a simple upper respiratory tract infection may set one back by as much as RM 50.00 inclusive of consultation and medication. Most clinics these days are charging reasonable sums between RM 5 to RM 15 for consultation. Some are even omitting consultation charges altogether in view of the rising costs of basic healthcare. The introduction of the MOH’s ‘original seal’ to prevent forgery of drugs contributed much to this.
There is no denial that most clinics rely on the sales of medications in order to remain financially viable. From my personal experience, the charges for medications by private clinics are not necessarily higher than pharmacies. In fact, since each practitioner has a stockpile of one’s own preferred drugs, the cost price of the medications can be much lower than that obtained by the pharmacists who need to stockpile a wide variety of drugs. It is therefore a misconception that pharmacies will provide medications to patients at a much lower cost all the time for all medications.
Retracting dispensing privileges from the private clinics will only force practitioners to charge higher consultation fees in order to sustain viability of their practices. In the end, the patients end up paying a greater cost for the same quality of healthcare and medications. Inevitably, much of the increase in healthcare costs will also be passed on panel companies who will then be paying two professionals for the healthcare of their employees. 
In this season of spiraling inflation, this proposal by the Ministry of Health is ill-time and poorly conceived. 
Unequal Distribution of Medical and Pharmacy Services
As it already is, private general practice clinics are mushrooming at an uncontrolled rate. A block of shoplots in Kuala Lumpur may house up to five clinics. Does Malaysia have a corresponding number of pharmacists to match the proliferating medical clinics? If and when clinics are disallowed to dispense medications, the market scenario will become one that heavily favors pharmacists. The struggling family physician suddenly loses a significant portion of his revenue while the pharmacist receives a durian runtuh overnight. 
The situation is worst in the less affluent areas and rural districts where the humble family physician may be the solitary doctor within a 50km radius and no pharmacy outlets at all. For example, there are no pharmacies in Kota Marudu, Sabah and only one in the town of Kudat. Patients seeking treatment in these places will get a consultation but have no avenue to collect their prescription if doctors lose their dispensing privileges. 
The absence and dearth of 24-hour pharmacies is also a pertinent issue. At present, many clinics operate around the clock to provide immediate treatment for patients with minor systemic upset. These clinics play an important role in reducing the crowd size and the long waiting hours at the emergency departments of general hospitals. 
Without a corresponding number of 24-hour pharmacies to dispense urgent medications, the role of 24-hour clinics will be obtunded. The MOH’s plans of implementing its doctors-prescribe-pharmacists-dispense policy will merely backfire and result in the denial of services to patients. 
A Bigger Problem Is The System Itself
The increasing number of medical centers around the country is not necessarily in the patients’ best interests or an indicator of improved healthcare provision. Most clinics and medical centers serve an overlapping population of patients. A person may be under a few different clinics simultaneously for his chronic multiple medical problems, resulting in a scattered, interrupted medical record. One doctor may not be informed of the interventions and medications undertaken by the patient at another practice. The concept of continuous care and a long term doctor-patient relationship is practically improbable. 
This is unlike the system in the United Kingdom where each family physician is allotted a certain cohort of patients for long term care. The doctor remains in full knowledge over his patients’ progress, making general practice one that is rewarding and meaningful. 
The trouble-ridden Malaysian healthcare system prevents optimal clinical practice especially for doctors in the private sector. 
Until the Ministry of Heath puts in place a more systematic and organized approach to healthcare, patients will still be denied optimal medical services despite a clear division between the roles of doctors and pharmacists. The process of prescribing and dispensing is but one step in the cascade of events that may result in harm being done to the patient. Role separation between the doctor and the pharmacist will not eliminate drug-related malpractice and negligence, as I have illustrated in the real clinical scenario above. 
Loss of Clinical Autonomy
Private practitioners in Malaysia are at present enjoying a reasonable sense of autonomy over the health of their patients. In many ways, the freedom of clinicians to make decisions with adequate knowledge of the patient’s needs and circumstances is a plus point in clinical practice. 
Involving the pharmacists in the daily management of every patient removes a great part of the doctor’s control over the clinical circumstances of the patient. He may prescribe one drug only to be overruled by the dispensing pharmacist later. The clinician has privy to much information about the patient’s circumstances that are available only in the patient’s medical records. It is based on this information that a clinician makes decisions on the final choices of medications for the patient. 
A dispensing pharmacist does not have access to such priceless clinical history and may very well make ill-informed decisions in the patient’s medications. Once again, my introductory scenario demonstrates how pharmacists can help perpetuate a patient’s mismanagement. 
Selective Implementation of Rules
Rules in any game should be fair and just and implemented on both parties. If doctors are to be prohibited from dispensing, shouldn’t pharmacists too be forbidden from diagnosing, examining, investigating and prescribing? 
Yet this is exactly what takes place everyday in a typical pharmacy. 
I have seen with my own eyes (not that I can see with someone else’s eyes anyway) pharmacists giving a medical consultation, performing a physical examination and thereafter recommending medications to walk-in customers. It is also not uncommon to find pharmacies collaborating with biochemical laboratories to conduct blood tests especially those in the form of seemingly value-for money ‘packages’. These would usually include a barrage of unnecessary tests comprising tumor markers, rheumatoid factor and thyroid function tests for an otherwise well and asymptomatic patient. 
Pharmacists intrude into the physicians’ territory when they begin to do all this and more. 
Doctors may occasionally make mistakes due to their supposedly inferior knowledge of drugs despite the fact that they are trained in clinical pharmacology. 
In the same vein, pharmacists may have studied the basic features of disease entities and clinical biochemistry but they are nonetheless not of sufficient competency to diagnose, examine, investigate and treat patients. Pharmacists are not adequately trained to take a complete and thorough medical history or to recognize the subtle clinical signs so imperative in the art of differential diagnosis. 
In more ways than one and increasingly so, pharmacists are overtaking the role of a clinical doctor. Patients have reported buying antibiotics and prescription drugs over the pharmacy counter without prior consultation with a physician. 
If the MOH is sincere to reduce adverse pharmacological reactions due to supposedly inept medical doctors, then it should also clamp down on pharmacists playing doctor everyday in their pharmaceutical premises. Patients will receive better healthcare services only when each team member abides by and operate within their jurisdiction. 
The move to restrict doctors to prescribing only while conveniently ignoring the shortcomings and excesses among the pharmacy profession is biased and favors the pharmacists’ interests. 
The Root Problem is Quality
A significant issue in Malaysian healthcare is that of the quality of our medical personnel. This includes doctors, dentists, nurses and pharmacists, therapists, amongst others. A substantial number of our doctors are locally trained and educated. If current trends are extrapolated to the future, the number of local medical graduates is bound to rise exponentially alongside the unrestrained establishment of new medical schools.
The quality and competency of current and future medical graduates produced locally is an imperative point to consider. Competent doctors with a sound knowledge of pharmacology will go a long way in improving patient care and minimizing incidence of adverse drug reactions. The very fact that the MOH resorts to the drastic step in prohibiting doctors from dispensing medications indicates that it must be aware of the high prevalence of drug-related clinical errors. 
Much of patient safety revolves around the competency of Malaysian doctors in making the right diagnosis and prescribing the right medications. Retracting dispensing rights from clinicians therefore, will not solve the underlying problem. Our doctors might still be issuing the right medications but for the wrong diagnosis. In the end, a dispensing pharmacists will still end up supplying the patient with a medication of the right dosage, right frequency but for the wrong indication. 
Patient safety therefore begins with the production of competent medical graduates. The problem lies in the fact the same universities producing medical doctors are usually the same institutions producing pharmacists. It is really not surprising, since the basic sciences of both disciplines are quite similar. Therefore, if the doctors produced by our local institutions are apparently not up to par, can we expect the pharmacy graduates who learnt under the same teachers to be much better in their own right?
Among other remedial measures, my personal opinion is that the medical syllabus of our local universities is in desperate need for a radical review. There is a pressing need for a greater emphasis on basic and clinical pharmacology. At the same time, the excessive weightage accorded to paraclinical subjects like public health and behavioral medicine need to be trimmed down to its rightful size. Lastly, genuine meritocracy in terms of student intake, as opposed to ‘meritocracy in the Malaysian mould’, will drastically improve the final products of our local institutions. 
The MOH’s Own Backyard Needs Cleaning
Healthcare provision in Malaysia has undergone radical waves of change during the Chua Soi Lek era. The most sweeping changes seem to affect the private sector much more than anything else. The Private Healthcare Facilities and Services Act typifies MOH’s obsession with regulating private medical practice as though all doctors are under MOH’s ownership and leash. 
An analyst new to Malaysian healthcare might be forgiven for having the impression that the Malaysian Ministry of Health is currently on a witch hunt in order to make private practice unappealing and unfeasible in order to reduce the number of government doctors resigning from the civil service. 
Regardless of MOH’s genuine motives, it must be borne in mind that private healthcare facilities only serve an estimated twenty percent of the total patient load in the whole country. The major provider of affordable healthcare is still the Ministry of Health and probably always will be. Targeting private healthcare providers therefore, will only create changes to a small portion of the population. Overhauling the public healthcare services conversely, will improve the lot of the remaining eighty percent of the population. 
At present, the healthcare services provided by the Malaysian Ministry of Health is admittedly among the most accessible in the world. The quality of MOH’s services however, leaves much to be desired. Instead of conceiving ways and means to make the private sector increasingly unappealing to the frustrated government doctor, the MOH needs to plug the brain drain by making the ministry a more rewarding organization to work in. 
The MOH needs to clean up its own messy backyard before encroaching into the private practitioners’. 
An indepth analysis of MOH’s deficiencies I’m afraid, is not possible in this article. 
MOH’s “To Do List”
The prescribing-dispensing issue should hardly be MOH’s priorities at the moment. 
I can effortlessly think of a list of issues for the MOH to tackle apart from retracting the right of clinicians to dispense drugs.
Private laboratories are conducting endless unnecessary tests upon patients and usually at high financial cost despite their so-called attractive packages. In the process, patients are parting with their hard-earned money for investigations that bring little benefit to their overall well being. Mildly ‘abnormal’ results with little clinical significance result in undue anxiety to patients. More often than not, such tests will result in further unnecessary investigations. The MOH needs to regulate the activities of these increasingly brazen and devious laboratories. 
Medical assistants trained and produced by the MOH’s own grounds are running loose and roaming into territories that are far beyond their expertise. It is not uncommon to find patients who were on long term follow up under a medical assistant for supposedly minor ailments like refractory gastritis and chronic sorethroat. A few patients with such symptoms turned up having advanced cancer of the stomach and esophagus instead. The medical assistants who for years were treating them with antacids and multiple courses of antibiotics failed to notice the warning signs and red flags of an occult malignancy. They were not trained in the art of diagnosis and clinical examination but were performing the tasks and duties of a doctor. There is no doubt that the role of the medical assistant is indispensable in the MOH. Just as a surgeon would not interfere with the role of an oncologist, medical assistants too must be aware of the limits of their expertise. MOH will do well to remember the case of the medical assistant caught running a full-fledge surgical clinic in Shah Alam in late 2006. 
Adulterated drugs with genuine risks of lethal effects are paddled openly in road side stalls and night markets. They are extremely popular among folks from all strata of society who rarely admit to the use of such toxins to their physicians. It is possible and highly probable that many unexplained deaths taking place each day are in some way related to the rampant use of such preparations.
Non-medical personnel are performing risky and potentially lethal procedures daily without the fear of being nabbed by the authorities. These are mostly aesthetic procedures. Mole removals, botulinum toxin injections and even blepharoplasty are carried out brazenly by unskilled personnel and usually in the least sterile conditions. It makes a mockery of the plastic surgeon’s years of training but above all, proves that the MOH is indeed barking up the wrong tree in its obsession to retract the dispensing privileges of medical practitioners. 
Closing Points 
In summary, a patient’s health is affected by many factors – a doctor’s aptitude is merely one step in a torrent of events. The health seeking behaviors of patients play an imperative role in the final outcome of one’s own health. Most harm to patients can only occur as a result of unidentified minor errors in the management flowchart of a patient. If allowed to accumulate, such errors converge as a snowball that threatens the long term outcome of an ill person. 
There are a multitude of other clinical errors apart from prescribing and dispensing, some of which are not at all committed by trained medical staff. The MOH must get its priorities right by first overhauling an increasingly overloaded public healthcare service. 
Lastly, the difference between a drug and a poison is the dose. A toxin used in the right amount for the right condition is an elixir. A medication used in the wrong dosage and for the wrong indication is lethal poison.

8 comments:

Kick Ass Mama Wannabe said...

Hmmmm so did you get permission to use this picture of the pharmacist that you posted up? I am sure that is a privacy violation. I am sure you know that already.

Btw, the lady decided on her own to self medicate and ignored follow ups with her doctor and his opinions, so how is this the fault of the doctor or pharmacist?

Beast K6 said...

Dr Quek, you published a photo of me in your blog post. This was done without my permission, and aggravating the situation, the positioning would misleadingly imply to readers that I was the pharmacist in your anecdote about Mrs Ong. Kindly remove or replace the offending photo. Thank you.

Dmoonz said...

Dr Quek, you seem to have a very lop-sided view on several issues. You brought up the issue of laboratories collaborating with pharmacies and hence ‘intruding’ into the physician’s territory. We must acknowledge the fact that screening, is of utmost importance in primary prevention and public healthcare, especially in diseases such as diabetes and hypertension. In all healthcare systems, physicians should not look at themselves as the sole provider, but merely part of a multi-disciplinary team. Therefore, we must commend the community pharmacies and laboratories for complementing the GPs, and in bringing health awareness to the public. In your MOH’s “To Do List”, you went out to hit at private laboratories again, saying they are unscrupulous and conducting unnecessary tests. I must remind you that under the Pathology Act 2007, all licensees of laboratories must include a registered medical practitioner. If that is the case, can we also blame medical doctors for being in cohort, for these ‘unscrupulous’ deals? How about private medical centres? We do know for a fact that some of the screenings done in private hospitals are business-dominated.
I wish to rebut your point on unequal distribution of medical and pharmacy services – This is always a ‘chicken or egg first’ situation. A study was conducted by USM on distribution of community pharmacies in the state of Penang, and it was found that the public can find a community pharmacy within every 1km radius of the island. Using Kota Marudu as an example is totally biased, as market forces previously did not make it feasible for a private community to thrive there. Can you also comment; what is the percentage of public seeking private healthcare in Kota Marudu? If there is a demand, community pharmacies, even 24-hour pharmacy services will sprout in that area (some public hospitals in Malaysia already have 24-hour pharmacy counters). Let us not be left behind, just because certain communities are catching up at a slower pace. An analogy will be the teaching of science in English in Malaysia. Just because our rural students cannot catch up, the system was scrapped, severely affecting urban students.
The WHO and the International Pharmaceutical Federation (FIP) have long recognized the importance of dispensing separation. Putting aside advanced countries like Australia and UK (since you mentioned NHS in your article), countries like Indonesia, India, Taiwan, and South-Korea have successfully adopted this practice. I don’t see why we should not explore this with an open mind.

Pharmacist Anonymous said...

Thank you for being so truthful doc.

1. Most clinics these days are charging reasonable sums between RM 5 to RM 15 for consultation. Some are even omitting consultation charges altogether in view of the rising costs of basic healthcare.

Being part of the professional team, I believe u understand the term Evidence Based Medication (well u are trained in Clinical Pharmacology aren't u?) well. So pls substantiate these claims.


2. In fact, since each practitioner has a stockpile of one’s own PREFERRED drugs, the cost price of the medications can be much lower than that obtained by the pharmacists who need to stockpile a wide variety of drugs. It is therefore a misconception that pharmacies will provide medications to patients at a much lower cost all the time for all medications.


Now its all about MONEY sense here isn't it?
What about the BEST choice or most SUITABLE drug for the patient? Instead of PREFERRED or best MONEY sense? Pharmacist stock a wide variety because we know NO ONE DRUG is suitable for all.
And you wonder why Doc gets cheaper rate from drug manufacturer? There's nasty term we all hate to hear: Drug pusher?


3. There is no denial that most clinics rely on the sales of medications in order to remain FINANCIALLY VIABLE .Retracting dispensing privileges from the private clinics will only force practitioners to charge higher consultation fees in order to sustain VIABILITY of their practices.

VIABILITY is not equivalent to a life of luxury I believe. FINANCIALLY VIABLE AND FINANCIALLY COMFORTABLE is not quite the same as well.
Cost to cost, both professional pays rental (or a doc can OWN a shop easily), pays for staves. Most pharmacies are air-conditioned, 12hrs a day, with stocks expiring and non returnable, do not charge for minor 'consultation' or 'test', do not have panel backing. In short, a much higher operational cost and lower profit (its a business after all). I wonder if such term as VIABILITY can be used so loosely?


4. The absence and dearth of 24-hour pharmacies is also a pertinent issue. At present, many clinics operate around the clock to provide immediate treatment for patients with minor systemic upset.

That's very thoughtful of you. BUT
How many 24 hrs clinics are there actually? Are they being utilised? Are they manned by doctors all the time? Are they charging a normal rate to HELP patient, possibly RM10-rm15 consultation?

How bout none 24hrs regular clinics who rest from 12-2pm and 4-6pm and such? Where will those patients go during those period then my dear thoughtful doctor?


5. Doctors prescribe and pharmacists dispense. It’s the international role of each profession and very much the standard practice in most developed countries.

The Ministry of Health however, has failed to take into account the local circumstances in mooting this inaugural move in Malaysian healthcare.


Arent we aiming to be a developed nation by 2020? Wawasan 2020? Its one small step forward but there's so much stifling resistance sensed from your words. Give Malaysia a chance to be a developed nation!

Pharmacist Anonymous said...

6. This is unlike the system in the United Kingdom where each family physician is allotted a certain cohort of patients for long term care.

You actually know why BECAUSE :The Ministry of Health has taken into account the local circumstances in not mooting this suggestion of yours in Malaysian healthcare.

That's a load of hypocrisy isn't it? On one hand (point no.5 above) you are saying MOH doesn't take local circumstances in consideration and on the other u are looking up to these systems already in place in developed nation.


7. In many ways, the freedom of clinicians to make decisions with adequate knowledge of the patient’s needs and circumstances is a plus point in clinical practice.

Dear doc, that's great plus points indeed! But having a few line scribbled on a card/note is not ADEQUATE knowledge of the patient's need. Do u know why patient come to pharmacists? Its not that we are FREE. We are not FREE ( in temporal sense) we are FREE ( in monetary sense). Patient don't get to spend the time they need with you doc! We look at all their medication (not purchased from us and no financial interest). You probably look at Mrs Ong medication, like 3 of them? We are visited by many Mrs Ong in a day with bags of medicines. How many Mrs Ong did u spend time with in a day my dear doctor?

8. Rules in any game should be fair and just and implemented on both parties. If doctors are to be prohibited from dispensing, shouldn’t pharmacists too be forbidden from diagnosing, examining, investigating and prescribing?

Dear doctor, while reading your blogs. I am sighing and shaking my head all the way down. The ministry wants the best for the best patients. We, the pharmacist also wants the best for the patients. I assumed, as a doctor, although not representative of others, you want the best for the patients too! Why then do u ask a pharmacist not to help in patient care just because something, something not yours to begin with, was taken away from you? Must the patient suffers because your financial stats show some decline?

9. It is also not uncommon to find pharmacies collaborating with biochemical laboratories to conduct blood tests especially those in the form of seemingly value-for money ‘packages’. These would usually include a barrage of unnecessary tests comprising tumor markers, rheumatoid factor and thyroid function tests for an otherwise well and asymptomatic patient.

Isn't there a doctor behind those lab? Isn't private doctor also order those tests and send them to the very same lab, outsource in short? So why does the same lab doing same tests in a private clinic is not a barrage of unnecessary tests but it is when its done in a pharmacy who didn't charge the customer because its a B2C model bypassing a business middleman (its you I assumed).

10. Pharmacists intrude into the physicians’ territory when they begin to do all this and more.

Can we say physicians intrude into territory when physician begins to dispense medicine?

Pharmacist Anonymous said...

11. Doctors may occasionally make MISTAKES due to their supposedly inferior knowledge of drugs despite the fact that they are trained in clinical pharmacology.

Oh please! You started this blog by taking a swipe at an assumed real scenario. I am not going to dig up the numerous 'ocassional' mistake. Its not a place to throw dirt at each other. MISTAKE is not something we should take lightly in our field. MISTAKE may means life, whether its occasional or not. Which is why doctor and pharmacist need to work together to minimise if not eliminate MISTAKE!

You use the term inferior? I will not. But if I can confidently help with minor ailment and REFER them when necessary. Why can't you prescribe confidently and CONSULT when necessary? We are professional in our league and field and we should well acknowledge there.


12. In more ways than one and increasingly so, pharmacists are overtaking the role of a clinical doctor. Patients have reported buying antibiotics and prescription drugs over the pharmacy counter without prior consultation with a physician.

Where are your confidence my dear doctor? We are not taking over and we will not take over because we know, we are PHARMACISTs and we are proud to be just PHARMACISTs. And are you sure they are just buying from pharmacy counter? How bout buying from private clinic REGISTRATION COUNTER?


13. Competent doctors with a sound knowledge of pharmacology will go a long way in improving patient care and minimizing incidence of adverse drug reactions.

Dear doctor you are defying competent doctors as someone with sound knowledge of pharmacology? How bout surgical skills? Differential diagnosis? Do I hear some identity crisis? BUT you do realise we need to minimise incidence of adverse drug reactions, leave that to the professional, your partners in patient care, us, the PHARMACISTS.


14. The very fact that the MOH resorts to the drastic step in prohibiting doctors from dispensing medications indicates that it must be aware of the high prevalence of drug-related clinical errors.

Kudos! U got some facts right! Drastic? Yea it is! Not financially drastic in our eyes or patients' eyes or Ministry's eyes ( u seem obsessed with whose eyes actually see). Drastic measure to avert those clinical erros ASAP!


15. Our doctors might still be issuing the right medications but for the wrong diagnosis. In the end, a dispensing pharmacists will still end up supplying the patient with a medication of the right dosage, right frequency but for the wrong indication.

BRAVO!! U got it right again this time! BUT u really need to start knowing your pharmacist well. In fact, the ministry organise quite some Know your medicine and Know your pharmacist campaign. I strongly suggest you join them. We do not end up dispensing like u said. The pharmacist will call you up, WILL NOT OVERRULE you but saving grace, quietly call away from the patient, advise you, discuss with you, and ULTIMATELY wait for you go to CHANGE to the RIGHT one. That's if you pick up your friendly neighbourhood pharmacist's call at all.

Pharmacist Anonymous said...

16. Therefore, if the doctors produced by our local institutions are apparently not up to par, can we expect the pharmacy graduates who learnt under the same teachers to be much better in their own right?

Where are you getting or what are trying to imply here my dear doctor? Are you getting tired after writing such a long blog focusing seemingly on many thing but actually one thing which is worrying about the financial change of some doc ? if what u said above is true. Its a nightmare for all Malaysian, dispensing separation or not, so what's the point here doc?

17. There is a pressing need for a greater emphasis on basic and clinical pharmacology. At the same time, the excessive weightage accorded to paraclinical subjects like public health and behavioral medicine need to be trimmed down to its rightful size.

Err.. are you envious of Pharmacist profession? U seem to be suggesting the Ministry to train a doc more like a pharmacist than a doc? Identity crisis again? You are sounding desperate or trying to intrude into pharmacist territory?


18. It must be borne in mind that private healthcare facilities only serve an estimated TWENTY PERCENT of the total patient load in the whole country. The major provider of affordable healthcare is still the Ministry of Health and probably always will be. Targeting private healthcare providers therefore, will only create changes to a SMALL PORTION of the population.

Small portion u said? So what's the big fuss and big hooha about?
20% u said? How many out of that 20% is 24hrs btw?
Pharmacists serve both private and public healthcare patients because there's no conflict in all sort of interest in both population to private pharmacist.

19. The prescribing-dispensing issue should hardly be MOH’s priorities at the moment. Adulterated drugs with genuine risks of lethal effects are paddled openly in road side stalls and night markets.

I can't comment fully on your todo list since I do not intrude into others territory. But dispensing separation for PUBLIC INTEREST is a pressing and urgent issue!

As for adulterated drugs.. my dear doctor. Do you know there's a group of hardworking pharmacist who give up practicing and goes around under hot sun to tackle those and occasionally threatened by these illegal paddlers? There are called Enforcement Pharmacist, DEA in short! MOH is already doing that! They even visit you annually and offer you assistance but much to your resistance and denial mostly. I can personally attest to that because I witnessed with my OWN EYES. I strongly suggest you get to know your MOH and your pharmacist before you post further comment that's ridiculing yourself.


Pharmacist Anonymous said...

20. Lastly, the difference between a drug and a poison is the dose. A toxin used in the right amount for the right condition is an elixir. A medication used in the wrong dosage and for the wrong indication is lethal poison.

Dear doc, even in your conclusion. You sounded like a pharmacist more than a doc. Shall I be happy that someone whom i have high regard in his own field actually tries to be ME?

My conclusion. This whole article sounded extremely biased with unsubstantiated claimed, twisted opinion and focusing only a financial interest instead of general public interest. In fact, it has the desperate tone of a sulky kid whose lollipop was taken away so others can share on it.

My real conclusion. We do not take any Hipo Oath. BUT We have the patients' interest in heart. Most of us work 12 hrs a day. I am extremely tired at this hours 1.30am but what's wrong should be right. We are running business and we hope for good returns but our priority is our patients. We are for dispensing separation not for more business. We are for better healthcare.

One small step from MOH, one giant leap for public healthcare.

Dear doctor, I am sorry if I ridiculed you in anyway. I try not to. In each profession, there are bad eggs, there are bad docs, there are bad pharmies as well.

My wish, let's work together for the best of the patient, shall we? I am ready!