...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....
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 no 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.
14 comments:
On lack of 24 hours pharmacies. Well, if there is a demand, there will be a supply like everything else. Trust me on this. Supply and demand is the name of the game in this world.
Dude, this can be made into a paper and be presented to MOH to help it catch up with the better systems in developed countries and come up with one that works in Malaysia.
Agreed with you. Ultimately, the main issue is who got the money? This is a lose-lose situation for the patients. Somebody got to pay either the HMO or the patient.
Great article. Keep on writing!
One more problem which would arise from this situation is the worsening of antimicrobial resistance. Even at present, qualified doctors are prescribing antibiotics for illness not requiring antibiotics, with the typical example of fever and flu. The situation will only get worse if pharmacists are given the sole right to dispense medicine, enabling everybody to grab antibiotics off the shelves for illness which don't require the use of antibiotics, hence worsening the problem of antimicrobial resistance. If nothing is done to the escalating problem of unscrupulous usage of antibiotics, Malaysia will face severe problems with antimicrobial resistance in the future.
It seems not many people understand the legal and professional duties of a pharmacist. Here are a few:
1. A pharmacist job is to spot any mistake on the prescription eg., wrong dosage, wrong combination of drug etc. And to alert the original doctor prescribing about these mistake. It's his professional and legal responsibility to do so. In Western countries, pharmacists are considered the better expert on drug, not the doctor unlike the misguided perception in 3rd world Malaysia. Don't have to take my word for it, go ask any Western doctor and lawyer.
2. A pharmacist CAN NOT just change the drug without consultation with the original doctor prescribing it.
3. For certain medication, eg. Antibiotic, a pharmacist can not give it without a doctor's prescription. That's an offense.
As can be seen, the whole purpose of separation of prescribing and dispensing is the EXTRA safety of patient. POTS do not emphasis on patient's safety but rather on inconveniences and cost and I find that a bit disappointing. AFAIK safety always comes with a price tag. But I suppose life is cheap in Malaysia.
In conclusion. 2 wrong do not make a right. It's wrong for the doctor not to subject their prescription to be scrutinized by pharmacist for any possible deathly mistakes (unless doctors think they can make NO mistake). And it's equally wrong for pharmacist to give certain medications WITHOUT a doctor's prescription (because they are ONLY trained in drug but not diagnosis except for minor ailments) or change a prescription without the agreement of the doctor.
And it's equally wrong for POTS to disallow my earlier post on BOTH the wrong of doctor and pharmacist. Whether this post is being posted will speaks volume about the character of POTS on his ability to take comments that's very different from his. If my earlier post has been disallowed due to technical issue, then I apologize.
Fully agree to what's happening to the health system of malaysia.
I'm a 5th year med student, and I also have first hand experience how atrocious the system can be..
I have patients who brings in questionable medications from their GPs. Eg, a quinolone for a viral URTI (upper respiratory tract infection)? this is getting way out of hand!
I,myself whom my own relatives, who believe 100% to what her pharmacist tells her.. even selling her a whole crateful of 'vitamins' after dx a long list of ailments from just looking at iris (iridology), despite having follow-up at MOPD in a goverment hospital.
When she had her angiogram done. She showed me her radiographs.
She even scoffed at me, (when I honestly told her, that I am not trained enough to give her a proper explaination on angiograms), saying even her phamacists can read the radiographs! (tsk.. coming from the same pharmacist that 'practise' iridology..tsk..)
I am truly impressed with your writings, and please keep up the good work.
By the way, i have seen a pharmacist who takes history and performs physical examination, just like any doctor. She even uses a stets to take bp the classical way!
Kong,
I did not receive any further comments from you in this post apart from the first one.
I will only prohibit comments that will bring harm and potential harm to my loved ones.
As you can see, i even allow comments that harp on my character and motives with no relevance whatsoever to the post title.
I treasure dissenting views as I too am here to learn.
Please re-post your comments earlier. I'd be interested to hear.
Regards.
This hot off the press. If price is of paramount importance instead of service & safety, may be we should let our local supermarket supply medication instead.
"Wal-Mart Stores Inc., the world's largest retailer, announced Monday it would expand its discounted prescription drug program to offer 90-day supplies for $10 and add several women's medications at a discount. It also said it would lower the price of more than 1,000 over-the-counter drugs. The move marks the third phase of a company program that began in 2006 to provide a 30-day supply of generic prescription drugs for $4. The Bentonville-based company said the program has saved customers more than $1 billion."
POTS. When I made the 1st posting, it wasn't being published. Only 2 possibilities, either you disallow or there is some technical problem (either I press but not delivered or like one of those mystery emails that takes days to reach recipient). But having read a lot of your posting and you a Christian, I suspect the latter and hence add a clarifier to my post. And it is so I apologize.
Thank you.
Doctors please visit YB Lim Kit Siang's blog n look for the same post. Many don't understand the separation in countries like UK and USA. They just know a pharmacist dispenses drug and that is all. What about the background of the entire system? Some don't even know that pharmacist cannot and should not dispense without prescription,they argued let the patients choose! Further, they don't know that NHS was designed in a way to allow the separation for e.g.doctors don't collect fees fr patients but they r paid according to number of patients assigned under them. An analogy wld be,u can't just grab any graphics card off the shelf n install it just because u think it's good because ur entire pc system may not support it, u must change other parts or find a graphics card which ur pc system wld support.
We aspire so much to follow the 1st world countries in separation of work portfolio between doctors and pharmacists, in other words doing only what we are trained to do (doctors prescribe and pharmacists dispense) - which is precisely the situation in all government facilities. But, to try to impose this on the private practitioners is quite unfair unless the MOH also introduce the compulsory healthcare insurance system (ie. Medicare, etc.) and appointment system based on locality, extant in the 1st world countries. This is to safeguard the interests of the doctors, because it is at their expense that the pharmacists prosper.
At best, if we want to emulate a system, let's emulate everything and not just half-heartedly. At worst, if we can't do that, maybe we should just elect a more far-sighted Health Minister.
We have been arguing on who should dispense, apparently whoever gets to dispense will be able to make money until we forgot about the big problem of our health system.
The health system look really good but I just wonder how long the govt can afford to subsidise health cost. At the moment, we pay RM2,bring back big bulk of medicine.
I think the govt must plan to switch to health insurance,compulsory health insurance for everyone. Of course retirees and children exempted. Working folks need to pay a monthly fee for health insurance, then this will solve a lot of problems.
It is true that Malaysian are used to the one stop practise. If there is no price control, the public will never agree to separation of prescribing and dispensing.
Therefore, I suggest MOH must start the health insurance scheme because it can solve a lot of problems including separation of prescribing and dispensing.
Hate to niggle, but rheumatoid arthritis cannot be serologically "proven". And a short coure of steroids is unlikely to cause severe edema. She probably had diabetic nephropathy.
Most GPs have dismal knowledge and there is very little impetus to pursue retraining. Instead of griping about dispensing rights, they should concentrate on updating their knowledge. Pharmacists are essential to good clinical services. That they are poorly distributed and practicing to shoddy standards today only speak of shortsighted MOH policy (poor planning, poor enforcement) and do not in any way detract from that truth. As one of your commenters quite elegantly put it, two wrongs do not make a right.
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