Playing doctor

Pharmacists may be switching your medications?

When you hand a pharmacist a prescription, you expect to get the medication your doctor ordered. But because of a perfectly legal loophole in rules that govern how drugs are dispensed, you may not — and the consequences can be dire.

Via MMR.

It sounds the same, looks the same and may function the same, but may not neccesary be the same.

One good reason why doctors should be allowed to dispense their own drugs.

Rules are man-made, and it is made by people with peanut brains.

Whose ignorance?

No room for ignorance in hospital wards? (The Star, 19th Dec 2008)

I AM a senior doctor who works in a government hospital with house officers. Having read letters and comments by these house officers and their parents regarding the harassment by their senior colleagues, let me share some of my experiences.

> A middle-aged man, admitted to ward for severe diarrhoea, died due to hypovolemic shock (life-threatening fluid loss). The reason: The house officer on call did not check the patient’s vital signs documented in the record chart.

> A house officer during his morning rounds continued serving potassium supplement even though the patient has hyperkalemia. The reason: He did not review the patient’s drug chart during rounds. He did not trace results of blood tests taken two days ago.

> A young man was transferred from a district hospital for chest pain. The doctor who first saw him had missed the ECG findings of acute myocardial infarction (severe heart attack).

As a result, the man received delayed treatment, and ended up with heart failure. The doctor was a house officer from my hospital, sent out to the district hospital after having completed two years of house officer training.

> A man who collapsed in the ward at 7am was left unattended. The house officer who was on call the night before had left the ward to take a bath, even though he had been informed that the patient was unstable. The patient died due to a delay in administration of CPR.

These are some of the scenarios where the house officers got a shelling from me, not only because of their severe deficiency in knowledge, but due to their attitude and half-hearted manner when dealing with patients.

Then there are house officers who habitually come late to work, even later than their senior colleagues. And there are house officers who don’t take blood investigations on time for patients with dengue fever and never bother to trace the results on time, putting patients at risk.

There are also house officers who smoke in the doctor’s room and house officers who go out drinking late into the night, and are unable to come in to work the next morning due to a severe hangover.

These are the house officers that I have scolded. They grew up, finished their two years’ training and became my colleagues.

Some of them became my good friends, and appreciated what I had taught them. Yet, some will not even look at me when me meet and keep on making silly mistakes when treating patients.

I do not scold house officers for no reason. I don’t get paid for that. I don’t expect them to be superb in knowledge, but the basic knowledge that was acquired from medical schools must be there when they start working.

How do you call yourself a doctor when you do not even know how to perform CPR? Most importantly, one must work with a conscience. Yes, they are allowed to make mistakes, but never at the expense of the patient’s life due to their lousy attitude or severe deficiency in knowledge.

To the parents of these young doctors, have you heard the other side of the story before defending your children? Did they tell you why they got scolded at work?

And if you find out that your child caused a patient’s death, simply due to his poor knowledge and lousy working attitude, will you be able to sleep well at night?

To the house officers who complain a lot, if you can’t even handle negative comments from your senior colleagues, how can you survive when you face demanding patients and family members?

It’s disheartening to see that the public is trying to sensationalise this issue without hearing the other side of the story.

As for myself, I will still scold them if I need to. Of course, I will praise my house officers if they have done well. I don’t mind being unpopular, because it’s not a popularity contest, and my conscience is clear.

A DOCTOR,

Seremban.

Is it the MO or the HO's ignorance?

This senior MO is very misguided.

It's never be the HO's sole responsibility to the patient's management care. In fact, the MO holds the entire responsibility.

First of all, the HOs are not even registered. For me, they are merely 'clerk', for that, they are usually the first ones to 'clerk' the case in the ward. Exception are when the patient is referred from A&E, where the MOs are supposed to attend to them immediately in the A&E.

In fact, all new cases admitted to the ward should be informed to and reviewed by the MO in-charge. All the problem cases should also be reviewed regularly by the MO.

Putting the entire blame on the HO is outrageous.

The HOs are under training and they are just there to learn and assist the MOs.

The MOs (or even the specialists) are the ones that should shoulder all responsibilities in any adverse events occured in the patients under their care.

It is their negligent for failure to review the patients themself.

Announcement

"ALLOPURINOL IS NOT INDICATED FOR THE TREATMENT OF ASYMPTOMATIC HYPERURICAEMIA."

Malaysia Adverse Drug Reactions Advisory Committee (MADRAC) has received reports of adverse reactions related to the use of Allopurinol.

Allopurinol: Information for Prescribers.

Allopurinol is one of the most effective medications to treat gout and has been widely used by most patients with gout. However, there are precautions that need to be taken, especially in patients who may develop serious side effects.

The Malaysian Adverse Drug Reactions Advisory Comittee (MADRAC) has received 280 reports of adverse reactions related to the use of allopurinol since the year 2000. Twelve of the reports involved fatality. Among the adverse reactions reported, 80% were skin reactions, including mild reactions such as rash and itchiness as well as severe life threatening reactions such as Steven Johnson Syndrome and Toxic Epidermal Necrolysis.

Allopurinol works by preventing the formation of uric acid (a protein metabolite that is present in the blood and released in the urine). Due to its capability in blocking uric acid production, it can prevent gout attacks and the formation of kidney stones or other kidney problems.

It is indicated for recurrent gouty arthritis attacks, primary or secondary hyperuricaemia associated with gouty arthritis, uric acid nephropathy and recurrent uric acid stone formation.

Allopurinol is not indicated for moderately elevated uric acid or non-gouty arthralgia or arthritis. It has no pain or anti-inflammatory activity. Therefore it has no value in the treatment of acute gout attacks. It is not indicated for the treatment of asymptomatic hyperuricaemia.

Doctors or prescribers ahould be more selective before prescribing allopurinol to their patients. The risk benefit profile should be evaluated. For long term control of gout in patients who have frequent attacks, the xanthine oxidase inhibitors like allopurinol may be used to reduce production of uric acid.

Treatment of chronic gout should not be started until after an acute attack has completely subsided, usually 2-3 weeks. The initiation of allopurinol treatment may precipitate an acute attack, therefore colchicines or a suitable NSAIDs should be used as prophylatic and continued for at least one month after hyperuricaemia has been corrected.

If an acute attack develops during treatment for chronic gout, then allopurinol should continue at the same dosage and the acute attack should be treated in its own right. Treatment for gouty arthritis must be continued indefinitely to prevent further attacks of gout.

National Phamaceutical Control Bureau,
Ministry of Health, Malaysia.

Source: Berita MMA, October 2008.

At Dewan Rakyat

12th Paliament (First Term) 3rd Meeting
27th August 2008

Dato' Rashid Bin Din (Merbok) asked the Minister of Health to state whether the government will implement the National Medicine Policy which was approved by Parliament in October 2006, whereby the doctors will diagnose and the pharmacists will prescribe the medicines.

Deputy Minister of Health (Datuk Dr. Haji Abdul Latiff Bin Ahmad): Tuan Yang Di-Petua, the government has actually implemented the separation of prescribing function which was done by medical practitioners and dispensing done by pharmacists in all government health facilities and also private hospitals.

Currently, the governemnt has not yet proposed to implement the separation of function for private medical practioners and pharmacies in the retail sector because of lack of pharmacists in this sector. Thank you.

Dr. Haji Mohd Hayati Bin Othman (Pendang): Yang Berhormat Deputy Speaker, assuming this October 2006 National Medicine Policy is implemented in the retail division, does the Ministry already have monitoring to carry out monitoring in the pharmacy stores so that those who manage these pharmacies do not at all sell under the counter medicines without prescriptions from doctors.

This is because, I am concerned that sometimes they can sell medicines, grades that are only prescribed by doctors but they sell them under the counter without any monitoring. Therefore, my questions are there enough officers to carry out monitoring? Thank you.

Datuk Haji Abdul Latiff Bin Ahmad: Thank you for the question from Yang Berhormat Pendang. It is like this, if we look at whether monitoring is done or not. Monitoring is indeed done from time to time in the retail sector. We do not wait till this policy is imposed to private doctors and only then we want to conduct monitoring. Monitoring is continuous but what has become the issue now is whether the approach made which involves about 8,000 private medical practitioners who prescribe and also dispense medicines- whether this will make it difficult for them and convenience for the public. The Ministry is of the opinion that for the time being it is convenient for the people to seek treament and prescription as well as medicines in the same place. Thank you.

Dr. Lee Boon Chye (Gopen): Thank you. From the aspect of separating prescription and dispensing of medicines, is the Ministry aware that this was implemented in foreign countries especially in Singapore and had failed. Secondly, has the Ministry ever received feedback especially from consumer associations, etc. in this issue? I feel that it is important that the rights of patients to choose either he want the medicine from the doctor concerned or from the pharmacy. Thank you.

Datuk Dr. Haji Abdul Latiff Bin Ahmad: The Ministry is aware and we know, we already have recommendations from FOMCA and also the Consumer Association of Penang, but we are strongly of the opinion that for the time being, it is not yet time for use to separate prescription and also dispensing among medical practitioners. Thank you.

Source: Berita MMA, October 2008.

Cytusm, doc, pharm

Look like someone out there was launching a cyber attack against me.

This was because of the things I wrote about pharmacists and dispensing.

But, why I wrote that "10 reasons why doctors should maintain the rights to dispense"?

It all started when NST first wrote about doctors to be disallowed from dispensing medicine in March 2008.

It was followed by another report quoting the MPS president, who said:

"With serious risks to health due to improper medication, it made better sense for patients to get their drugs from a pharmacist who would have spent four years acquiring the knowledge than from a doctor who had none.

"Doctors are only familiar with medicines that they often prescribe, not knowing adverse reactions and drug interactions. However, pharmacists are constantly in touch with the drugs industry".

His statements were totally unfounded and inflammatory.

This come to show, how ignorant, misinformed and biased of the pharmacists' perceptions about doctors.

I am here not to start a war with the pharmacists. I was just sharing on how sometimes it was difficult to work in a system where doctors prescribe and pharmacists dispense.

But then, before PMS president opens his mouth again, he should study first whether pharmacies in the country are really prepared to take over the dispensing job solely.

The fact was, more than one half of the health cares, especially the Ministry of Health, have always been practicing separate dispensing. But, the way the system was run, showed that it was still not up to expectation as it was thought.

There was still a lot of shortfalls where the authorities, be it doctors or pharmacies, are not bother to dwell into. Everyone just want to mind their own business, as long as they get to draw the salaries, who really cares about what the patients get.

I do admit, I have not seen how other countries, like Australia, run their dispensing system but the fact was, Malaysia has always been running its own system in its own way.

The recent political situation and drama, especially in regards to racial issue and ISA-things-like-that, indicate that we are very much way beyond at what others want to see a developed country should achieve.

Again, I am not here to make fame by criticizing other people. What can this small and humble blog do?

Everyone is entitle to their opinion and I am here just to share my 2-cent personal experiences.

No offend intended.

Am I, or you the doc?

Note: This is not a pharm bashing site. If you feel offended by my writing, then I apologize.

Such a remark could invoke strong reaction from pharm who think doc are super-egoistic.

Anyway, I am here to share some of my recent encounters:

During my visit to a district hospital last week, I had prescribed Gamma Benzene Hexachloride (GBH) 1% to a patient with scabies. Later, the patient stormed into my room informing me that I had prescribed wrong medication to her.

She was apparently told by the pharm that the said lotion was meant for 'kutu' (head lice). I called up the pharm to clarify and was told that they 'usually' prescribed Emulsion Benzyl Benzoate (EBB) for scabies and not GBH.

I have told her that, well, I have been prescribing GBH all these while for my patient in my current hospital. Unconvinced, the pharm then passed the phone to someone presumably more senior to speak to me.

Anyway, as the number of patients were building up outside the door, I was just not in the mood to argue and I just had to agreed to give the patient EBB.

Firstly, the patient has already fixed in her mind that the medication I prescribed to her was for head lice after been told by the pharmacist. Secondly, I just didn't want the patient to blame me just in case she suffers any adverse effect.

Also few months back, I wanted to prescribe Permethrin 5% lotion to my patient with scabies and it was not available in my hospital. I wrote a prescription for the patient to get it from the private pharmacy.

Later, on follow up, the patient showed me the cover of the drug dispensed to her. It was GBH 1%. I told the patient that was not the drug I prescribed to her and she said she was told by the pharm that it was the same and can be used for scabies treatment.

Well, these two scenarios illustrate how the way doc prescribe can be influenced by how the way pharm dispense, essentially there is dissociation of what the patient is supposed to get.

By the way, the truth fact is, many doc and especially pharm, don't really know what are the currently available treatments for scabies, and which one is the most effective?

Here is a link to an article for those who is interested: Effective therapies in scabies.

Dissociation

I am kind of fed up with the environment over here. The culture is so inconducive to work in. A lot of things just seem not right to me. Am I just too sensitive? There seems to be 'disassociation' in the flow of work.

I told myself, that is enough. I don't want to just sit behind the scene and expect other people to make the move, which I have come to the sense that it will never happened.

Here were what I have done, where others will not do:

1. An ophthalmologist from a big hospital referred a young patient with severe left eye herpes-zoster involving V1 distribution, all the way 30km for me to treat!

I was so much puzzled on why a consultant specialized in eye care could not even treat a disease condition involving his territory? Next, I was even more disturbed when I found out that before this patient saw the ophthalmologist, he had gone to two clinics seeking treatment for the same problem. Guess what was prescribed to him? The first clinic gave him T. Acyclovir 400mg TDS and the second clinic gave him T. Acyclovir 200mg QID, both for two day duration, which were both inadequate.

So, first I wrote a sarcastic reply letter to the ophthalmologist, telling him how to treat herpes zoster. Secondly, I wrote two other letters to the two GP clinics informing them about their serious mismanagement. I can't really tolerate species who called themselves doctors giving treatment to patient half-heartedly and without any sense.

2. I prescribed antibiotic to a patient with infected wound. As all my prescriptions were keyed in online through the computer, I didn't realize that I have typed the duration wrongly as for two months instead of two weeks.

My patient came back to me after few days complaining of intolerance to the antibiotic given and I was shocked that she brought along a big plastic bag containing two months supply of antibiotic! I was disappointed with the pharmacists, who so called want to do the 'check-and-balance' thing on doctors, didn't even call me to clarify.

So, I picked up the phone to call the supervisor in-charge of pharmacists to let her know that doctors are not 'tiger', so that they should not be afraid to call the doctor in-charge to clarify things if they sense something is grossly abnormal.

3. I admitted a patient to the ward for wound infection and signed the request form for IV Augmentin to be given.

Well, after three days, I received back the form from the pharmacist with a small note suggesting to me to change to oral form or use IV Unasyn, because they have run out of stock. Who they think they are, telling me how to treat my patient? They didn't even have the courtesy to call the prescribing doctor personally to inform about the unavailability the drug.

So, I picked the phone and called the ward supply pharmacist in-charge to tell them that they have no business in telling off the doctors what to do, especially by writing a small note at the corner of the request form, after three days! Why is there serious lack of communication between doctors and pharmacists?

4. A patient in the ward noted to have severe hyponatremia, but clinically, she was alright.

The medical officer kept pumping in numerous pints of IV sodium chloride to try do correct the electrolyte imbalance as well as taking the blood daily, without trying to find out the cause. However, I noticed that many other patients had sodium level less than 130 mmol/L as well. Therefore, it must be something wrong with the lab results. But, two weeks have gone and I am still seeing many of my patients with very low sodium level. Nobody even bother to look at the results and the lab didn't even bother to rectify the problem.

So, I picked up the phone and called the scientist in-charge of the chemical pathology lab and told him that, their machines really need some serious calibration and quality control.

5. While doing our routine ward round, my consultant called out to the nurse in-charge of our patient and wanted to show her how a particular wound dressing should be performed.

Instead, she turned a sour face and grumbled some sentences unwillingly to do the dressing. She was so rude and as a very junior nurse, she showed no respect at all to the consultant and everyone of us.

So, I called up the nursing sister giving her a long lecture on how she should counsel her nurses and to teach them how to behave appropriately.