Storyformydoctor 1.0

Playing doctor

2009-06-06T22:35:00.003+08:00

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?

2008-12-21T12:19:00.003+08:00

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

2008-12-01T19:04:00.000+08:00

"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

2008-11-29T19:40:00.001+08:00

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

2008-09-27T00:05:00.001+08:00

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?

2008-09-26T23:46:00.000+08:00

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

2008-06-20T22:35:00.000+08:00

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.

Why are the sugar levels of patients with diabetes treated in government hospitals or clinics poorly controlled?

2008-06-15T20:14:00.000+08:00

Is it necessary to do HBA1c in diabetic patient, irregardless of the fasting blood sugar (FBS)?

Well, according to this medical laboratory technician and the visiting chemical pathologist, it is not necessary.

It is kind of irritating sometimes, seeing this kind of comment in the patient's lab result print out. Yes, as if the clinician is stupid.

That is what I said, irrelevant people passing comments, especially from someone who is not clinician. They are way out of touch.

Anyway, my patient who has DM more than 5 years, was on maximum Gliclazide and Metformin, with the FBS ranging from 6.8 to 9.2 mmol/L.

Nobody had bothered to do at least a baseline HBA1c and planned a target for sugar control. Everybody was writing "continue the same" and review in 4 months.

Ok, his FBS was 6.8 mmol/L and the HBA1c was 9.1%. Are you satisfy?

Obviously, I am not.

So, why are the sugar levels of diabetes patients managed in the government hospitals or clinics are poorly controlled?

First of all, many medical officers in the health clinics are ignorance of the importance of periodically checking on the HBA1c level. Furthermore, certain centres restrict the availability of the test to be done because of cost reason.

But, what other choices do we have in the government setting in term of drugs availability? Extremely restricted!

Let us examine a few facts.

In the health clinics, we have only Glibenclamide, Metformin and Insulin. Some districts do not even allow Gliclazide without specialists' signature (ask the pharmacists). How ridiculous?

Bigger hospitals have Acarbose, while Rosiglitazone, Diamicron MR and Insulin Glargine are only available in the tertiary hospitals and those with Endocrine subspeciality units.

In the mean time, many clinicians are reluctant to add on Acarbose because it may not bring down the HBA1c much (about 1.0%) and its frequent associated GI side-effects (up to 30%).

On the other hand, many patients are very reluctant to start on Insulin probably because of fear, poor eye-sight, poor social support and so on; even if you insist them on taking it, they will not be injecting it anyway.

That brings us to no choice for a physician like me sitting in a big tertiary hospital. Rosiglitazone and Insulin Glargine are so restricted and the latest group of anti-diabetic agent, Sitagliptin (Januvia) is non available.

That explains a frustrating physician like me treating diabetes patients in the government set up and the reasons why the majority of patients with diabetes are poorly controlled.

By the way, is there a changing trend in the future?

Read: Intensive control does not prevent major cardiovascular events in type 2 diabetes (MMR).

Why retail pharmacies are loosing bussiness?

2008-06-08T15:38:00.000+08:00

Not too long ago, the pharmacists and doctors were exchanging words over the media and internet on dispensing rights.

The pharmacists wanted 'exclusive' rights to themselves because the developed countries do so, and our country should also follow so. They also believed they are more than qualified to do the job than doctors because doctors know less about pharmacology than they do.

Anyway, here is not the platform to debate such a 'chicken-and-egg' issue anymore, cause it will never end without hurting each others' egos.

From another angle of view, I was wondering why the pharmacists were so vocal about their struggle of getting the exclusive rights and also why the doctors, particularly GPs were so reluctant to give away their roles too?

Many people and especially the pharmacists believe it was going to do with business, profit as well as money. All these about reducing prescribing error claims, check and balance, and things like that, are probably not that really significant.

No doubt, the pharmaceutical industry is a big money out there, but let's think again, was it the GPs clinics that drew away patients from getting their drugs dispensed from the private retail pharmacies?

Was it because of the GPs, that the pharmacies were not getting enough business for them to operate 24 hours?

But let's consider from another aspect.

I guess, the major rival to retail pharmacies is not from the GPs. What do the GPs get by charging patients RM30 for 3 medication for flu? Nothing, absolutely nothing. The RM30 is for consultation, and the medications are given free.

But, let see what my neighbor was getting for RM5 from the government hospital every four months. She has diabetes, IHD, hypertension and dyslipidaemia. For just mere RM5, she was getting 10 types of medications (Ticlopidine, Isordil, Vastarel, Metoprolol, Perindopril, Amlodipine, Gliclazide, Metformin, Insulatard, and Simvastatin).

So, ponder again, the big rival to the retail pharmacies is not from the the private GPs but from the government hospitals and clinics (which have already practiced separate prescribing and dispensing for that matter of fact).

I believe, that is why, the retail pharmacies are not in the business.

But, when GPs continue to dispense their own medicine be relevant?

I learned that a visitor to US relating how he spent RM1000 equivalent in US currency just for a simple cough, and that did not include medications. He also lamented how fortunate we are in Malaysia where we could simply walk into any GP clinic anytime and pay RM50 for consultation including even original drugs.

So, are we now really prepared to have total separate system where patients only see GPs for prescriptions and then walk somewhere else for medications to be dispensed by private pharmacists? How would the health care cost be if such practice is happening?

I doubted so, as long as the patients are flocking to the government hospitals for treatment of chronic diseases.

I therefore see the relevant of the National Health Financing Scheme now, if the authority or MOH thinks that pharmacists should have 'exclusive' rights to dispensing.

In the move to decongest the government clinics, the MOH could then send most of the patients with chronic ailments to the private GPs and perhaps also pay the private pharmacists to dispense the medications.

Well then, again, the National Health Financing Scheme is another big controversial issue.

Read:
Doctors dispensing medicine.
Roping in the private clinics.
Private clinics roped in to help.
NHFS-will it materialize?

Outsource patient care for chronic illnesses to private clinics?

2008-06-04T00:49:00.000+08:00

Outsource patient care for chronic illnesses to private clinics?

Well, our current health minister said private clinics may soon be roped in to help the public hospitals or clinics ease its patient load.

Minister Datuk Liow Tiong Lai said that if implemented, patients with chronic ailments would be sent to the clinics for follow-up treatment and medication.

He said the Government would pay for the consultation fees and medication of patients referred to private clinics.

Read: The Star, 28th May 2008.

By the way, our ex-health minister thinks otherwise. He suggested that the role of the doctors in detecting health complications could be pushed to the nurses who shall be trained to do the job because of shortage of doctors.

However, I don't think the idea as suggested by our ex-health minister was good and fair. The responsibility of the doctor should not be passed on to the paramedics just because there is shortage of doctors in the government hospitals or clinics.

Furthermore, there is also a serious shortage of trained nurses in the government health facilities as well.

I have encountered certain nurses who were trained in special fields (e.g. diabetic counselor nurse) left their job later due to promotion and transfer.

Such idea may not solve our main core issue, that is the shortage of doctors as well as overcrowding of patients in the government hospitals and clinics .

I therefore, see such suggestion by our current health minister as something more feasible and relevant.

Related read: MMR

All over Aqueous cream

2008-05-31T11:31:00.000+08:00

I thought after a while, the 'dispensing' issue could have been buried deep somewhere; but I still find people searching for 'dispensing-rights-kind-of-stuff' and the links were referred to the '10 reasons' post I made earlier. Some student pharmacists felt disheartened and some were angry on what I wrote.

But anyway, it was not my intention to offend pharmacists in particular, or even wanting to pick up some 'fight' over the issue in the cyberworld or something like that, but I was just be frank.

I do not believe in total monopoly and I certainly do not believe that there is one system perfect.

Off issue, lately I am kind of frustrated of seeing patients in the clinic. The major bulk of the consultations are dealing with patients with dry skin problem. The work load is getting heavier and the patients are more demanding nowadays.

It seems that we are unable to discharge the patients to the health clinics for follow up. This is all because of some issues with the dispensing pharmacies.

It seems that the pharmacies in the health clinics do not dispense Aqueous cream in large quantities, i.e. 500gm. No matter how much a doctor writes in the prescription, patients are only given, the most, 60gm. I don't really understand why.

Patients ended up been referred back to our clinic just that we are able to provide the 500gm of cream here. No matter how much I complained; to my boss, to the pharmacists, nothing positive really moved.

One thing funny about these patients was, they think the Aqueous cream is 'sabun' or soap. Why? This was because the pharmacists or 'dispensers' told them so.

No matter how countless time I wrote the prescriptions with the instruction 'to use as emollient', the patients would always came back complaining of not getting enough.

What? You think we are charity organization giving out free soap?

Anyway, my current consultation is computerized. I prescribe online and the pharmacists are supposed to get the prescription electronically. This practice is supposed to cut down on prescribing errors.

But, even with this, the pharmacists or dispensers did not even get the message across.

It was my routine practice of putting a note to inform the pharmacists to instruct the patients to use the Aqueous cream as 'moisturizer' but yet I still encountered a patient stomping into my clinic yesterday clarifying that he was given 'sabun' by the pharmacists, which in fact, I had even explained to the patient otherwise, before he left.

I then looked at the container, and the word 'sabun' was written on top. The patient seemed to trust what the pharmacist said more that I said. That really frustrating.

I wasted my time explaining to him and yet he was confused.

What I started doing since yesterday was, to write the instruction in BM, since they don't seemed to understand my written English.

I wrote, 'Sila sapu sebagai pelembap'.

I just hope with this, no patient is going to stomp into my clinic in that manner again.

Keeping fingers crossed.

Why am I not happy with separate dispensing?

2008-04-20T15:24:00.000+08:00

While this ‘dispensing’ issue is fading from its heat, I am here again with probably my last posting on such issue. I hope this will not bored everyone to death.

After I posted some opinions about why doctors should be allowed to continue to dispense medications, I received quite a number of feedbacks, mainly from pharmacists who think they should have exclusive rights because doctors are less knowledgeable than them in regards to practicing pharmacology.

Some went on to dig about how some doctors are so unethical, greedy and bashed them on dispensing practice, which everything in their eyes are wrong, because ‘developed’ countries don’t practice so.

A student pharmacist in oversea might have interpreted my writing differently, mean while another pharmacist also think I am exaggerating.

Anyway, I don’t want to dwell into issues of doctors versus pharmacists again on who is smarter, knowledgeable, greedier and ethical or who makes the most mistakes.

The reason I wrote 2 entries about dispensing rights was not to show that doctors are better than pharmacists, and so on. What I tried to illustrate was, pharmacists are certainly not the only BEST person to dispense. Whatever unethical practices labeled on doctors can also be practiced by pharmacists. Why made use of such excuse when they want to monopolize the practice?

I am working in the government hospital where there is separate prescribing from dispensing. In one day, I could see more than one hundred patients and what the heck am I bother about dispensing?

I don’t deny that, the pharmacists are important and have contributed significantly to this aspect, but, I don’t believe such system of dispensing is the most appropriate.

Here, I would just like to share some experiences on occasions where in my opinion; some dispensing practice by pharmacists (in my hospital that practice separate dispensing) could be inconvenience and did not benefit patients.

I am in no way trying to imply all pharmacies or pharmacists are like that, but I just want to point out some dissatisfaction as a clinician who hold a ‘gun’ but the ‘bullets’ are controlled by the pharmacists.

If doctors have any say in dispensing, I am very sure doctors would make sure things are carried out to benefit patients because they see and treat patients directly.

1. On Shortage of pharmacists:

Whether one still aware of it or not, there is still a markedly big shortage of pharmacists (though doctors too) in the country. Some pharmacists in the district hospitals cover few hospitals and clinics, not to mention, many smaller clinics don't even have pharmacists dispensing. Even in major hospitals, the role of ‘dispensing’ has not been fully carried out by pharmacists. While doctors have been doing 24 hours call for ages, I am yet to see pharmacists stay 24 hours just solely to dispense drugs (do let me know if there is, just in case I am outdated).

2. On Supply and stock of drugs:

If pharmacists want to practice dispensing, they must always ensure that all drugs are available at all time.

Let me tell you one case that really upset me till today. Once, a young patient of mine who was on S/C Mixtard, presented with DKA and nearly died because the pharmacy had run out of stock for Mixtard. He was asked to buy it himself. The patient was unemployed and he could not afford it. So, when such situation happened, who should take responsibility? One might want to blame the patient, but in reality, would anyone care?

As a prescribing clinician I am deeply disturbed. Why would anyone care whether the patients get their medications or not? Doctors prescribe and the duty of the pharmacist is to dispense, the concept of what pharmacists want to believe. The question is, who really make sure patients get what they are supposed to get?

But then, things could be different, let say, if one day I practice on my own and dispense. I would definitely make sure my patients get the drugs and enough supply I prescribe to them.

3. On Control of drugs:

Pharmacists who control the drugs, change the drugs from original to generic, or changing brands at their own fancies, in the excuse of cost issue without considering whether the drugs work for the patients or not.

As a practicing government clinician, I am supposed to write only generic names. So, what the heck shall I bother about what patients get? But then, for instance, I have patients who were on Mesalazine for ulcerative colitis, had their brand changed from Pentasa to Salafolk out of a sudden. Patients who were stable on the initial drug came complaining about flares because of the change of brand. As a clinician, am I not concerned, but would the pharmacists care?

I also have RA and psoriatic patients on Methotrexate complained of flares after the pharmacists changed the original to generic. So, is such practice done in the benefit of the patients? Do patients have a choice because they seek treatment from the government hospitals and only pay chicken fee of RM 5.00?

4. On Availability of drugs:

I am frustrated when prescribing certain medications because we are restricted by unavailability of the drugs. I have worked in many hospitals and some pharmacists prefer to stock certain drugs only. When they don’t have the drugs that I want, they suggest alternative. As a clinician, I am frustrated because I could not prescribe what I wanted as I am limited by choices. What we clinicians want is the flexibility to prescribe medications that we are familiar with and not limited by what the pharmacies have.

5. On Prescription instruction:

I was unhappy when the pharmacist cut my supply of Acyclovir from 7 days to 5 days for treatment of chicken pox and this really happened in a place I used to practice. Do I make up story? No. Many of such malpractices exist. This is happening to our government hospitals that practice separate dispensing without many people knowing it. Some pharmacists do not follow prescriptions instruction.

If pharmacists want to reason out that they want to make sure we doctors do correct prescription, but on the other hand, who are there to check whether they dispense according to instruction or not?

6. On Inconvenient dispensing:

Currently, we have certain policy (don’t ask me who started it first) where we are not supposed to keep stock of medications, especially IV antibiotics in the ward. Sometimes the pharmacists come to the ward to conduct spot check on this.

We used to keep IV antibiotics in the ward because sometimes when we need them urgently, there is delay, as the pharmacists are not available immediately to dispense the antibiotics to us. When dealing with life and death of patients, we simply can not delay instituting treatment just because the pharmacists don’t stay in 24 hours to just solely dispense the medications. Every second actually count in determining the outcome of the patients. One would find, many of the drugs that doctors prescribe middle of the night when on-call are not available immediately to patients. Again, I want to ask, if doctors can stay on-call for 24 hours, can pharmacists do the same?

(But do keep me updated if nowadays pharmacists do stay in on-call, in view of more pharmacists are retained in the government hospitals doing compulsory services).

7. On Pharmacists' influence:

I used to work in a district hospital where there was no other medical service available in the evening. Patients would come to our A&E (because we opened 24 hours) seeking treatments for many cold cases like URTI, etc. Our A&E had thus been turned into OPD-liked to serve the rural folks who don’t have access to other medical cares. Our pharmacist controlled the stocks and availability of drugs to be dispensed in the A&E. As doctors who do the prescribing and dispensing job, we were frustrated as we were limited by choices of drugs dictated by the pharmacist. During our monthly drug meeting with the hospital director and the pharmacist, all of us requested to add a few more drugs in the A&E for us to treat patients with different clinical presentations. The pharmacist had not only turned down our request but went on to suggest that our A&E should not be turned into OPD-liked. What's more, this pharmacist covered two hospitals and he had no idea how we doctors run the A&E. So, can anyone tell me, was the pharmacist been fair to the patients with his egoistic thoughts? (This was what I meant by this pharmacist who tried to be smart).

Again, my intention of mentioning these few examples was not to make pharmacists looked as bad that they should not be dispensing. I just want to illustrate why certain practices can be inconvenient to us, practicing clinicians.

If the MOH does go ahead with the total separate dispensing in near future, I just hope that , what I have encountered in the government hospitals that practice such policy, do not happen in the private sector.

I really wish to hear what other doctors who work in countries that practice total separate dispensing say.

Before I end this post, for those who are still ‘soaking their feet in the salty foreign seas’, must take a look in our health care system in depth and figure out whether whatever ‘developed’ countries practice, could be applied over here or not, before they start exerting on exclusive rights.

Whether the separate dispensing practice would be totally enforced or not in near future, I would still maintain that doctors keep their rights to dispense as they wish. Doctors have been practicing dispensing since ancient time.

Pharmacists can go ahead with their dispensing role (nobody is stopping them) and I think it is just fair that patients be given a choice, whether to get the drugs from their doctors or from other pharmacies. Policy can still be modified and enforced to suit everyone’s need, be it doctors, pharmacists or patients, without doctors ever losing such rights to dispense.

It is the government's money

2008-04-19T17:46:00.000+08:00

Read the Star, 18th April 2008.

Crowded: The waiting room at the specialist clinic in Seberang Jaya Hospital is packed with patients and their family members.

I just wonder if our Health Minister's hope of seeing that the waiting time for patients to see specialists to be shorten to 30 minutes, could be materialized or not.

I doubted very much given the situation we are in now.

Let's just imagine if 100 customers start lining up in the bank as the bank opens at 9am, do you think all of them could get their transaction done in 30 minutes?

Given the recent rise of all food prices as well as health care cost, I foresee more and more patients would jammed up the government specialist clinics. Why is it so?

Because the medical cost is heavily subsidized that all patients pay only RM5. And, what kind of service patients expect from these poor overworked government doctors?

Cheap, efficient, fast and more importantly, free and quality medications.

When their demands are not met, they start politicize the issue.

No doubt, most patients are poor, but the ones who open their big mouths are not. These are most well to do ex-government servants (particularly teachers) as well as some individuals who think they are the only ones pay taxes, who think the government doctors owe them lots.

Let me tell you what happened few days ago in the clinic.

One patient who has a chronic condition came on a non-appointment day complaining of the same old problem of few years which does not seem to resolved (otherwise it is not called chronic).

When my collegue suggested some other options, the patient was not keen on the idea but instead demanded that he be given double supply of some expensive drugs, because he was tired of coming too often to the hospital and having waited so long to see doctors.

When my colleague did not give in to his demand, there was some mild commotion. Before this patient left the room, he passed the remark, " It is the government's money, and not yours!".

Can you imagine how this dedicated government doctor felt, when he came early in the morning to complete his ward round, quickly left to the clinic with the hope of clearing the crowds as fast as he could, but in the end been slapped with some hurtful remarks?

I don't think the issue of congestion in the government specialist clinics would ever resolved with just some grumbling and publicity over the media.

We really need to think deeply why is such scenario happening?

Perhaps people should re-look at the idea of certain health scheme, e.g. National Health Financial Scheme to solve such problem.

I believe, with a good scheme, patients are given choices of seeking treatment at private centers, thereby solving part of the congestions we see in the government specialist clinics.

10 reasons why doctors should maintain the rights to dispense

2008-04-04T02:18:00.000+08:00

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.

Here are my personal encounters with bad dispensing from pharmacists (who think they should have exclusive rights to dispensing) and my frustration of working with the government pharmacists (some who think they are smarter):

1. There are not enough pharmacists.
I was having a bad sore throat one day and I didn't want to go to the government hospital for free medication. Instead, I wrote a prescription and wanted to buy it from the pharmacy near my house. It was only 8.30 pm and I was told the pharmacist was off duty.

NST: In 2004, there were only 3,927 registered pharmacists with about 1,540 retail pharmacies or one for every 16,445 persons.

2. Not all pharmacies have certain medicine.
I was looking for Differin gel (for acne) and went to 4 pharmacies in Bukit Jambul Complex, but none of them had it. I even went to the famous pharmacy opposite the hospital and they didn't have it too. Not only that, none of them have Retin-A gel either. Therefore, I wasted precious time looking for a simple kind of medicine.

I once went to 3 pharmacies in one shopping complex looking for Pementhrin 5% loition for treatment of scabies. None of them had it.

3. Pharmacists offer alternative medicine when they don't have the prescribed item.
I once wrote a prescription to my sister to buy Tranexamic acid for menorrhagia from a nearby pharmacy but was told they did not have it and my sister was offered Primolut (Norethisterone), which was a hormone. Very wrong!

4. Pharmacists did not follow instruction on prescription.
I once treated a patient in the goverment district hospital for Klebsiella pneumonia and wrote a prescription of the antibiotic Cefuroxime for 7 days (and specifically told the patient about it). The patient came back and complained he was only given five days supply.

5. Pharmacists try to overrule doctors instruction.
I had Chicken pox in 2002 and wrote a prescription for Acyclovir for 7 days from my hospital. I was given only five days supply instead. When I called up the pharmacist, he told me 5-day supply was enough (minimum).

6. Pharmacists implementing unfair policy.
I once wrote prescription of Chlorpheniramine for 30 tablets for my patients with chronic eczema, but the pharmacist in the government district hospital dispensed 10 tablets only. When I called up to clarify, I was told it was their policy to dispense a pre-packed 10 tablets at any one time.

7. Pharmacists conveying wrong information to patients.
I wrote a prescription of Carbamazepine for a patient with neuropathic pain. Later the patient refused to take it after the pharmacist had told her, it was for epilepsy.

8. Pharmacists (as human being) do dispense wrong medicine by mistake.
I once wrote a prescription of Bactrim for a patient with urinary tract infection in my previous hospital and later I found out that the patient was given Magnesium trisilicate, as both are quite similar in appearance.

9. Pharmacists who think they are smarter.
I once wrote a prescription of Enalapril 5mg BD (twice daily) for hypertension. A young pharmacist in the hospital called back to advice me to give Enalapril 10mg OD (once daily) because Enalapril can be given OD to make the patient more compliant.

During one of the meeting with the pharmacist in the district hospital, I requested to stock Metoclopramide in the A&E to treat patients with vomiting. My request was turned down as the pharmacist argued that there was already Stemetil available to treat vomiting. The pharmacist reasoned out that he felt A&E should not be turned into OPD for stocking to many medicine there. Mind him, the district hospital A&E does good service to the villagers as there is hardly any private GP opened after 9pm.

10. Pharmacist playing doctors.
My auntie who has diabetes and hypertension, has been buying medicine from the pharmacy as it is cheaper according to her. The pharmacy also offer to measure her blood pressure using the electronic device as well as cholesterol and glucose checking by finger prick.

MMR: Doctors dispensing medicine II.

Gun without bullets

2008-04-01T10:29:00.000+08:00

I was brought up to believe, traditionally a doctor is such a noble being. He/she is able to diagnose an illness and prescribe as well as to "dispense" medicine to relieve symptoms or to cure the disease. The Sinseh or Chinese Physicians do also diagnose, prescribe and dispense their own traditional medicine. Where would one find Sinseh diagnose a condition and ask the patient to get the medicine from someone else or herbalist (if ever such profession exist)?

So, what happen if someone owns a gun but doesn't have bullets?

Here are some questions and answers related to my posting:

What is the hottest topic among health care providers these few days until even LKS and Malaysia Today blog about it?
The dispensing rights between the doctors and pharmacists.

What is dispensing (medicine)?
To give out or to distribute (medicine).

Who has the rights to dispense in Malaysia currently?
1) Doctors. 2) Pharmacists.

What has the pharmacists been demanding for the past 20 years and now?
The exclusive rights to dispense medicine, no one else.

Why is the rights so important?
Pharmaceutical industry is an extremely profitable business. There is a huge market out there. One can become rich (like doctors?) with such rights. This can be equate to automobile companies with APs (exclusive rights to import certain cars).

Who are practicing separate dispensing currently?
1) All the government hospitals and clinics in Malaysia (Actually not entirely true as many of the dispensing role are done by "dispensers" because there are shortage of pharmacists in the country).
2) All the private hospitals in Malaysia.

Who are not practicing separate dispensing?
All private General Practitioner clinics and most of the individual Specialist Clinics.

Why are they not practicing it?
1) There are not enough pharmacists.
2) Smaller clinics could not afford to hire pharmacists to dispense.

Why are pharmacists unhappy about it?
They are losing income or business for not been able to get enough prescriptions for them to dispense. That is why they are resorting to selling all sort of stuffs (like supermarket), such as health supplements, milk powder, self-grooming stuffs and even food stuffs like mineral water.

Why are doctors refuse to give away their rights?
Primary care or General Practice in the private sector is very profitable (one can not denied) and very competitive as well. Many GPs resort to lower their consultation fees in order to get the patient volumes and gain from dispensing medicines. Take for example, many GPs lower the cost to charge per patient (in a package of consultation plus medications) in order to get accepted as "panel" for many companies. This lowers the cost of health care.

What happen if doctors loose the rights?
Many will raise the consultation fees and health care is going to cost more with the separate dispensing of drugs.

While John Chang and Dr. Khoo Kah Lin can go and debate who and why pharmacists should be or not given the exclusive rights, I am more concern if implementation would be successful if ever the pharmacists won the rights.

This patient has been buying the above three medications from the pharmacy for the past two years without a doctor's consultation and prescription for frequent joint pains.

My few concerns:
1) Will patients ever understand the danger of not consulting the doctors for their problems and to buy medicine from the pharmacies because they are cheaper?
2) Will enough enforcement be there to make sure pharmacists only dispense medicine with only prescription from doctors?
3) Will patients willing to spend more on separate prescription and dispensing (higher cost of health care)?

Meanwhile, few possibilities I could imagine if doctors and pharmacists want to cooperate to share the pie:
1) Doctors to hire pharmacists and pay them accordingly to dispense in the clinics.
2) Doctors and pharmacists to open joint venture and share the profit accordingly.

Related links:
MMR

Welcome Back

2008-03-02T14:54:00.000+08:00

I am back now with this new blog. Welcome back.