This article is also posted in the Dobbs Doctors forum in this thread
Doctor’s Right to Dispense Medicine
Dr. Lee Yan San, Past President, MMA
MMA was asked to participate in a forum on dispensing of medicine at the 2 day International Clinical Pharmacy Symposium in July 2002 co-organised by the International Medical University (IMU), School of Pharmacy and the Ministry of Health. I was asked to represent MMA in a round table discussion, which includes members of MPS and the President of FOMCA. This article was prepared for this seminar.
MMA feels that at the present moment, doctors should continue to dispense medicine for their own patients. This system has served both the patients and doctors well. It is both convenient to the patient, economical and entails a lower risk of mistakes, as doctors usually prescribe drugs he is more familiar with and thus kept in stock. Supplying of medicines is part of the total care of the patient and provides convenience and care continuity expected of by the patient
However, Pharmacists will still continue to play an important role, as doctors will continue to write prescriptions for those patients who prefer to obtain medicine from the pharmacist. At present, if doctors give up their right to dispense, patients will loose out, as the scenario in our country is not ready for sole dispensing by pharmacists.
Doctors being responsible for diagnosis would be more knowledgeable about the most appropriate medication and their method of use and in tailoring the treatment regime. Doctors are trained to diagnose and treat which is of course their main role. Treatment includes giving the appropriate medicine to the patient. Therefore doctors have every right to dispense medicine if they choose to do so. The qualification of both pharmacists and doctors to dispense should never arise as both are equally qualified with regards to knowledge of the drugs prescribed as both have undergone lessons in pharmacology and therapeutics. Nowadays, drugs are supplied in forms convenient and easy to use. Hence there is no real need to have a special skill to dispense.
It is important to distinguish between dispensing and prescribing. There is no controversy as to who should prescribe medicine. Pharmacists should not dispense medicine without the prescription of doctors as far as schedule A & B drugs are concerned. Since the old days, doctors have been dispensing their own medicine by carefully weighing each portion and compounding them together before giving to the patients to take. Now dispensing medicine is even easier with ready calculated dosage in the easy to use form of tablets or capsules and with ample information accompanying the medicine. This has compensated for the increase in the number of drugs available. This should therefore not be the reason for taking dispensing right from the doctors.
Unethical Practice of Pharmacists.
Diagnosis and treatment cannot be the role of pharmacists who are not qualified to do so. They may supply the drugs ordered by the doctor. It is important that pharmacists working in the private pharmacies be ethical and willing to work as a team with and not against doctors. Many doctors have been complaining to MMA through feed backs from their patients that some pharmacists have been practicing like doctors. They not only take BP readings and do blood glucose using glucometers but also attempt to give advise on treatment to their clients which they are definitely not trained to do. It is not uncommon to hear from our patients that they have been buying scheduled medications from the pharmacists without a doctor’s prescription. Many have presented to doctors with side effects of the medicine such as hypoglycaemia from taking anti-diabetic medication obtained from a chemist without proper advice from a doctor and other side effects from taking certain high blood pressure medicine. Over the counter sales of antibiotics is illegal and surely is also one of the reasons for the emergence of resistant strains of bacteria. Recently, one patient of mine told me that a pharmacist has dispensed for her a course of antibiotics after she complained to the pharmacist that she has trouble using the vaginal pessaries given by her gynaecologist.
The government must be very strict in monitoring the practice of pharmacists. For example, in Singapore, very recently, one pharmacist was fined $20,000 and suspended from practicing for 9months for dispensing cough mixture containing codeine without a doctor’s prescription.
Pharmacists must also not give repeats without the approval of the prescribing physician. Regular follow up by the doctor is very important to make sure that his patient’s illness is under good control without any complications including side effects from the medications taken. Regular follow up will reduce mortality and increase life span.
Not Enough Pharmacists.
At the moment, there are too few pharmacies in the country. Most are concentrated in busy town areas. At the present moment, clinics grossly outnumber pharmacies even in urban areas in this country. If pharmacies are given the mandate to dispense, I do not think they will be able to cope. Furthermore, there are hardly any pharmacies in the rural areas. For example, in Sydney, where pharmacists do the dispensing, pharmacy outlets outnumbers the clinics. There, the pharmacist also personally does the dispensing. “Chemists” as they are called there, can be found almost everywhere and there are usually more than one in most major streets. Moreover, the working hours of the “Chemists” are much longer than the clinics as they are usually opened till late at night and in some places they also offer 24 hours service. This should be the case in Malaysia before the MOH can even consider allowing pharmacies the sole right to dispense medicine. If this is implemented, the pharmacist must personally attend to the patient and also personally dispense the prescription prescribed by the doctor.
Inconvenience to Patients
In Malaysia, we have a good system that is very convenient for the patients. After seeing a doctor and then having to search for a pharmacy to buy the medicine is very impractical at the moment; mainly due to lack of pharmacies in the country. The patients will have to go through again the ordeal of finding a parking space, search for a pharmacist, and wait for another period of time before getting the medicines they need. This applies even more if the patient needs the medicines urgently. Recent traffic jams and parking problems have added to this inconvenience.
Exact Medicine Prescribed:
Pharmacists may not have the drugs the doctor has prescribed which causes more delay and inconvenience to the patient. Every doctor has his own favourite medicine, which they use more often mainly because they are more familiar with and have better faith in that medicine. The doctor’s own dispensary will definitely have in stock the medicine the doctor uses. If the patient goes to a pharmacist and is told that certain medications are not available, the patient will have to go back to the doctor for a change of prescription. Doctors may be forced to use another drug, which the doctor may not be thoroughly familiar with. Alternatively, the patient will have to go hunting for another pharmacy that carries the medicines the doctor has prescribed.
Furthermore, the brand of the particular medicine the pharmacist has in stock may not be acceptable to the doctor who prescribes it. He may doubt its potency and reliability. Not all the brands of medicine are as reputable as being claimed. For a drug to be up to mark, the formulation including the base substance is important and will affect absorption and the shelf life of the drugs. Some manufacturers do not use the same formulation as the original patented drug and thus although the amount of active substance is the same, the potency and duration of action may differ, so may the shelf life of the drug. Here stringent quality control is extremely important. Pharmacists must be willing to cooperate with the doctors and only dispense the brand of medicine the doctors prescribe. Pharmacists must be willing to look into the feasibility of storing not one brand but a few popular brands of the same drugs as well as keeping complete stock of essential drugs. Drug substitution by pharmacies posed by the need to compete with low prices is also a real danger. It may not be in the interest of the patient.
The Role of a Clinic Dispenser:
It is true that in a clinic, the dispenser does the dispensing of medicine, which the doctor has already explained to the patients. The dispenser’s main role is to explain to the patients the indication for each drug (which the doctors should have explained in full before) and how to take them. The dispensers must be taught to be alert and to relay to the patient the doctor’s instructions accurately. They must be taught to check and double-check each time to make sure that the right medicine is being dispensed. It is important to teach the dispenser how not to take any risk and to ask the doctor whenever he or she is in doubt. The doctors must explain carefully to his or her patients why certain drugs have been prescribed and for what indications and warn them of any impending side effects without panicking the patients.
Anyway, in most pharmacies in Malaysia, the pharmacist himself also does not personally do the dispensing either. Even in hospitals, dispensers and not pharmacists do the dispensing of medicine. The Pharmacist’s role in the hospital is more a supervisory and advisory one in addition to making certain that supply of drugs is adequate. A trained dispenser can equally be used in the clinic and should not be the reason why dispensing in clinics should be discouraged.
Problems of Prescription Error:
Doctors may occasionally commit prescription errors according to some survey in US. Pharmacists claim that they will pick up these errors when they dispense a prescription. As discussed earlier, in Malaysia, at present, pharmacists usually leave the dispensing to their workers, and therefore they will also not be there to perform such tasks. However, even if pharmacists do the dispensing themselves, they will just routinely fill up the prescriptions unless an obvious mistake has been committed. I feel that the doctor’s own dispenser who is very familiar with that particular doctor’s practices will be a better person to pick up any mistake in a doctor’s prescription and will just clarify with his doctor before dispensing the medications. It is more likely for the doctor’s own dispenser who is familiar with his style and practice to pick up any discrepancies than a dispenser in the Pharmacy. Moreover, in Malaysia, doctors only use drugs they are thoroughly familiar with and thus kept in their own dispensary. They are very concerned with its side effects and how his patients will respond to the medications. Here, the doctor’s reputation is at stake and he will want to see his patients get better without any undue side effects from his medications.
Sole Dispensing Right:
I do not think doctors have objections to Pharmacists dispensing medicine, a role they are certainly trained for, but at the moment it is just not practical for them to be the sole dispenser of medicine. There are many problems that need to be addressed before it can even be considered. Some of the problems, as discussed earlier, include the present attitudes of many pharmacists, not enough pharmacists to cater for the sick, the inability to find a Pharmacist after hours, pharmacists not having stock of the exact drugs which the doctors have prescribed and the many inconveniences to the public.
Before the dispensing right can be taken from doctors, all such salient points must be closely looked into and corrected if necessary or the public will loose out.Doctors and pharmacists should be able to work together to serve the public effectively and economically. The doctors and the pharmacists should come to a healthy compromise. All the above points should be worked out with a reasonable solution in mind. Pharmacists must stop playing doctors, they must never dispense Scheduled A & B drugs without the doctors’ prescriptions, and they should not repeat prescriptions without the doctor’s approval. They should co-operate with the doctors fully and be willing to ring up the doctors to discuss prescription they may need to alter.
Until all these can be agreed upon and when there is enough pharmacists in the country including rural areas, doctors should not agree to give up dispensing medicine as it will be more beneficial to their patients if they dispense medicine themselves. They know what to dispense and what to tell the patients regarding the medicines they have prescribed.
In the future, I foresee that doctors starting new practices may not even want to set up a drug counter in their clinics. Nowadays, there are many problems in managing such a counter which includes difficulty in hiring good staff and managing the inventory of the drug such as keeping track of their expiring dates especially when drug prices have escalated so much. It is not true that dispensing medicine in a clinic is a lucrative side income of medical practitioners. The doctor’s main income is from consultation. In the past, medicines were very cheap and doctors were able to absorb the cost. Doctors do not profit from the sale of medicines but only from consultation. I would like to stress that the issue is not so much a professional one of competence in the physical delivery of medicines but that of economics and convenience to the patient.
What the pharmacists need is to have a representative who can work with MMA to come to a solution. Antagonistic approach as seen in the past will not solve the problem. The problem should be discussed in an intelligent manner considering all the aspects that will affect the two professions as well as the consumers. Even at the present moment, most doctors will not mind sharing dispensing with the pharmacists. This will also save them from storing too many different drugs and will give the pharmacists some share in managing their patients but the pharmacists must stand on the right grounds and perspective. The time is definitely not right at the moment for the pharmacists to take over completely in the dispensing of medicine. However, I agree that sooner or later this may happen but only when patients can benefit by such an arrangement. It is still a long way off judging from the present scenario.
MMA has already started to prepare doctors for the future by encouraging itemisation of bill to educate the public what consultation fee is all about so that patients will not be confused with the cost of medicine. MPS should start doing the same by reaching out to its members to practise more ethically and win the trust of doctors. What MPS has done in the past is to ignore the problem and brush away the issue by still insisting on proof of something, which has become common knowledge. This antagonistic approach will not solve the problem. It reminds me of a teacher with good intentions complaining to the student’s father that his son has done something wrong. Instead of talking to the child and correcting him for his own good, the father insists that his son can do no wrong and keep on asking for proof!
Most pharmacists are ethical and willing to work hand in hand with doctors. They should not suffer because of the wrongdoing of some black sheep in the profession. It is high time that MPS sieves out the black sheep. They should acknowledge their existence and take proper action to rectify the situation in order to win the trust of the medical profession.
Of course there will still be a few doctors who believe, no matter what, dispensing should never be taken away from them even when pharmacists have proven themselves capable in terms of ethics and other issues, which I have brought up earlier. What MMA wants, is to keep up with the times so that we can all provide the best possible health care to the public.
Let water find its own level with the least disturbance to the patient. Legislation would create unnecessary problems and be counter productive.
(My thanks to Dr. Chan Kok Ewe, former Professor of Pharmacology, University of Malaya, for reading through the article and made some useful suggestions.)