Friday, July 10, 2009

Medical Consultation and Dispensing by Pharmacists

Since the day I entered medical school, a contentious issue is that the doctor should be confined to seeing the patient, making the diagnosis and writing out the prescription, then the patient moves on to get his medications from the pharmacist. Till this day, this debate is still ongoing.

There are several issues involved here:

1) Will patient accept these arrangements, having been so used to getting all his treatment at the one-stop centre the doctor’s clinic?

2) Cost will definitely go up;

3) Inconvenience to the patient;

4) While the number of pharmacists has increased and the shortage of pharmacists is not as acute as 5 years ago, we have the problem of distribution of pharmacists since most of the pharmacists are clustered around the major town. Most pharmacies do not operate 24 hours. How is the patient going to get his medications at night?

In most medical practice, the dispenser is not a trained pharmacist. They are trained just to read the prescription and dispense the medications often with no idea about the functions and the side effects of the drug been dispensed. This may not be the most ideal condition to dispense medications. However, in the Malaysia context, it has served us well with minimum cost and hassle.

Some Malaysian pharmacists unfortunately do not function professionally. They would sell medications without a proper prescription. Most pharmacists would not even bother to tell the patient of the side effects of the drug. In fact, the patient hardly has any opportunity to interact with the pharmacists in a pharmaceutical outlet. What is worse is that some pharmacists also branch out into other healthcare activities that should be the domain of the doctors.

Hence, the present arrangement where the patient gets to see his doctor and his medications in a one-stop centre setting seems to be acceptable.

我踏入医学院那天,医学界已经在讨论一个争议性问题,认为医生的职责应限于为病人诊断和开药方,然后由病人凭药方到私人药店配药。直至今天,辩论仍持续进行中。


实行看病和配药分家制前,有几项问题必须探讨:

1) 病人既已习惯在同处看病和配药,他们能否接受新的安排?
2) 成本必定上涨
3) 对病人造成不便
4) 药剂师人数近年来不断生增加,而且多数分布在主要城镇。问题是,药店非24小时营业,那病人在晚上问诊后要到哪儿购药?


在多数情况,配药师并非经过培训的药剂师。他们只受训阅读配方和按配方开药,通常他们并不了解有关药物的功能和副作用。这并非最理想的做法。然而在马来西亚,这钟低成本和省麻烦的做法相当普遍。

不幸的是,我们发现国内一些药剂师没有专业地执行工作。他们没有根据处方售卖药物。一些药剂师甚至懒得告诉病人该药物的副作用。事实上,病人在药方买药时几乎没有机会和药剂师沟通。更糟的是,一些药剂师还兼任其他本由医生担杠的医药活动。

因此,维持目前挂号、诊病到配药一站式医疗服务似乎是最可行及被接受的做法。

11 comments:

alpha-banting said...

quote “In most medical practice, the dispenser is not a trained pharmacist. They are trained just to read the prescription and dispense the medications often with no idea about the functions and the side effects of the drug been dispensed. This may not be the most ideal condition to dispense medications. However, in the Malaysia context, it has served us well with minimum cost and hassle.“

Dear Y.B. If that is the govement's position, then please don't continue to waste the billion's of tax payer's money in opening up more and more faculties of pharmacy and training thousand's of pharmacist. what logic is there when you produce these professionals and yet do not give them the scope to practise professionally and contribute to the upgrading of the healthcare delivery of the country?? And you are producing a bigger and bigger pool of disillusioned professional.
if the present system is really well / good enough, and since we have perpertual shortage of doctors, my humble suggestion is to stop producing more pharmacist, retrain all the pharmacist into doctors,convert all pharmacy faculties into medical faculties to solve this shortage, and produce thousands and thousands of dispensers to expand the present "well-served" system.
...disillusioned...

varaman00 said...

I THINK DATO' SERIs view is very one sided towards the doctors. And i'm not suprised as Your are a doctor too... As a normal citizen, i prefer to buy medicine at pharmacy as it cost me lesser compared to Dr. And as i know, Dr are not dispensing medicine at clinic. Its done by a dtsff who dont have any knowledge about drug. to make it worse, if she not able to read the handwriting of Dr, she might end up giving wrong medicine to patient. That will be serious condition. Furthermore, its become a business for Drs to sell medicine as they sell even samples given by medical reps. So who is making money here? So its the best to get diagnosed by Dr and get medicine from pharmacy. As a citizen, i feel entitled to get consultation about the medicine that i'm goin to consume. As i know, so far most of the Health Minister were doctors, so i'm not suprised by MOH supporting Dr rather than pharmacist. In the end, people are at lost... U never seen and listen to the side of people... If India Can have their own dispensing right, is Malaysia bigger than India??

Tuanku said...

Hello Dr Chua,

I totally agree with your open comments pertaining to the medical consultation and pharmacists' roles in Malaysia.

It is indeed sad to learn that the current doctors and pharmacists are not working together to achieve the aspiration of the nation (i.e. to provide good services and cheaper health care to all Malaysians ) Both doctors and pharmacists are profit oriented and less care provided to their patients. Hence, BN govt has also failed to maintain health facilities and provide quality services to the Rakyat. Today you can imagined that majority patients are immigrant workers and illegal foreigners enjoying free medical facilities from our Malaysian hospitals and clinics whereas Malaysians of all races prefer to seek medical consultation and treatment from private clinics and hospitals.

Several negative reasons are as follow:-

(a) Poorly trained local specialists, nurses and medical officers in many govt hospitals, clinics and medical care centres;

(b) Foreign doctors employed by BN govts have difficulty to communicate and understand Malaysian patients culture.

(c) A single Malay monopoly in govt hospitals and clinics caused discrimination and marginalisation of other non-Malay patients in Malaysia.

(d) Local universities unwilling to take non Malay smart students in their medical intakes yearly caused brain drain of good local non Malay doctors are willing to serve in other foreign soils than Malaysia.

Similar, local patients dont have trust and confidence on the separation of professions between doctors to consult them and pharmacists to dispense the medicines. As mentioned by Dr Chua that there are many shortfalls and weaknesses in separation of doctors provide medical consultation and pharmacists dispensing roles in Malaysia.

Yes, I had a very bad experienced of seeking a medical consultation from a local specialist here. The specialist prefers to dispense the medicines in his clinic rather than allowing me to purchase the prescribe medicines from my brother-in-law, a pharmacist operating a pharmacy outlet.

I was told that the specialist will charge the same full bill with or without medicines. Finally, I accepted his medicines, then consulted my pharmacist pertaining to those medicines given. I was shocked and angry to know that the specialist prescribed many generic medicines from India but charged exorbitant prices of genuine medicines from Swiss for my stomach ulcer problem. According to my pharmacist if I take a better quality genuine medicines, then my ulcer can be cured instantly with small dosages instead of taking many generic tablets. True enough that I took the genuine quality medicines can heal my ulcer faster after few tablets to replace the volume of generic tablets. To add salt into my injury, I was expected to go for entroscopy and scanning from this specialist after completing his generic tablets. Finally my boddy was cured by my pharmacist using a better quality medicines.

The current global recession caused many middle income and poor patients seek medication and consultation from pharmacist are cheaper than doctors. Nevertheless, the patients objectives are to recover faster from sickness and illness irrespective of who cure them - Doctor vs Pharmacist today.

Cheers !!

TUANKU PERAKIAN

Abu Dhabi, Middle World.

Steve said...

蔡医生,

或许你说的没错。
但是我觉得,就我国的医疗制度而言,大部分的医生都没有很多关于药物的知识。医生很多时候都只是给病患他们可以赚最多钱的药物,不一定是对病患最好的! 我也见到过不少医生,今天先开了一种药,吃了不好,再来,然后在换一种,根本是拿病患当白老鼠!

最好的制度,应该是医生和药剂师一起合作,才可以开诊所,医生看病和建议需要什么类型的药物,药剂师开药。

邻国新加坡就不会像我们这里一样,满街都是pharmacy店。。。

I swear said...

I wanted to be a pharmacist when I completed my STPM. There was already talks in early 1990s that doctor should stopped selling drugs and leave that to pharmacists. See the money sign$$$$$.I did not get to study pharmacy (no thanks due to our quota system).

Anyway after 20 years, they are still talking about it. Imagine how we cannot decide on something so simple after 20 years of talk talk and talk.

Gozo Shioda said...

Doctor in Malaysia is the judge (clinician), jury (diagnostician) and executioner (pharmacist). There is lack of check & balance and this is a recipe for medical misadventure.

M'sian are sacrificing safety for convenience and Dr Chua SL being a medical doctor is perpetrating and advocating such practice.

alphaguy said...

Hello Dr. Chua,
First and foremost let me thank you for opening this topic, which has not been solved, eventough many Health Minister's have come and gone.Is Dispensing by Pharmacist a novel idea. No this has been the practice of all developed and developing countries around the world. The docter has his job of diagonising and prescribing medication whereas the pharmacist is supposed to dispense. Countries like India has adopted for last 60 years and have no problem.
2. Cost will be cheaper as Docters make huge profit on selling medication, whereas pharmacy's charge a 15 to 20 % margin of profit. Why do you think patients come to pharmacy now. If the docter is cheaper the patients will go to the docters clinic.
3. This inconveient is temperary, the minute that dispensing is the sole perrogative of the Pharmacist, more and more pharmacy will flourish in every taman, thus negating this assumption. Even 24 hr Pharmacy will be the norm.

4. We will soon saturate with large pool of pharmacist and many will open their pharmacy in every nook and corner.

We must move forward for the respective professional do their job as prescribed and we need Doctors and pharmacist to work for the benefit of the patient. That must be our goal.

Alpha- Semenyih.

Pearls said...

There are good and bad points la..

Everybody must not forget that there are still quite a large number of ignorant and illiterate Malaysians around and if this doctor diagnose and prescribe while pharmacist dispense medication practise is to be enforced, these ignorant and/or illiterate, especially the old ones will have helluva headache time!

Number 1, these people will find it very hard to understand why the tedious practise of having to see a doctor and later, go to a pharmacy to buy the medicine from the pharmacist. Dah la, sick.. dah la, not tip top condition, some more here go there go... Not all pharmacy is located near a doctor's clinic mah!

Number 2, dealing with pharmacist can be a headache even for an educated and "know a little bit of things" adult. Some pharmacist can be 'hard' on the patient. Questioning this and that.. than recommending this and that. It can be very confusing and "painful" for anyone!

Number 3, such practise is bound to be abused. Some people will forge a doctor's prescription, some will claim lost of prescription and begged to be given the required medication.. The whole list la. Malaysians are creative lot of people when they want something.

Number 4 of course is a big inconvenience practise! Ya, ya, ya.. easy for all to say but try handling a 1 year old kid at a doctor's clinic where you have to wait for hours and than wait again at the pharmacy! It can drive you nutz! And so what if you save a few bucks here and there? Will these few bucks saved good enough to compensate if something happen to your sick child? And let's not forget that employers are not very kind to parents who has to take their sick child to the clinic.

If you ask me, I dont think we are ready for such practise as yet. However, it doesnt mean we must not move towards that direction.

Progressive steps have to be taken to move towards that direction. Let's start by enforcing this practise in ALL hospitals. Get people used to this practise. Than slowly spread it out to clinics and all. Is not something you expect to yield results in a year or two la. Be realistic la!

Stop all this doctors are still dispensing medication at their clinics even they are housed at big hospitals nonsense. Put a serious stop to such practise.

Cut the waiting time at pharmacy level. You will be surprised at how tortoise these pharmacists are. GOD! I had to wait 45 minutes just to get my medication and there wasnt many people. Mind you, this is at a leading private hospital! Can you imagine government hospital? FAINT I tell you! Times like this la, you just dont care if you have to pay a few mini mega bucks more for the medication and get it over and done with because you are in pain, you are not well and just want to whallop the medication and get better!

qaefe said...

There are several issues involved here:

1) Will patient accept these arrangements, having been so used to getting all his treatment at the one-stop centre the doctor’s clinic?
Yes. Will patient accept this? Did you ask them? Did you do an unbiased public survey when you were health minister? Or were you too busy to get up from bed or for whatever reason, do not want to?


2) Cost will definitely go up;
Can you be sure? Show us the mathematics oh great master of economics

3) Inconvenience to the patient;
How inconvenient can it be? Have you done a survey? How many percentage of people claim it is inconvenient?

4) While the number of pharmacists has increased and the shortage of pharmacists is not as acute as 5 years ago, we have the problem of distribution of pharmacists since most of the pharmacists are clustered around the major town. Most pharmacies do not operate 24 hours. How is the patient going to get his medications at night?
Tell me this. At this moment, why should a pharmacy open 24 hours? Will they have customers? Maybe you are right. Maybe they will get a lot of customers who walk in in the middle of the night to buy emergency contraceptive pills when they get themselves a hitch

In most medical practice, the dispenser is not a trained pharmacist. They are trained just to read the prescription and dispense the medications often with no idea about the functions and the side effects of the drug been dispensed. This may not be the most ideal condition to dispense medications. However, in the Malaysia context, it has served us well with minimum cost and hassle.
Right indeed, if you consider lives lost being minimum cost and hassle since they do not need to spend money on medication anymore. Just spend on the burial and that's it

Some Malaysian pharmacists unfortunately do not function professionally. They would sell medications without a proper prescription.
Ahem. Can you describe to me what's a proper prescription? I don't think you know what a proper prescription is

Most pharmacists would not even bother to tell the patient of the side effects of the drug.
As if most doctors bothered

In fact, the patient hardly has any opportunity to interact with the pharmacists in a pharmaceutical outlet. What is worse is that some pharmacists also branch out into other healthcare activities that should be the domain of the doctors.
Ehhhhhhhhh, isn't this what the doctors are doing? Branching out into other activities that should be the domain of pharmacists?

Hence, the present arrangement where the patient gets to see his doctor and his medications in a one-stop centre setting seems to be acceptable.
Hell yeah, especially if you can scam the patient into believing everything you say like what you are doing now. Yeehah!

pharmalogik said...

inconvenience bla bla bla
talking about pharmacy next to the clinic? when i was about to open my own pharmacy, i choose a shop to rent on the same row of 3 clinics. and then u know what happen? a doctor asked the shop owner (his friend i guess) not to rent to any pharmacist!!!

give me the dispensing right, i will open 24 hours. no problem.

long waiting time in pharmacy? i can guarantee u can be served within 5 minutes.

cost going up? pharmacist can personally send medicine to you as well. just call me.

-MINT- said...

patients are now given a choice to choose, to buy medications from doctors or pharmacist. In my opinion, if for some reason patients prefer convenience over safety in dispensing, then get the first supply from your doctors. Some medications are meant to be taken short term, if that so, then collect them at the clinics. But for long term medications, like anti hypertensive and anti diabetis medication, u can opt to go to your nearest pharmacy to collect your monthly supplies.

However, patients must realize the benefit of getting drugs from pharmacy. I believe in most retail pharmacies we have lots of time dedicated to the patients. When asked about side effects and problems concerning the drugs, pharmacist will be more than willing to provide information about the medication. You just need to ask.

secondly are you guys aware that the person who does the dispensing at clinics are sometimes just plain ordinary people with no medical background? Would you prefer that person to explain to you on proper ways to use the medication to your love ones? or your child? who is there to detect errors if the wrong medication was given??

The reason for the shortage of pharmacist is because the government had just increased the government service period from 1 year to 4 years commenced on year 2002. even the government acknowledged the importance in the role of pharmacist. Therefore, you will be seeing many more pharmacist next year as many will be released from government hospitals to serve the community in retails.

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