All I ever said is, when it comes to dispensing, pharmacist is the better person. I have never say pharmacist is as good as doctor in diagnosis and that sort of stupid stuff.

So which part I said is considered finger pointing? Would appreciate you pointing it out.

If what I said is correct, then it can not be called finger pointing.

Btw, let me tell you this, in bolehland, if gov wants to do something, no one can stop. So is gov really sincere in running the trial? I think you already know the answer.

Did i say SPM leavers can do a better job than pharmacists? I only mentioned "who can", not "who's better". READ READ READ PROPERLY LARRRRRR
Again, pls read properly before replying.
I acknowledged that pharmacists are in better position to dispense. I had mentioned numerous times in my posts.
I am just doubting the compatibility of such change with our current health care system. Most countries with dispensing right have a CENTRALIZED HEALTH CARE DELIVERY SYSTEM, unlike Msia.
Again, READ properly before replying.
Yeah, how do you expect the system to be better just by tweaking one subsystem, when all other subsystems are in trouble as well?

There are more important issues to be solved. Like health care personnel overworking. This issue has greater potential to kill patients.

Did i say SPM leavers can do a better job than pharmacists? I only mentioned "who can", not "who's better". READ READ READ PROPERLY LARRRRRR

well you did, from your very early post of talking about dispensing right given to pharmacist because of their advance level of human right in those developed countries. and your doubt of how safe and efficient a pharmacist can dispense compare to a doctor. you are more to generalizing pharmacist as whole rather than focused on to the pharmacist in msia or msia healthcare system.

you are sure? i am not to be honest from my observation. and i have seen plenty of dispensers in the dispensary of the clinic have none of any sort of qualification either.

I acknowledged that pharmacists are in better position to dispense. I had mentioned numerous times in my posts.

I thought i have already apologized for that matter?

Hmm, that's my observation with private clinics in Melaka and some in KL.

You have been reading too much of those conspiracy novel. Beginning to see a sinister plot in every move. But I like conspiracy novel so let's do some detective work here, shall we?

Firstly, In every conspiracy novel and movies, there must be a motive. Please tell us what is the possible motive?

For me, I can think of the following possibilities:
1. The pharmacist pay the government to give them dispensing right.
2. The SPM leaver is tired of giving out medicine and got scolded by patient because she can't answer what is that blue pills for so she paid the government to force the pharmacist to do it.
3. The doctor are fed up also so pay the government to get the pharmacist to do it.
4. The health minister wife asked for it.

Which one do you think it is 

"Who Can" mean they are all equally good. No one is better than the other.

WRITE WRITE PROPERLY LARRRRR

Bring out the champagne 

We have a break through. I may be wrong but I think this is the FIRST time you acknowledge pharmacist is the BETTER person to do dispensing.

If all Malaysian doctors also acknowledge yet, there is light at end of tunnel for improved patient safety in Malaysia. Of course, only a trial can confirm the usefulness in Malaysian context.

Hey fren, u might not visit enough clinics....based on my personal observation, i can say, roughly estimated 80% is hiring SPM leavers in KL ( my job requires me to visit private clinics a lot in KL...clarify 1st  ).

Well, can't totally said it is wrong, but with shortage of qualified nurses/medical assisstant...

You forgot one:
5. There's really not enough pharmacists, thus such trial is a sure failure. Why bother wasting money? 

We have a break through. Finally you understand my post. I already stated so many many pages ago.
Yup, perhaps. But doctors do double check with the medication if the dispenser is a SPM leaver.

Yup, perhaps. But doctors do double check with the medication if the dispenser is a SPM leaver.

I keep asking, how do you know? Since you said it there isn't enough, please provide proof.

On pharmacy figure in Klang Valley, between the Health Ministry and you, I would rather take the HM's word and not yours. Just plain logic. Because keeping track of how many pharmacy is their business, not yours.

So no offense when I say I just don't believe your word about this.

a) Total number of pharmacist (private + public)
Year / Number
1999 — 2318
2000 — 2333
2001 — 2567
2002 — 2828
2003 — 3104
2004 — 3506
2005 — 4012
2006 — 4292

a) Total number of doctors (private + public)
Year / Number
1999 — 15503
2000 — 15619
2001 — 16146
2002 — 17442
2003 — 18191
2004 — 18246
2005 — 20105
2006 — 21937

Too tired to go through past posting. But your objection to doing a trial are:

1. Not enough pharmacy
2. Doctor has been doing it for long time already
3. doctor are just as good as pharmacist in dispensing medicine.

By admitting pharmacist is the better person to do dispensing, we have settled No.2 and 3.

Just to add on & clarify some points here...

On the PILOT PROJECT....the places marked to start off this pilot project is not only confined to Klang Valley, up north, George Town is included, down south, JB is in, as well as another 2 places. However, the pullback here is there is no date being set at the moment on when to start this...but hope it will starts in 2009.

The always brought up reasons for not starting the dispensing separation will always be down to lack of pharmacists, especially on private side...which is quite true. But the situation should improved in few years to come with more pharmacist completing their government compulsory service, with the 1st batch coming out on 2009, starting April...

Trust me, the chance of that happening is small. Too small for comfort.

Doctors Prescribe, Pharmacists Dispense, Patients Suffer

by Product Of The System

Real Life Scenario

Madam Ong is a 52-year-old lady with a twelve-year-history of hypertension and diabetes. She complained of generalised lethargy, lower limb weakness, swelling and pain. She brought along her cocktail of medications for my scrutiny. Her regular medications included the oral antidiabetics metformin and glicazide and the antihypertensives amlodipine and irbesatan. Madam Ong also had a few episodes of joint pains three months ago for which she had seen two other different doctors. The first doctor suspected rheumatoid arthritis and started her on a short course of the potent steroid prednisolone. Thereafter, she developed increasing lower limb swelling for which a third doctor prescribed the powerful diuretic frusemide.

Madam Ong was not on regular follow-up for hypertension and diabetes. Additionally, she has been re-filling her supply of steroids and diuretics at a pharmacy nearby with the purpose of saving up on the consultation charges.

I took a more complete medical history and performed a thorough physical examination. I concluded that this lady’s health was in a complete mess.

She was under sound management by the family physician until the day she defaulted follow up and was started on prednisolone by a doctor who was unaware she was diabetic. The steroid probably helped in relieving her arthritic pains though the suspicion of rheumatoid arthritis was never proven serologically.
However, it also worsened her sugar and blood pressure control and weakened her immune system.

Her legs swelled up because of the fluid retentive properties of the steroids. In addition, early signs of cellulitis were showing up around her legs due to a weakened immune function. The diuretic prescribed by the third doctor helped a little with the swollen limbs but she became weak from the side effects of diuretics.

Madam Ong’s problems escalated when she decided to forgo her doctors’ opinion altogether and decided to self-medicate simply by collecting all her medications from the pharmacist who supplied them indiscriminately. Unknowingly, the pharmacist had added to the lady’s problems in spite of the wealth of knowledge the pharmacist must have possessed.

The above scenario is a fairly common scene in the Malaysian healthcare. We see here an anthology of errors initiated by doctors, propagated by the patient’s health seeking behavior and perpetuated by a pharmacist.

Noteworthy but Untimely Move

The Ministry of Health is set to draw a dividing line between the physician’s role and the pharmacist’s, restricting physicians to prescribing and according dispensing rights solely to the pharmacists.

Such a move virtually has its effects only upon doctors in the private practice and particularly the general practitioner who relies on prescription sales for much of one’s revenue.

Doctors prescribe and pharmacists dispense. It’s the international role of each profession and very much the standard practice in most developed countries.

The Ministry of Health however, has failed to take into account the local circumstances in mooting this inaugural move in Malaysian healthcare. The logic and motive behind the Ministry of Health’s proposal is in fact laudable, but only if the Malaysian healthcare scenario is more organized and well-planned.

Spiraling Healthcare Costs

In the United Kingdom, all costs are borne by the National Healthcare Services. In the United States, despite all the negativity painted by Michael Moore’s Sicko, most fees are paid for by health insurance without which one cannot seek treatment. In these countries and many European nations, there is hardly any out-of-pocket monetary exchange between patients and their clinicians.

This however is not the case for Malaysia. Most patients who visit a private clinic are self-paying clients. The costs of consultation and medications are real and immediately tangible to patients. A visit to the general clinic for a simple upper respiratory tract infection may set one back by as much as RM 50.00 inclusive of consultation and medication. Most clinics these days are charging reasonable sums between RM 5 to RM 15 for consultation. Some are even omitting consultation charges altogether in view of the rising costs of basic healthcare. The introduction of the MOH’s ‘original seal’ to prevent forgery of drugs contributed much to this.

There is no denial that most clinics rely on the sales of medications in order to remain financially viable. From my personal experience, the charges for medications by private clinics are not necessarily higher than pharmacies. In fact, since each practitioner has a stockpile of one’s own preferred drugs, the cost price of the medications can be much lower than that obtained by the pharmacists who need to stockpile a wide variety of drugs. It is therefore a misconception that pharmacies will provide medications to patients at a much lower cost all the time for all medications.

Retracting dispensing privileges from the private clinics will only force practitioners to charge higher consultation fees in order to sustain viability of their practices. In the end, the patients end up paying a greater cost for the same quality of healthcare and medications. Inevitably, much of the increase in healthcare costs will also be passed on panel companies who will then be paying two professionals for the healthcare of their employees.

In this season of spiraling inflation, this proposal by the Ministry of Health is ill-time and poorly conceived.

Unequal Distribution of Medical and Pharmacy Services

As it already is, private general practice clinics are mushrooming at an uncontrolled rate. A block of shoplots in Kuala Lumpur may house up to five clinics. Does Malaysia have a corresponding number of pharmacists to match the proliferating medical clinics? If and when clinics are disallowed to dispense medications, the market scenario will become one that heavily favors pharmacists. The struggling family physician suddenly loses a significant portion of his revenue while the pharmacist receives a durian runtuh overnight.

The situation is worst in the less affluent areas and rural districts where the humble family physician may be the solitary doctor within a 50km radius and no pharmacy outlets at all. For example, there are no pharmacies in Kota Marudu, Sabah and only one in the town of Kudat. Patients seeking treatment in these places will get a consultation but have no avenue to collect their prescription if doctors lose their dispensing privileges.

The absence and dearth of 24-hour pharmacies is also a pertinent issue. At present, many clinics operate around the clock to provide immediate treatment for patients with minor systemic upset. These clinics play an important role in reducing the crowd size and the long waiting hours at the emergency departments of general hospitals.

Without a corresponding number of 24-hour pharmacies to dispense urgent medications, the role of 24-hour clinics will be obtunded. The MOH’s plans of implementing its doctors-prescribe-pharmacists-dispense policy will merely backfire and result in the denial of services to patients.

A Bigger Problem Is The System Itself

The increasing number of medical centers around the country is not necessarily in the patients’ best interests or an indicator of improved healthcare provision. Most clinics and medical centers serve an overlapping population of patients. A person may be under a few different clinics simultaneously for his chronic multiple medical problems, resulting in a scattered, interrupted medical record. One doctor may not be informed of the interventions and medications undertaken by the patient at another practice. The concept of continuous care and a long term doctor-patient relationship is practically improbable.

This is unlike the system in the United Kingdom where each family physician is allotted a certain cohort of patients for long term care. The doctor remains in full knowledge over his patients’ progress, making general practice one that is rewarding and meaningful.

The trouble-ridden Malaysian healthcare system prevents optimal clinical practice especially for doctors in the private sector.

Until the Ministry of Heath puts in place a more systematic and organized approach to healthcare, patients will still be denied optimal medical services despite a clear division between the roles of doctors and pharmacists. The process of prescribing and dispensing is but one step in the cascade of events that may result in harm being done to the patient. Role separation between the doctor and the pharmacist will not eliminate drug-related malpractice and negligence, as I have illustrated in the real clinical scenario above.

Loss of Clinical Autonomy

Private practitioners in Malaysia are at present enjoying a reasonable sense of autonomy over the health of their patients. In many ways, the freedom of clinicians to make decisions with adequate knowledge of the patient’s needs and circumstances is a plus point in clinical practice.

Involving the pharmacists in the daily management of every patient removes a great part of the doctor’s control over the clinical circumstances of the patient. He may prescribe one drug only to be overruled by the dispensing pharmacist later. The clinician has privy to much information about the patient’s circumstances that are available only in the patient’s medical records. It is based on this information that a clinician makes decisions on the final choices of medications for the patient.

A dispensing pharmacist does not have access to such priceless clinical history and may very well make ill-informed decisions in the patient’s medications. Once again, my introductory scenario demonstrates how pharmacists can help perpetuate a patient’s mismanagement.

Selective Implementation of Rules

Rules in any game should be fair and just and implemented on both parties. If doctors are to be prohibited from dispensing, shouldn’t pharmacists too be forbidden from diagnosing, examining, investigating and prescribing?

Yet this is exactly what takes place everyday in a typical pharmacy.

I have seen with my own eyes (not that I can see with someone else’s eyes anyway) pharmacists giving a medical consultation, performing a physical examination and thereafter recommending medications to walk-in customers. It is also not uncommon to find pharmacies collaborating with biochemical laboratories to conduct blood tests especially those in the form of seemingly value-for money ‘packages’. These would usually include a barrage of unnecessary tests comprising tumor markers, rheumatoid factor and thyroid function tests for an otherwise well and asymptomatic patient.

Pharmacists intrude into the physicians’ territory when they begin to do all this and more.

Doctors may occasionally make mistakes due to their supposedly inferior knowledge of drugs despite the fact that they are trained in clinical pharmacology.

In the same vein, pharmacists may have studied the basic features of disease entities and clinical biochemistry but they are nonetheless not of sufficient competency to diagnose, examine, investigate and treat patients. Pharmacists are not adequately trained to take a complete and thorough medical history or to recognize the subtle clinical signs so imperative in the art of differential diagnosis.

In more ways than one and increasingly so, pharmacists are overtaking the role of a clinical doctor. Patients have reported buying antibiotics and prescription drugs over the pharmacy counter without prior consultation with a physician.

If the MOH is sincere to reduce adverse pharmacological reactions due to supposedly inept medical doctors, then it should also clamp down on pharmacists playing doctor everyday in their pharmaceutical premises. Patients will receive better healthcare services only when each team member abides by and operate within their jurisdiction.

The move to restrict doctors to prescribing only while conveniently ignoring the shortcomings and excesses among the pharmacy profession is biased and favors the pharmacists’ interests.

The Root Problem is Quality

A significant issue in Malaysian healthcare is that of the quality of our medical personnel. This includes doctors, dentists, nurses and pharmacists, therapists, amongst others. A substantial number of our doctors are locally trained and educated. If current trends are extrapolated to the future, the number of local medical graduates is bound to rise exponentially alongside the unrestrained establishment of new medical schools.

The quality and competency of current and future medical graduates produced locally is an imperative point to consider. Competent doctors with a sound knowledge of pharmacology will go a long way in improving patient care and minimizing incidence of adverse drug reactions. The very fact that the MOH resorts to the drastic step in prohibiting doctors from dispensing medications indicates that it must be aware of the high prevalence of drug-related clinical errors.

Much of patient safety revolves around the competency of Malaysian doctors in making the right diagnosis and prescribing the right medications. Retracting dispensing rights from clinicians therefore, will not solve the underlying problem. Our doctors might still be issuing the right medications but for the wrong diagnosis. In the end, a dispensing pharmacists will still end up supplying the patient with a medication of the right dosage, right frequency but for the wrong indication.

Patient safety therefore begins with the production of competent medical graduates. The problem lies in the fact the same universities producing medical doctors are usually the same institutions producing pharmacists. It is really not surprising, since the basic sciences of both disciplines are quite similar. Therefore, if the doctors produced by our local institutions are apparently not up to par, can we expect the pharmacy graduates who learnt under the same teachers to be much better in their own right?

Among other remedial measures, my personal opinion is that the medical syllabus of our local universities is in desperate need for a radical review. There is a pressing need for a greater emphasis on basic and clinical pharmacology. At the same time, the excessive weightage accorded to paraclinical subjects like public health and behavioral medicine need to be trimmed down to its rightful size. Lastly, genuine meritocracy in terms of student intake, as opposed to ‘meritocracy in the Malaysian mould’, will drastically improve the final products of our local institutions.

The MOH’s Own Backyard Needs Cleaning

Healthcare provision in Malaysia has undergone radical waves of change during the Chua Soi Lek era. The most sweeping changes seem to affect the private sector much more than anything else. The Private Healthcare Facilities and Services Act typifies MOH’s obsession with regulating private medical practice as though all doctors are under MOH’s ownership and leash.

An analyst new to Malaysian healthcare might be forgiven for having the impression that the Malaysian Ministry of Health is currently on a witch hunt in order to make private practice unappealing and unfeasible in order to reduce the number of government doctors resigning from the civil service.

Regardless of MOH’s genuine motives, it must be borne in mind that private healthcare facilities only serve an estimated twenty percent of the total patient load in the whole country. The major provider of affordable healthcare is still the Ministry of Health and probably always will be. Targeting private healthcare providers therefore, will only create changes to a small portion of the population. Overhauling the public healthcare services conversely, will improve the lot of the remaining eighty percent of the population.

At present, the healthcare services provided by the Malaysian Ministry of Health is admittedly among the most accessible in the world. The quality of MOH’s services however, leaves much to be desired. Instead of conceiving ways and means to make the private sector increasingly unappealing to the frustrated government doctor, the MOH needs to plug the brain drain by making the ministry a more rewarding organization to work in.

The MOH needs to clean up its own messy backyard before encroaching into the private practitioners’.

An indepth analysis of MOH’s deficiencies I’m afraid, is not possible in this article.

MOH’s “To Do List”

The prescribing-dispensing issue should hardly be MOH’s priorities at the moment.

I can effortlessly think of a list of issues for the MOH to tackle apart from retracting the right of clinicians to dispense drugs.

Private laboratories are conducting endless unnecessary tests upon patients and usually at high financial cost despite their so-called attractive packages. In the process, patients are parting with their hard-earned money for investigations that bring little benefit to their overall well being. Mildly ‘abnormal’ results with little clinical significance result in undue anxiety to patients. More often than not, such tests will result in further unnecessary investigations. The MOH needs to regulate the activities of these increasingly brazen and devious laboratories.

Medical assistants trained and produced by the MOH’s own grounds are running loose and roaming into territories that are far beyond their expertise. It is not uncommon to find patients who were on long term follow up under a medical assistant for supposedly minor ailments like refractory gastritis and chronic sorethroat. A few patients with such symptoms turned up having advanced cancer of the stomach and esophagus instead. The medical assistants who for years were treating them with antacids and multiple courses of antibiotics failed to notice the warning signs and red flags of an occult malignancy. They were not trained in the art of diagnosis and clinical examination but were performing the tasks and duties of a doctor. There is no doubt that the role of the medical assistant is indispensable in the MOH. Just as a surgeon would not interfere with the role of an oncologist, medical assistants too must be aware of the limits of their expertise. MOH will do well to remember the case of the medical assistant caught running a full-fledge surgical clinic in Shah Alam in late 2006.

Adulterated drugs with genuine risks of lethal effects are paddled openly in road side stalls and night markets. They are extremely popular among folks from all strata of society who rarely admit to the use of such toxins to their physicians. It is possible and highly probable that many unexplained deaths taking place each day are in some way related to the rampant use of such preparations.

Non-medical personnel are performing risky and potentially lethal procedures daily without the fear of being nabbed by the authorities. These are mostly aesthetic procedures. Mole removals, botulinum toxin injections and even blepharoplasty are carried out brazenly by unskilled personnel and usually in the least sterile conditions. It makes a mockery of the plastic surgeon’s years of training but above all, proves that the MOH is indeed barking up the wrong tree in its obsession to retract the dispensing privileges of medical practitioners.

Closing Points

In summary, a patient’s health is affected by many factors – a doctor’s aptitude is merely one step in a torrent of events. The health seeking behaviors of patients play an imperative role in the final outcome of one’s own health. Most harm to patients can only occur as a result of unidentified minor errors in the management flowchart of a patient. If allowed to accumulate, such errors converge as a snowball that threatens the long term outcome of an ill person.

There are a multitude of other clinical errors apart from prescribing and dispensing, some of which are not at all committed by trained medical staff. The MOH must get its priorities right by first overhauling an increasingly overloaded public healthcare service.

Lastly, the difference between a drug and a poison is the dose. A toxin used in the right amount for the right condition is an elixir. A medication used in the wrong dosage and for the wrong indication is lethal poison.

Perhaps. Then why did the authority concerned withdrew the decision to run the trial? You think we doctors and DAP can force the gov to do that?

You want proof, here:

Source
Now let's us look at number of doctors in Msia:

Source
The number of pharmacists is roughly 1/5th of that of doctors. When there are only 4292 pharmacists available in the whole of msia back in 2006, you think there's enough pharmacists in Klang Valley?  It doesn't take a genius to answer this question.

2. Educate public regarding role of pharmacists.

Perhaps. Then why did the authority concerned withdrew the decision to run the trial? You think we doctors and DAP can force the gov to do that?

You want proof, here:

Source
Now let's us look at number of doctors in Msia:

Source
The number of pharmacists is roughly 1/5th of that of doctors. When there are only 4292 pharmacists available in the whole of msia back in 2006, you think there's enough pharmacists in Klang Valley?  It doesn't take a genius to answer this question.

A very good article by YB Lim Kit Siang:

Source

I strongly advice a thorough reading of this article before replying, especially Mr. Opti.

I see lack of education and awareness being the main issues. Heck, even our resident doctor Hypermax don't fully comprehend the role of pharmacist, what more the common public?

If consumers can realize the safety issue, they may be more willing to foot the bills just like more willing to pay extra for car's ABS/airbags things. But if they don't realize the benefit, why would anyone want to pay extra? I wouldn't.

I am disappointed with LSK. For a person of his position and supposed wisdom, he should at the very least know about the extra safety issue and give a more balanced opinion before opening his big mouth. But from the look of it, he is a ignorant as any 3rd citizen. He really should travel a bit more and see how advanced country does thing.

As for the number of pharmacists, when there are only 4000 plus in the whole of Msia (both private and gov), you think there will be enough in Klang Valley? Use your brain. I am beginning to doubt your capability as  a pharmacist.

What's wrong with your eyes? I have said MANY times that the authority DID NOT WANT TO cancel the decision.

It was the complain from DAP (remember, the BN lost a lot of seat after Mar-08 so take DAP complain seriously) that make the authority withdraw it.  I have shown you the link before. Go check it out.

Get that into your hard skull please.

You are the ignorant one. If countries like UK, patients don't have to pay extra, as NHS will cover the cost.