In Malaysia, many patients with one or more chronic diseases tend to visit different physicians or specialists, and for subsequent refills of their medications, many choose to pick them up at local community pharmacies for convenience. It is an undeniable fact that a number of patients are price-conscious as well when it comes to replenishing their chronic medications.
Such practices pose a difficult situation for both the patients themselves and also health care professionals, as inter-professional communication is almost non-existent in our current health care practices. Physicians from different institutions do not communicate with each other, and doctors certainly do not effectively communicate with pharmacists or dietitians or nutritionists or any other health care professionals, and none of these professionals talk to each other either.
The missing link in communication between health care providers is the key that prevents optimum therapy outcomes for patients, and the lack of dispensing separation adds to the same problem as there isn’t a connected system to effectively regulate the entire health care process from diagnosis to prescribing medications to the dispensing of medications.
The severe disconnection in the health care system makes it impossible for any provider to be fully informed of the patient’s current health condition and his or her complete list of medications and supplements. Such dysconnectivity in health care not only affects the patient outcomes, but also raises issues in terms of medication safety.
Putting Patient Outcomes First
Putting patients first means that we really put the patients’ best interest as a priority whenever we provide any kind of care as health care practitioners. The quality of care that is provided to patients should be all-rounded and be completely without bias.
What it means to be “all-rounded” is to be able to provide a solution to patients’ health complaints while also educating them on their health conditions and medications to help them understand the state of their health. In addition to patient education, we should always provide health care empathetically and with respect for those that seek such care from us.
In my pharmaceutical practice, I often hear complaints from customers about their experiences with their health care providers whenever they asked questions about their health conditions.
One of the more commonly heard complaints is their provider replying with “even if I explain, you wouldn’t understand” following the patient’s questions about their health. While I don’t know the prevalence of such questionable quality of care, the lack of empathy and professionalism from these stories is rather upsetting.
During my time in the United States, we were trained to provide health care with empathy, respect and professionalism. Patients seek help from health care professionals because that is our profession, and it is our duty to uphold our profession and to basically “do our job” to educate and to provide the necessary care to our patients.
After all, what passion drove you to pursue a health care degree in the first place?
The recently released National Health and Morbidity Survey 2019 (NHMS 2019) pointed out that as many as 35.1 per cent of Malaysian adults have low health literacy — that’s one-third of the population! Low health literacy has long been a public health issue in Malaysia as it was also pointed out in NHMS 2015, and at that time the recommendation from the Ministry of Health (MOH) was “to address the issue of low health literacy, health professionals and community must be knowledgeable, aware, and responsive to the health literacy of patients and population.”
Normalise Health Care Interprofessional Collaboration In Malaysia
One of the key strategies adopted by many healthcare practices around the world is Inter-Professional Collaboration in Health Care. Inter-professional collaboration occurs when two or more professions work together professionally to achieve a common goal, and that common goal would be to deliver the highest quality of care to mutual patients in the health care setting.
According to the World Health Organisation (WHO), the implementation of inter-professional collaboration and learning to work together with mutual respect fo each other’s perspectives allow for multiple disciplines to work more effectively and efficiently as a team to ultimately improve patient outcomes.
“For health workers to collaborate effectively and improve health outcomes, two or more from different professional backgrounds must first be provided with opportunities to learn about, from and with each other,” WHO’s Framework for Action on Inter-Professional Education and Collaborative Practice states.
In the same text, the WHO also explained that comprehensive services in a wide range of healthcare settings can be provided with inter-professional collaboration between health care professionals and that “it is within these settings where the greatest strides towards strengthened health systems can be made.”
The Role Of A Pharmacist In Improving Patient Outcomes
In the US, pharmacists serve as the medication safe use checkpoint, whereby the proper use of a medication is thoroughly evaluated before dispensing to ensure that the right medication is given to the right patient in the right dose by the right route and at the right time.
It is our duty to ensure that there is no drug-drug or drug-food or drug-dietary supplements interactions for those that are on multiple medications and/or dietary supplements.
In addition, having access to patients’ lab reports is crucial in determining the appropriateness of many drugs on the market — whether the patient should continue taking the same drug, change the dose of the same drug or switch to another — it often depends on obtaining and studying the patients’ certain lab parameters that would allow pharmacists to truly exercise our expertise.
As such, important lab parameters are usually provided for pharmacists in the US for approval before certain drugs are dispensed both in the hospital and community settings.
It is also common practice for pharmacists to request for certain lab reports before certain drugs are dispensed to certain patients.
In other words, pharmacists are trained to interpret lab reports and are able to provide appropriate recommendations related to one’s pharmacotherapy upon studying their lab results.
Simply put, the whole dispensing separation system adopted by many parts of the world allow for medical doctors to focus on diagnosing and monitoring a patient’s disease, while pharmacists monitor the drug therapy.
Such a practice allows for inter-professional collaboration with effective communication to optimise patients’ outcomes from their pharmacotherapy and at the same time greatly minimises medication errors or inappropriateness.
In Malaysia, private general practitioner (GP) clinics do it all — from consultation to diagnosing ailments to dispensing medications. The main concern of such practice is the potential conflicts of interest as GPs profit from the prescribing and sale of prescribing medications.
This may lead to unnecessary and/or over-prescribing as cited by Dr. Vivienne Mak and Dr. Mohamed A. A. Hassali in their editorial published on the Journal of Pharmacy Practice and Research.
Furthermore, current practices in GP clinics do not hire pharmacists to dispense medications. Most of the workers in GP clinics do not even have any pharmaceutical training, especially those that dispense medications to patients that visit the clinic.
Such a practice means that no one checks on the safety and appropriateness of the medications, nor would they know anything about the drugs that they are dispensing in terms of cautions and side effects. Ultimately, it takes a pharmacist’s expertise to understand and dispense medications.
In my experience, some GP clinics dispense medications without proper labelling of the medications according to MOH standards, and most of them do not take the initiatives to find out whether the patient is taking any other prescription or non-prescription medications or dietary supplements before dispensing the medications prescribed.
Pharmacists in the US verify prescriptions before dispensing them, and if there is a valid reason to reject the prescription, the prescriber’s office would be contacted to either amend the prescription or to issue a new one.
Any sort of medication cannot be dispensed unless a registered pharmacist has verified its appropriateness for use for that particular patient. Presently, such inter-professional collaboration isn’t practised in Malaysia without dispensing separation policy in place.
The long-time argument from various organisations including the medical associations against dispensing separation in Malaysia is that such policy would increase health care costs for the public and that there may not be pharmacies readily accessible in rural areas.
While it is understandable that GP clinics with dispensing privileges may be suitable for the rural areas, the argument that the separation of dispensing policy would drive up health care costs for the public may not be true as shown in a local study, where consumers may end up paying more getting the same brands of medications from the GP clinics compared to community pharmacies.
The Poison Act 1952 mandates that pharmacists can dispense Group C poisons without any prescription from medical doctors. Group C medications are mostly drugs targeted towards common ailments such as the common cold and flu, cough, fever, headache, etc.
Over-the-counter (OTC) medications are also readily available in community pharmacies for minor ailments when prescription-strength medications are not needed.
Nonetheless, it is a fact that there are bad apples among community pharmacies. Some may not put patients’ best interests first and may also be profit-driven in their daily business operation. However, the entire profession and the entire pharmacy industry should not be blamed for the fault of a few bad examples.
In this new decade that begun with the Covid-19 pandemic, there is a new generation of pharmacists who strongly believe in putting patients first. We are also confident in the benefits of inter-professional collaboration.
In my practice, we educate and encourage our patients to regularly follow up with their medical doctors, and also to regularly obtain the necessary lab tests for their specific conditions because we as health care professionals understand the importance of disease progression monitoring.
Mutual Respect Between Professions
There isn’t one health care profession that is superior to the other as every health care professional play an important role in the medical field, and there should be mutual respect between professions.
Medical doctors are trained in diagnosing illnesses and prescribing medications, and pharmacists are trained to be drug experts, hence their duty to dispense medications.
Dietitians are trained in medical nutrition therapy hence their expertise in diet planning, nurses are trained to provide direct care to patients, and physiotherapists are trained to rehabilitate patients’ mobility, function and well-being. The list goes on.
It is only when health care professionals can mutually respect each other’s profession and be able to learn from each other that inter-professional collaboration is possible.
SL is a doctor of pharmacy (PharmD) graduate and a passionate community pharmacist based in Kuching, Sarawak.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
