3 years ago, i wrote an article about a pharmacy which was treating patients like a doctor‘s clinic. In fact that was the 2nd time I wrote about the same pharmacy. For the first, I sent an official complain to Jabatan Kesihatan/KKM and for the 2nd I sent the letter to JKN. However, I never received any further feedback from any one of them. Typical of any government agencies which never provide any feedback. Wonder whether it is under Official Secret Act!
While over the last few years, I do see patients being prescribed medications by pharmacist which they should not be prescribing in the first place, I just kept quiet as I felt it is worthless complaining. I have seen Prednisolone being given by pharmacist without prescription and even NSAIDS being given continuously without even knowing the patient’s renal status. Worst still, I have even patients buying Methotrexate from pharmacy without even my prescription.
Last week, yet again I saw the VERY SAME pharmacy/pharmacist prescribing the following 2 medications to a patient with poly arthritis of 1 year duration!
According to the patient, she was not even examined by the pharmacist. He just listened to her complains and gave her the medications above. One is a steroid(Betamethasone) and another is Sulphasalazine! Patient developed allergic reaction to Sulphasalazine and THANKFULLY, she stopped the medications. Sulphasalazine contains sulphur and allergic advise should always be given as it can cause Steven Johnson Syndrome and Toxic Epidermal Necrolysis. I will always advise patients about allergic reaction whenever I prescribe Sulphasalazine. Furthermore, this is a generic Sulphasalazine! Finally, one fine GP referred this patient to me.
So, what action has the JKN taken to this pharmacy? How in the world they can continue to prescribe these type of medications to the general public? I forwarded yet again this picture to a colleague of mine in JKN for further action. While I don’t expect anything much but at least I have done my job to protect the public.
ON another note, why did this patient even landed up with a pharmacist? Sometimes, we are to be blamed for all these issues. Patient had seeked multiple consultations from various GPs and Klinik Kesihatans but was only given NSAIDS. Patient has clear-cut Rheumatoid Arthritis. Her RT wrist is almost fused now.
Then we have TCM practitioners who are happily treating patients with “so-called” herbal medications which obviously contains steroids. The moment the patient walks into my clinic, I will give them a spot diagnosis and most of them will be shocked! An obvious Cushing’s syndrome. Serum Cortisol levels will be < 16 in almost all these cases. I do this just to prove to the patient that they have been taking exogenous steroids. Interestingly, recently I came across a patient who was given intravenous infusion by a TCM practitioner over the last 2 months. It was given periodically with tapering dose durations. The patient has Rheumatoid Arthritis. The patient definitely looked Cushingoid. Was he giving steroid infusions? “ Hari ini masuk ubat, besok boleh lari lor“, exactly what the patient told me! Obviously it is steroids! I wonder whether the person giving it knows that these are all steroids and nothing miracle! Or are they giving western medicine in the name of herbal medicine?
I call a spade, a spade all the time. Many do not like me because of this but I have my principles. Patient safety comes first in all instances. Sometimes, we doctors are to be blamed for all these distrust going on out there. While I have said that patients are becoming more and more naturalistic, claiming we are giving chemical to destroy their kidneys etc, doctors are also venturing into unethical medicines. Unethical practices are NOT uncommon nowadays. I have seen enough steroids being given by doctors themselves. Just saw a 76 year old man with OA knees given betamethasone daily for the last 3-4 years. The daughter is asking me why is his skin becoming thin with easy bruising! How am I suppose to answer that when I know exactly what’s the answer. I saw a patient with generalised body-ache being given Prednisolone 5mg tds! Am I outdated or something? Many doctors out there still do NOT label their medications despite the law mandating it. Eventually business and profit takes over you, either consciously or unconsciously!
It’s called “Prostitution of Medicine“, a word described by the late Prof TJ Danaraj, the founding Dean of University Malaya medical faculty. Commercialisation of medical education and medical practise will eventually lead to this. Medicine is used to make money. It’s not a noble profession anymore.
The world on the other hand is going mad, especially in Malaysia where race and religion is used for business. WE have doctors promoting anti-vaccination (circulating in Facebook) and home birth. In fact, my wife just saw a HO who refuse to vaccinate her child! She is still doing her Housemanship. Interestingly, her husband who is not a doctor is not against it !We have doctors promoting supplementary products claiming can cure every illness in the body. We have an apex University promoting miracle water, suppose to cure 150 illness. We have syariah compliant dental clinics , whatever it means! What’s next ? Halal and Non-Halal clinics/hospitals? Trust me, we will be seeing more and more of these type of issues creeping into this country.
The practise of medicine is never the same anymore. I enjoyed practising medicine during the first 10 years of my service when patients listens to you and unethical practices were almost unheard of. Now, it saddens me when I see patients refusing medical treatment, refusing vaccines, unethical doctors, lost of clinical medicine and the rise of investigative medicine(make money for corporate guys). The rise of vaccine preventable infections like Diphteria and Measles are part of the consequences of our society’s ignorance. Wondered why our medical forefathers created medical councils run by medical practitioners to control the ethical practise of doctors? They had predicted few centuries ago that medical practise can be misused for profit and the world of medicine will eventually undergo slow death.
Many youngsters will realise all this when they start their practise. With more and more doctors being produced with huge debts behind them, medical business will only get worst! While my books will hit the stores within the next 2-3 months, I am now preparing for my 3rd book which hopefully will be released next year.
Selamat Hari Raya 2016 to everyone……………
Pagalavan's Avatar 
Spot on Doc!
That’s why I always said (too) that the medical fraternity need to clean their own backyard first, before pointing fingers and condemning the sinseh/bomoh/beautician/pharmacist malpractice. Giving ozone blatantly, and trying to back up with some German studies, will further confuse the already confused public. And putting up FB page with clinic name in the photo, but promoting “alternative treatment to cancer” using alkaline water and cranberry extract tablets are just another laughing stock for the pharmacists and sinseh fraternity. Funnier still, these doctors talk like as if they know a lot and very experienced (compared to the other more junior doctors) in the DOBBS and MPCN sites. LOL!!
Well said!
Unfortunately there will always be a few black sheep that spoil the name of the fraternity. Even more unfortunate is the fact that they are mushrooming and people seem to trust them
Well said… Nothing but true… There’s a lot of pure abuse in the medical field…. Also lack of medical knowledge is to blame… Many patients prefer to listen to the coffeeshop drs for advice rather than the actual Dr. We are living in a laid back society where most of the people do not know what they are prescribed with and also there’s lots of drs put there still do not label their medicines… I’ve come acrossed drs selling expired meds intentionally and also with simple labels such as allergy… Pain, fever… Which is entirely opposite of the law.. There’s also many practitioners out there that do not discuss and explain the medical conditions to their patients and always assume I’m the Dr and you just listen la… In fact no discussion of what is the patient’s actual medical conditions… There’s lots of wrong doing in Malaysia by medical practitioners and sad enough this has been on going since 30 years back…. So without any finger pointing , there’s much to be done by the MOH in educating the people and create more awareness… We’re at least 20 behind Western countries in terms of medical knowledge… Worse of all.. An example, patients don’t even know he/she had type I or type II diabetes… Nor they can differentiate RA or AS… again they are clueless that it is auto immune disease… Hopefully one day our society will change for good
Yes, exactly. That’s why I feel we should look at our own backyard first. There must be some form of check and balance system for doctors. The only way this can be done is when we have a National Health Financing system where anything can be audited.
the pharmacist getting revenge aright..
for the ruuf shit that the doctors doing lololol
Those who practice anti vaccination are the worst. They cause their children to be very sick or die is one thing, but infecting other children who are too young or have conditions that make vaccination a contraindication is another. I guess it’s nature’s way to cull the herd. Take out people with the stupid gene before they get the chance to breed
I love to read your articles. I’m not a doctor but it’s gives me some knowledge about medical world.
Expect deviant doctors to increase in number. It is expected when many unqualified students get to become doctors. Coupled with the excess of doctors, and the debt many start with on graduation, expect crass human nature to take over from professional altruism in medical practice.
The irony is most deviant doctors are those senior ones in the fraternity! Even those antivaxxer…
Yes, of course. The doctors tsunami has just only hit junior MO level. In the next 2-3 years, it will hit postgraduate training. Wait till it hit private practice.
Maybe patients need a “consultant” to advise them who to consult, in the very near future. 😉
I agree with some of your points. If Malaysia has prescriping separation between doctors and pharmacists like UK, Singapore or Australia. A lot of the problems would be solve. None of the pharmacists will dispense without a RX and doctors can’t sell or dispense medicines in their own clinic without a pharmacist. Everyone has their own responsibilities. Unfortunately, we are living in a developing country.
Doctors in Singapore are allowed to dispense medications.
In countries where there is complete separation, both doctors and pharmacists both work within the same healthcare system, eg the NHS, or both are paid through a common health financing payor system, like Medicare in Australia.
In the USA, where the bulk of healthcare is private (insurance based), doctors are allowed also to dispense directly from their clinics. However, it’s still not a common practice (accounting for only 10% of scripts at the moment), but ironically it is been touted as one of the strategies to reduce the cost of the exorbitantly expensive healthcare system there! And it reduces non-treatment, as up to 30% of scripts issued never get filled by patients.
Therefore, proponents of complete prescribing/dispensing separation should look at history, and at what is happening in other countries, and realise that the ideal of separation can only work efficiently in an environment with clearly defined practice and reimbursement system. Any free for all system, as exist in Malaysia, will invite the inevitable abuses and cost escalation.
Dear doc, fingers pointing is common in every industry. In Malaysia, unfortunately we don’t adopt Dr prescribe pharmacist dispense system. Eg NHS system as in the UK. We claim ourselves towards an advanced country, yet our health care system moving backwards. Even if we don’t talk about the NHS system, there’s no patients information database between government hospitals, private hospitals and private clinics. We had seen patients missed their meds from government hospitals and visit a private clinic, for HBP meds, only to get a duplicate of the meds. Patients went back home to discover one generic med and one ethical med. Both meds were taken. Results? Non compliance in meds doesn’t happen only within docs and pharmacist, it happens everywhere. Let’s face it, it’s a fact. Health care system in Malaysia isn’t perfect. Everyone in the industry, especially private ones, try to make more profit from their health care services. Two factors play in the profit margin ie medication and consulting fees. If there’s a great health care system that could be enforced to ensure no wrongdoings to each party, equal chance for “cari makan” for docs and pharmacist, patients are well taken care of, I’m sure majority of the health care players and public would be happy to oblige. We’d seen pharmacists who undercut roles of doctors, we’d also seen doctors who sell direct sale products to patients. These aren’t medical practitioners. These are business heads who think more about their profits rather than medical ethics. Cheers
I can foresee problems that may arise from DS. This week alone i had to scope 3 patients with acute UGIB secondary to NSAIDs, given OTC without prescription for joint ailment. Most these are old patients. Had they been seen by a dr and proper workup done, followed by proper analgesics with follow up, its potentially preventable cause of UGIB
To be frank, doctors have also caused this. BUT pharmacist should not be giving NSAIDS continuously.They should know the consequences
Yes, exactly. All these problems can be solved if we can come up with a National Health Financing Scheme. Only then all prescriptions can be audited and a check and balance system could be formed.
I guess you can say we have good infrastructure in place ( GPs, KKs, KSM, Pharmacies, Private Hospitals, Private labs, Government hospitals, Institutions) but poor operational setup. Some genius has to meld all these into one cohesive, workable healthcare provider system.
The first step: Define the roles of the pharmacist and the doctor. It is not unusual that very bright students have opted for pharmacy and not so good students have become doctors. Now if qualifications are recognized by the law of the land, everyone has to accept that. It is also not unusual for early bright sparks to fade and late bloomers to shine. We have to accept that the pharmacist knows best about medications and the physician the intricacies of diagnosing and then prescribing. The pharmacist can question the rationale of the prescription but is ill equipped for a proper diagnosis. Hence the dispenser cannot become the prescriber but the converse is true as the prescriber bears full responsibility for his/her patient. So, a doctor can dispense but a pharmacist cannot diagnose. Any point of care testing (POCT) should be allowed to the pharmacist especially because it is just that: a point in the care of the patient when the diagnoses are not made yet. This is where the haggling and patient’s knowledge levels and affordability kick in. It is after all a free market folks.
The second step: The gargantuan task of having a payment, reimbursable scheme/schemes that are crosstransactional. For example if a poor patient lands in a 5 star rated hospital as an emergency, the scheme must work for the person in life saving situations until such time the patient is transferred to a facility paying under the said patient’s scheme. Of course this is open to abuse and that is why ER everwhere have to have very discerning medical officers. People should have the freedom to top up, such as copayments or out of pocket if the person is so happy with the current management.
The third step: Devise disruptive, innovative ways to provide health services for eg, uber doctor, supermarket screening, health department managing city wastes, drainage, parks & abandoned land.
Then, doctors shouldn’t dispense drugs to patients. If they don’t want pharmacists to interfere with their jobs, they shouldn’t interfere with pharmacists’ job at the first place. And if the RUUF shits are going to be implemented, then malaysia doesnt need any pharmacist…why cant doctors just do what are they suppose to?Take India as an example…they dont have to go through conflicts like this because of the dispensing rights separation
Everyone want to “cari makan”. That’s the problem.
In Malaysia, it is almost impossible to implement the complete separation of consultation and dispensary jobs. In other countries, the separation of consultancy work and dispensing of drugs can be done because most of their doctors and pharmacists work under a centralized healthcare system or under the same hospital. For example, just look at our neighbour country Thailand, you hardly can any clinic, if there is one exist. Even if you want to seek consultancy for flu or fever treatment, you have to see a doctor at the nearest hospital and you have to collect your medication from the dispensary in the same hospital or their named panel only nearest to your home.Here in our country, our ministry is proposing separation without looking at our healthcare structure first. Sole proprietor clinics and pharmacists are everywhere running their own businesses. If this separation of duties are to be implemented here in our country, you will definitely see patient buying their medication directly through the pharmacist without having to spend the extra money to seek consultation from a doctor first.
Hi dr pagalavan,
I wanna ask, in ur opinion is twinning programme in medicine good? How about the quality?
Thank u
Depends on which one you are talking about
doctor pagalavan, i hope u will success to educate public from being a human stone age.
If the public do not trust doctors, then what is the reason behind they took medicine given by retail pharmacists?
Can pharmacist who were never trained to diagnose during their uni days, examine me better than doctors?
I know is common sense that wrong diagnosis is lethal to anyone,
but why doctor spend so much time to become specialist?
Why cant doctor just skipped the training part and dispense specialist medicine/treatment like retail pharmacist?
Isn’t that much faster?
Do we have prescription software in Malaysia to proofread prescription error like in oversea?
Do we have any software/machine to check for dispensing error in Malaysia?
I am so confused..
No such prescription software in Malaysia. We do not have a national health financing scheme in Malaysia to monitor doctor’s prescription practices.
As for the rest of the questions, you are living in an ideal world! In reality, patients will always go where it is the cheapest!
Greetings sir,
Can I have your email address please? I need your opinion regarding housemanship. And its pretty personal. Hope to hear from you soon. Thank you.
Pagal72@gmail.com
[…] keep increasing. A lot of black sheep are appearing in our noble profession as I mentioned in my last blog post. A new medical indemnity scheme has been introduced this year. Interestingly, since the new scheme […]
Very said to hear about this, prositution medicine really bad
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