Dear Miranda,

Indeed, this is a valued question. In India also most of the general practitioners (GP) do the same practise. They keep some of the generic medicines such as PCM, ibuprofen, Cetrizine, Domperidone, PPIs, Aspirin, Vitamins, and many more. What they do is, they don't fully prescribe to the patients instead GPs prescribe half of the medicine as prescription and other half they dispense from clinic.

This type of dispensing and prescribing system has advantages & disadvantages of its own. For example, it avoids any incorrect dispensing by Pharmacist if GP is dispensing whole prescription. Secondly, doctor can advise patient about medicines that he is dispensing, in this way better doctor-patient counselling occurs.

On the other side, this type of system puts the doctor in full control and monopoly issues may arise. Pros and cons will be always there but its all about how one is ethically practising his duty.

Personally I think it is a problem to have a connection between prescriber and provider. It is tempting for many to increase their income with sales of unneccessary drugs.

Hello Miranda,

Indeed, this is a interesting question. We also have some what same system in India but the difference is 'Dispensing' not 'selling'. In India, General Practitioners (GPs) keep commonly used medicines such as PCM, PPIS (Rabe/Pantoprazole), Aspirin, Vitamins, Ibuprofen and other anti-inflammatory drug in their clinic for the purpose of direct dispensing to patients. They do prescribe drugs from outside the clinic i.e. from Pharmacy store. Therefore, Indian GPs prescribe in two half, first half is direct dispensing to patients and only doctors know it. Exactly they don't sell in this way but they charge patients via consultancy fee. However, In rural India where Pharmacy stores are not available or far to reach, there the system is same as yours.

Pros and cons will be there for any system. In this case, patients get better counselling regarding their medications from doctor. Doctor can advise patients on their dosing schedule, side effects of drugs and any other specific precautions that patients should care about. This is one of the best advantage of this system. Secondly, it avoids any mistakes in dispensing by Pharmacists. Isn't it!

If we talk about disadvantages then this system gives full control to doctors and raises issues of monopoly.

It is the problem of almost all the countries. Actually it should be provided by only pharmacist. But specially in India no one is following this.

It without consulting the pharmacist some of the medicines are just poisons. So the patient should take care about this.

It happens in most parts of our country too, and we can't say that it won't cause any danger. In addition to OTC drugs some chemist shops also made available many drugs without any authorized prescription which can lead to drug overuse issues. Again a strict rule of availing the medicine can have grave dangers in case of emergencies, but the looming danger of disadvantages/misuse asks for such a rule ( a little flexibility is suggested).

In my suggestion I should ask the general public to look up some info about the prescribed medicine in the internet as such info are made available by many organizations, thanks to their effort, just for our knowledge.

PS: No offense to medical practitioners and pharmacy, and thanks for their great work in making this world disease free

Dear Miranda

In my point of view there is no advantages when medical practitioners prescribe medication.The prescription of medication should be done by physicians only because in school of medicine the student learn to do diagnosis of the illness , how and when prescribe the medication.When medical practitioners prescribe medication there are possibilities of drug causes more problems than solutions.

Interesting question! In Switzerland, it depends on the region whether or not a GP is allowed to dispend (sell) medication. GPs with so called self dispensation usually generate a higher income, which may be an advantage as it can attract young doctors into the field and to work in the countryside. The other advantages are clear: for the patient it is a big comfort, especially if he is disabled or sick, not to have to go to a pharmacy after the consultation with the doctor. The GP has also a better control on the patients compliance. The disadvantage may be, as mentioned earlier, the conflict of interest, when GPs generate income by selling drugs. However in Switzerland, not higher but even lower total costs could be found in regions with self dispensation.

Thanks all of you for your responses. I'm not a medical doctor, but many of my students are in the process of becoming a doctor.

This is one of the reasons why I value this RG forum. We can discuss the things that we are concerned about; more than just our research questions.

We will wait to hear from our other RG members. I believe many of us have some concern (or direct experiences) in this matter. Have a great day!

I am a doctor in Sweden with goverment finaced health care. It is very tempting to increase income if your selling your goods. It feels ethically better

Michael

Hello Michael, I think that being tempted to do something that profits us is a condition that affects all humans.

My dad used to say, 'We can't prevent birds flying over our heads but we must prevent them from making a nest there'. Our well-being is not determined only by the material goods we have. Have a good weekend!

In my view, such practise should be discouraged since the practitioner tends to prescribe / give what he has and not what the patients need

Interesting question, from my experience in many Arabic countries the physicians provide (sell) the medicine at their clinics or polyclinics. The problem is that the patients received their medicines without counseling. There are a lot errors and DRP's (Drug Related Problems) happened. May be due to work load. For the good outcome of treating patients the dispensing of medications (in our countries) should be by authorized pharmacists.

Regards

In some countries, some pharmaceutical businesses rely on medics to 'push' their products to their patients. The patient is trapped by need and circumstances to buy medicines and tests even though they can not afford the costs of their own treatments. This health care 'system' dispenses health care if one can afford it. In these circumstances, people are 'persuaded' to do this because as patients they don't possess the knowledge or the alternatives to do otherwise. This enriches the pharmaceutical industry and/or the doctors that use those products in their treatments particularly where they have been encouraged by the pharma 'reps' from drug companies to favor one brand over another.

There are other countries, where Medical practices (even in rural areas) are situated near to a readily accessible dispensaries complete with a trained pharmacist. These doctors don't take their salaries in profits from their prescriptions and medications. They are paid sufficiently as medics so they don't need to own the dispensary.

Thanks Jean, Yaser, Giriyappa and other RG friends for your contributions. I really do not know if the situation where GPs dispense medicine will change, in my country.

Have a great day!

Hello Jean,

Indeed, you have picturized the healthcare scenario of a developing country in a kind way! But I must say when it comes to profit making, they just treat patient as a 'subject' not a 'patient'. Being a pharmacist all these years (though only eight year till date!), I have seen a lot malpractice. However, now a days in INDIA they are acting stringently regarding all the aspects of healthcare field and let us hope for the best outcome.

I am a pharmacist, although not working at dispensary. Judging this argument needs a lot of other things to be considered.

Developed & developing countries (urban areas):

Yes, I do accept that selling medicines by a medical practitioner will leads hazards and it ultimately causes unnecessary morbidity and burden to patient.

Developing (rural) & under developed countries:

Problems with general practitioner selling the drugs like lack of counseling, inadequate knowledge regarding drugs and drug related problems, One has to think about the most important aspect that, at least patients are getting basic health service. Many of the practitioners are not willing to practice in rural areas. Only way to encourage to do so, is increasing there profits by selling drugs in addition to the prescribing.

In conclusion, I want to say that general practitioner can sell/dispense drugs which is also ethical and useful to the societies of developing (rural) and under-developing countries.

Dear Miranda, I liked the proverb:) "We can't prevent birds flying over our heads but we must prevent them from making a nest there"

Hi Kapil, Tejas and others, do you know of places (countries, states) where it started off with medical practitioners providing the medication; and then the situation changed; so that laws were laid down that only pharmacists can dispense medicine?

Were the professional pharmacy bodies in those countries (or states) the ones who took on this challenge to push the laws into effect?

HI Miranda,

I don't think so that there will be such country where only pharmacist can dispense. Answer to your second question is like an ocean of laws and regulations. I would like to share a few of them with all of you.

http://www.e-laws.gov.on.ca/html/regs/english/elaws_regs_110058_e.htm

http://www.deadiversion.usdoj.gov/pubs/manuals/pharm2/index.html

Drugs and Cosmetics Act and Rules, Gov. of India

Hi Miranda,

Such an action is happening your neighbouring country, Singapore, which is on the way to prevent doctors from dispensation. (It turned out to be a long way since the middle of the 00's)

Astonishingly, none of the "leading" developed countries has applied an extremely restrictive policy to keep doctors 100% away from the pharmacy business. In fact, there are still practice of doctor-dispensing in U.S., Great Britain, and Canada, UNDER LAW! (I have attached several legislation documents below for your reference.)

Definitely there are pros and cons of doctor-dispensation,(Ref. 1) with ethical consideration to be the most concerned one. However, instead of stop doctors from dispensing, there are alternatives such as working on standardization and transparency in terms of treatment recommendations/guideline, prescription, dispensation, reimbursment, and, drug adminstration (e.g., to enusre that the patient actually swallowed that pill).

This is particularly relevant for developing countries. Building a wall between the clinics and the pharmcies does not solve the issue to the bone. For example, a doctor can have his/her cousin, who happens to be a pharmacist, to be the owner of the next-door pharmcy and share the profit from the medications. Alternatively, the pharmacy owner may send a pretty girl to lobby the doctor, in order to reach coalition which is conflict with or hazardous to patients' interests. In such cases, if happen unfortunately, the effort of separating doctors from medication dispensation may merely add management cost with limited effectiveness. On the contrary, public and law enforcement personnels may benefit from transparency on accessibility to the information and assessment on what and why the doctors have prescribed, and the subsequent dispensations no matter by the prescriber his/herself or by other people.

Hope it helps for you to build stronger arguments in your work!

Following are some information:

1. Doctors Dispensing Meds: Pros and Cons of the One-Stop Shop Model. http://www.carecloud.com/blog/doctor-dispensed-medications/

2. Calls build to stop doctors dispensing. http://www.scmp.com/article/502814/calls-build-stop-doctors-dispensing

3. House: Stop Doctors From Dispensing Drugs. http://www.sunshinestatenews.com/story/house-stop-doctors-dispensing-drugs

4. MOH to stop GP clinics from selling medicine. MOH to stop GP clinics from selling medicine.

5. Profiting From Pills: Should Doctors Dispense? http://www.pharmalive.com/profiting-pills-should-doctors-dispense.

6. Regulations under the Health Act 2009: Market entry by means of Pharmaceutical Needs Assessments. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/212872/Chapter-15-dispensing-doctors-services.pdf

7. Physicians Dispensing Drugs. (Alberta, Canada). http://www.cpsa.ab.ca/Libraries/Res_Messenger/M128-Physician_Dispensing_Drugs_insert.pdf

In Nigeria more than 30 years ago, physicians gave patients their prescriptions in the clinic. These doctors were more intimate with the patients, personally see them often and there were less likely issues of litigations raised in cases of unexpected outcomes.May I also add that pharmacies were few and Regulatory authorities non functional. There was less emphasis on patient safety and universal best practice standards; with the resultant higher unreported medical errors and morbidity . It has changed a lot since then and now very few medical practitioners in the rural areas where pharmacist are rare stock common "over the counter"" medications. By and large ,physicians write prescriptions and pharmacists dispense usually though issues are still occasionally dealt with among the two professional Regulatory bodies. In future it may have to be seen whether the division of this aspect of patient care impact positively on the patient who need the personalized doctor's dispensing for his psychology .In the developing areas of the world,our policy makers still toy ;sadly enough with the important issues of "Patient safety " and "Standard Qualty " of professional ethics.

This is a very good question. If physicians are allowed tp prescribe and dispense, then pharmacists should be given the permission to prescribe as well !!!

I think the skills should be separated to avoid and minimize the negative influence of pharmaceutical industry on prescriber and dispenser.

In my country prescription is performed by practitioner and the pharmacist dispense it. I think that avoiding a confusion of role is very important. However, every country has its own laws in this field and it is relevant also the presence/absence of a National Health Service, which modulates the costs in relation to the real need. An occult influence of Pharmaceutical Companies cannot be avoided anyway.

No in my opinion(may be globally) selling part is the role of the pharmacist ,diagnosis and prescribing should only be done the doctors.

Dear RG friend, I think there was a misunderstanding. Personal opinion is one thing, the laws and the Health Service of each country is different. I think that everybody cannot avoid to agree with you on the division of roles between the physician and the pharmacist, but other considerations could be taken into account when discussing possible outside influences dictated by the economic profits of the pharmaceutical companies and the real relationship cost / benefit.

Thanks for your responses, all of You :)

VERY informative and interesting.

in the modern day medicine,the GPs role is not to dispense the medications, for the patient safety and ethical reasons pharmacists are licensed for the dispensing and counseling on medication management.

Dear Miranda Yeoh and All, 

The US has long kept the roles of diagnosing, treating and prescribing separate from compounding, counseling and dispensing. The main reasons are  'conflict of interest' and provision of a 'checks and balance' system. 

This avoids physician temptation to prescribe more meds than necessary or "diagnose" imaginary diseases in order to obtain more income from the prescriptions themselves or an additional charge to administer the meds. In addition, it provides a second pair of eyes to review the medical/pharmaceutical 'orders' to see if they are warranted, contraindications and/or for drug interactions.

I am sure there are a few more reasons, but these are the main two. I do hope all countries that do not separate these two roles will be able to overcome and finally separate them for the good of their citizens. 

A concern that I have is: currently in the US we are seeing a bit of a blend with pharmacists now administering immunizations, and prescribing anticoagulants etc, in some pharmacy settings. This concerns me because it is a role reversal and the pharmacist does not have the full medical history available, that the medical doctor would have. This is mainly being 'pushed' by the health insurance companies so that they pay less for a pharmacist to do this than for a physician. Subsequently less physician's are carrying or stocking certain vaccines and referring them to pharmacists, which puts a burden on the patient to visit 2 different professionals and locations.

Unfortunately we are not seeing the same payment or reimbursement for pharmacists, as we see for physicians, t counsel pt. or administer the meds. This is an ongoing hot topic in the US among pharmacists, government and health care insurance companies. The laws have changed to allow such 'work' to be done by pharmacists, but there seems to be no actual payment to pharmacists in addition to their normal practice role, for administration of meds and counseling. The patient pays for the immunization, but the pharmacist does not benefit from that payment. He or she makes the same hourly wage whether he/she administers a medication or not. [if you are wondering the Pharm D is required to get additional training and certification to perform immunizations.]

So while the US has traditionally kept the roles separated, we are  NOW seeing some aspects of prescribing and administration of medications being performed by pharmacists. However these particular meds and administration of drugs/injections and prescribing do not require diagnosis, per se. The pharmacist is limited in what he or she can prescribe or administer. An outpatient may be prescribed a specific anticoagulant by a physician and the pharmacist orders the blood draws, reviews the lab results, writes for changes in the dosage [prescription], fills the prescription and counsels the patient. A person comes to the pharmacy for an Hep B vaccine series of 3 immunization injections. The patient has never seen a doctor for this or may have been to a doctor who told him/her to get the 'shots'. But the pharmacist is not paid extra to give the immunizations, even though new law has passed that they are allowed to get reimbursement from the insurance companies. The reimbursement may cause pharmacists to 'push' for the immunizations. I already see advertisement for such immunizations at large pharmacies. Yet if they are administering, they have a right to be paid like a physician would be.

I hope that I have painted an accurate picture for you all to see why the US has separated these roles, and what new laws allow and do not allow pharmacists to administer drugs. 

The current laws do not allow the pharmacist to diagnose per se, but rather to review labs, and adjust certain/specific meds and treat by immunization only.

I believe this may be a bit off topic, but again it shows the specific roles and why they are separate for the most part, and which may overlap.

Respectfully to all,

Jeanetta Mastron

Thanks for all updated information given