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A clear statement by the President of the PSS of the stand of pharmacists towards such unregulated products of unproven worth ... will help prevent distrust and misunderstanding between our two professions.

Much has recently been said and written about the different roles of doctors and pharmacists in healthcare in Singapore. These have now been clarified by the Ministry of Health as being entirely complementary. In summary, doctors diagnose, prescribe and may also dispense; pharmacists dispense and aIso advise the public regarding options in self-medication.

I recently wrote a letter (as a member of the public, rather than as a Council Member of the SMA, or even as a doctor) to the Straits Times on that subject, and following its publication, I received several phone-calls from SMA members. From these, it became clear that inspite of the Ministry’s statement, several points regarding these complementary roles still needed clarification, in order to reduce the chance of misunderstanding between members of the two professions. The main points are:

1. Will pharmacists aIways dispense what doctors prescribe? 
Some doctors have a lingering fear that pharmacists will not always dispense their patients’ medicines exactly as prescribed. A clear statement from the PSS that pharmacists will always dispense a prescription exactly as written, will be very helpful in dispelling that myth. Unfounded fears expressed to me have included the possible substitution of the doctors’ prescription either with a generic “equivalent,” a different medicine from a similar therapeutic class, or even an OTC preparation with a claimed similar effect, without prior consultation with the doctor.

The poorer therapeutic effect that might result from such substitution is surely a vaild concern of the doctor, and this in turn is a logical reason for his reluctance to write a prescription to be filled outside the clinic. I know that such fears may seem ridiculous to some doctors and pharmacists. Nonetheless, a clear statement that a patient will always leave the pharmacy with exactly the same drugs as prescribed, will go a long way towards preventing misunderstanding between many prescribing doctors and dispensing pharmacists.

2. Do pharmacists professionally support unregulated products with unconfirmed claims of efficacy and safety?
The most outstanding displays in the community pharmacy are the numerous well-stocked shelves of unregulated products (eg herbal remedies, weight-loss products, spot-slimming creams, anti-cellulite ointments, cholesterol-lowering agents, memory enhancers etc), where neither safety nor efficacy claims have been independently evaluated (eg by the Ministry of Health). Even if the retail pharmacist makes no overt attempt to substitute part of a prescription with any of these questionable products, many doctors fear that their patients will be tempted to try a course of such self-medication instead of taking the prescribed drugs as needed, with resultant harm to themselves. We can thus understand why some doctors are reIuctant to have their patients visit a pharmacy just to get a prescription filled.

... doctors diagnose, prescribe and may also dispense; pharmacists dispense and also advise the public regarding options in self-medication.

Most doctors are skeptical of products that have not been properly tested in placebo-controlled cIinical trials, with results openly published in peer-reviewed journals. Thus, even the most cleverly packaged products are to us of dubious benefit until otherwise established. However, many such products blatantly claim on their labels _ even without verifyable basis _ that they can relieve troublesome symptoms, and actually cure some serious illnesses.

Unless the Pharmacist _ the only health-care professional present in the pharmacy _ categorically refutes these dubious claims, they may be seen as “endorsed by a health-care professional.” This is not a minor matter, as the products and their claims are by themselves already extremely seductive to the lay-person, who is less discriminating than usual because he may be desperately searching for a non-drug “miracle” cure to his disease. However, can a pharmacist avoid endorsing such dubious products, even passively, when the pharmacy he works in is so filled with them? A clear statement by the President of the PSS of the stand of pharmacists towards such unregulated products of unproven worth, and also a clarification of whom pharmacy staff would ordinarily promote such products to, will help prevent distrust and misunderstanding between our two professions.

3. Saying that complementary roles exist for doctors and pharmacists is not good enough to cultivate trust.
The complementary roles of the doctor and the pharmacist have been clearly spelt out by the Ministry of Health. However, such a declaration of itself is not adequate. The cultivation of trust and mutual professional respect between the two professions, necessary to make this more than just lip-service, begins with a better understanding of each profession by the other. For example, knowing details about the undergraduate curriculum and subsequent professional training, the beliefs and attitudes towards medicines _ detailed enough to know which of such beliefs and attitudes are shared values and which are not _ will determine how much trust one profession will place in the other, when providing joint health-care to the patient.

For example, on the one hand, pharmacists may feel that doctors, by dispensing in their clinics, may limit the pharmacist’s professional role in the retail pharmacy. In fact, not many pharmacists may know that the SMA encourages its members to write a prescription to allow the patient to independently fill at a pharmacy of his choice, whenever this is so requested by the patient.

However, on the other hand, doctors need to be sure that following the SMA’s advice, by writing such prescriptions, will never be to the detriment of the patient. They must be confident that when a patient brings a prescription to the retail pharmacy, he will leave both with the medicine as prescribed, and with dispensing advice of at least the same standard as from the clinic. This is especially important as the sharing of medico-legal liability of such joint provision of health-care is not clearly spelt out, should anything untoward happen to the patient.

Only when a relationship exists between doctor and pharmacist that is strong enough to allow mutual trust in joint health-care, will it make sense to ask the next question _ of whether such a relationship is indeed also to the advantage of the patient. Perhaps a clear answer to the recurring issues listed above, and a short reply educating doctors about the pharmacist’s undergraduate curriculum, will be a small start.