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Letter to the Editor

19 March 1998

The SMA News
Singapore Medical Journal

Dear Sir,

I refer to Dr Lee Pheng Soon's article titled "Do doctors and pharmacists understand and trust each other enough?" published in the February 1998 issue of the Singapore Medical Journal.
   I would like to commend Dr Lee Pheng Soon for bringing up cogent issues that affect the doctor-pharmacist relationship. It would be beneficial for the Pharmaceutical Society of Singapore (PSS) to clarify established and perceived misconceptions and assumptions with regards to pharmacists' roles, responsibilities and training.

  1. On the question of dispensing exactly according to prescription, pharmacists are professionally and ethically obliged to do so. This is clearly stated in the Code of Ethics For Pharmacists Section D(2) which states "A pharmacist who has accepted a prescription for dispensing will dispense the prescription exactly in accordance with the prescriber's wishes and, in particular will not (except with approval of the prescriber or in an emergency) substitute any other product for a specifically named product even if the therapeutic effect and quality of the other product are identical." Hence fears that doctors may have with regards to therapeutic substitution are unfounded. Generic drugs are cheaper than branded ones. Therefore the question of generic substitution needs to be addressed by both doctors and pharmacists collaboratively in order to alleviate the economic burden on patients and reducing healthcare costs in the long run.
  2. On the question of unregulated health products and herbal remedies being stocked in the pharmacies, the offer for sale of such products should not be construed as unethical. The main problem lies in the fact that these products are not medicines and therefore are not regulated except as food items. The other issue is the promotion of these health products and quasi-medicinal products as health-giving by the manufacturer. Medical advertisement on the label and insert of a quasi-medicinal product are controlled under the Sale of Drugs Act. Medical advertisements in general are regulated under the Medicines (Medical Advertisements) Regulations of the Medicines Act. Consumers, doctors and pharmacists should report to the Ministry of Health if they find any quasi-medicinal product making unwarranted medical claims. Pharmacists are also critical of products that have not been properly tested. In the same way consumers practice self-medication, the purchase of health products must be carried out responsibly with information and advice from pharmacists and their doctors as safe-guards. Pharmacists are ethically bound to regard the health of their patients as their first consideration. Section A (3) of the Code of Ethics states that "A pharmacist should not encourage a member of the public to purchase or obtain more of a medicinal product than he may reasonably require." Therefore pharmacists have to exercise their professional discretion in dealing with purchases of health products made by members of the public. I am certain that doctors' fears that patients are more likely to try and self-medicate with health products if they were sent to a pharmacy is unfounded given the fact that such products are available in health food ships, supermarkets and even the grocers, places which the public is more likely to frequent.
  3. With regards to the undergraduate and professional training of pharmacists, they are well equipped to take on the complementary role as members of the healthcare team.
        The pharmacy undergraduate course offered at the National University of Singapore is a 3-year Bachelor of Science (Pharmacy) and a 4-year Bachelor of Science (Pharmacy) with Honours ( 3 years B Sc. Pharmacy + 1 year Honours) degree course. Starting from the present academic year (1997/1998), it will move to a full 4- year structure with most students graduating with a B Sc (Pharmacy) Honours.
        The objectives of the pharmacy undergraduate curriculum are two-fold: firstly, to establish a strong foundation in the pharmaceutical sciences and secondly focus on competencies in patient-oriented skills based on the medical sciences, clinical pharmacy and pharmacy practice.
       These are 29 essential modules and 10 elective modules in the course. One module is equivalent to 50 hours of instruction ( lecturers, tutorials, practical). The essential modules are distributed as follows: Pharmaceutical Chemistry (medicinal chemistry and pharmaceutical analysis) = 7 modules, Pharmaceutics (physical pharmacy, pharmaceutical technology, dosage form design) = 6 modules, Pharmacy Practice (pharmacy law, pharmacotherapy, therapeutic drug monitoring)= 9 modules, and Medical Sciences ( taught by the Faculty of Medicine- anatomy, physiology, pathology and pharmacology)= 7 modules. Doctors and pharmaceutical practitioners are invited to give some of the lectures in the modules mentioned.
       Upon graduation, pharmacy graduates have to satisfactorily complete a one year pre-registration training (similar to housemanship for doctors) at an approved training center (usually in a community or hospital pharmacy) under the supervision of a registered pharmacist based on an approved training syllabus before they can register as a pharmacist. During the on year period, pre-registration pharmacists also have to attend a series of compulsory lectures organized by the Pharmaceutical Society of Singapore for example: communication & presentation skills, community, hospital and industrial pharmacy, first aid, and therapeutic sessions. These lectures are delivered by pharmacy practitioners and doctors. At certain training sites, pre-registration pharmacists are attached to a GP clinic for interaction.
        After registration, there are continuing pharmacy education (CPE) opportunities just as there are CME opportunities. The Pharmaceutical Society of Singapore has a CPE accreditation scheme which is voluntary. Pharmacists can choose to attend lectures which are accredited by the Society.
  4. On the issue of patients being able to request prescriptions from doctors, it is very encouraging to note that the SMA encourages its members to oblige their patients if requested. It would be helpful to patients and lay public if SMA can make a public statement on this collaboratively through CASE of even with PSS. Most patients do not know they can request for such prescriptions.
        In light of what has been said, as responsible health professionals, there should be greater collaboration between doctors and pharmacists at all levels which can only lead to better understanding, co-operation and respect between the two professions. Doctor's and pharmacist's roles are complementary and we need to work as a team for the ultimate benefit of patients. The goal must be to collaboratively provide a high standard of healthcare that is affordable to all Singaporeans through more interprofessional dialogues and collaboration.

Thank you.


Yours sincerely,

Pharmaceutical Society of Singapore