Letters to the Editor
This site is supported by Health ONEFrom the Ethics File
DIFFICULTIES FACED IN THE HANDLING OF OPEN LETTERS OF COMPLAINTS
When the Singapore Medical Association (SMA) receives letters of complaints against doctors or clinics, the letters are forwarded to its Ethics Committee. Very occasionally, open letters of complaints are published in the Straits Times (ST) Forum Page. There were two such letters this year, both relating to dispensing of medicine in clinics. We describe how these two cases were managed to illustrate to our members the difficulties encountered in handling such open letters.
A letter from a ST reader, Mr Tan Swee Keng, regarding the training of staff dispensing medicine in clinics (see Letter 1A) was published in the ST Forum Page on 3 July 1998. The SMAs reply appeared in the Forum Page. ST on 7 July 1998 (see Letter 1B).
(Letter 1A. Mr Tan Swee Kengs open letter to Forum Page, ST 3/7/98)QUALIFIED TO GIVE DRUGS?
Recently, I learnt that a friend was taking up a part-time job as a clinic assistant. This would include dispensing medicines based on the doctors prescription.
This worries me because she is a business diploma holder and has no knowledge of medicine.
It worries me that at clinics, patients collect medicines from nurses and, in my friends case, non-medical personnel. Wrong medicines may be dispensed, or the doctors instructions misunderstood.
My questions to the Singapore Medical Association are:
TAN SWEE KENG
(Letter 1B SMAs reply published in Forum Page, ST 7/7/98)CLINIC STAFF HAVE TRAINING
I refer to the recent letter asking about the dispensing of medicines by clinic assistants who are neither pharmacists nor pharmacy technicians (ST July 3).
The way medicine is practised differs slightly in each country, having evolved to meet needs specific to that country.
One such result in Singapore is the many clinics scattered all over the island, each offering good quality, affordable, "one-stop" consultation and dispensing services. Conveniently located, they are open long after normal hours, sometimes even every day of the year.
Precisely because of such decentralisation and long hours, and also because it is more cost-effective, most of these clinics do indeed function without in-house pharmacists.
After reaching a diagnosis and selecting a treatment appropriate for the individual patient, the doctor then writes the prescription, advises the patient on the medicine and, if relevant, the side-effects to watch out for.
The dispenser need only give the correct amounts of the correct medicines to the patient labelled accordingly, and repeat the instructions on how and when to take it. All these details would have been specified by the doctor in the prescription.
Dispensing staff may also repeat the warnings of side-effects as a reminder, if appropriate.
The writer worries that staff, recruited without any formal training in health care, may not carry out these dispensing duties adequately.
Clearly, the job of dispensing as described is well within the capacity of appropriately educated staff after they have completed their in-house training.
The doctor is directly responsible for ensuring that the necessary standards are met by his clinic staff.
Many doctors want their clinic assistants to receive more than just informal in-house training.
For this purpose, the Singapore Medical Association (SMA) has been conducting formal training courses for health-care assistants for 12 years, the last seven under the auspices of the Institute of Technical Education (ITE) and supported by the Skills Development Fund.
ITE awards a certificate in health care, which is recognised by the state, to those who have completed the training requirements. At the end of last year, 2,286 people had participated in this training programme.
The course is fairly comprehensive. For example, the module covering dispensing practice has 36 class-hours of theory and practical training. The classes conducted outside office hours are also open to part-time staff.
Many clinics now have at least one employee who has been formally trained and state-certified in this manner.
The SMA believes that this practical, cost-effective way of delivering ambulatory care has served it well over the years. The method has made private primary care accessible and affordable to its people.
Therefore, Singaporeans need not fear that their medicine is dispensed by clinic staff who are inadequately trained.
Restricting dispensing only to a pharmacist would be an extravagant waste of this highly-trained professional time in most cases. It would be similar to insisting that bank tellers be qualified accountants.
For the minority of cases that may wish the extra attention of a pharmacist, beyond that which the doctor in a busy clinic can provide, the doctor will gladly give an external prescription to be dispensed at the nearest pharmacy.
DR CHEONG PAK YEAN
As the reader, Mr Tan has expressed concerns that his friend may not be adequately trained for the responsibilities, SMA decided to sponsor Mr Tans friend for the ITE Health Care Assistant Course. We therefore proceeded to locate Mr Tans address from various published directories. We managed to find a Tan Swee Keng in the Singapore Pharmacy Boards Register of Pharmacists. We confirmed with Mr Tan by phone at his pharmacy on 7 July that he was the said Straits Times reader and wrote to him on 9 July regarding the SMAs offer (see Letter 1C). Mr Tan replied on 15 July (see Letter 1D).
The SMA is grateful for the opportunity to explain to readers of the ST the details about the training of clinic staff.
The second case arose because of a letter published in the Forum Page ST on 6 February 1998 written by a certain Jacqueline Arcus. She complained that her medicines dispensed by a clinic "cost three times" that of a retail pharmacy (see Letter 2A).
In our reply to the letter by Ms Arcus published in the Forum Page ST on 10 February 1998, we addressed the points raised. We further invited Ms Arcus to write in to SMA with the details of her charges and the medicines prescribed, as well as other cases of over-charging known to her (see Letter 2B).
As we did not hear from Ms Arcus after a week, we decided that it was our duty to contact her to obtain details of the allegations made so that we can proceed to investigate her complaint. We tried to obtain Ms Arcus address from various sources, such as published directories and statutory sources. We were unable to locate any person with the family name of Arcus in all these directories and sources. Further, we were able to confirm that no Singapore citizen has the family name of Arcus.
We therefore wrote on 23 February to the Straits Times to inquire if Jacqueline Arcus was a pseudonym and to seek assistance to contact her (see Letter 2C). A further letter 13 March was sent out (see Letter 2D). To date, SMA has not received a reply to these two letters.
(Letter 2A. Letter by Ms Jacquelin Arcus published in Forum Page, ST 6/2/98)DOCTOR CHARGED EXORBITANT PRICES FOR MEDICINE
Many of us who visit the doctor today are
blessed with the efficiency of in-house pharmacies at the doctors. We are saved that
extra trip to the pharmacy to obtain medicines that have been prescribed to us.
(Letter 2B. SMAs reply to Ms Arcus letter published in Forum Page, ST 10/2/98)TOTAL FEES AT CLINIC MAY VARY ACCORDING TO DIFFERENT FACTORS
I refer to Ms Jacquelin Arcus letter
"Doctor charged exorbitant prices for medicine" (ST, Feb 6).
Consultation with general practitioner (GP)/family doctor:
Consultation with specialist:
The consultation fee
consists of two components: the remuneration to the doctor, and the other to cover the
clinics costs, such as staff, rental and other expenses.
We presume she would have evidence, statistical or otherwise, to justify that public statement.
We would appreciate it if Ms Arcus could write to the Ethics Committee of the Singapore Medical Association, giving the details of charges and medicine prescribed in the case mentioned.
The SMA will investigate it and any other cases known to her, and give her a written reply.
DR CHEONG PAK YEAN
FORUM PAGE: "DOCTOR CHARGED EXORBITANT PRICES FOR MEDICINE" (ST FEB 6 1998)
We refer to the above-mentioned letter from Miss Jacqueline Arcus and our response to her letter published on 10 February 1998 in your Forum page. In that letter, we have explained how medical clinics compute their charges. We have also invited her to write to us with details of the alleged case of exorbitant prices of medicine and other such cases known to her so that we can investigate these cases. To-date, we have not heard from her.
We have tried to locate her name from the telephone directory but have not been able to find an entry under that name or anyone with the family name of Arcus. We have also checked with the National Registration Office and have received confirmation from an officer-in-charge that Jacqueline Arcus is not in their list of Singapore citizens.
In the interest of the public, we have to investigate the allegations in her letter. To this end, we would appreciate it if you could confirm the following:
We would appreciate it if the Straits Times could assist us in our investigation by furnishing us the details of her name, addresses and contact numbers so that we can contact her.
We hope to receive your reply soon.
DR CHEONG PAK YEAN
(Letter 2D. SMAs second letter to ST on 13/3/98)LETTER TO THE FORUM PAGE: "DOCTOR CHARGED EXORBITANT PRICES FOR MEDICINES" (ST FEB 6 1998)
We refer to our letter of 23 February 1998, a copy of which is attached for your easy reference.
The Council of the Singapore Medical Association has directed me to investigate the matter raised by Ms Jacquelin Arcus in her letter of 6 Feb 1998. In our letter to the Forum Page of 10 January, we invited her to furnish details of the case of exorbitant prices of medication she had encountered. To date, she has not contacted us. We would like to contact her to assist us in our investigation.We look forward to receiving your reply to our letter of 23 February 1998. K
DR CHEONG PAK YEAN