Case 1

(Letter 1A. Mr Tan Swee Keng’s open letter to Forum Page, ST 3/7/98)

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 doctor’s 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 friend’s case, non-medical personnel. Wrong medicines may be dispensed, or the doctor’s instructions misunderstood.

My questions to the Singapore Medical Association are:

(Letter 1B SMA’s reply published in Forum Page, ST 7/7/98)

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.

DR CHEONG PAK YEAN

PRESIDENT, SMA

As the reader, Mr Tan has expressed concerns that his friend may not be adequately trained for the responsibilities, SMA decided to sponsor Mr Tan’s friend for the ITE Health Care Assistant Course. We therefore proceeded to locate Mr Tan’s address from various published directories. We managed to find a ‘Tan Swee Keng’ in the Singapore Pharmacy Board’s 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 SMA’s offer (see Letter 1C). Mr Tan replied on 15 July (see Letter 1D).

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’.

(Letter 2A. Letter by Ms Jacquelin Arcus published in Forum Page, ST 6/2/98)

Many of us who visit the doctor today are blessed with the efficiency of in-house pharmacies at the doctor’s. We are saved that extra trip to the pharmacy to obtain medicines that have been prescribed to us.
Unfortunately, in some cases, that extra trip would be worth it for the money saved.
During a recent visit to my doctor, I was surprised to find that my medicine from the in-house pharmacy cost three times what I had paid a few months ago at a local pharmacy. They were of identical brands.
Armed with the unused tablets, I returned to the doctor, explained the situation and asked for a friend.
I was given a refund with no comments made.
I waited intently for an apology, an explanation that there had been a disastrous mistake, but I was met with silence.
I went back to the local pharmacy that same day and found the price identical to that a few months ago.
This incident has made me uneasy. Questions about trust are raised.
For instance, are doctors using their in-house pharmacies as a way to increase their profits?
How many people realise that they are paying exorbitant prices for medicines that are cheaper in the local pharmacies?
In my case, I have started seeing two images of the medical doctor _ the kind, wise benefactor wishing me well in his or her office, and when I reach the in-house pharmacy, the ambitious practitioner stealing from my purse indirectly.

(Letter 2B. SMA’s reply to Ms Arcus’ letter published in Forum Page, ST 10/2/98)

I refer to Ms Jacquelin Arcus’ letter "Doctor charged exorbitant prices for medicine" (ST, Feb 6).
Clinic fees usually cover both consultation and medicine.
The June 1996 SMA Guideline on Consultation Fees released recommends the following:

The consultation fee consists of two components: the remuneration to the doctor, and the other to cover the clinic’s costs, such as staff, rental and other expenses.
It does not cover medicine, procedures and investigations, which are charged separately.
A survey of housing estate GP clinics conducted by the SMA in 1996 found that the mean professional remuneration was $9.23 and the mean cost of practice was $9.81, giving a total mean consultation fee of $19.04.
For medicine dispensed in clinics, the SMA recommends that charges be based on pharmacy selling prices.
A prescription fee may be levied instead of the usual consultation fee under certain circumstances.
The total bill size for professional services in clinics may therefore vary according to a number of factors.
Ms Jacqueline Arcus generalised from her personal experience when she asked. "How many people realise that they are paying exorbitant prices for medicines that are cheaper in the local pharmacies?"

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.

DR CHEONG PAK YEAN
PRESIDENT, SMA

(Letter 2C. SMA’s letter dated 23 February 98 to the Editor, ST to enquire about Ms Arcus’ contact)

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:

1. That "Jacquelin Arcus" is the name of the person who wrote the letter to the Forum Page which was published on 6 Feb 1998;

2. That "Jacquelin Arcus" is her statutory/legal name. If not, we would like to know her statutory/legal name.

3. That the Straits Times has verified her status in Singapore viz citizen, permanent resident, professional/work pass holder, visitor etc; and the legal identifier viz NRIC, passport number, etc.

4. That the Straits Times knows how to contact her and her office and/or home addresses.

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.

DR CHEONG PAK YEAN
PRESIDENT, SMA

(Letter 2D. SMA’s second letter to ST on 13/3/98)

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.

DR CHEONG PAK YEAN
PRESIDENT, SMA