From:  Express Healthcare Management - India - July 15 2004

Dispensing doctors?

The interdependence between pharmacy and medicine runs back through the ages, and while the tendency towards specialisation has effected a clear separation of pharmacy from medicine, there is still some overlapping of jurisdiction and of practice as well, say Goan pharmacists Arlene Avileli, Pooja Borkar, Shailaja Mallya and Raj Vaidya.

DISPENSING doctors is the term used for a doctor who buys and stocks medicines from a wholesaler/ stockist/ manufacturer and prescribes and hands them over to his patients. Thus, such a doctor does both the tasks, of diagnosing and prescribing, as well as dispensing. Generally, in almost all cases, the doctor recovers at least the cost of the medicines, besides taking his consultation fees.

There is little opportunity to blame prehistoric practice for carrying on sidelines, for there was only one to carry — the practice of medicine. The interdependence between pharmacy and medicine runs back through countless ages, and while the tendency towards specialisation has effected a clear separation of pharmacy from medicine; there is still some overlapping of jurisdiction and of practice as well.

In Bruges, medical practitioners were forbidden to dispense medicines under heavy penalties. In 1683, a dissension arose between the physicians and apothecaries in Belgium and apothecaries came out victorious, for in Bruges a law was passed preventing physicians from dispensing their own remedies under heavy penalties. The College of Physicians of Philadelphia having declared that any connection with or monied interest in apothecaries stores, on the part of physicians, should be discountenanced.

In like manner, an apothecary being engaged in furthering the interests of any particular physician, to the prejudice of other reputable members of the medical profession, or allowing any physician a percentage or commission in his prescriptions, is unjust towards that profession and injurious to the public.

In today’s era, where medicine and pharmacy have emerged clearly as different fields/ specialisations, it is felt that a medical doctor should diagnose, which is no-easy, one minute feel of a patient. He should also suggest a prescription and end here. A pharmacist’s task is to study the prescription, authenticate it and check for possible errors. He should then supervise/ dispense the medicines, which is also not an easy, one-minute talk with a patient. Thus, diagnosing and prescribing, and dispensing are both areas that require specialisation. Amidst this, the unfortunate trend of doctors doing the job of dispensing in addition to diagnosing and prescribing often causes confusions and problems in various aspects.

[British pharmacists are increasingly crossing that boundary, with government approval, to both prescribe and dispense, as well as retailing recently prescription only medicines for profit - Ed]

The practice of pharmacy demands knowledge, skill, and integrity on the part of those engaged in it. Pharmacists are required to pass certain educational tests in order to qualify under the laws. It is inimical to public welfare for the pharmacist to have any clandestine arrangements with any physician in which fees are divided or where secret prescriptions are concerned.

Many dispensing doctors tend to get tempted to stock and dispense bulk packings, or products which give them good profit margins or schemes, or high cost products because they are not under price control and give sizeable profits. For example; FMG injections, costly vaccines, etc. Of late, the doctors also have another option of stocking and selling generics of standard companies and make heavy profits.

The conduction of business of both professions by the same individual involves pecuniary temptations, which are often not compatible with a conscious discharge of duty. It is unprofessional and highly reprehensible for apothecaries to allow any percentage or commission to physicians on their prescriptions, as it is unjust to the public and hurtful to the independence and self-respect of both the professions concerned. [See above - Ed]

Majority of the public is not aware of the prevalence of quacks. They unknowingly go to quacks for diagnosis and treatment. Along with qualified doctors, quacks also stock and dispense medicines. Due to lack of awareness and poor laid down standards, quacks easily succeed in stocking and selling medicines, which might be spurious or of dubious quality. High profit products of not-so reputed companies carry with them the possibility that they could be of not-so-good quality or even sub standard/ spurious.

Dispensing of drugs

Dispensing is an area of competence of pharmacy staff rather than the medical profession. The functions of prescribing and dispensing are kept separate, principally to avoid a conflict of interest on the part of the prescriber, who could profit from both prescribing and selling medicines.

This separation also optimises the rationality of therapy by having pharmacy staff or pharmacists, who are specialists in this area, review prescriptions and ensure good practices in dispensing. In addition to prescribing, doctors find it profitable to dispense drugs on their own, knowing the fact that the patient will be unable to refuse.

Advantages for doctors include:

Heavy margins: With dispensing, heavy margins are earned by doctors with high cost products and products with huge schemes or discounts.

Secrecy: Some doctors believe in the ‘secrecy theory’ wherein the name of the medication given can be kept secret by doctors.

A doctor normally does not tell the patient the reason for which the medicines are prescribed. The patients fear to question the doctors and thus take whatever is given. Dispensing cum administering of injections is done most often, wherein the patients are not told what injection is being given. It could be a steroid for pain or inflammation, or even an antibiotic for fever or even a placebo like Water for Injection!

Dispensing vs non-dispensing doctors

The difference between dispensing doctors and non-dispensing doctors is quite evident from their prescribing habits. Various studies from various parts of the world conclude that dispensing doctors prescribe significantly higher amount of medicines, injections, antibiotics , mixtures, cough preparations and analgesics per patient. The higher prevalence of prescriptions are strongly associated with ‘symptomatic treatment’ (ie; a drug was prescribed for every symptom), general over-prescribing of antibiotics and prescription of medicines with lower clinical value. For example; dispensing doctors prescribed analgesics and psycholeptics more frequently in treatment of upper respiratory tract infections.

The practice accepted by dispensing doctors puts the interest of dispensing doctors before the interest of the patient.

However, prescribers who also undertake dispensing can provide an important alternative access to medicines in areas where there are no pharmacy services.

Drug laws in the United States

Dispensing by prescribers in USA is subject to certain laws regarding the requirements, restrictions and enforcement.

As per the US laws: No prescriber shall dispense prescription drugs or dangerous devices to patients in his or her office or place of practice unless all of the following conditions are met:

• The prescription drugs or dangerous devices are dispensed to the prescribers own patient and the drugs or dangerous devices are not furnished by a nurse or physician attendant.
• The prescription drugs or dangerous devices are necessary in the treatment of the condition for which the prescriber is attending the patient.
• The prescriber does not keep a pharmacy, open shop, or drugstore, advertised or otherwise, for the retailing of dangerous drugs, dangerous devices or poisons.
• The prescriber fulfils all labelling requirements imposed upon pharmacists under the Drug Act, all recordkeeping requirements and all packaging requirements of good pharmaceutical practice, including the use of childproof containers.
• The prescriber does not use a dispensing device unless he or she personally owns the device and the contents of the device, and personally dispenses the dangerous drugs or dangerous devices to the patient - packaged, labelled and recorded in accordance with point (4) above.
• The prescriber, prior to dispensing, offers to give a written prescription to the patient so that the patient may elect to have filled by the prescriber or by any pharmacy.
• The prescriber provides the patient with written disclosure that the patient has a choice between obtaining the prescription from the dispensing prescriber or obtaining the prescription at a pharmacy of the patient’s choice.

Storage requirements for drugs

A prescriber who dispenses drugs pursuant to Section 4170 shall store all drugs to be dispensed in an area that is secure. The Medical Board of California shall, by regulation, define the term ‘secure’ for purposes of this section.

In the USA, 45 of the 50 states have some type of regulation. However, the interpretations and implementation of these regulations have met with difficulties due to a lack of resources, ability or authority to inspect dispensing doctors, a lack of clarity on who is responsible for enforcement, and the imprecise wording of the laws.

Other countries

In countries such as Scandinavia and Germany, the two professions continue to be separate. For example in Denmark the law does not allow a person to practice medicine and pharmacy at the same time. Doctors dispense injections and drugs only in special circumstances, such as emergencies.

Paying for a consultation is not accepted in all cultures. In India and Pakistan, patients do not generally accept paying a consultation fee, and the common way doctors generate an income is by dispensing (selling) drugs. This is also the practice in Japan, Mexico and South Africa. In 1991, over 80 per cent of all doctors in these countries dispensed medicines. In Japan, the law allows dispensing by doctors if ‘medically necessary’. Drug expenses in Japan in 1993 were found to be 30 per cent of the total healthcare bill, compared to other developed countries, which spend about five per cent on drugs.

To be concluded later

The writers are community pharmacists, Hindu Pharmacy, Panaji, Goa

(24/8/04)