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Made in the Philippines: Psywar

Reviving pharmacy

WORDS are powerful, and this could not be better exemplified than by the controversy over a single word being used in Senate Bill 1900, "An Act Regulating the Education and Licensure of Physicians and Their Practice of Medicine in the Philippines and for Other Purposes."

The bill revises the older Medical Act and now defines the physician's roles to include the following: "to diagnose, treat, operate or prescribe and dispense any remedy for any human disease, injury, deformity, physical or mental condition."

Sounds fine. Unless you're a pharmacist, and you notice the word "dispense." The Philippine Pharmaceutical Association, a nationwide organization of pharmacists, has issued a strong statement opposing the inclusion of this function among a physician's functions. Under current laws, there's a very clear distinction about what professionals can do in relation to medicines: prescribing is limited to physicians and dispensing to pharmacists.

We tend to think of pharmacists mainly as people who sell medicines. You go to a drugstore and assume all the people behind the counter are pharmacists. Actually, most of them are sales clerks, with some training on medicines. What the law requires is that there be at least one licensed pharmacist supervising the sales clerks.

The dispensing of drugs involves more than just selling the products. Dispensing includes a careful check of the prescription, to make sure the right drug is given. We all know about malgraphicus medicus, the bad handwriting of physicians that can be confusing. The physician may have prescribed Losec, an anti-ulcer drug, but careless dispensing could mean Lasix being given to the patient, which makes a world of a difference because Lasix is a drug to induce urination.

A trained pharmacist looks out for these differences and more. The pharmacist is also expected to advise the patient on the proper use of the drugs, not just how much to take but when to take them. Even simple advice like taking a medicine after meals is important because there are many drugs that should not be taken on an empty stomach because they can irritate the stomach or intestines. (Examples are aspirin, and pain-killers like ibuprofen, found in Alaxan and many other brand-name preparations.)

A pharmacist is also expected to check a physician's prescription to make sure the medicines do not conflict with, or duplicate each other. In hospitals, pharmacists will even advise the nutritionists and food preparers about avoiding certain foods that could affect the medicines.

Most importantly, dispensing is about people. A pharmacist is there to make sure the medicines are appropriate to the patient, taking into consideration the person's illness, age, sex, even socioeconomic background, as we will see in a while.

All these responsibilities are part of dispensing, a function that is reserved, in most countries, for pharmacists.

There are two main reasons for this specific division of labor:

First, pharmacists are trained to handle medicines, all through the four years of college, and, for others, several more years of postgraduate work. Older readers will remember how pharmacists used to compound the drugs, mixing different ingredients to make a particular medicine. That is no longer done today, but in principle, a well-trained pharmacist still knows what ingredients go into each product. Physicians are also trained in drugs but this is limited to a few courses in pharmacology since they have to take many other subjects.

The second reason why dispensing is reserved for pharmacists is to avoid a conflict of interest. If a physician is allowed to prescribe and to dispense drugs, you can imagine him prescribing more drugs because that would mean the patient will be purchasing more drugs from the physician as well. The temptation isn't just to prescribe more drugs, but the most expensive ones.

In the real world, of course, there are many ways of getting around this division of prescribing and dispensing roles. Many physicians, especially in rural areas, simply set up a pharmacy next to their clinic, with the pharmacy run by a relative. Then, too, there are pharmacists who sometimes succumb to the promotions of drug companies to promote particular brands. Nevertheless, a legal separation of the two functions is still important, at least to give patients some protection.

Pharmacists are upset with the proposed new Medical Act because it further infringes on a profession that is already greatly weakened. The old function of compounding medicines has been taken over by large drug companies. Even the selling of drugs has gradually been taken over by large chains like Mercury, so independent pharmacists are rapidly disappearing.

Pharmacists remain in great demand in Western countries. There is, in fact, a less known brain drain going on as our pharmacists leave for countries where they're better appreciated. In other countries' hospitals and pharmacies, pharmacists continue to play major roles, checking on all prescriptions and advising patients. Recognizing that pharmacists are often the first health professionals to be consulted by someone who is sick, some Western countries have even modified laws to allow pharmacists to take on a semi-prescribing role, for example to advise someone on family planning options.

My pharmacist friends say there shouldn't be any competition between physicians and pharmacists. It's all a matter of fairness to all concerned, health professionals as well as patients. A physician is busy enough handling all kinds of other responsibilities so the minute details of dispensing medicines should be left to pharmacists. If anything, we should be reviving pharmacy rather than further weakening the profession.