Dispensing in the Doctor’s office in Jamaica

Lack of regulatory oversight puts patients’ lives in danger!

Medical doctors and nurses are often credited for their roles in healthcare more so than any other professional group. The roles of the pharmacist, medical technologists, radiographers, nutritionist and other health professionals, while acknowledged, are often overlooked. However, these are the persons in the shadows assisting with the correct diagnostic testing and treatment. A medical doctor is trained to diagnose diseases and recommend appropriate treatments, and this is essentially what gives him or her the respect that comes with the qualification. However, any reasonable doctor will admit that if there is no medical technologist or radiographer then diagnosis is delayed and if nursing care is limited, then patient care will be affected. Doctors are not able to efficiently do it all, even though they are trained with all the basic competencies. To provide the best patient care, the complementary services of all the health professions must be recognised and the lines of demarcation protected. In other words, a doctor undertaking the roles of nurse, radiographer, medical technologist or pharmacist is impractical and can put patients’ lives in danger. Doctors are trained to work with other health professionals to provide the ideal service however, the practice of some doctors in Jamaica has shifted to the provision of a one stop shop for all medical services without any consideration of quality care for patients.

Some unsuspecting patients, in rural parishes and to a lesser extent in the corporate, are visiting their doctors in good faith and are being exploited for the doctors’ personal gain. These patients go to the doctor where they are lured by low advertised fees which balloons significantly at the end of the visit. A visit which starts out as low as $500 – $1000 becomes $5000 or more. The explanation is that the visit included lab screening, doctors’ assessment and provision of drugs. While a few labs have entered arrangements for doctors to extract bloods to be sent to the labs for testing, the practice of doctor dispensing totally disregards the role of the pharmacist. A role which is downgraded to an untrained receptionist. The practice of dispensing by untrained personnel is dangerous. Receptionists are unable to identify prescribing errors, drug interactions and counsel patients on medications. The problem of unregulated doctor’s office dispensing is becoming more prevalent in the western parishes which has an influx of Asian doctors who practiced similarly in their home countries. Any unregulated practice means that there is no assurance of standards. This compromises the quality of care that the patient is due.

There is also the ethical issue of conflict of interest on the part of the prescribing doctor. The doctor will tend to prescribe drugs that are in stock at his or her office rather than what is in the patients’ best interest. Doctors offices are also not legally recognized as pharmacies and as such the environment and medications are not subjected to the rigorous inspections that registered pharmacies undergo to ensure the medications are stored under ideal conditions, are not expired and are dispensed and labeled appropriately. Legally, according to the Pharmacy Act, only registered pharmacies under the supervision of a registered pharmacist can dispense medications to the public. The reason doctors continue to get away with this practice is the lack of regulatory oversight of doctors’ practices. The Medical Council does not inspect doctors’ offices. However, the Medical Council does register these doctors and should play a role in monitoring unethical and illegal practices. There should be greater monitoring of the practices of doctors especially those who were trained in other jurisdictions and have sought to be registered and to practise in Jamaica. It has been noted that this unethical behavior is more common among non-Jamaican doctors. The medications dispensed from these offices have poorly written instructions and inappropriate packaging with very little or no additional warnings. This practice has become disgraceful and it is unacceptable for any Jamaican to be subjected to it, in a country where quality pharmacy services are available in both private and public sectors. The Medical Act of Jamaica stipulates that a registered medical practitioner shall be deemed to be guilty of conduct that is disgraceful in a professional respect, if he-

If the Medical Act deems it disgraceful to have any person, even acting in the capacity of Assistant, perform services which require professional skills on a patient, why would the medical profession not give the profession of pharmacy the similar consideration? The matter of dispensing of medication is more than counting and packaging of pills. Hence the reason for the recognized and highly regulated profession of pharmacy. Additionally, why are foreign (or any) persons allowed to disregard our laws and practices and compromise the quality of care that every Jamaican citizen is due? The Guide to Ethical Practice in Jamaica, a publication of the Medical Council of Jamaica, clearly outlines that doctors should be cautious of situations where there could be abuse of privilege or a conflict of interest. One example is that financial interests in pharmacies should be noted. The Pharmacy Regulations also address the matter of pharmacists dividing profits with doctors from prescriptions written by the doctor. It is very clear therefore that both the Medical Council and the Pharmacy Council have legislative and policy documentations which disagree with doctors gaining financially from prescriptions written by them.

Traditionally, in countries where dispensing of medications occurs in a doctor’s office, the practice has been based on absence of pharmaceutical services within a certain distance. Ethically, it is justifiable to provide medications under extenuating circumstances. However, in these jurisdictions, doctors who dispense should not be within a certain distance of a pharmacy, must prove that his/her patients would not otherwise have access to pharmaceutical services and must only charge for the cost of the drug sold and not add a markup for profit. These doctors’ offices would also have to conform to regular inspections and must be set up in accordance with the laws for appropriate storage of drugs and dispensing procedures. Once pharmacy services are available and accessible, doctors must only provide emergency or immediate care to patients. In an article comparing dispensing practices in India and the United States by researchers from Ohio University, the practice of physician dispensing in India was heavily criticized and a call made for regulatory oversight. The authors noted that while “physicians and pharmacies should be allowed to generate income by treating sick people; the process should be regulated and ethically acceptable, without exploiting patients who place their trust in healthcare providers.”

The recent arrest of a fraudulent doctor is even more reason for concern. If a person who purports to be a doctor is considered fraudulent and a crime, why is it that a person who assumes the role of a pharmacist is not likewise treated as committing fraud? Is it because this is done in a doctor’s office that allows it to be treated differently? Another observation with these doctors is that they write their prescriptions in such a way that makes it difficult to read and the prescribers’ information is missing, therefore the patients are forced to return to the practice to have their medications dispensed. There is also the practice of writing expensive items on the prescriptions when the patient chooses to go to his or her regular pharmacies so that the cost is seemed prohibitive at the pharmacy then the patients on returning to the doctor’s office receives completely different medications from what was originally written. It is only on returning to discuss the medications with the pharmacist that these things are discovered. Many of these same patients end up going to their pharmacists for advice on the drugs they received at these practices.

Pharmacists are trained for four to five years and are experts in identifying drug interactions, appropriate dosages and they can counsel patients as well as advise doctors on the right drug to prescribe for a condition. The matter of dispensing from a doctor’s office must be carefully considered by the patients. According to a report from Johns Hopkins in 2018, medical error was the third leading cause of death following heart disease and cancer. Although is are very little documentations of errors in Jamaica, pharmacists can attest to contacting doctors daily to recommend adjustments to prescriptions for errors detected. Many errors are identified by a pharmacist. What happens when the pharmacist is bypassed? What happens when there is no buffer between the prescriber and the patient?

Some community pharmacists are lamenting that they may have to close their doors as they are unable to operate with the same doctors from whom they are expected to receive prescriptions. This undue pressure can lead to unethical practices among pharmacists/pharmacy owners who may assume the role of the doctor and begin to prescribe as a matter of survival. This tit for tat would never resolve this problem as the patient would still be in danger from receiving medication for an incorrect diagnosis. The model situation is for each health care provider to correctly assume his/her role and provide optimal patient care. The difference between the doctors and the pharmacist however is that the pharmacy is regulated, and that pharmacist/owner would be subjected to fines up to a million dollars or six months to a year in prison and would be unable to practice if found guilty of dispensing prescription only items without a prescription. Medical doctors do not have these penalties in law.

There is also the growing concern of counterfeit medications as more and more persons are importing medications illegally and some of these products are not tested for quality assurance. Community pharmacies are regularly inspected and must keep records of drugs bought and sold. When a patient obtains his or her medication from the community pharmacy, that patient can be assured of the authenticity of the drug that it has been imported, tested and distributed under strict supervision. The chances of receiving counterfeit medications would be significantly reduced or almost nonexistent.

Patients need to understand the roles of the doctor and the pharmacists and appreciate that they work better together rather than one taking over the role of the other. Doctors are trained to be experts in diagnosis and identification of treatment however to ensure that the right drug is given in the right dose for the right condition to the right patient, the pharmacist is the trained professional for this role. Patients should refuse to fall in the trap of the one stop shop and risk their health. If the receptionist is offering medications and writing labels that is not what you are accustomed to at the pharmacy, refuse to have your prescriptions dispensed by an untrained person. Ask for your prescriptions and go to a trained registered pharmacist in a registered pharmacy. Check your prescriptions to ensure that the medication name is clear, the instructions are clearly written and the doctor’s name and address for completeness and ask the doctor to write legibly the names of the medications that are being prescribed so that you can also be certain that what is being dispensed is what was prescribed.

Shereen Dawkins
Bpharm (Hons), MA Healthcare Law and Ethics