ORIGINAL ARTICLE

Pdf version

PROFESSIONAL TRAINING AND ROLES OF COMMUNITY PHARMACISTS IN MALAYSIA: VIEWS FROM GENERAL MEDICAL PRACTITIONERS

Hassali MA¹ BPharm, MPharm (Clin Pharm), PhD, Awaisu A² BPharm, MPharm (Clin Pharm), Shafie AA¹ BPharm, Pg Dip (Health Econ), PhD, Saeed MS³ BPharm, MPharm (Clin Pharm)
1 Lecturer and Researcher, Discipline of Social & Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 Penang, Malaysia [Mohamed Azmi Ahmad Hassali, Asrul Akmal Shafie]
2 Doctoral Research Fellow, Dept of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 Penang, Malaysia [Ahmad Awaisu]
3 Postgraduate Student, Dept of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 Penang, Malaysia [Mustapha Salih Saeed]

Address for correspondence: Dr Mohamed Azmi Ahmad Hassali, Discipline of Social & Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 Minden, Penang, Malaysia. Telephone: +6046533888 ext. 4085,
Fax: +604-6570017, Email address: azmihassali@usm.my

Funding: No funding was received to conduct of this study.

Conflict of interest: None to declare.

INTRODUCTION

Community pharmacists are the most accessible health professionals to the general public and in many parts of the world, pharmacists are increasingly being recognized as a source of professional health-related advice.¹ They supply medicines in accordance with a prescription or when legally permitted, sell them without a prescription and they maintain links with other health professionals in primary health care.² In recent years, pharmacists have become increasingly involved in patient care and have expanded their traditional role of preparing and dispensing medications to also influencing the prescribing process and delivery of pharmaceutical care.^3-5 In tandem with this, there has been a shift within community pharmacy practice; increasingly, patients are turning to pharmacists for a more holistic approach to their care.⁶

In an institutional setting such as a hospital, general medical practitioners are more familiar with the roles of pharmacists, who are often part of the healthcare team.⁷ In the context of community-based settings, however, the links between general medical practitioners and community pharmacists are less formalised.⁸ Malaysia’s healthcare system is a two-tier system consisting of public and private sectors. The public healthcare system, funded fully by the government and financed mainly from taxes on earned income, provides services to everyone through a network of tertiary care centres, general hospitals, district hospitals and health clinics. The private sector, which consists of private hospitals and general practice (GPs) clinics, provides both curative and preventive health services on a non-subsidised, fee-for service basis and mainly caters for those who can afford to pay. In the context of private sector, medication utilization in the community setting, at current, dispensing of prescription medicines still follows a traditional ‘dispensing doctors’ system in which general practitioners still dispenses medications as a part of their professional practice. The 1952 Poison Act13 and other laws in place granted the right for registered medical practitioners to exercise this responsibility and presumably the ongoing controversies and imbroglio stem from this Act. Therefore general medical practitioners practicing in private clinics (GPs) are legally allowed to prescribe and dispense medications in their clinics. From the statistics quoted in the Malaysian Pharmaceutical Services Division 2006 Annual Report,¹⁴ there were 4,266 registered pharmacists working in both public and private sector in Malaysia (i.e. a pharmacist-population ratio of 1:5,860). In term of community pharmacies, there are about 1,700 pharmacies nationwide (i.e. pharmacy-population ratio of 1:15,828) (unpublished report from Pharmaceutical Services Division, Ministry of Health, Malaysia).

An international study had highlighted the professional cooperation between prescribers and pharmacists in cognitive services such as patient counselling, drug therapy monitoring and adverse drug reactions (ADR) reporting.⁹ Different perceptions by pharmacists and general practitioners concerning the pharmacist’s role could reduce the quality of their cooperation.¹⁰ Additionally, lack of communication and misunderstanding of roles by general medical practitioners and other members of the primary health care team has been reported to undermine the potential of the primary health care team.¹¹ It is important that pharmacists understand medical practitioners’ expectations of them and how they value the pharmacists’ input regarding patients care.¹² One of the main reasons for opposing introduction of separation of functions between clinics and pharmacies in Malaysia is  the acute shortage of community pharmacists practicing in the country compared to GPs and due to the uneven distribution of community pharmacy outlets throughout the country.¹⁵ In the current Malaysian context, there are no published studies looking at the expectations and perceptions of GPs on the roles and training of community pharmacists. This pilot study is a cross-sectional survey to evaluate the perceptions of general medical practitioners in district A with regard to the professional training and role of CPs.

METHOD

Research design and population
A survey was distributed to all private general practitioners (GPs) in district A. Currently in Malaysia, most general practices are solo practice. A list of GPs practicing in district A was obtained from the Health Department. At the time of the study (July 2007 - October 2007), there were 388 private clinics in the state and 183 of these were located in district A. Of these, 160 general practice clinics were selected for the study. Medical specialists were excluded as most of the specialist practitioners in the community setting might also be working in institutionalised setting and may have contact with pharmacists in these institutions. This in return will make them more aware on the roles of pharmacists compared to their counterparts working as GPs. The selected clinics were approached by a researcher to ask for their willingness to participate in the survey. A self-administered questionnaire was distributed to them on the first visit and effort was made by the researcher to collect the questionnaire distributed on the same day. Completion and return of questionnaire was considered as consent to participate in the survey.

The survey instrument
The initial survey items were developed by using information from a literature review and discussions with three pharmacists, two pharmacy educators and two general practitioners. Content validity and clarity of questions of first draft of questionnaire was reviewed and assessed by five general practitioners. The final version of the questionnaire consisted of two parts: demographic data of the GPs and a set of opinion statements regarding community pharmacists’ roles and training for which respondents were required to indicate their level of agreement using a 5-point Likert scale response format (from strongly agree to strongly disagree).

Data analysis
Descriptive and inferential statistical tests were undertaken to analyze the demographic characteristics and perception scales using Statistical Package for Social Sciences version 13.0 (SPSS Inc, Chicago, IL). Fisher’s exact test was applied to observe the influence of age, gender and years of experience on the practitioners’ opinions. Fisher’s Exact test was used because it is considered to be more appropriate for skewed data, as obtained in this survey. Furthermore, as a rule of thumb, if 25% or more of the cells in the table have expected frequencies less than 5, or if any expected frequency is less than 1, then Fisher’s exact test is preferred over the chi-square test. A two-sided 99% confidence level Monte Carlo estimate of Fisher’s exact p-value was computed. An a priori p-value of 0.05 or less was considered to be statistically significant.

RESULT

Demographic data
Of the 160 questionnaires distributed, 80 were completed and returned (response rate 50%). More than two-thirds (71%) of the respondents were men. Mean age (±SD) of the GPs was 45.7 (±9.9) years, with a range of 27 to 72 years.  The ethnic groups of the respondents were 37% Chinese, 32% Indian, and 22.5% Malay (Table 1). More than half of the participants (56.3%) were graduates of Malaysian universities and their years of experience as GPs ranged from one to 48 years.

Table1. Demographic characteristics of the study participants (N = 80)

Demographic characteristic	Number (%)
Gender
Male	57 (71.3%)
Female	23 (28.7%)
Race
Malay	18 (22.5%)
Chinese	30 (37.5%)
Indian	26 (32.5%)
Others	6 (7.5%)
Country of Graduation
Malaysia	45 (56.3%)
Others	35 (43.7%)

General medical practitioners’ perceptions toward community pharmacists’ roles and training
GPs ‘disagreed’ or ‘strongly disagreed’ that community pharmacists are well educated in or well trained to perform: clinical therapeutics (42.5%); diagnosis of minor illnesses based on the patient’s signs and symptoms (52.5%); selected screening tests such as glucose and cholesterol tests (52.5%). A statistically significant difference (p = 0.03) was observed between male and female practitioners in responses to the statement on clinical therapeutics knowledge. With the exception of this, there were no significant differences in responses across other demographic categories.

Responses to statements exploring the respondents’ perceptions towards community pharmacists’ roles are shown in Table 2. General medical practitioners ‘agreed’ or ‘strongly agreed’ that: they should consider the community pharmacists’ recommendations whenever there is/are any problem(s) with the prescriptions given by them (46.3%); community pharmacists are the best health care professionals to educate patients about the safe and appropriate use of their medications  (52.5%); community pharmacists are in the best position to assist patients in selecting appropriate non-prescription medications (46.3%); they feel comfortable if community pharmacists refer patients to them for further medical evaluations  (76.3%); if dispensing separation is to be implemented in the future, they will work closely with the community pharmacists to monitor patients outcomes of drug therapy (77.5%). The majority (61.3%) also were aware that the profession of pharmacy has tremendously changed from a product-oriented to a patient-oriented one. There were no significant differences between the respondents’ answers across demographic groups.