Their hands may be blessed with cure, but not with good handwriting. Prescriptions from doctors in Pakistan are often illegible, missing instructions on dosage, and list unnecessarily a large number of expensive branded drugs.
A recent study published in the Pakistan Journal of Medical Sciences reviewed 1,100 prescriptions in Peshawar. The study revealed that 59 per cent of the prescriptions were barely legible, and many others offered incomplete directions about dosage and use. More importantly, certain expensive drugs were overprescribed even when generic cheaper versions were available in the market.
While being one of the poorest countries in the world, prescription medicines are unnecessarily expensive in Pakistan. Health-related expenses consume a large portion of household budgets of the very poor in Pakistan. At the same time, illegible and incomplete prescriptions filled by unlicensed pharmacists often selling counterfeit medicines add to the burden of disease. Hospitals, pharmacies, and clinics in Pakistan need to be subjected to a stricter regulatory regime to limit the spread and prevalence of disease.
Unlike pharmacies, hospitals and clinics are staffed by trained and experienced doctors. However, this is worth little when the prescriptions they write are either not legible or are incomplete. The good doctors in Peshawar though are not the only one with sloppy handwriting. In the United States alone, more than 7,000 deaths are attributed to doctors’ sloppy handwriting. Over three billions prescriptions are written in the United States every year. Illegible handwriting, unclear abbreviations and dosage instructions are the reasons behind mistakes that prove fatal for thousands of patients.
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The Peshawar study of 1,100 prescriptions revealed some very disturbing trends. Some 89 per cent prescriptions did not bear names of the physician and 20 per cent prescriptions did not bear the physician’s signatures. In 64 per cent of the cases the physician did not mention dosage and in 55 per cent of the cases the duration of treatment was missing.
One wonders if the doctors are not outlining the dosage and the duration of treatment, who is?
The contents of prescriptions reveal two additional sources of concern. First, prescriptions on average carried 3.3 drugs, which, according to the authors, is significantly higher than the WHO recommended standard of two drugs per prescription. Of the six facilities from where these prescriptions were sourced, prescriptions from the private for-profit facilities listed higher drugs per prescription than those collected from public-sector medical facilities.
The other major concern was about the frequent dispensing of painkillers that were listed on almost 62 per cent of the prescriptions. Addiction to prescription opiates is a known problem that often leads to detrimental consequences. However, doctors in Peshawar are rather cavalier in prescribing opiates. I witnessed this first-hand in the early 90s, when I accompanied a friend to the Psychiatric Hospital, which believe it or not is located in Peshawar Jail. I wonder if there was ever an audit done of the drugs in the hospital’s internal pharmacy.
Another study of prescriptions collected from patients admitted to the psychiatric ward at the Lady Reading Hospital in Peshawar revealed similar disturbing trends.* Instructions for use were mentioned only 50 per cent of the time and fewer than one in five prescriptions mentioned the total quantity to be dispensed. But more importantly, all prescriptions included only branded, and hence more expensive, drugs rather than the cheaper generic drugs.
Even when prescriptions are legible, there is still no guarantee for the patient to get the right medicine in Pakistan where fake drugs are ubiquitous. Kulsoom Parveen, who chaired a Senate health committee, claimed that “at least 30 per cent of medicines bought in the country are either counterfeits or substandard.” This trade is facilitated by the very large number of illegal pharmacies. The Pakistan Pharmacist Association claims to have only 4,000 registered pharmacists in Pakistan, but
25 times more merchants [are] dispensing medicines illegally.
Caring for disease eats into the disposable earnings of low-income households. With $2 billion in pharmaceutical sales, households in Pakistan spend an awful lot on drugs when the per capita GDP is still shy of $1,300.
It does not help when doctors prescribe expensive branded drugs as a quid pro quo for gifts and junkets made possible by the big pharma. Such practice should be discouraged, or better banned. The College of Physicians and Surgeons of Ontario, Canada’s largest medical regulator, is set to issue a new ethics policy that will prevent doctors from accepting gifts from a pharmaceutical company. “When we talk about gifts or things of value … we’re saying ‘No, you should not accept them anymore.’ We are moving the posts here,” said Dr. Marc Gabel, president of the College. Ontario in Canada is not alone. Stanford University in 2006 instituted a similar policy that banned faculty members from accepting gift of any kind from the pharmaceutical industry.
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The welfare of low-income patients will improve if doctors find ways to reduce health care costs; they can help by prescribing low-cost generic drugs. And while they are at it, they should try to write clearly. A slight improvement in doctors’ handwriting will do wonders for patients’ wellbeing.
Raza UA, Khursheed T, Irfan M, Abbas M, Irfan UM. Prescription patterns of general practitioners in Peshawar, Pakistan. Pak J Med Sci 2014;30(3): doi: http://dx.doi.org/10.12669/pjms.303.4931
- Salman S, Ismail M, Awan NR, Anees M. Patterns of prescription writing in psychiatric clinics. J Postgrad Med Inst 2013; 27(3):290-6.