Online Pharmacies! Just a click away...

The world is changing and e-stores are taking over the online world. It isn't a wonder, then, that the online pharmacy business in India is already taking off and is expected to reach great heights.

However, as all things new, there are very few regulations and laws dealing with the same, with the result that some of them have already faced problems with the authorities over spurious drugs being sold without prescriptions etc etc.

The point of this blog is to let out a few ideas and suggestions as to how this can work, especially in a place like India, where we are so used to service and convenience that we feel it is our birthright to have everything delivered to our homes!! Of course, there are working couples, old and infirm grandparents who can't make the walk to the chemist but at the end it's just a matter of convenience and let's be honest about this point and just agree!

The simplest solution is what is being followed by most portals online today. Partner with a pharmacy which has its licenses in place and use the online portal as just a point of contact with the consumer to collect their orders. I see nothing wrong with this concept as long as the onus is on the pharmacy to maintain the prescriptions it claims is mandatory to be supplied to confirm the order. This puts the responsibility solely on the dispensing pharmacy and leaves the online portal to be free of lawsuits, at least to a point where prescriptions and documentations are concerned.

The other solution which I think is the right way forward is to have stand alone e-pharmacies tie up with Doctors in the area to form a network so as to be able to obtain and confirm prescriptions by them. The model is simple, fool proof and would probably even benefit all involved. An example to highlight this would be if you lived in my area, you visit an online pharmacy which operates/delivers to our area, click on the medications you need as per my prescription and the pharmacy because it has a tie up with me along with others in the area and has some method to receive my prescription in electronic format, digitally signed, so they can legally dispense the medication. There also will have to be a confirmation check in place either via a coded SMS or simply a call to the clinic asking whether the patient did indeed receive this prescription. The best thing would be for the pharmacy to collect the physical copy of the prescription from the patient at the time of delivery. A simple flow chart that Boots online pharmacy uses is shown below.

While this is all good and hearty, the problems that can come up are many. There has to be a regulation on all fronts, from the authorities, to the Doctors using these pharmacies to self regulation by them. Silly things like expired drugs, substitute medications, improperly labelled medications, delayed delivery etc just will not work. An easy and no questions asked return policy is a must in such cases. It will build trust in the consumer and ensure repeat visits and orders online.

The e-pharmacies regulating themselves is an interesting point from another point of view as well. Most e-commerce sites will go to the ends of the earth to provide 100% secure payment gateways to ensure the safety of the consumer. Why not invest the same amount in legal requirements for dispensing drugs. I'm sure the IITian and IIMians can come up with a secure way to obtain electronic prescriptions and keep a check on expired drug stock and illegal medications. We do have a few online pharmacies already who are doing a good job. Off the top of the head, netmeds, mchemsit, merapharmacy and 1mg come to mind.

Despite all this, we will still have problems, because, you know, this is India. Nothing is done without Jugaad!! So, we will have some players, trying to make a quick buck by selling over the counter drugs at lightening deals and discounts. We will have those festival specials where they try and get rid of their soon to expire stock. We will have 'performance enhancing' medications being sold 'exclusively' under the aegis of naturopathy and all herbal preparations. We will have a few shipping stones in place of medications. Look, there are bad eggs everywhere. This doesn't mean we give up. Look at the US. A study conducted by NABP in September 2013 found 96.7% online pharmacies there were 'rogue' meaning they did not comply with US laws and regulations. 

There is one more unique problem in India. We are the land of 'pathies'. We have ayurveda, homeopathy, allopathy, naturopathy, herbopathy, patni ka pati and a whole lot more! Most of these do not have separate regulations and dispensing guidelines. While I have nothing against other pathies, it's only the pharmaceutical problems I am highlighting here.

We also have a host full of quacks! Every neighbourhood white coat man prescribes medications right from a bone setter to a superspecialist PhD. A very eloquent lawyer who wished to remain unnamed laid this argument in court during one of these cases against online pharmacies. "When the physical pharmacies hardly ever follow rules regarding prescriptions and dispensing, how are the online pharmacies expected to fall in line."

 

Like most law and order problems in India, there are enough laws but not enough enforcement. Hopefully, this new turn of events will make the people in power see reason and bring about a new law and guideline for online pharmacies. Even if they don't, I see a bright future for them. They are here to stay and will probably do better than the online groceries out there. What do you think?

Rural Posting at Primary Health Centres (PHC). Why Doctors find alternatives?

Why is it so difficult to find Doctors who would work in rural areas? Maybe the problem lies with the fact that even after making it a mandatory posting for obtaining the degree, there is still no headway into solving this divide.

Let's start with the very basics. Most state governments would want their doctor's to work in the villages. Since the seniors are too smart to fall into this trap, they bring out a rule that says every Doctor who finished his/her internship must serve compulsory rural service.

This could in fact be a great rule to sort out the medical problems of the country. Unfortunately, like most great things here, the implementation is sorely missing.

The postings are given in a jiffy at most city hospitals that act as medical tertiary outposts for these centres which are commonly called PHC's or Primary Health Centres. Once you get posted there, you are supposed to go and report there for duty.

The trouble sort of begins here. You are told the address of the PHC and that is it!

No instructions on what to carry and what to expect. No clarification on where you will be staying. Nothing on who to meet, when to go, what to do once you get there.

Assuming you decide to take the plunge (now it's not an option remember), you reach the PHC only to find it locked up on most days.

                                    

If you are lucky and it is open, the medical in charge is almost never there.

The peon would most likely show you to your chair (there is no way in hell that you get a cabin because more often than not the entire PHC is the Cabin). 

                                                 

The person running the show is usually a qualified nurse who finds it in her heart to take you under her wing and explain things to you. If she doesn't, there is no way you are going to survive there.

The medical in charge usually finds out that a fresher has been posted and is out of his mind with glee since he now officially need not work anymore. He will come in within a day or two to sign your joining letter and disappear promptly.

The problems are just beginning. Remember, most Doctors trained in India are pretty much useless after their internship. They need to be mentored and taught the craft of intelligent practice since most of the PHC's aren't stocked for goats!

                                     

Gloves are a luxury, tablets are rarely if ever present. Injections seem to be the norm until you realise it's the same injection being given for a variety of problems. 

You basically learn nothing of medicine but become a master in the art of referrals and dealing with irate relatives who obviously do not realise that there is nothing you can really do at such centres due to a lack of material and quality.

                                        

There is no question of getting paid well, most of the time you do not get paid at all! The living conditions are deplorable to say the least and there is no security to speak of. Come to think of it, there is hardly any security at the major hospitals in the cities so expecting it here is ridiculous. (Remember all the instances of relatives beating up doctors)

                                         

If you somehow manage to finish your posting, getting the required signatures to prove you have done it is another post in itself.

Let's look at some positives.

If the govt can somehow improve living conditions, pay a decent wage and provide some sort of mentorship, most Doctors would be happy to work there. Discipline the seniors in charge of the PHC, the medical officers and the security and I see no reason for us to refuse. Until they do so, however, I don't see how young doctors can be expected to do their job. This invariably leads to corruption and bribery to complete the post and yes it happens even today.

Let's hope for the best!

P.S. (The pics are actual PHC's supposedly functioning)

Is English Important To Medicine?

Language has always been a big issue in India, and more so in Maharashtra and Bombay or Mumbai depending on which side of politics you're on. That it was a big issue in the field of medicine has only just started to receive prominence.I've been meaning to write about this for a long while now, but haven't got that push required. I think this week's post graduate examinations were just what I needed.

A twitter friend of mine is an examiner for Medical Students. The Consultant I work with is also an examiner for DNB (Diplomate of National Board) students. Both these intelligent and hard working doctors give up their precious time and practice to examine students in their viva-voce exams and decide whether they are fit to practice medicine. I always wondered how an examiner felt when coming across thousands of students, some of whom excel at medicine and some who are just about there with medicine but speak English fluently.

I would think that holding a command over the language would give the student an immense advantage over his counterpart who would falter in grammar, no matter where he stood on the knowledge scale of medicine. This comes from personal experience as well. I don't think I was even half as good as other students appearing for their examinations with me, but I could speak English well (almost better than half the teacher's taking my exam) and that gave me an upper hand. 

From a patient point of view, the whole thing takes a rather wierd turn. Some people would prefer talking in their native tongue to their doctor and some would cringe if a doctor didn't know how to speak English well. 

My view on this is that if the books are written in English and the syllabus is taught in English and the exams are conducted in English, the students must, simply must have a working knowledge of the language. That being said, would it be too bad an idea to have a compulsory cut off for English along with the Sciences that we need after college? Should English as a language be a subject along with Anatomy, Physiology and Biochemistry?

I think it should. Please let me know what you think....