Pharmacy Graduates should be provided residency training opportunities-Adil Haider


Proceedings of PSHSP 3rd Int. Conference-III
Pharmacy Graduates should be provided
residency training opportunities-Adil Haider
Pharmacists should be an important member
of the healthcare team

KARACHI: Dr. Adil Haider Dean Aga Khan University Medical College was one of the guest speakers at the Pakistan Society of Health-System Pharmacists 6th National and 3rd International conference held here on September 28th 2019. He pointed out that more than fifty pharmacists are working at Aga Khan University Hospital and they are having an impact on the patient care. Most of the pharmacists are at present employed in the pharmaceutical industry and many others go abroad after graduation. Almost 90% chemist’s shops in Pakistan he said, do not have qualified pharmacists which is unfair. Pharmacists are partner in difficult decisions to diagnose the disease. As is well known the five principles are that the patient must take the right drug, in right dose at the right time for the right disease. Pharmacists should be a truly valued member of the healthcare team. Doctors need the assistance of pharmacists. We do not know why the pharmacists are not playing their role in various hospitals. In fact they should be doing this in all institutions.

Pakistan Society of Health System Pharmacists core team with Guests photographed from
(L to R) are Mr. Abrar Ahmed, Tassawar Baig, Zaad Hashmi, Arif Ali, Haris Aziz, Abdul Latif
Sheikh, Ms. Samina Badar, Asim Rauf, Ruqaiya Qureshi, Salwa Ahsan, Yasir Hashmi,
Masood Ahmed, 
Umaimah Muzzamil, Mariane Ivy, Jamshed Ahmed & Jibran Bin Yousuf.

Continuing Dr. Adil Haider opined that pharmacists should be provided increased opportunities for training. They should be provided residency training facilities in healthcare facilities. It will raise the standard of care. Patients should also understand the value of pharmacists in medical therapy management. It will also improve patient’s understanding. Some patients are prescribed drugs by different specialists and it is the pharmacists who knows better about how to take drugs that are safe. These measures will raise the standard of pharmacists in Pakistan, he added.

Developing leadership
in Pharmacy

This was followed by a panel discussion on developing leadership in pharmacy and the panelists included Ms. Shagufta Hassan, Dr. Bashir Hanif, Dr. Tahir Shamsi, and Dr. Omar Chughtai from Chughtai Lab. Participating in the discussion Dr. Bashir Hanif said that we do not pay much attention to pharmacy and we do not get involved in it. To establish a better pharmacy system is not an easy job. In the beginning we had lot of challenges. Pharmacy did not get much focus at Tabba Heart Institute. We were just concentrating on procurement and processed rather than to have a system. It is essential to have a leader who can lead pharmacy services. We were fortunate to get a good leader in pharmacy who is now focusing on the system. Now pharmacists are a part of the team taking ward rounds. We seek help of the pharmacists and we need to develop this culture in our healthcare institutions. The pharmacists are authorized to intervene in case of wrong dosage and help in drug prescribing. They are much better informed about the drug interactions. In the process our physicians are also get educated. We will try to have a clinical pharmacists as a part of the team to take rounds. Now we have electronic order system and their presence can minimize the medical errors. But still there can be some problems in dosage hence the pharmacists can educate the physician and the nurses. He was of the view that all stake holders should be involved in decision making. Another advice he offered was that at times there is shortage of drugs, there are problems in storage and pharmacists can be very helpful regarding decisions about drugs thereby educating the patient as well as physicians.

Dr. Tahir Shamsi consultant hematologist pointed out that at their institution NIBD they have a two years fellowship programme. No drug is prescribed outside the protocol. The drugs is an area which is taken over by the clinical pharmacists who is involved in patient care. Pharmacists, he agreed, should be part of the clinical team. They cannot prescribe drugs but they can challenge the prescription looking at the dosing, pharmacokinetics. Clinical pharmacists, he further stated, are not available, we have to produce them. They work with residents in hematology and we have a very busy programme.

Ms. Rida one of the trainees at NIBD giving further details of the programme said that the fellowship includes three major parts. One years is in the Ward floor. They work with nurses, residents. They take care of any drug interaction taking place. Six months are spent in the OPD Clinics. Here we work with the consultants. We are involved in counselling of the patients, providing them information about drug interactions. The trainees also learn about the diseases. Patients need drug monitoring and there is a need for appropriate dose adjustment. These patients are getting many antifungal, immunosuppressant drugs. The trainees are also involved in total parenteral nutrition (TPN). They work in support care in end of life cases working with the residents. She felt that these trainees need to work in all specialties and get trained as clinical pharmacists. This should be just like House Job for the doctors. They can be utilized and will fulfil the need and missing link in our health system.

Dr. Tahir Mughal from SKMCH emphasized the critical role played by the leadership which should be kept in mind in the big picture of health services. You need a team to achieve the desired objectives and the bigger picture in mind. We need to give due importance to followers. We must see can we develop these young men and women to the level that we desire? It is only possible if we give them decision making powers. Working environment should be changed. It is also important how to monitor your team and inspire them. His advice was to engage the people, listen to them, and give them some statistics. Decision making, empowerment will help you to achieve your goal. We at SKMCH train many pharmacists, they go out. Our turnover is very high. How to retain them is also important. At times it is the money, at times the motivation and career prospects. Get some opinion from your staff. They may be frustrated. At times doctors may ask questions which the pharmacists may not know. Just ask them that you will check. Lack of appropriate knowledge is one of the most important problem hence we need to equip the people with knowledge. Ensure to have a clinical support system which encourages the pharmacists to learn. Focus the pharmacists to learn and ask them to overcome their fears. Once they remove their fears, they will be easily successful, Dr. Tahir Mughal remarked.

Dr. Omar Chughtai from Chughtai Lab said that 90% of chemist’s shops have no qualified pharmacists. We have the rules but it is the implementation which matters. We at Chughtai Lab, he said, have one hundred seventy five medical centers. We started the pharmacy service quite late. We wanted to improve the patient care. First we did not know what to do. We later found it and it has placed us in a much better strategic position. The pharmacists can guide our patients on drug use on OPD basis. These pharmacists, he further stated, are essential part of the healthcare team.

Dr. Tahir Shamsi remarked that many pharmacists are now working at NIBD. They are working as clinical genetic counsellors, chief research analysts and may other positions. Dr. Bashir Hanif remarked that it was high time that we realized the importance of clinical pharmacists.

Earlier Mr. Sohail Zindani Founder and Mentor at Learning Minds in his presentation discussed in detail the real meaning of word THRIVE saying that it will help the participants retain what he was going to say in the next few minutes. T he said, stands for Take it easy. There are people who will continue to struggle but there are some who are keen to learn. Continuing Mr. Suhail Zindani said that we are all going to die one day, if we remember that we will never feel depressed. Fast lane to happiness is for the criminals. We have taken the life too seriously. Let us remember that the world will be much better without you irrespective of the fact how important you may be. He further went on to say that there are some people who suffer from psychological constipation, they cannot laugh and they cannot digest somebody else laughing. The reason is that they do not place it up with depression.

H stands for happiness which Mr. Sohail Zindani remarked was most important. People who work hard will become successful. But at times despite that, you may not be successful. Carry on the business based on economic conditions. Feel happy after every success as God made us all happy. R stands for re-imagine. Just decide I will make it in the rest of my life, re-imagine your careers. Meet those people who are happy. Happiness of the parents is very important. Remember, followers can also change the course of their leaders. Artificial intelligence is going to take the job of many and their existence will be in doubt. Future is not what we know, cognition is going to change everything. I stands for involve everybody. Involve people beyond your circle. Improve your circle of friends it will help your perspective grow. V stands for Vision where you wish to reach. E stands for excellence. If you think today should be better than your yesterday, you are at a loss. Better than what yesterday, he asked? Whatever you wish to do, do it in a grand style, he remarked.

Medication Safety: Challenges for
Pharmaceutical Manufacturers

This session was moderated by Dr. Obaidullah Director, Drug Regulatory Authority of Pakistan. In his introductory remarks he said that medication safety is a very rare thing. Now we are entering an environment where we can talk about it. There are challenges for the pharmaceutical manufacturers, Regulators and Healthcare Professionals. All the above stakeholders talk about safety, efficacy and quality of drugs. There are responsibilities of regulators before the grant of registration which is pre-registration. Then it is the shared responsibility of all the stake holders after registration. Now at this stage regulators have a secondary role but it becomes the first responsibility of healthcare professionals and those with marketing authorization.

Pharmacovigilance, he pointed out, was the responsibility of the drug regulators. Monitor the ADRs, signal detection system, risk benefit analysis, risk minimization. It is important to have a functioning Pharmacovigilance system. Some of the pharmaceutical manufacturers are doing it well, some are thinking to go for Pharmacovigilance. There is a legal framework. WHO has established the ADR Center at Uppsala Sweden. We in Pakistan have so far issued 1409 patient safety alerts, we had 599 spontaneous reporting by healthcare professionals. We have received 850 reports from different studies. Recalls, he clarified, is done, all over the world and there is nothing to be worried about.

Dr. Sultan Ghani pointed out that we need to ensure and improve patient safety in regulations. At times it does not involved active molecules. Formulations can be a problem. Hence it is the responsibility of the manufactures to provide for monitoring of the drug throughout its life cycle. They cannot escape the responsibility by saying that they have given the drugs to distributors, retailers. Drug manufacturers are responsible till the drug reaches the patient. They should re-think about their responsibility. They must ensure proper distribution, proper storage. At the retail pharmacy things can go wrong. They must know how to handle and store the drugs. Now we have many qualified pharmacists available who can be employed.

Mr. Khalid Saeed highlighted how to strengthen the Pharmacovigilance and patient safety system. Pharmacists, he felt, should be closely involved with the patient. Patient safety is very important from the drug formulation point of view. They do not consider that patient safety is their target. They give emphasis to quality, safety, efficacy and affordability. All these have been replaced by patient safety. Final product safety is still at the regulatory level. Now drug manufactures are conscious about safety and they are concerned with quality. At present about six thousand chemists shops in the country are manned by qualified pharmacists.

Dr. Adnan Chief Drug Inspector at Drug Testing Laboratory talked about how post marketing surveillance and how it works. Proper storage of drugs is essential because light and heat can result in their deterioration and they may lose their potency. It is the duty of retail pharmacies to ensure that. Drug regulators intentions are not wrong when we pick up samples. Drug manufacturers should ask the pharmacies to remove the recalled batches, drugs from their working shelves. No work has yet been done on the Pharmacovigilance at Sindh level. We need to strengthen the drug testing laboratory, he added.

Dr. Saif Ur Rehman Khattak Director at DRAP discussed about the recall system, international recall and the voluntary recall. At times voluntary recall is taken as a crime by the regulators. Most drug manufacturers, he opined, are by chance in this profession while some others are incidentally in this business. They are not full industrialists and do not acknowledge their responsibilities. Drug regulations are not taken as a scientific problem. Quality, safety and efficacy of the drugs is the responsibility of the drug manufacturers, he reiterated.

Mr. Sohail Mateen CEO and GM at GSK Consumer Healthcare stated that many precious lives are lost due to medication errors but we do not have the local data. Pharmacovigilance is very important. There are lot of developments taking place in technology and at times things do go wrong. Drug interactions do take place. FDA takes years before clearing any new drug but still there are problems. He highlighted the importance of putting a strong Pharmacovigilance system in place. Lot of self-medication takes place. We have strong regulations, information received is assessed and data is being circulated. At present there is a very little difference between the MNCs and the National drug manufacturers but still some people are happy to use drugs brought from overseas. MNCs can help the national pharmaceutical industry. We need to take care of adverse events taking place. Social Media ecosystem has become very important. Industrialists, drug regulators both agree that Pharmacovigilance should be given importance to ensure patient safety. However, let us not re-invent the wheel and industrialists, regulators should work in collaboration.

Dr. Kaiser Waheed Chief Executive of Medisure Pharma participating in the discussion said that whenever the industry voluntary recalls a particular batch, patients get frightened and they stop using that particular brand. Those brands get a bad name. He also complained about the attitude of the doctors and retail chemists towards the recall. He was of the view that recall is always related to a particular batch and not the brand. If the perception is not cleared, it will be the drug manufacturers as well as patients who will suffer.

Capt. Iqbal Managing Director of High Q Pharmaceuticals said that media plays up the voluntary recall and the drug regulators should not justify this to prosecute the drug manufacturers. Recall is a routine overseas, he added.

Mr. Haroon Qasim Managing Director of PharmEvo pointed out that it was their motivation which helped them to start Pharmacovigilance at PharmEvo. When our team discussed it and came to know that it involves lot of cost, we still decided to go ahead with that motivated by the patient safety and medication safety. Pharmacists have an important role in manufacturing, administration of drugs in proper dosage. Despite the fact that it was a very expensive exercise as a responsible company we decided to go for Pharmacovigilance. Whatever we do we are talking to all the stake holders. Pharmacists can play a vital role in saving lives of people. We need to implement strict regulations in retail pharmacy. All chemists’ shops should be manned by qualified pharmacists. It is important that we all must adopt Pharmacovigilance in the pharma industry. We can do it if we work as a team.

During the discussion it was also pointed out that the prevalence of sub-standard drugs was much low in Pakistan as compared to India and overseas people prefer drugs manufactured in Pakistan. Drug administration is a problem and not the number of drugs. Prescribing pattern and drugs abuse should be stopped. Mr. Haroon Qasim also pointed out that at times it is our own colleagues in the pharmaceutical industry who being the competitors try to create confusion and fiasco. They must realize that it is a health issue and not the issue of competition. Giving an example of recall related to the molecule Valsartan, he said, the DRAP was very helpful but it was the competitors in the pharma industry who were responsible for creating un-necessary confusion among the healthcare professionals and the public. He highlighted the importance of collaboration and facilitation. Now the issue related to Ranitidine is being misused. It is a voluntary recall. The major issue is with the drug manufacturers and he advised them not to use it as a ploy to harm their competitors.

Pharmacy Practice

This panel discussion was moderated by Mr. Jibran Bin Yousuf. Taking part in the discussion Ms Salva Ahsan Chief of Pharmacy at Shifa International Hospital Islamabad said that we all have to contribute towards patient safety irrespective of the fact whatever the organization is doing. We need to develop SOPs. We have to take care with conviction and practice not preach. At times the system may not be properly designed. Patient safety does not start and end in pharmacy. It is important how nurses, doctors look at it, how emergency room, Operation Theatre people handle the drugs. We have to look how drugs are being used all over the hospital. Go out of pharmacy and check how drugs are being handled. Patient safety culture should be supported and involve the community in everything.

Dr. Shamim Raza from AKUH highlighted the significance of data and expressed the satisfaction that all the major healthcare facility pharmacies were at present headed by pharmacists trained at AKUH as well as all over Pakistan. Culture towards patient safety is evolving in various organizations. We can witness positive change in the society as well. There are improvements in prescription, in regulation. Provinces are also being involved and a positive change will come. Changes are coming in DRAP as well. We are inculcating something which should be a culture in the society. In the days to come, we will have no choice left but to use drugs carefully. We need more collaboration. DRAP should be more proactive while dealing with public hospitals. They need training and designing a system. Poly Pharmacy culture between pharmaceutical industry and healthcare professionals is a problem. We hope with more awareness, working will improve and we will have better coordination with DRAP, he added.

Dr. Aasma Hamid HOD of Pharmacy at DUHS Ojha Campus said that there is no difference between public and private hospitals. There is lack of infrastructure. We have now established a secretariat and we are inducting pharmacists as and when their services are needed. There are knowledge gaps. We have started an internship programme and to begin we have enrolled a few students. We are trying hard. There is some resistance and it is difficult to work in a public hospital. We hope to start clinical pharmacy. We are working with scarce resources. She opined that every public hospitals must have a proper pharmacy as private hospitals have a well-established Hospital Pharmacy.

Mr. Yasir Hashmi GM Ehad Healthcare stated that they have started a chain of community pharmacy. Almost forty thousand pharmacies can be established in Pakistan. He warned that if we do not change, robots are going to replace the pharmacists. We need to establish community pharmacy in Pakistan. If we make mistakes in selection of drugs, administration of drugs, it is the patients who will suffer. We are at present supervising a number of hospitals and the state of affairs at many hospitals as regards pharmacy services is very disappointing. We need to take care of all these issues, develop our indicators of community pharmacy, clinical and operational indications should be developed. It is high time that we establish and strengthen the community pharmacy, he remarked.

Ms Sumaira Khan Head of Pharmacy from Tabba Heart Institute said that it was not easy to work at a cardiac centre. At times one has to take risks. At times I was amazed to listen to the doctors. One has to be open and ready to accept advice. It is the vision of the leadership to take different options. It is important to streamline the process which should be based on outcome. In case of no good outcome, patient safety will be compromised. We have to look at the medicines prescribed to the patients at the time of discharge. Let us have clinical pharmacists and go for the best when we wish to employ the chief pharmacist who help you build the professional capacity of other colleagues.

Mr. Kelum Jayasuria Manager Pharmacy Services Asiri HealthGroup from Sri Lanka stated that education was a problem in their country. Most of the pharmacists are trained with part time teaching. We have no PharmD programme in our country. We do not have proper hospital pharmacy service either. Currently lot of unethical practices are going on as regards promotion. Pakistan on the other hand is doing very well. We wish Pakistan should help us. Our Pharmacists should be better educated. We have lot of complaints from doctors in our hospitals. Doctors have accepted our proposals in the private hospitals but consultants in public hospitals are still reluctant.

Mr. Yasir Hashmi stated that discount feasibility in community pharmacy is yet another problem. We now see good established pharmacy services at Lahore and Islamabad but in Karachi we still have lot of problems. It will take time. He suggested that the practice of offering discounts should be discouraged.

Bridging the Gap between
Academia and Practice

Mirza Tassawar Baig moderated the discussion related to bridging the gap between Academia and pharmacy practice. The panelists included Dr. Rafiq Alam Dean Ziauddin College of Pharmacy, Dr. Iqbal Azhar Faculty of Pharmacy from University of Karachi, Dr. Arif ullah Khan Dean Pharmacy Riphah University, Dr. Azhar Hussain Dean Hamdard University, Dr. Noor Jehan Dean Dow College of Pharmacy, Dr. Azhar Hussain Dean Hamdard University.

It was pointed out that academia can play a role in bridging the gap between pharmacy practice. The issues related to internship in pharmacy were highlighted. Dr. Noor Jehan said that changes in curriculum are needed to improve patient safety. We need to redefine the expectations from the academia. Pharmacy Council is working on changes in curriculum and it is hoped the whole process will be complete in the next three to six months. There is no chemistry in curriculum being taught in Sri Lanka. We need to be flexible in designing the curriculum keeping in view the needs of the country as well as pharmaceutical industry. We need to give more emphasis on research and academia is also taking up these issues.

Prof. Iqbal Azhar stated that we have made a good start. It is the joint duty and responsibility of all of us. Implementation is based on certain factors. Other partners needs to be aggressive on curriculum changes and bridging the gap. It is the HEC which approves numerous postgraduate programmes and it is essential that they must agree. Public sector universities, he said, do not have their own hospitals. Instead of decreasing the gap, we should not widen this gap. Now universities are losing their autonomy. Most decisions are taken by the Higher Education Commission rather than the academic councils or Board of Advance Studies, he remarked.

Dr. Arif from Riphah University said that their curriculum is patient safety oriented. We changed the curriculum long time ago. We need more clinical pharmacists. PhD in pharmacy need to be trained and produced keeping in view the country’s demand.

Dr. Naheed Memon from LUMHS stated that there is a miscommunication between the academic and the pharmacy practice. Pharmacists are not welcomed by the physicians. We need to have the same structure at all hospitals, pharmacists should be recognized. They are not involved in the discussion during the ward rounds by the physicians. Pharmacists are there to intervene and facilitate the physicians to ensure safe medications.

It was also pointed out during the discussion that pharma industry was getting larger share of pharmacists, hence it is essential that they provide internship during the start of the second year. We also need to address research projects in the curriculum. We already have a very packed programme in the curriculum.

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