Scenario in a Klinik Kesihatan

I have a patient discharged from a hospital to our clinic, and he is on life-long tiotropium bromide Handihaler (Spiriva) and Symbicort Turbohaler for chronic pulmonary obstructive disease (COPD). As these medicines are not in the formulary our pejabat kesihatan daerah (district health office), the hospital is to supply us with those medicines.


When I called up the hospital, I was told that my clinic has to find an alternative since the hospital in low on budget and will no longer supply those medicines to my patient. So this prompted my mini search (or rather, refreshing of) COPD guidelines.Tiotropium bromide (List A*) [Spiriva] is a long-acting anticholinergics (duration: 24 hours) used for the long term maintanance treatment of bronchospasm and dyspnoea associated with COPD. It is usually added to standard therapy (e.g. inhaled steroids, theophylline) and the dose is 18mcg od.

Symbicort Turbohaler (List A) contains budesonide (a glucocorticosteroid) 160mcg and formoterol (long-acting beta2-agonist, duration: 12+ hours) 4.5 mcg; the dose is 1-2puff bd,max 4puff bd.

My clinic only has MDI salbutamol, MDI budesonide and MDI Berodual. MDI Berodual contains ipratropium bromide (a short-acting anticholinergics; duration: 6-8 hours) 20 mcg/dose and fenoterol hydrobromide (short-acting beta2-agonist); duration: 4-6 hours)50 mcg/dose.

According to the GOLD guidelines, an inhaled glucococorticosteroid combined with a long-acting beta2 bronchodilator is more effective than individual components in reducing exacerbations and improving lung function and health status.

Regular treatment with long-acting bronchodilators is more effective and convenient than treatment with short-acting bronchodilators.

GOLD guidelines: Therapy at each stage of COPD

Guidelines according to NICE

Since my patient is on a long-acting bronchodilator and inhaled steroids, his stage of COPD must have necessitated the use of these medicines, and that the short-acting bronchodilator and short-acting anticholinergics in my clinic are not sufficient for his condition. These are conveyed to the hospital and arrangement is made for them to supply us with those medicines currently, after which my budget-strained clinic has to exchange similar-valued medicines with tiotropium and Symbicort Turbohaler from the hospital for my patient's life-long supply of medicines. I believe that patient's care should not be compromised even when he is under follow-up in a clinic !

PRP Posting

Congratulations to all B106!! Now that it is over and done, the next big thing after convocation (the attire/shoes hunting, booking of hotels/plane tics for family etc.) and perhaps, graduation trip, at this juncture in your life is none other than the provisionally registered pharmacist (PRP) placement location.


By now, the uni would have gotten you all to fill up the necessary forms and what awaits you all is the SPA interview. My seniors had told me that whatever state you fill (for your posting) in the previous forms are not that important, it is THE FORM which you will be filling in during the day of SPA interview that counts...so you do have some time to think about it before your interview.


Now the interview is just a formality but a grand senior had told me that a few friends of hers failed the interview. They were asked 'if we send you to sabah/sarawak, would you go?' and they answered 'no'. My senior's reasoning is that the gov is trying to see if we 'menurut perintah'so probably the political-correct-cum-neutral answer is 'I will go but I will be sad that I am leaving my parents in my home state'. (Disclaimer: I am no HR manager in the gov sector)

For fledgling pharmacists in overseas who would like to practise their PRP year (known as 'pre-reg' in UK) back home, do visit HERE as my friend ka keat has put up a comprehensive guide on PRP application.


But I digressed. Back to the posting location; after the spa interview, we will be placed by KKM to a particular STATE, the exact hospital which we will be posted to lies on the Jabatan Kesihatan Negeri (JKN) of the particular state. If you are placed in a certain state, (based on past examples), you will most likely be in the state for some time as cross-state transfer is very difficult indeed and you need really valid reason or strong cable.


I am sure as resourceful as all bpharmers are (thanks to all the portfolios and PBLs)*cough*, you all would have done or must be doing your 'research' and are pondering over factors like:
-the love for clinical (hospital) or bureau?

-higher allowance for those who from west malaysia who get placed in east malaysia (but higher chances of getting smaller districts in east malaysia in 2nd year)


You should MAXIMISE your chances of getting what you what by being willing to 'compromise'; you probably would like to consider putting other state in the THREE choices that you have instead of filling them up with hospitals/institutions in kl/selangor (if you are from kl/selangor)


When I filled up my choice, I did it based on probability. If you look at the Second Schedule of your Registration of Pharmacists Act 1951, there is a list of premises that you can be posted to. There are 13 premises (10 hosps, bureau, bhg farmasi, cawangan penguat kuasa farmasi) in Selangor, 3 in WP Kuala Lumpur (I didn't know then that HKL is a 'separate entity', so in actual fact only Hosp Putrajaya and cawangan penguat kuasa farmasi fall under WP Kuala Lumpur).


Although there are hospitals like Hosp Tg. Karang, Kuala Kubu Baru, Banting and Sabak Bernam in Selangor, based on probability, Selangor is still the sensible choice (to me). At that time, I was thinking, how 'ngam' can it be, right? So I bit the bullet and never did take the middle ground.


I was posted to Hosp. Sabak Bernam (the furthest hosp in Selangor!!). Now, here are the probably-not-so-known-facts to you all: a prp who is posted to district hospitals like Hosp Sabak Bernam, Hosp Banting will get to do their clinicals in Hosp Klang or Hosp Selayang! So if you get the place, don't think you will be missing out and quickly appeal for placement at another state. And as most seniors who get postings out of their home states will tell you, after some time, you will see past all the initial frustrations/disappointments.......


To me, getting over the posting (for those who do not get what they want) is indeed like the Kubler-Ross Model: 5 Stages of Grief

1. Denial
'This can't be happening to me..... (name of state), I am not 'related' to it in any way (not even my parents' hometown)'


2. Anger
'Why me? It is not fair!!' 'He/she who................(fill in the blanks yourself) get that but I get this?'


3. Bargaining
'I'd rather be in that hospital in (name of state) although it is very hot!!'
'I don't mind working in (name of state) as I love the food there!'


4. Depression
[Thankfully, so far there is nobody that I know of who was in this stage]


5. Acceptance
'It is going to be alright. It is just one year'
'At least I get to come back on weekends'


So to bite the bullet or not to? to have a soft landing or not to? Please analyse the market yourself....the rumoured rough numbers of frps leaving gov service, the number of fresh graduates like you all going into the job market, any shortage in a certain state, the number of ppl with cables..... At the end of the day, there is just so much we can do, but we should still maximise our chance nonetheless. Wherever you may be, do keep an open mind and embrace your profession with passion=)