I was a little surprised and amused to see that even in the US antibiotics
are prescribed over the telephone. Developing countries, including Bangladesh, are not immune from this practice.
Dr. Kunin discussed antibiotics prescribed over the telephone and offered suggestions for dealing with telephone
requests that could not be better. These suggestions are no doubt universally applicable and should be followed
by all prescribing physicians.
The situation is most unfortunate in several ways in Bangladesh. Any new product, including a new antibiotic, generates
enthusiasm in physicians, which is multiplied many times through the persuasive influence of pharmaceutical representatives
with gifts in hand. No mechanism or legislation exists for periodically assessing the competence of prescribing
physicians. No legal action is taken [for physician error], even if a serious mistake leads to a fatal outcome.
The relatives of the victim accept it as fate, and no complaint is lodged. A prescribing doctor is thus virtually
immune and has a free hand to issue free prescriptions indiscriminately. Why only antibiotics? He can prescribe
anything, from vitamins to vincristine (or any chemotherapeutic agent), for anything, from the common cold to cancer.
Regulations are not effective because regulatory mechanisms are weak. In this situation, ethics must prevail. The
safety of the patient is a physicianís responsibility, and inappropriate prescription [practices] must be
considered an offense by way of violation of ethical principles. Ignorance of the clinical situation not uncommonly
leads to unethical actions. This ignorance cannot be taken lightly. The telephone cannot replace personal contact,
observation and examination of the patient before a prescription is offered. Coupled with ignorance, prescribing
over the telephone invites dangerous consequences.
People often ask for free prescriptions for many reasons. For example, a patient may ask the attending doctor for
a free prescription for some other member of the family to avoid further financial involvement. Also, an influential
group may consider it a pride and privilege to get a prescription by telephone. Or people living in remote areas
may request prescriptions by telephone to avoid expense and a very uncomfortable journey to the physician or clinic.
In many cases, treatment is continued through telephonic instructions.
I believe the best way to protect the consumers (patients) is to educate and motivate the prescriber. If they follow
ethical principles with dedication, the people whom they serve benefit. Quality of care must not yield to pressure
or promotion. Widespread continuing medical education can remedy this social malady. I suggest Dr. Kuninís
advice on antibiotics is equally applicable for all prescriptions, including the widely promoted vitamins and tonics,
which may offer nothing but an economic burden to many who do not have enough money to buy the essentials.
Over-the-counter products are another challenging problem in many developing countries. You can buy and get anything
you want provided you have money; no prescription is needed. There is no "prescription product," in the
true sense. In this case, the best way "to offer good medicine" to the patient is a political one: ban
any "bad medicine" from the country. The Bangladesh Drug Policy of 1982 banned useless or harmful medicines,
many of which were outdated. This legislative act had a tremendous impact on prescribing physicians. Many became
aware of bad medicines for the first time.
Continuing medical education is, therefore, a must, and all possible means to educate physicians and patients must
be adopted. To this purpose, APUA is doing a good job with regards to antibiotics. I hope its efforts and activities
are extended further and all who deal with antibiotics uphold the philosophy and policy of this alliance.
Professor N. Islam, President
Univ of Science & Tech,
I read with interest Dr. Calving Kuninís commentary on the
prescription of antibiotics over the telephone. Dr. Kunin clearly feels that such prescriptions are poor medical
practice and that they may be indefensible in court.
As an infectious disease fellow who covers general medicine and infectious disease practices, I have observed that
the prescription of antibiotics by phone is very common. As justification for condemning this practice, Dr. Kunin
related anecdotal cases in which the prescription of antibiotics by telephone was associated with adverse outcomes
of varying severity. He cited no objective data on how common these, or any, adverse events are and, more importantly,
if an office or emergency room visit could have prevented them. The real question is: Are there fewer adverse outcomes
when antibiotics (or other drugs) are prescribed after direct contact with the patient than when through telephone
contact only? If such data exist, they should have been cited.
Furthermore, one could take issue with the implications of these examples. In the case of the young man with a
prosthetic valve on anticoagulation therapy when prescribed tetracycline who subsequently had a massive cerebral
hemorrhage, this incident could easily have been avoided by asking the patient if he was taking other medications.
This information could have been obtained via telephone just as easily as in person.
Regarding the woman who abused antibiotics but was able to obtain a prescription by telephone before a trip to
Mexico: if the prescribing physician had required an office or clinic visit, the woman probably would still have
obtained the prescription. She was determinedly seeking antibiotics and would have been as unlikely to disclose
her history of antibiotic abuse in person as she was over the phone.
In my opinion, the anecdotes that Dr. Kunin cite simply illustrate the importance of taking a good history and
arranging for proper follow-up. They do not illustrate the danger of telephone prescriptions per se. Many patients
regard an office visit as a major expense and inconvenience. They often require arranging time off from work or
child care during the appointment. Requiring that patients be seen in person after hours or on the weekend before
treatment means either an even more expensive and inconvenient emergency room visit or delaying treatment until
regular office hours.
When patients demonstrate classic presentations of some common illnesses, prescriptions by telephone can save time
and expense and can result in more convenient and less costly treatment provided a proper history is obtained,
that the prescribing is done carefully and that follow-up is arranged.
In the absence of data documenting that the prescription of antibiotics over the telephone is associated with an
increase in adverse outcomes, a blanket condemnation of this common practice based on anecdotal reports is unjustified.
Appropriate data are needed to answer this important question in a scientific manner.
John D. Goldman, MD
Dept of Internal Medicine
Polyclinic Medical Center
Harrisburg, Pennsylvania, USA
Dr. Islam's comments from Bangladesh are right on the mark. I see
no ready solution. I regret that Dr. Goldman was irritated by the notion that a history, physical examination and
pertinent laboratory tests are useful before embarking on antimicrobial therapy. Perhaps he would be more comfortable
practicing in Bangladesh. I suggest that he read the following article:
Kunin CM. 1993. Resistance to antimicrobial drugs: A worldwide calamity. Ann
Intern Med 118:557-561.
Calvin M. Kunin, MD
Ohio State University
Columbus, Ohio, USA