AETCOM

Question 1

Communicate effectively with a patient with empathy and ethics on proper use of prescribed drug
therapy

Communication is defined as successful transmission of ideas, opinions and information through a

common system of written or spoken words, symbols, signs, behaviour or actions.

• Verbal communication

• Non verbal communication

• Eye contact, facial expression, voice tone, body position and posture, comfort zones,
touch

• Barriers to Communication

• Environment – privacy, noise, crowding

• Client – timid, shy, diseases affecting communication

• Doctor – lack of awareness, attitude

• Time

• Hospital support staff

• Distancing tactics – looking at watch, talking on mobile, asking patient to hurry up

Ethics includes the following components

1. Beneficence – intention to do good

2. Autonomy – right to take informed decision

3. Non malificience – intention to do no harm

4. Distributive justice – treat all patients equally

5. Confidentiality – information of patient

6. Conflict of interest – treatment not to be influenced by any person, material and money
 1. Question no 2

Communicate with the patient regarding the optimal use of

a) Drug therapy - answer given in previous question 1

b) Devices - nebulizer, MDI, SPACER
c) Storage of medicine

HOW TO USE A NEBULIZER

What is nebulizer?

A device that turns liquid medicine into a mist. As the patient breathes, the mist of medicine
moves into the lungs. The nebulizer is usually connected to a machine that pushes air through
the nebulizer.

What are the conditions requiring nebulizer treatment and name few drugs given by this
route?

Bronchial asthma, COPD, chronic respiratory diseases

severe allergic reactions causing swelling of airway

what are the instructions on how to use a nebulizer?

Read the booklet carefully, take expert advise.

1. Wash your hands with soap and water

2. Prepare the machine – keep on a hard surface, check air filter whether it is clean or not

3. Prepare the medicine – if premixed open it and place it in the nebulizer medicine
container

4. Connect the medicine container to the machine using the tubing

5. Place the mouth piece between your lips or use a mask

6. Turn on the machine and breathe in and out slowly and deeply through your mouth

7. The treatment is over when there is no mist coming out. Usually 10 to 15 minutes

8. Rinse your mouth with water or saline after each treatment, if you use a mask wash your
face.

How to take care of nebulizer?

Clean the drug container, face mask with soap water. Allow them to dry.

Alternately use disinfectant solution.

Device 2 - Metered dose inhaler and spacer usage guidelines

STEPS TO FOLLOW

1. Hold inhaler upright and shake well

2. Check dose per actuation and prescribed dose

3. Remove inhaler cap

4. Assemble spacer

5. Now put mouth piece of spacer between teeth (do not bite) and close lips to form good
seal.

6. Breath out gently into the spacer

7. Keep spacer horizontal and press down firmly on the canister once

8. Breath in and out normally for 3 or 4 breaths

9. Remove spacer from mouth, breath out gently.

10. If more than one dose needed, repeat the same.

11. Remove inhaler from spacer, replace inhaler cap.

12. Rinse or gargle your mouth to remove drug deposited in pharynx

13. Wash your spacer in warm water with soap or detergent and allow to air dry
 MDI AND SPACER

C .STORAGE OF MEDICINE

The manufacturers standards of

1. Identity

2. Purity

3. Quality

4. Staility

5. Potency

6. Efficacy
 7. Safety of the drug is only expected if stored in specified conditions as per the
manufacturer.

Various environmental factors such as

• Temperature

• Humidity

• Light

• Air

• Microbial contamination affect the Shelf life/expiry date of the drug

BENEFITS OF OPTIMUM STORAGE

1. Prevents harm due to alterd physio chemical property or contamination

2. Assures efficacy
3. Positive treatment outcome
4. Prevents accidental intake by children or other relatives
5. Cost effective use of medicine reduces need of repeated buying

Physician must communicate regarding

1. Why to store properly

2. Optimal storage condition
a. Cool place means – temperature between 10 to 25 C
b. Cold place means temp. between 2 to 8 celsius Eg. insulin
c. Freeze – few vaccines
d. If storage not specified store at normal room temperature
3. Alternate possible method
4. Storage during travel
a. Avoid exposure to light and heat
b. Use of cold box
5. When to discard – looks or smells differently, contamination, already expired
Question number 3

Motivate patients with chronic diseases to adhere to the prescribed management by the health
care provider

CASE SCENARIO

A 40 year old male patient with low socioeconomic back ground is diagnosed with moderate
hypertension. He was prescribed with tab. Telmisartan 40 mg and advised for life long
treatment. Patient is not willing to take the medication because of his low socioeconomic
status and fear. Communicate with the patient about the cost and adherence to the treatment
advised?

ANSWER

 Explain the disease and advantages of medication adherence (hypertension- is a chronic

and life time disease, treatment improves health and productivity)

 What is non compliance or non adherence?

o Extent to which patient fails to take medications or treatment recommendations

as prescribed by the health care provider

 Explain the consequences of non adherence – (leads to immediate problems like

headache, dizziness and long term severe consequences like risk of MI and CVA

 Explain the measures to be taken to motivate the patient to adhere

o try to convince the patient that cost of medication is les when compared to cost
of long term implications

o Use of generic medicines and procure from government hospitals

 What are the different types of cost incurred by the patient?

o Direct cost – cost incurred by patient, patient family, health care system and
community

o Indirect cost – loss of productivity to the individual and society

o Avoidable costs – costs incurred for patients suffering from complications

Question 4

4. .Explain to the patient the relationship between cost of treatment and patient compliance?

Guide to physician to improve cost communications

pneumonic - IDEA

• I – INQUIRE
• Iniate discussion on cost of treatment, inquire financial status and hard ships of
the patient
• D- DISCUSS
• Current recommended treatment and its rationale and evidence
• Alternate treatment options
• E- EDUCATE
• Confirm patients understanding
• Educate on both benefits of adherence and risk of not receiving treatment
• A –ACT
• Start treatment as per agreed shared discussion
• Use low cost generic drugs
• Do not prescribe extravagantly
• Do not use unnecessary or minimally beneficial medicines

Strategies to address financial barriers in medication adherence

• Assess affordability of patients

• Rational prescribing

• Use generic medicines ,

• drugs from NLEM LIST

• Low cost medicine availability from

• JAN AUSHADI KENDRAS

QUESTION 5

5. Demonstrate an understanding of the caution in prescribing drugs likely to produce

dependence and recommend the line of management

What is drug addiction?

 Continue using drugs causing dependence, inspite of knowlwedge regarding its harmful
effects
 Unable to stop using drugs( compulsive use or craving)
 Impaired behavioural control and dysfunctional emptional response
 Patient often neglect other obligations – social and work due to drug use

What is drug dependence?

• Some or all characters of drug addiction

• Drug tolerance – wants larger doses or frequent doses

• With drawal syndromes

Name few Prescription drugs that cause dependence

• Opioids – morphine, codeine, meperedine

• Anxiolyics/ sedative and hypnotics – alprazolam, diazepam,
CNS stimulants – methyl phenidate, modafinil, amphetamine, dexamphetamine

TREATMENT APPROACH

Pharmacological intervention
 Treatment of withdrawal syndrome
 Substitution therapy – eg. Methadone
 Aversion therapy - disulfiram
 Antagonist therapy- naltrexone for opioids
Psychological intervention
Educate patients
Rehabilitation
Case scenario 56 year old male, known smoker for 21 years, attended general surgery OPD
with intermittent claudication was investigated and diagnosed as a case of thromboangitis
obliterans. Explain him about his present condition and motivate him for cessation of smoking
habit and communicate him effectively regarding optimal use of nicotine transdermal patch.

Answer

 Explain the patient the nature of disease and cause of symptoms

o The pain occurring is due to vasoconstriction and smoking is a cause for the
disease and further worsens the disease

It may lead to further complications

 Explain option of nicotine patch and advantages which can help in stopping smoking

o It contains nicotine but not other toxic chemicals in tobacco smoke such as tar
and carbonmonoxide

o Reduces unpleasant withdrawal symptoms and cravings of stopping smoking

o and prevent him from multiple diseases like COPD, lung cancer

 Instruction on drug use -Right way of using the drug, how to apply, duration of
treatment

o Chew nicotine chewing gum slowly until there is a nicotine taste

o Once you feel the taste, keep nicotex chewing gum in between the cheek and
your teeth

o Nicotine will be absorbed from the nicotex chewing gum

o Chew the nicotex chewing gum when the taste fades

Warnings

o recurrence of disease with incomplete and noncompliance to usage

o tissue death (gangrene) leading to amputation of fingers or toes

o Future consultations –

o come back earlier if symptoms worsen

o Patient may be advised to come back with few investigations done to save time

o Conclude the consultation – ask the patient if he/she understood or not, repeat
the instructions, and if there are any queries
QUESTION 6

6. Demonstrate the ability to educate public & patients about various aspects of drug use
including drug dependence and Over-The-Counter (OTC) drugs.

DRUG DEPENDENCE:

It is a state that develops due to the adaptation (tolerance) produced by resetting of

homeostatic mechanisms in response to repeated drug use.

Ex: Alcohol, amphetamines, cocaine, nicotine, opioids

OVER THE COUNTER (OTC) DRUGS:

DEFINITION :

OTC are drugs which can be sold in the pharmacy without prescription of registered medical
practitioners for self-medication by public.

Ex: Analgesics, antacids, antifungal agents (topical), anti-histaminics and decongestants, eye
drops, and hair growth promoting drugs (topical)

PUBLIC MUST BE EDUCATED ABOUT THE FOLLOWING POINTS THAT THEY MUST DISCUSS
WITH THEIR PRESCRIBER:

1. About the effects of drugs:

 Why is the drug needed?

 Which symptom will disappear, and which will not?

 When is the effect expected to start?

 What will happen if the drug is taken incorrectly or not taken at all?

2. About the side effects of drugs:

 Which side effect can occur?

 How to recognize them?

 How long will they continue?

 How serious they are?

What action to take?

3. Instructions to take drugs:

 How the drug is to be taken?

 How long to take the drug?

 How to store the drug?

Warnings and precautions:

 When the drug must not be taken?

 What is the maximum dose to be taken?

 Why to take full course of treatment if I am relieved earlier?

4. Regarding future consultation:

 Is it required to consult back and when?

 In what circumstances should I return earlier?

 What information will be needed at my next visit?

Q. According to you, the use of over the counter drugs is rational?Discuss its advantages and
disadvantages

Characteristics of OTC Drugs:

• Considerable high safety margin

• Almost no abuse potential

• Easy to administer and shows its effects rapidly after administration

• Do not mask any underlying potentially dangerous conditions

• Adequately labelled for its use

• Symptoms are easily identified that need treatment with OTC drug

Indian Regulations:

• OTC refers to those drugs which can be stored and sold from the grocery counter and
general store without obtaining any license under the D&C Act 1945.

• In terms of Rule 123, the drugs listed in Schedule K of the D and C rules ,1945 do not
need a license for sale by shop other than a chemist’s shop.
Advantages of OTC Medicines

• Direct and rapid access to medicines without prescription.

• Available at pharmacists as well as grocery stores

• No physician visits

• Decreases health care costs

• Promotes self treatment for minor illness (like fever,headache etc) decreases the
burden of healthcare system.

Disadvantages of OTC Medicines

• Self medication can be dangerous if diagnosis is incorrect . A minor symptom (say

headache) may be cue for a more serious disease.

• Increases chance of drug interactions with prescription medicine

• OTC medication may delay doctor’s visit for a serious treatable disease

• Risk – benefit ratio is uncertain

• Illiteracy may be burden for safe and effective use of OTC drugs

• A cause of polypharmacy

Q2. How will you educate public about responsible use of over the counter drugs

• Responsible use of OTC drugs

• Do not self treat on the basis of assumption to avoid further complications.Be sure
about diagnosis and then take OTC medicine

• Do not use OTC medication for longer duration or at higher doses than recommended.

• Always read warning and C/I of its use. Contact physician if any confusion.

• Check expiry date during and after purchase and safely dispose which have expired.
“Schedule K “drugs

• Aspirin

• PCM

• Analgesic balms

• Antacid preparations

• Gripe water for use of infants

• Inhalers containing drugs for treatment of cold and nasal congestion

• Syrups, lozenges, pills ,tablets for cough

• Skin ointments and ointments for burns

QUESTION 7

7. Demonstrate an understanding of the legal and ethical aspects of prescribing drugs.

Case 1 : A physician is taking rupees 300 as consultaion fees from poor patients and
spends an average time of 10 minutes for each patient while he is taking 600 rupees
from rich patients and spents average time of 20 minutes on each patients. Is this an
ethical practice

Four principles are :

• Beneficence: Always treat patient with an intention to do good and for benefit.
• Autonomy: Respect for the patient's right to informed decision-making capacity.
• Nonmaleficence: Always treat the patient with an intention to do no harm.
• Distributive justice: Treat all patients equally (right of all).

In the above case the physician is not practicing ethically as distributive justice is not
there

Case 2 : A physician was treating a patient for his chronic illness and prescribed an off
labelled drug without discussing with a patient though there are standard of care
(Labelled drug) for that particular condition. The patient suffered an adverse reaction
due to the off label use of the drug. What are ethical and legal aspects of prescribing?
Give your opinion above the case.

In the above case the physician has not given respect for the patients autonomy
 ETHICAL ASPECTS OF PRESCRIBING
1. Rational Prescribing
• Use evidence-based, medically justified drugs
• Ensure benefits outweigh risks
2. Conflict of Interest
• Prescriptions must be patient-centered
• Avoid influence from pharma incentives or personal gain
3. Respect for Autonomy & Beliefs
• Provide full information for informed decisions.
• Consider moral, cultural, and dietary beliefs (e.g., vegetarianism)
4. Truth-Telling & Transparency
• Clearly communicate diagnosis and treatment options
• Avoid exaggeration or minimization.
5. Remember and respect Professional Boundaries
• Act within your competence and qualifications
• Consult specialists when needed
• Equity in Care - No discrimination based on gender, race, religion, caste, or
socio-economic status. Mandatory care in medical emergencies
• Legal & Regulatory Compliance - Adhere to national laws and ethical medical
standards

6. Managing Prescription Errors

 Implement systems to detect and prevent errors
 Disclose and manage errors honestly and empathetically
7. Prescribing Off-Label medicines
 Inform patients about off-label use
 Monitor closely for effects or side effects
8. Confidentiality of the Patient
 Keep all patient information private
 Share only with consent or legal requirement
9. Prescribing in Sports Medicine
 Do not prescribe for performance enhancement
 Maintain health-focused intention
10. Use of Social Media by Physicians
 Avoid sharing identifiable patient data
 Maintain privacy, professionalism, and avoid misleading claims
11. Investigations & Secret Medicines
 Recommend tests judiciously
 Never prescribe “Secret medicines” (medicines with undisclosed ingredients)
LEGAL ASPECTS OF PRESCRIBING

1. Generic Drug Prescribing

• Prefer generic/non-proprietary names

• Ensure availability before prescribing

• Educate patients on benefits and sources

2. Rational Prescribing

• Avoid overuse, underuse, and misuse

• Prescribe only when necessary, and cost-effectively

3. Diagnosis Documentation

• Include definitive or provisional diagnosis in every prescription

4. Fixed-Dose Combinations (FDCs)

• Use only approved and rational FDCs.

5. Legibile prescribing

• Write clearly or use digital tools (typed/printed)

6. Use CAPITALS

• To reduce misreading

7. Avoid Prescription Errors

• Be cautious with units (e.g., mg vs mcg)

• Avoid decimal errors (e.g., 0.5, not .5)

8. Mandatory Components of a Legal Prescription

• Prescriber’s Details

• Name, registration number, qualifications

• Full address, phone, email, and emergency contact

• Patient’s Details

• Name, age, gender, address

• Height and weight if relevant

 • Prescription Parts

• Superscription: "Rx" symbol

• Inscription: Drug name, dosage, strength

• Subscription: Instructions to the pharmacist

• Transcription (Sig): Directions for patient use

• Prescriber’s Signature & Date: Must be signed and dated by hand

9. Display of Qualifications

• Mention only NMC-recognized degrees

• Don’t claim specialty without accredited qualification

QUESTION 8

8. How to optimize interaction with pharmaceutical representative to get authentic

information on drugs

1. Explain the advantages and disadvantages of meeting a medical sales representative.

Benefits of ethical interaction between doctor and medical representatives are:

 They provide useful information to health professionals.

 They provide various items like medicine samples, patient’s education leaflets etc. which
can be given to patients.
 They provide conference registration fees, sponsorship for arranging conferences or
CME, various medical gadgets and free drugs for research that helps in enhancing
scientific knowledge of medical professionals. But, these should comply with law,
regulations and guidelines of the land.
 They support and provide logistics in screening of various diseases, disease awareness
camps etc. which help physicians and patients in several ways.

Disadvantages of unethical interaction between doctor’s and MR:

  Primary objective of detailing and interaction i.e., to provide up to date information of
the drugs is completely neglected. So, doctor may not be aware about indications, side
effects, drugs interaction and contraindication of the drugs.
 IRRATIONAL PRESCRIBING OF DRUGS BY DOCTOR: Doctor prescribes only that particular
medicine more to increase sales, irrespective of the presence of better alternative.
 POOR TREATMENT OUTCOME: patients will not be cured properly.
 INCREASED FINANCIAL BURDEN TO THE PATIENT: Repeated doctor visits, investigations,
treatment of ADR, decrease in quality of life and increase in financial burden to the
patient.
 LEGAL PROBLEM TO THE DOCTOR.
 LEGAL PROBLEM TO THE PHARMACEUTICAL COMPANY – for rewarding unethical
benefits to the physician.
 DEFAMATION TO DOCTOR

2. Explain your understanding of an “authentic drug information”

CONSISTENCY OF PRODUCT INFORMATIPON:

The format and content of drug information to be conveyed in all promotional materials are
regulated by national laws and regulations.

Deviations from those norms led to inadequate, inaccurate, unethical, falsified or biased
promotional claims.

ACCURATE AND NOT MISLEADING:

Promotional information should be scientifically sufficient, accurate, balanced, legible,

understandable and complete enough to enable prescriber to apply his/her wisdom to judge
the therapeutic appropriateness of the drug for patient population or a particular patient.

It should not be distorted or exaggerated by omission, commission or in any other way.

SUBSTANTIATED (VALIDATED or AUTHENTICATED):

Promotional literature should be justified by reference(s) of good quality and scientific

evidence(s)

3. What do you mean by unethical promotional practices? What are the various ways of doing
such promotion?
UNETHICAL DRUG PROMOTION:

Takes place in various ways like false exaggerated, controversial and ambiguous claims about
indications.

Intentionally suppressing the risks, contraindications and side effects.

Providing various incentives or gifts to physicians.

Disease awareness campaigns biased towards drug promotion etc.

FALSE SHAPING OF MEDICAL OPINION:

Pharmaceutical companies may exaggerate a doubtful, simple, non-serious condition or

functional disorder as serious medical condition that needs pharmaceutical treatment by
various types of promotion for marketing their drug.

OPPORTUNISTIC DATA MANIPULATION:

By manipulating study data and diagram, pharmaceutical companies may modify and represent
the study results in their favor to show that their drug is better than another drug where
actually none exist.

GHOST MANAGEMENT:

Refers to entire process and various steps in research, analysis, writing and final publication of
the articles, which is controlled and shaped by some anonymous persons/ organisations with
conflict of interest and published under the name of renowned academics to make the article
credible and transparent.

The article is published for promotional purpose showing the various uses and better aspects of
the drug of interest.

OFF LABEL PROMOTION:

The off label use of prescription drugs, always render huge commercial prospect for the drug
companies.

The off-label use refers to the prescription of drugs for non-approved indications depending on
some scientific and medical opinions/evidence (and not by properly generated scientific data or
evidence)