A recent verdict by the Singapore Medical Council (SMC) Disciplinary Tribunal on a breach of medical confidentiality by a psychiatrist has caused much confusion in the medical community.

SMC fined Dr Soo Shuenn Chiang of the National University Hospital S$50,000 for not verifying a caller’s identity before writing a memo referring a patient to the Institute of Mental Health.

The caller turned out to be the patient’s brother — who used the memo to obtain a personal protection against the patient — and not her husband as he had claimed.

Over 8,000 people, including many doctors, have signed a petition in support of Dr Soo, saying that he had “acted in his professional capacity to help someone access mental healthcare promptly”.

“Most of us in his position, would have done the same in the same manner because we are doctors aiming to heal, not investigators aiming to verify truth,” added the petition, a second one on the ruling after an earlier one went offline.

The Ministry of Health on Saturday said it was “looking into” the SMC ruling. Why has the ruling led to such an uproar and what are its implications for healthcare in Singapore?

WHAT ARE THE RULES AND RAMIFICATIONS

Actually, SMC has set very clear and strict rules on medical confidentiality in its ethical code and ethical guidelines (ECEG). Patients have a right to expect doctors to keep their information confidential, unless there are very good reasons for sharing the information.

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Disclosing patient’s medical information without consent can only be done when it is mandated by law, when the primary doctor is discussing the case with another doctor, or when such disclosure is in patients’ best interests.

The latest SMC ruling implies that even if an immediate family member asks for the patient’s medical information, it is not advisable for the doctor to provide it. The best way to protect patient’s medical confidentiality is not to divulge any information to any third party, till the patient has consented to it.

Without doubt, Dr Soo has breached the ECEG. But if the ECEG is to be followed strictly, our healthcare system will be inefficient. Let me explain why.

(1)   Communication between doctors

A patient is often managed by more than one doctor, and good communication between these medical professionals on the patient’s condition and care is critical.

Currently, doctors often phone each other to discuss medical problems of their common patients. If the patient had investigations such as laboratory tests and imaging studies done at one clinic, it would often fax or email the results to other clinics.

Doctors assume patient would agree to her medical information being shared between clinics.

But the new SMC verdict has raised questions on whether patient’s consent would first be needed. Is this efficient and practical?

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Besides, if someone calls up my clinic asking for a particular patient’s information, I have no way to verify if the caller is truly another doctor.

The safest way would be to ask the patient to collect his results at my clinic, and then he can pass his results to other doctors. But what if the patient is too sick to do so?

Surely, the doctors cannot insist on not releasing the information to another clinic if this is at the detriment to the patient’s medical care. But doing so could open the doctor to a complaint and SMC disciplinary action.  

(2)   Communication with relatives

Currently, if a caller identifies himself as the patient’s spouse or immediate family member, and is able to provide identifiers like name, NRIC, and date of birth, and ask for medical information of the patient, doctors would normally oblige.

However, Dr Soo’s verdict means that doctors and their assistants have to ensure that the callers are truly who they say they are. How do we do so?

And again, do we have to ensure that the patient has indeed agreed for his information to be passed on to a family member?

(3)   Communication with patients' employers

When a worker is hospitalised, especially if the admission is work-related, it is common for the employer to call to enquire about the patient’s condition and progress.

This is especially so if the employer has to foot the worker’s medical bill.

Again, it is not easy to ascertain if the caller is the employer. Even if the caller is indeed the employer, the issue of patient consent crops up again.

The safest way is to pass all medical results to the patient, and let the patient decide how much information he or she wants their employer to know.

(4)   Communication with regulatory authorities

Certain diagnosis, such as salmonella enteritis and acute viral hepatitis, are notifiable diseases by law. I have to inform MOH within 24 to 72 hours of diagnosis.

Often, I would receive follow-up calls from MOH asking for extra clinical information, such as restaurants the patient has visited, and countries he has travelled to before admission.

But in light of the latest SMC ruling, I will need to do my due diligence to ensure the caller is indeed an MOH officer.

It will be safer for me to vet the officer and his staff pass in person at my clinic, before releasing any medical information on the phone. How will this affect the way authorities deal with contagious diseases, especially in an epidemic?

(5)   Communication with patients

The medical relationship between my patients and I do not end at the end of the consultation at my clinic.

Very often, my patients contact me by phone or email about their conditions, investigations, treatment, and possible adverse events a few days or even weeks after the consultation.

I always try to help and provide necessary information, but how can I be sure the caller or the emailer is indeed my patient?

It will be safer to ask the patient to come to the clinic to meet up in person.

In a nutshell, trust has long been the underlying imperative among doctors, nurses, patients, and their relatives.

Doctors often assume patients tell them the truth, and most, if not all, requests from patients and their relatives are genuine.

But Dr Soo’s case is a rude wake-up call that all medical staff ought to follow the SMC guidelines in their entirety.

It also means doctors may appear inflexible, inefficient, and even “cold-blooded” in refusing to help patients.

But the rules that we have to comply leaves us no room for any deviation, most likely to the detriment of healthcare in Singapore.

ABOUT THE AUTHOR:

Dr Desmond Wai is a gastroenterologist and hepatologist in private practice.