SINGAPORE — Complaints by patients which are frivolous and take up too much resources should be screened early on before disciplinary hearings. 

The ethical code for doctors could also be made clearer.

These are part of an exhaustive list of recommendations released by a workgroup that aims to protect the safety and welfare of medical patients, and to improve the structure and processes of the Singapore Medical Council (SMC).

The recommendations were made public on Tuesday (Dec 3) and accepted by the Ministry of Health (MOH).

While some of the recommendations can be incorporated into SMC’s processes now and taken up immediately, MOH said that others will require legislative changes.

Mr Edwin Tong, Senior Minister of State for Health, said on Tuesday that these will be in place by the first half of next year.

WHY THE REVIEW WAS DONE  

The 12-member workgroup was set up in March and tasked by MOH to review and make proposals regarding the taking of informed consent from patients as well as the SMC’s disciplinary process.

This came after orthopaedic surgeon Lim Lian Arn and psychiatrist Soo Shuenn Chiang were penalised by an SMC disciplinary tribunal, triggering heated debate within the medical fraternity here who questioned the complex set of rules relating to what doctors have to do to get permission to treat patients. Thousands of people also signed a petition against the hefty fines imposed.

Dr Lim was fined the maximum S$100,000 for failing to inform a patient of the risks or complications that could arise from a steroid injection to her wrist.

Dr Soo was fined S$50,000 for not verifying a caller’s identity and sharing confidential information about a patient’s condition with her brother, who had posed as her husband.

Both their convictions were later overturned by the High Court after SMC appealed against the disciplinary tribunal’s initial decisions.

The workgroup thus had to determine the applicable standard of care when taking informed consent, and how the standard is to be judged.

It also had to review the efficacy of the SMC’s regulatory functions and processes, to ensure that outcomes are fair, independent and consistent.

WHAT THE RECOMMENDATIONS ARE

A total of 29 recommendations were put forth and here are some of the key ones from the workgroup’s report.

1. Complaints against doctors and SMC’s disciplinary process

The workgroup heard that doctors wanted “frivolous and vexatious complaints” to be filtered out early in the disciplinary process.

Ms Kuah Boon Theng, co-chairperson of the workgroup and a lawyer, said at a press conference on Tuesday that while such complaints are few in number, they take up a lot of resources to address.

Some examples include:

·         Individuals who are unable to get medical information about spouses from a doctor, so that it can be used in divorce proceedings.

·         A relative who is unhappy that a medical procedure has been carried out on a loved one, even though it was the patient who had asked for it.

·         Business disputes between two medical professionals.

The report said that having an inquiry committee focused on dealing with complaints that are “frivolous, vexatious, misconceived or lacking in substance” could help filter them out early.  

While SMC has a complaints committee, it takes time to form, and one reason is because the committee’s chairman must be an SMC member, the workgroup said.

Instead, it suggested that any doctor with sufficient experience sitting on disciplinary committees will qualify to act as the chairman.

Doctors who were interviewed by TODAY before this had said that they welcomed proposals to improve the disciplinary process of the SMC.

Ms Kuah, who is also the managing director of the Legal Clinic, said that 23 recommendations were made, which were grouped under the following five categories:

·         Improvements to structure

·         Improvements to process and procedure

·         Reforms to the role of mediation in the disciplinary process

·         Enhancing training

·         Streamlining and increasing transparency in the appeals process

The main aim is to speed up proceedings, produce fairer results and enhance transparency, and increase the use of mediation.

On the matter of mediation, Ms Kuah said that an average of 155 complaints were received a year since 2015.

However, only 2 per cent were referred to mediation and this could be an avenue more frequently taken.

The report stated that one in five complaints against doctors arose due to poor communication. 

Dr Tan Chi Chiu, a gastroenterologist who chaired a working committee to review the SMC’s guidelines on medical ethics in 2016, said then that when people complain after procedures go wrong, investigations often throw up a similar issue: Patients felt that they were not told enough to make an informed decision.

The MOH said, without elaboration, in a press release on Tuesday that 90 per cent of complaints do not involve professional misconduct.  

To address this issue, the workgroup suggested empowering SMC to direct both the complainant and doctors to take up mediation upon receiving a complaint.

Mediation sessions come at a cost, and the workgroup also recommended that SMC subsidise patients to increase the likelihood that they will attend the sessions, though it will be subject to a cap of a certain number of hours. 

The report did not detail what the cap is, but Ms Kuah said that it is likely the patient would not have to pay anything.

2. Informed consent

The workgroup said that a clear standard should be set when it comes to medical professionals’ duty to advise, which will be based on the practice and opinion of a responsible body of doctors.

Ms Kuah said the caveat is that if a patient asks for certain information, it cannot be withheld from them.

“The doctor cannot withhold information solely to steer the patient in a certain direction in terms of treatment.

“We want to ensure that patient autonomy is respected. But at the same time ,we want to give doctors a little more certainty on what they are supposed to do.”

3. Streamlining the Ethical Code and Ethical Guidelines

Ms Kuah said that streamlining the Ethical Code and Ethical Guidelines (ECEG) to “basic and useful” principles will make it clear for medical professionals.

The workgroup had received feedback that the ECEG was akin to a “prescriptive list of do’s and don’ts”, when it should just be an ethical code.

Apart from the list being lengthy, Ms Kuah said that it may not take into account exceptional circumstances where the doctor needs to exercise good judgement.

“It is impossible to address all of this in the ECEG,” she added.

The workgroup proposed that the ECEG should be revised to focus on prescribing the principles to be adhered to in each scenario, and not prescribing a particular action to be taken.

WHY DO THESE MATTER?

Dr Wong Chiang Yin, a member of the workgroup, said after the press conference that the recommendations can help prevent doctors from practising “defensive medicine” — which is essentially making decisions to limit their chances of being sued rather than out of a patient’s best interest.

Referring to orthopaedic surgeon Lim Lian Arn, he said that many doctors stopped offering steroid injections after the case made the headlines, because they did not want to be sued.

Of the doctors that continued to offer such basic services, Dr Wong — a public health physician who works in the private sector — said that they raised prices by as much as eight times.

“These are the negative effects that societies eventually have to bear if doctors turn more to practise defensive medicine.”

Other examples of defensive medicine, the report said, include overloading patients with details that may not be necessary out of fear that they may sue the doctor for not providing enough information.

The report said that once the recommendations are implemented, genuine complaints will be able to be resolved faster.

The workgroup estimated that this can be done as fast as within four to six weeks, as opposed to the 18 months now. Some cases have been known to take up to six years to resolve.

Professor Chee Yam Cheng, president of SMC, said in a statement on Tuesday that the council welcomes the workgroup’s recommendations to the MOH.

Singapore’s three professional medical bodies — the Academy of Medicine, College of Family Physicians Singapore, and the Singapore Medical Association — agreed.

In a joint response, they said that they will continue to provide assistance to SMC and be sources that the council may draw on when executing the proposals.