Improving the way complaints against doctors are dealt with

The Singapore Medical Council (SMC) regulates and disciplines doctors through a stringent disciplinary mechanism.

The disciplinary process must not only be fair, just and accurate, it must be seen to be so by doctors and Singaporeans. A negligent or errant doctor must be rightly penalised, not just to punish his wrongful act, but to serve as a deterrent to other doctors.

Whenever a doctor is penalised by the SMC, the verdict is scrutinised by all practising doctors, who will rightly take heed and make adjustments to their normal practice if necessary.

At the same time, if doctors perceive that a SMC ruling is problematic and has potential negative implications for healthcare practices, they will be unhappy and may protest.

This was what exactly happened recently with two SMC verdicts involving a psychiatrist and an orthopaedic surgeon.

In the wake of this, the Ministry of Health (MOH) has formed a 12-member workgroup to review the SMC disciplinary process.

Many doctors, including myself, have been actively debating on how the SMC disciplinary process can be improved. Here are what we know of the current practices and some of the thoughts we have on the topic.
 

1. How does SMC do their due diligence to ensure the complaint is genuine?

Currently, a complainant would submit a complaint in writing. A SMC staff will interview the complainant, who has to make a statutory declaration on his complaint.

SMC then sends it on to its Complaint Committee (CC) for evaluation. If the CC finds the complaint valid, it would be referred to a Disciplinary Tribunal (DT), which will summon the accused doctor for a hearing.

SMC has to ensure the complainant is of sound mind, reasonable, and speaks the truth. Can this be done without fail every single time with a mere interview by an SMC staff?

More strikingly, no members of the CC and the DT will get to ask the complainant questions. Clearly, this is not ideal and should change.

Similarly, the defendant’s lawyer should also have the right to cross examine the complainant.

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2. Should we use mediation more?

Mediation is a quick method to disputes over treatment, at a much lower legal cost. According to SMC, some complaints which the CC deem have no ground for investigation will be referred for mediation.

Yet currently, there is little information on how many cases are referred for mediation and whether this is a policy preference of SMC.

Would it be feasible for SMC to try mediation in the first instance when a complaint is received, rather than to send it on straight to the CC?

3. How are members of the Disciplinary Tribunal (DT) selected?

Currently, each DT is made up of a chairman — from a pool appointed by the Health Minister — and two or more members. The chairman is either a senior doctor or lawyer. If the chair is a senior lawyer, the DT will have three other doctors that come from SMC’s Complaints Panel.

This comprises 100 doctors and 50 “laypersons” recommended by healthcare institutions and professional bodies. If the DT is chaired by a doctor, then he will be supported by a legal service officer and another doctor, also from the Complaints Panel.

In some recent cases, the doctors in the DT are not necessarily experts on the medical specialty that is the subject of the hearing.

The advantage of such system is that there is less conflict of interest. But the downside is that the unrelated doctors may not fully understand the scope and limitations of the defendant’s work.

On balance, it would be better for SMC to include doctors of the same specialty in the DT as far as possible.
 

4. Should DT members be paid?

Currently, DT members are not reimbursed for the time spent on working on a case.

As a consequence, private doctors who run busy practices tend to decline the invitation to be in the DT.

Having full time working doctors in DT is important, as it ensures its decisions are relevant and up to date.

To help ensure a good mix of private practitioners, reimbursing doctors for their time spent at DT will help.
 

5. Does SMC council review decisions of DT before finalising it?

Any DT decision has tremendous ramifications on how local doctors practice. The SMC Council ought to study the implications and plan for mitigation measures before the decision is made public.

If this was done for the two recent cases, the fallout would have been better managed.
 

6. How can SMC control the legal fees?

When a case goes before a DT, SMC hires an external law firm to act on its behalf to prosecute the doctor.

The doctor will in turn have his own defence lawyer, who is typically appointed by the doctor’s indemnity insurer.

SMC’s legal fees are in part paid by doctors through their medical registration and annual practising certificate fees.

With the recent high-profile cases, indemnity insurance premiums as well as SMC’s practising fees for all medical doctors are set to rise in future.

This cost will eventually be passed on to the patients and the Government.

This is not in the interest of any of the stakeholders in our healthcare system.

Ironically, while there is a fee benchmark for medical fees, there is no similar benchmark for legal fees.

Perhaps SMC can pay their lawyers by a block charge so, as to discourage lawyers from deliberately dragging the case to a longer duration.

Indeed, while the current disciplinary process has worked well for decades, perhaps it is time to relook the system to ensure the local disciplinary process is fair and just, at a cost effective manner

ABOUT THE AUTHOR:

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