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Disciplinary rulings for doctors can be ‘too draconian’ or ‘too lax’: Gan Kim Yong

SINGAPORE — Acknowledging the flaws of the present disciplinary system for doctors here, Health Minister Gan Kim Yong on Monday (April 1) said that the rulings of some disciplinary tribunals have swung between being “too lax” and “too draconian”.

Health Minister Gan Kim Yong said that how standards of care are applied in specific situations have to be clearer, such as the communication of medical information to patients’ family members and the taking of informed consent.

Health Minister Gan Kim Yong said that how standards of care are applied in specific situations have to be clearer, such as the communication of medical information to patients’ family members and the taking of informed consent.

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SINGAPORE — Acknowledging the flaws of the present disciplinary system for doctors here, Health Minister Gan Kim Yong on Monday (April 1) said that the rulings of some disciplinary tribunals have swung between being “too lax” and “too draconian”.

Delivering a ministerial statement in Parliament on protecting patients’ interests and supporting the medical community, Mr Gan also conceded that the recent high-profile cases involving orthopaedic surgeon Lim Lian Arn and psychiatrist Soo Shuenn Chiang drew “unexpectedly high fines”.

Mr Gan’s comments came weeks after the Singapore Medical Council (SMC) said that it was appealing to reduce the fines imposed on Dr Lim and Dr Soo, after it reviewed the “appropriateness” of its disciplinary tribunal’s judgements.

Dr Lim, who is in private practice, was handed a S$100,000 fine for failing to obtain informed consent from a patient before giving her an injection.

Dr Soo, who practises at the National University Hospital, was fined S$50,000 for failing to verify a caller’s identity before he wrote a memo referring a patient to the Institute of Mental Health.

While these cases drew large fines, Mr Gan said that there have also been instances where the sentences were “too low”.

“Some sentences are not commensurate with the circumstances of the case. Despite their best efforts, some disciplinary tribunals are too lax, while others are too draconian and the SMC has had to appeal to the court against sentences meted out in these cases,” he added.

DELAYS IN DISCIPLINING DOCTORS

The consistency and fairness of sentences is not the only issue dogging the present system.

Mr Gan said that there have been serious and, in some cases, “egregious and wholly unacceptable” delays in the process.

Hold-ups are unfair not only to complainants seeking closure but also to doctors, as they may prejudice their defence, affect their practice and livelihood, and inflict unnecessary anxiety.

Right now, a complaints committee — which investigates every complaint filed with the SMC — takes up to two years or longer to reach a conclusion.

Some cases are then referred to a disciplinary tribunal, which takes another two years or longer. If an appeal is filed against a tribunal’s ruling, that means more time is needed again.

While the SMC has made efforts to clear cases more quickly, Mr Gan said that the process “generally takes too long”.

HARD TO GET DOCTORS TO SERVE

The SMC, Mr Gan said, has found it challenging to draw doctors to serve on its complaints and disciplinary committees, or as experts.

Right now, its complaints committee, for example, is taken from a panel of 100 senior doctors and 50 laypersons.

The shortage of doctors who can serve is partly due to the small community of senior practitioners here, Mr Gan said.

It is also difficult to get experienced doctors to commit themselves, owing to the opportunity costs and heavy investments of time, he said, noting that the system must be strengthened to improve support for doctors who serve.

Despite guidance in the SMC’s ethical code and guidelines, Mr Gan said that there is also a “wide variance” in interpreting standards of care.

“While the guidelines cannot cater for all scenarios, we need greater clarity on the application of the standards in specific situations, such as the communication of medical information to patients’ family members and the taking of informed consent,” he added.

STEPS BEING TAKEN

Last month, the Ministry of Health (MOH) named a 12-member workgroup to review the SMC’s disciplinary process for doctors here.

Helmed by Associate Professor Ng Wai Hoe, deputy group chairman of SingHealth’s medical board, and Senior Counsel Kuah Boon Theng of Legal Clinic LLC, the group will also look at how doctors obtain informed consent from their patients.

The workgroup, which will consult widely, is expected to complete its work by the end of the year.

The ministry has also established a “sentencing guidelines committee” to ensure that disciplinary tribunals’ rulings are fair and consistent. This committee is also expected to develop the guidelines by the year’s end.

Dr Lim Wee Kiak, a Member of Parliament for Sembawang Group Representation Constituency, asked if present cases being reviewed by disciplinary tribunals will be deferred until the new rules are out.

To this, Mr Gan said that ongoing cases before the tribunals must continue so as to prevent “further undue delay”, but the MOH and SMC will look at providing greater support to the tribunals and streamline the process where possible, so that their decisions are more considered.  

CLEARER PRACTICAL GUIDELINES

As the issue of when and how doctors should get consent from patients is being thrashed out, Mr Gan said that the workgroup will make recommendations to the Government on all aspects of informed consent and guide doctors on the “what, where and how” in doing so.

“The intent is to address the needs of the patients while providing the medical community with clear practical guidelines, so that doctors do not have to second-guess what is needed in each case,” he added.

“It will also consider whether legislation will be necessary in order to achieve these objectives and to set out the tests to be applied.”

Mr Gan noted, however, that the relationship between doctors and patients is unique and dynamic. It is thus neither possible nor desirable to be overly prescriptive, he said.

The MOH also intends to issue legally binding clinical-practice guidance in specific areas.

The aim is to ensure that healthcare professionals align their practices with the rest of the healthcare community and meet their ethical and legal obligations to patients.

This means that on informed consent, for instance, this guidance will explain the nature of information that will be deemed relevant and material to patients.

DEFENSIVE MEDICINE NOT DESIRABLE

Mr Gan said that there is a “real risk” of doctors adopting defensive medicine in the midst of uncertainty over informed consent.

Defensive medicine refers to the practice of ordering medical tests, procedures or consultations of doubtful clinical value to protect the physician from malpractice suits.

There is evidence that defensive practices are already happening, the health minister noted.

“Fearing that they might be called out should a complication occur, doctors are likely to overwhelm patients with voluminous information on multiple unlikely risks, protecting themselves legally, but confusing patients,” Mr Gan added.

This will be highly detrimental to Singapore’s healthcare system and damage the trust between doctors and patients.

“We should guard against turning into the kind of society where doctors care more about not being sued or disciplined by the professional body than about the patients’ well-being,” he said.  

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