Oktoberfarce

Hi folks. Many apologies for my absence in September. I was on the quest of my life last month. I macerated orcs, turned a whole mob of undead and even slayed a dragon. On the way, I endured untold physical hardship, fought with my darkest inner demons and I had stared into the eyes of death itself. And I have survived. Perceptive readers will know that I am talking about seeing through my son’s PSLE. Compared to today’s PSLE, Mount Doom was a walk in the park and Sauron was a piece of cake, dude.

I am back. Because “I am front” sounds rather uninspiring. (As you can see, there were some permanent side effects to surviving my son’s PSLE; one of which is I am even cornier now than ever before.)

And so it was on 1 October when I was celebrating the National Day of The People’s Republic Of China by chewing on my last vintage 2001 tin of Ma Ling luncheon meat, drinking my can of Chinese apple juice and eating White Rabbit candy that I noticed an article in The Straits Times which I originally thought was one of those April Fool’s joke article one gets every year in some newspapers. The only problem was that it was 1 October and not 1 April 2014. I also noticed that the tin of Ma Ling luncheon meat had expired about 13 years ago.

The article (on Page A2, 1 Oct 2014, The Straits Times) was titled “Susan Lim case: Court slashes SMC’s costs claims” – “it awards $317,000 of the $1.33M it claimed from surgeon”. The first paragraph goes like this, “Two years back, the Singapore Medical Council (SMC) had found surgeon Susan Lim guilty of overcharging. In an ironic twist, the High Court ruled that the legal bills sought by SMC from Dr Lim were themselves inflated, and slashed them from $1.33M to $317,000”.

The bulk of the $1.33M came from the $900,000 bill for work done by SMC’s lawyers. The Assistant Registrar who did the High Court taxation hearing reduced the $900,000 to $180,000. For the appeal hearing (because Susan Lim appealed to the Court of Three Judges), the bill was reduced to $70,000 from $150,000. One of the legal assessor’s bills was also slashed from $235,000 to $22,000. (In addition to having lawyers to represent SMC, SMC can also hire a legal assessor to advise SMC’s committees on points of law)

I am told by lawyer friends that a taxation hearing in the Courts is the Court’s way of guarding against overcharging. It is similar to what SMA used to do in its complaints committee when the Guideline of Fees existed. The main differences are that SMA only gives an opinion based on the GOF and it is non-binding. A taxation hearing decision is of course legally binding and the legal profession doesn’t really have any guidelines on fees.

From this Hobbit’s point of view, all this is actually good news for the medical profession and the public because if lawyers cannot charge so much against doctors who are defendants in SMC hearings, the likely consequences are

  • Our medical indemnity costs and subscription rates can go down
  • SMC’s lawyers also cannot charge SMC so much for cases when the doctor is found to be innocent and SMC bears the costs in these cases (in contrast to cases when doctors are found guilty and may have to bear SMC’s legal costs too)
  • SMC’s operating costs also go down with lower legal costs
  • And since SMC is funded by every doctor’s annual registration fees and some taxpayer’s money, the burden on the taxpayer is lessened, and our annual SMC registration fees don’t have to increase so quickly

Does this make sense? Sounds simple right?

Here comes the sucker punch. In the last paragraph of this news article: “SMC, which is understood to be appealing against the decision, declined comment when contacted yesterday”.

This not April Fool’s but an October Fool’s joke? This normally gentle Hobbit is so flabbergasted he wants to shave his hairy feet.

If The Straits Times is correct in it’s understanding (that the SMC is appealing), the SMC should declare what and why is it appealing against the taxation hearing decision?

Does the SMC think the Courts should cut the sums even lower? I.e. less than $317,000? If that is the case, then this Hobbit and I think 99.9% of SMC-registered doctors have no problems with the appeal.

If the SMC is appealing that the taxation hearing was unduly harsh and it’s lawyers should be paid more, then all doctors in Singapore (and even the public) should ask some serious questions about what is the role of the SMC and how the SMC is run and how decisions are arrived at in SMC.

• Firstly, the SMC is about safeguarding public interest by ensuring the medical profession practices medicine ethically. SMC is not about safeguarding SMC’s lawyers’ bill size.

• Secondly, has anyone in SMC looked at the bills its lawyers have been charging SMC in recent years? It doesn’t matter if SMC is paying the bills or the guilty doctors are. The fact is, the work done is for SMC, so SMC has to look at all the bills.  Could there have been many more bills that could have benefited from taxation hearings, if only the guilty doctors had the means and knowledge to use the taxation process of the Courts?

• Thirdly, since SMC certainly has the knowledge and the means to use the taxation process, would SMC consider sending the bills it had paid its lawyers to the Courts for taxation hearings if SMC comes into knowledge that a number of the bills it had paid can be possibly and probably reduced? Does the taxation process allow for retrospective analysis? Do we need a SECOND SMC Review Committee to look at the old and current “in-flight” bills?

• Lastly, since the SMC is a statutory body, would the Auditor General consider conducting an audit to see if any of the bills had been unnecessarily large in the last couple of years?

SMC, please do not decline comment. The monies SMC has in its accounts belongs to the profession and the taxpayer. The members and staff of SMC are mere stewards of these monies. We trust you as stewards. It is time you demonstrate that our trust is justified. This is no time to keep silent.

On a second note, the SMC has come up with draft Ethical Code and Professional Standards (ECPS). It has written to all doctors asking for feedback. You can access this document from the SMC website with your SMC password.

This hobbit strongly urges all of you to read the document even if you do NOT sleep, eat or poop for three days.

Because, in all likelihood, it will take you that long to get through it.

The old or current Ethical Code and Ethical Guidelines (ECEG) have a total of 8,076 words. The draft Ethical Code and Professional Standards (the Professional Standards is supposed to replace the Ethical Guidelines) have a total of 46,670 words.

These word-counts were arrived at by doing a “cut and paste” job from the PDF format to Microsoft Word format, so the numbers may not be entirely accurate but the numbers will make a reasonably good estimate for comparison purposes. In other words, the ECPS is at least 5.7 times the length of the current ECEG. In my bootleg Microsoft Word version of the ECPS, where the text size is size 10, it runs to 170 pages long.

In addition to the issue of length, you must take note of the following:

• The ECPS  “are to be regarded as the minimum stands upon which your performance and behavior may be assessed. As the disregarding of, or failure to abide by, these standards can potentially lead to deleterious consequences to patients and bring disrepute to the profession, such actions may subject you to disciplinary proceedings” (Introduction & Preamble, Section 1 (iv))

• “In this edition of the SMC’s ECPS, the use of the words “must”, “shall” or “will” indicates that the standard is generally to be met, save for extenuating circumstances” (Introduction and Preamble, Section 6)

• “Breaches of these guidelines (i.e. professional standards) could lead to your being asked to defend your actions. Disciplinary procedures for professional misconduct will refer to the ECPS as setting out the standards by which you will be judged”. (SMC Professional Standards of Practice, extract from introductory paragraph)

Now here is a sampling of these professional standards:

• When you work in teams, to ensure quality of care, you must “when delegating care within the team, be aware of the team members’ capabilities and limitations and compensate for any such limitations.” (Part A, Good Clinical Care,  Section 5(c)

• If you offer screening, “offer only testing modalities that have good quality evidence benefit” and “Advise patients on any important medical, social, psychological, financial or insurance implications of undergoing the tests and of the results that will be received” (Part B, Good Medical Practice, Sections 2.1.1 (d) and (h)

  • Behaviours which you must avoid include
  1. “Rude of inappropriate comments, excessive and unwarranted criticism or sarcasm” (Part D; Relationship with Colleagues Section 7ii(d))
  2. “Persistent lateness and tardiness in carrying out duties” (Section (ii)(f))
  3. “Lack of cooperation with team members” (Section (ii)(i)

• “Not put undue pressure on patients, for the purposes of earning a higher fee, to receive treatment from you in the paying class of your institution, or your private practice outside of your institution, when they can be reasonably managed by you in the subsidized classes” (Part H: Finances in Medical Practice, Section 1(iii)(c)) – (The point here is that even if you do not put any pressure, all your private patients may use this against you if they are not happy with you)

This Hobbit can go on and on. But the point that needs to be made is that if the ECPS is implemented in its current form, probably 95% or more of the profession cannot meet the requirements. And because most of these requirements are “strict liability” clauses (i.e. “must”, ”shall” or “will”) where the legal test is that they have to be met except for extenuating circumstances (which you, the defending doctor has to prove why it’s extenuating), there is a high chance that a lawyer can easily find you to have run afoul of one of the many, many clauses in this 46,670 word-long document. You really have little chance of professional survival should a patient or a colleague should to complain against you to SMC.

Some wise guy who has read this document joked to me that the draft ECPS is a “WMD” or Weapon of Mass Destruction. Another colleague thinks more of it like a Doomsday Device that we see in many sci-fi movies. He thinks a professional holocaust may be in the works.

So please, give your feedback now to the authorities. Maybe they will change their mind. And if not but at the very least, be acquainted with what the new ECPS will be about.

As for this Hobbit, I am an eternal optimist. Time to relax and have a beer. It’s Oktoberfest. I am sending my application to law school as soon as possible. I want to be SMC’s lawyer when I grow up.

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