Category: Ethics

Part 2: About That $100,000 Fine For An Injection

The practice of medicine must evolve with the times, and is necessarily ever-changing. How we change the practice of medicine is heavily dependent on new evidence gleaned from scientific discoveries as well as subjective factors such as patient expectations and even doctor’s expectations. These are not necessarily bad things

But change in medicine is never ever a good thing when the change is driven mainly by a change in medico-legal climate. Especially when these changes are fueled by fear and anger, whether they may be on the patients’ part or from the doctors’ perspective.

As we all know, fear and anger are two of the most powerfully evocative emotions in the gamut of feelings that the human race can muster. Fear and anger are two emotions that are often used by populist and irresponsible politicians to get more votes in election campaigning. Fear and anger, together, has a life of its own and spreads like wildfire.

But this is exactly what doctors are experiencing now in Singapore in the wake of the $100,000 fine by SMC on Dr Lim Lian Arn. Fear which has led to anger which in turn is feeding the original fear.

On 30 Jan 19, SMC issued a public statement of clarification of case, stating that “Doctors are not expected to inform patients of all possible complications”. This is helpful. But it is not enough. Let this Hobbit elaborate. We need to directly address:

  • Fear and anger over what is expected of the doctor to obtain an effective informed consent
  • Fear and anger over the magnitude of the fine ($100,000)

Fear and anger over what is expected of the doctor to obtain an effective informed consent

In short, the laundry list described in the charge and the Grounds for Decision was perceived to be setting a new standard of care. Thankfully, the 30 January 19 Statement by SMC has addressed this by saying a doctor doesn’t have to inform his patients of all possible complications. But it does say that “however, the DT indicated that it would be good clinical practice to document in the case notes that a patient had been informed and was agreeable to the injection, a proposition which no doctor would reasonably disagree with……; the Decision merely reminds doctors that they should document the fact that they have explained the treatment or procedure and the patient’s consent”.

Questions from this (also reasonable) Hobbit for the genius who drafted this document:

  • Must I document every “treatment or procedure” that I had explained to the patient and that he had consented? Treatment includes simple stuff like prescribing drugs, CRIB (complete rest in bed) and applying dressings. Every time you remove a urinary catheter, chest tube or drain, it is a procedure (let alone inserting one).
  • How does a junior doctor in charge of say, half the ward (about 15 to 20 patients) do this and have time for lunch and go to the toilet? Remember, every drug is a treatment, and practically everything you do in a ward is a procedure other than bathing and feeding the patient and bringing the patient to the toilet.
  • Does the person who drafted this understand what resources it entails just to achieve his one landmark sentence of “the Decision merely reminds doctors that they should document the fact that they have explained the treatment or procedure and the patient’s consent”?

Essentially, there are three “Categories” of activities a doctor prescribes or performs in vast numbers every working day:

  1. Treatment and procedures that require written consent from the patient
  2. Treatment and procedures that require documentation of verbal medical advice and patient consent in the casenotes
  3. Treatment and procedures that do not require written consent or documentation

In the past, the vast majority of treatment and procedure belonged to the last Category. We don’t document that we had explained the possible complications of most simple procedures or drugs and that the patient had consented. Now it appears that the default option is Category 2 instead – we have to document almost everything.

Can someone in SMC have a discussion with the Ministry of Finance on how Singapore will fund the resources needed for this new level of documentation?

For the avoidance of doubt, this hobbit thinks a H&L injection should fall under Category 2. But most daily procedures and treatments actually should remain in Category 3 and not be pushed up to Category 2.

One should not make sweeping statements like “a proposition which no doctor would reasonably disagree with” unless one really understood the practice of medicine as it happens on the ground given the resources this country allocates to healthcare. This new standard of documentation may already have happened in Beverly Hills, California, but it doesn’t happen here often at all, and certainly not in the public healthcare system.

Experts and “Expertism”

Much has been said about the expert opinion in this case. The Complaints Committee (CC) and DT accepted the expert opinion of what is the standard of care to be applied. It has been said often that the CC and DT did not act without expert advice and opinion.

This hobbit believes:

  • The answers you get depends on the questions you ask
  • People behave differently when they are labelled as “experts”. They have to display behaviour befitting that of experts (I call this “expertism”).
  • The SMC DT should concern itself with what constitutes basic or minimal behaviour that can be considered as NOT being guilty of professional misconduct, and not apply standards of good or best practice in disciplinary proceedings.
  • The SMC lawyer should likewise concern itself with establishing that the doctor failed to meet minimal standards consistent with professional misconduct and NOT good or best practice

The laundry list of complications that appeared in the charge and the Grounds of Decision was that of good or best practice, but not minimal ethical standards. Were the experts asked to give minimal standards or good or best practice? Even if they were not so asked, did the experts feel inadvertently compelled to give good practice standards because they were asked as “experts” – i.e. they had to display “expertism” in their answers?

Perhaps, when next time an expert is consulted, it should be specifically stated he is being asked to give minimal standards, below which, the doctor should be considered to be guilty of professional misconduct.

We should take a leaf from licensing of healthcare institutions. MOH licenses healthcare institutions such as hospitals so that they can provide health services. These are minimal standards. If these hospitals want to do better, they can go for accreditation such as the JCI accreditation scheme. But the two are different and we should not conflate them. Licensing ensures a minimal standard, accreditation puts in place good or best practices. Similarly, doctors are licensed because they are fit to practice and they are fined or they have their practice license suspended or taken away because they fail to meet these minimal standards of ethics and competence, not for higher or aspirational standards.

Paradoxically, “expertism” is easier to put in place than setting of minimal standards. One doctor describes this as “Google Medicine”. An expert can search for the list of complications on the Internet and furnish it to SMC in a matter of minutes. It is actually more difficult to decide what are the minimal standards one must achieve to obtain and maintain licensing. A good comparison is that of a Head of Department assessing residents: It is easy to decide who are the good residents who regularly impress you, but it is difficult to decide whether you would want to sign up and pass a marginally or poorly performing resident or not.

Fear and anger over the magnitude of the fine of $100,000

In this hobbit’s first column on this matter, he failed to mention a very important fact – statutory fines, such as the $100,000 fine by SMC, are not covered by medical indemnity schemes. Whether the fine is $1000 or $100,000, the doctor has to pay the full amount to SMC. A $100,000 fine is painful for even the richest doctor in Singapore, but it is financially crippling to many junior doctors such as residents and junior specialists.

Don’t get me wrong, fines should be punitive in nature. That’s why they are fines and the threat of this fine drives a person to behave correctly. But when the amount is so large such that it becomes an existential threat to the professional and the risk-reward ratio doesn’t makes sense to the professional, then a different type of behavior ensues.

In a market economy like ours, what options does any rational person do when he is faced with a financial penalty that is so large it becomes an existential threat? Let’s take the H&L injection as an example –

  1. He tries to insure it away. As aforesaid, this is impossible, and he has to pay the fine out of his pocket
  2. He tries to price-in the risk. The correct risk premium is probably out of reach of at least 70% to 80% of Singaporeans. For doctors in the public sector, they have no pricing power, because prices are set by the hospital or polyclinic administrators and doctors are paid a fixed salary and not paid for office procedures. The only people who can price in the risk and who have patients who are willing to pay the risk premium risk are the private specialists, who probably only serve the top 20 to 30% of Singaporeans. H&L injections will continue to be offered in this limited segment.
  3. He avoids the risk by not offering this service altogether. This is probably what has happened and most Singaporeans will find it more difficult to get a H&L injection nowadays than compared to a few weeks ago.

In case people in power do not understand (because they are probably the most well paid people in this country, let this hobbit state clearly – a $100,000 fine is an existential threat to a medical officer or resident, a GP or even an Associate Consultant.

The vast majority of people living on this island will now be deprived of a simple procedure  that is effective, very safe and was cheap.

Frankly, if I were still a young polyclinic Medical Officer with student loans to pay, I would stop giving H&L injections because a $100,000 fine would bankrupt me. It doesn’t matter if the $100,000 fine was for lack of informed consent or lack of documentation of getting an informed consent. The fact is, I cannot take the risk. Ask any professional risk management consultant and he will tell you that assessing any risk is not just about assessing the probability of incurring punishment but also related to the severity of the consequence (in this case, the punishment of $100,000).

The same goes for other junior doctors who perform all these high-risk procedures in the wards on a day-in, day-out basis. Fortunately, our junior doctors continue to display high degree of professionalism and dedication to their patients.

But the bottom line is – when the penalty is cripplingly great and the reward remains small, (because you cannot price-in the risk), most doctors (and most human beings actually) want CERTAINTY of avoiding the penalty. This is basic and rational behaviour. And the only certainty is not to offer the service. Any human being with average intelligence will come to this conclusion.

The fact is the Lim Lian Arn case has set a new standard for penalties. This issue has not be addressed at all by the 30 January 19 Statement by SMC.

It is interesting to note what Finance Minister Heng Swee Keat wrote today in the major newspapers “(a Zaobao reader) is right to caution against creating a public service culture where “Doing more means making more mistakes, doing less means making fewer mistakes; and if we do nothing we will make no mistake”. That would be the most serious mistake we could make”.

This is probably what has already happened in the ‘medical’ service culture now with regard to H&L injections given what has happened in the Lim Lian Arn Case: Do nothing, and so make no mistake.

Externality Effect

That brings us to  the issue of externality effect or “externalities” in short. This is a commonly-used term among policy wonks and economists. Wikipedia describes externality the cost or benefit that affects a party who did not choose to incur that cost or benefit.

We are where we are today because of the Externality Effect. If everything that happened in the Lim Lian Arn case only applied to Dr Lim, no one would be flustered. But in the Common Law system that we inherited from the British, precedents and case law matter a lot to all of us. While SMC is not exactly a court, but their Grounds of Decision serve as precedents and “case law of sorts” for future SMC cases.

Therefore these aspects of the LLA case have externalities (whether cost or benefit) that we, the medical profession at large, did NOT choose to incur:

  • How the charge (the laundry list of complications) was drafted
  • The suspension of five months that the SMC lawyers asked for
  • The fine of $100,000 which Dr Lim offered and which was accepted and the reasons for not imposing a suspension
  • The reasoning for the conviction and sentencing as given in the Grounds of Decision, including the effectiveness of any mitigation factors, if any
  • The need to document almost everything as given in the SMC Statement dated 30 Jan 19.

To this hobbit, the ONLY benefit or positive externality effect the profession derived from the Lim Lian Arn case is that not all cases of (lack of) informed consent will end up with a suspension and a fine may suffice (albeit a big fine).

The externalities of this case extend not just to the medical profession, but to ALL healthcare professionals that carry out procedures and prescribing and dispensing of treatment, including dental surgeons, pharmacists, physiotherapists, TCM practitioners etc. The magnitude of fines may differ, but the principles and effort of getting an effective informed consent should not vary much. For example, the TCM practitioner-patient cannot be less deserving of a less patient-centric advice process than a patient seeing a Western Medicine doctor, right?

The Limitations of SMC and the Government

A lot of criticism has been levelled at the SMC members, the SMC lawyers, the Complaints Committee, and the Disciplinary Tribunal recently. The four parties are often conflated in discussions but actually they function quite independently.

The first question to ask is, what gives SMC the right to even exist, and to investigate and punish doctors? The answer is the Medical Registration Act (MRA) which is passed by Parliament. Parliament passes laws like the MRA. Then the MRA is administered by MOH and SMC. The SMC’s power to publish the Ethical Code and Ethical Guidelines (ECEG), to punish and extent of punishment is provided for in the MRA. So in a sense, the SMC’s DT also has the power to interpret the SMC Ethical Code and Ethical Guidelines as well as the MRA itself. But like all laws in Singapore, the FINAL power to interpret any law or the final arbiter of any law does not rest with a ministry or a statutory board but the Courts. That is why the patient, doctor or SMC lawyer can all appeal to the Court of Three Judges (Sometimes five) if they are unsatisfied with the DT’s judgement. The Court of Three Judges always consist of High Court or Court of Appeal Judges, and sometime may even include the Chief Justice himself.

So in a sense, the SMC DTs and  the SMC lawyers must take guidance from the learned Judges when they pass judgment on SMC appeal cases brought before them. In recent years, a few precedents or case laws which may or may not have a bearing on the Lim Lian Arn include:

  • The Courts have on more than one occasion asked that SMC metes out more severe sentences to doctors
  • In the SMC vs Ang Peng Tiam case, a lifetime of good clinical practice record is NOT an effective mitigation plea. In fact, being senior may work against you. The only effective mitigation plea in this case was that there was a delay by SMC in processing this case.
  • In the Hii Chi Kok vs London Lucien Ooi case (Which is NOT an SMC Case, but a case brought by the patient directly against the surgeon through our Courts), the Modified Montgomery (MM) Test was first confected and applied. The MM Test will apply to all medico-legal cases (including SMC cases) in this country to test how medical advice is offered.

Of course, what these cases demonstrate and instruct are principles. Whether these principles are correctly applied (as the Judges would have wanted it) on the ground is a big question.

For example, is the five-month suspension or $100,000 fine appropriate in this case, given that “ there is nothing to suggest that the complications experienced by the Complainant were in any way permanent or debilitating” (Grounds of Decision, Para. 57)?

In the Grounds of Decision, it was recorded that the SMC lawyer asked the DT members to “not to give any weight to the mitigating factors such as the potential hardship to the Respondent (i.e. Dr Lim) arising from the conviction, the testimonials, character references and acts of community service and the Respondent’s long, distinguished track record”. (Para 33 of the Ground of Decision). In fact, it was recorded in para 27 of the same Grounds that had Dr Lim not submitted an early plea of guilt, the SMC lawyer would have asked for six to 8 months of suspension.

This hobbit wonders if this severe stance by the SMC lawyer was in some way influenced by what had happened in the Ang Peng Tiam case that was brought before the Court of Three Judges?

Also, in the indirect application of the MM Test through the drafting of the charge, should a laundry list of complications of a H&L test be listed out?

On 7 Feb, The President of the Pharmaceutical Society of Singapore, Ms Irene Quay wrote in a letter to The Straits Times, “it is important for the Ministry of Health (MOH) to provide clear guidance on the extent of informed consent for low-risk medications or medical procedures if the modified Montgomery Test is to be applied”.

To be fair to the government, MOH did not ask for the MM test to be confected or applied. That was the decision of the Judges. In fact, the Attorney General (AG) Chambers specifically asked for the Bolam Test and Bolitho Addendum to be retained in their submission to the Court of Appeal in the Hii vs Ooi case. But the Court of Appeal decided that the MM test will replace Bolam and Bolitho in Singapore on matters pertaining to medical advice.

I guess MOH and SMC are as much trying to understand what stiffer penalties mean and how should the MM test be applied in day-to-day medical advice situations when they administer the MRA. They can issue guidance, but it will be very challenging to have “clear” guidance when they didn’t come up with the MM test in the first place.

Who And What Are We Trying to Deter?

The main purpose of the SMC is to protect the public from bad doctors and in doing so, also serve justice. At the individual level, patients who have been harmed by doctors guilty of professional misconduct deserves justice from the SMC.  Justice has to be done, and has to be seen to be done.

Some have argued that stiffer penalties are necessary today to deter more doctors from practising medicine such that public confidence in the medical profession is not eroded. This is called deterrent sentencing. It is meant to deter others from committing the same act of professional misconduct and the objective of this is termed “general deterrence”. General deterrent sentencing is an intended potential externality. This is in contrast to “specific deterrence”, in which sentencing is targetted at preventing the specific doctor from erring again.

If you look at the latest SMC Annual Report, 12 doctors were given letters of warning and another 23 were given letters of advice. 12 cases were brought before Disciplinary Tribunals and concluded in 2017, of which two are pending appeal before the Court of Three Judges and two cases were concluded without any punishment for the doctor. Eight were actually censured and/or punished in some way. These numbers have been rather stable in the last 10 years. Even if we assume the worst-case scenario in which the two cases pending judgment before the Court of Three Judges will actually be punished in the end, the number for DT cases in which doctors will be found guilty of professional misconduct is 10.

Assuming that general deterrent sentencing is effective, how many doctors do we think we may have deterred from behaving in a bad way? Let’s give this a generous multiple of 10. 10 times 10 is 100. In other words, we have deterred 100 doctors from behaving in a bad way such that he is guilty of professional misconduct. By the same factor of 10, another 350 doctors or so would have been not served with letters of warning of advice because of the deterrent effect of stiff penalties.

The rest would not have committed the offence anyway, because this hobbit would like to believe most doctors in this country are still ethical and professional ones.

But in the fallout from the Lim Lian Arn case, thousands of doctors are now deterred from giving a H&L injection, a safe, simple and cheap procedure that would have benefited many tens of thousands of patients: Just because one patient wasn’t properly counselled and hence did not give an informed consent and thereafter she suffered complications that were not “permanent or debilitating”?

So we need to ask, who and what are we deterring? Do the cost-benefit numbers add up and make sense for the greater good of society?

Conclusion

The Chief Justice said in his speech at the opening of the 2016 Legal Year: “Medical care is of direct concern to all Singaporeans and we must act to avoid a situation where the practice of medicine comes to be adversely affected by the medical practitioner’s consciousness of the risks of malpractice liability.”

This “consciousness” has already come to pass in Singapore. The “situation” is already unavoidable.

This hobbit does not see any conclusive way out of the current problematic situation unless new laws are drafted by MOH and passed by Parliament to restore a more sustainable practice environment, not just for doctors, but for all healthcare professionals, and ultimately for the patients as well.

 

 

 

About That $100,000 Fine for An Injection

So, this is how the practice of medicine, as we knew it, dies in Singapore.

Not quietly or softly in the arms of compassion and empathy, but throttled inadvertently by the hands of a $100,000 fine.

Interesting Points

There are many interesting points about the case.

Firstly, there is the patient who complained against Dr Lim Lian Arn. It is interesting how the incident of the H&L injection took place on 27 October 2014 but she only complained against Dr Lim on 11 January 2016, some 14 months later. Especially when she was purportedly unhappy with the adverse effects and complications which are quick to surface and temporary: – pain and inflammation, discolouration, paper-thin skin and loss of fat and muscle tissues. What took her so long to complain?

Secondly, the SMC lawyer asked for a 5-month suspension for Dr Lim. This is mightily interesting. The ill effects suffered by this patient are far less serious than the one suffered in the Eu Kong Weng case. In the Eu Kong Weng case, also a case involving informed consent, the patient suffered serious complications. Dr Eu was suspended for 3 months and he appealed to the Court of Three Judges. The Judges upheld the (minimum) 3 month suspension but commented that had the law provided for less than a 3-month suspension, then a shorter period would have sufficed. But since the minimum period was a 3-month suspension, then the Judges had no choice but to uphold the 3-month period since they felt a suspension was indeed warranted. If so, on what basis did the SMC lawyer from Drew and Napier ask for a 5-month suspension? This hobbit does not understand. I hope SMC President, Registrar and members understand at least retrospectively why a 5-month suspension was warranted to be asked for by their lawyer.

Thirdly, we come to the doctor himself and his lawyer. Faced with the SMC lawyer asking for a 5-month suspension, this Hobbit speculates that chief on their mind is that they want to avoid a lengthy suspension. So, they pleaded guilty at first instance and offered to pay the maximum $100,000 fine or the minimum 3-month suspension. This is perfectly understandable because for a senior and successful orthopaedic surgeon in private practice, he probably makes more than $100,000 in 3 to 5 months. A 5-month suspension would mean he has no income in that period and worse, he has to bear the fixed costs of running a clinic, e.g. the rent and the pay of his clinic assistants and nurses. A secondary concern (if they think far enough) is that should they offer something low like $5,000 or $10,000, and should the SMC Disciplinary Tribunal (DT) accept, there is no guarantee that the SMC lawyer will accept and instead, he may choose to appeal to the Court of Three Judges. In other words, in trying to avoid what they deem as undesirable consequences, Dr Lim Lian Arn has to make a generous-enough offer such that BOTH the DT and the SMC lawyer will accept. In his self-interest, Dr Lim did as he was supposed to do. Nothing wrong with that. Perhaps this Hobbit would have done the same, given similar circumstances.

Fourthly, we go on to the Disciplinary Tribunal (DT) itself. Faced with an offer of $100,000, they had three choices – they can either accept or lower the fine, or still suspend Dr Lim. Thankfully and rightly, they decided that Dr Lim should not be suspended. They certainly couldn’t raise the fine, since the $100,000 was already the maximum amount allowed under the law. It would look very strange if they decided to lower the fine since the defendant already offered $100,000 even though the DT thought the closest comparison to this case was that of Dr Eric Gan, in which Dr Gan was fined $5,000. So, as expected, they decided to fine Dr Lim $100,000, the amount that Dr Lim himself offered. This Hobbit does not think the DT did anything questionable up to this point.

What is indeed questionable is the appropriate standard of care that this DT promulgated for taking an informed consent for an H&L injection.

They said that for the patient to give an effective informed consent, she should have been told of

(a) post-injection flare, in particular, that:

(i) the Complainant may experience increased pain and inflammation in the area injected that can be worse than the pain and inflammation caused by the condition being treated;

(ii) the onset of the post-injection flare is usually within two hours after the injection and typically lasts for one to two days;

(b) the post-injection flare can be treated by rest, intermittent cold packs and analgesics;

(c) change in skin colour including depigmentation (loss of colour), hypopigmentation (lightening), and hyperpigmentation (darkening);

(d) skin atrophy (thinning);

(e) subcutaneous fat atrophy;

(f) local infection; and

(g) tendon rupture.

To me, this is exactly the kind of “Information dump” that the Judges said should be avoided when they formulated the Modified Montgomery (MM) test for Singapore in 2017 in the Hii Chii Kok vs London Lucien Ooi case.

Fifthly, the MM Test itself, now obviously in full force in SMC trials, including this case.

The MM test replaced the Bolam-Bolitho (BB) test because the five Judges (in the Hii Chii Kok case) felt that in the provision of medical advice (which includes getting the patient to give an effective informed consent), the process must be patient-centric rather than doctor-centric. Nothing wrong with that in theory.

A few doctors, faced with disciplinary proceedings and medical negligence suits, relied on the Bolam test in their defence, almost to the point of abusing it. They would nominally come up with a few friendly “expert” opinions to justify their actions and pass the Bolam test.

This was the weakness of the Bolam test. But the Bolam test also had a strength – it provided for a reality check. The Bolam test required one to ask what was actually practiced on the ground by many doctors and took reference to such common practices.

This “reality check” element is somewhat missing in the MM Test. So, the DT accepted an information dump checklist as the required standard of care in giving medical advice when practically no one does this. The only reality check the DT was seen to undertake was that it accepted that it was not universal practice to get a written consent for a H&L injection.

Dr Lim Lian Arn was charged under the 2002 version of the SMC Ethical Code and Guidelines (ECEG). Many respected orthopaedic surgeons have been on the SMC as members since 2002. In fact, at least one of the current members is an orthopaedic surgeon. All the DT has to do is to ask these SMC-member orthopaedic surgeons if they routinely gave ALL such information to a patient going for H&L injection, and documented as such in the casenotes as well, to know what is the reality on the ground. This hobbit is quite confident that practically all orthopaedic surgeons who have been on SMC at any time since 2002 will fail this simple test. It’s just that none of their patients complained, unlike Dr Lim’s.

There is nothing in the published Grounds of Decision that suggests they did such a reality check. Indeed, the MM test itself does not include such an element of reality check except that it suggests that expert opinion could be taken into account when appropriate. The test of materiality (in deciding what information needs to be given) is solely from the patient’s perspective and nothing much about what was actually being practiced on the ground.

Nonetheless, the standard of care stated in the Grounds of Decision of the DT is Medico-Legal Reality.

What’s next

The H&L Injection

Lets’ get back to the procedure itself – H&L injection. This is a cheap, effective and common office procedure commonly done in the specialist and GP setting. But no more in the post $100,000 fine era. This hobbit would like to differentiate by calling the past the pre-LLA era and the current period as post-LLA era. (Dr Lim Lian Arn deservedly gets naming rights to such a momentous incident)

Ask any business school professor and he will tell you to price in the risk. Here is how you price in the risk:

Pre-LLA era price for a H&L injection by a GP – $50 to $150. Let’s take $100 as a reference price.

No of H&L injections you think you give before a patient complains: 100

No of complaint cases that will be successful (where you pay a fine of $100,000): 1 in 3

Estimate: 300 cases of H&L will result in 3 complaint cases, of which 1 will be successful

Economic cost: one $100,000 fine, AND estimated $200,000’ or about $70,000 a case of emotional distress, time lost, effort in preparing for the 3 cases of complaints etc.

Total price-tag for risk premium is $300,000 for 300 cases

Risk premium is therefore $1,000 a case

New Price for one H&L Injection: $1000 + $100 = $1,100

Conclusion 1: Price of H&L injection by a GP in the post-LLA era: ~$1100 (up from $100)

Of course, these numbers will only be significantly higher in the specialist setting. A H&L injection by a hand or orthopaedic surgeon may now cost $2000 to $4000 in the post-LLA era, after taking into account their own risk premiums.

Many patients in the HDB heartlands cannot afford this thousand-dollar jabs and the neighbourhood GPs know this too. Most of these patients will then be treated conservatively with brace and medication, resulting in more unnecessary pain or suffering by the patient (and may cost more than $100 but less than $1100). Or these patients will be referred to the public sector. This is not to say that the public sector doctors can do a better job than private GPs with better outcomes and therefore attract less complaints. It is just a simple transfer of the risk premium to the public sector where much of the costs are subsidised by the taxpayer. The richer GP patients will be referred to the private specialists because they can afford to pay the prices charged by the private specialists. The private specialists too may refer their poorer patients to the public sector.

The patient that will complain to the private GP sector will also likely complain in the public sector or in the private specialist sector. In the former case, the state/taxpayer takes up the risk and in the latter, the risk premium is covered by higher private specialist fees.

Incidentally, fee benchmarks currently do not cover office procedures like H&L injections.

To summarise – there will be little demand for a $1,100 H&L injection in the HDB estates, and GPs are also unwilling to take up this new risk premium for a hundred dollars or so. In simple economic theory, the demand and supply curves do not cross and there will be little or no transaction (i.e no volume of work). Consequently, the standard of care given in the Grounds of Decision of the DT, while now is Medico-legal Reality, will also in all likelihood effectively become Virtual Reality in the HDB Heartlands. How interesting.

Conclusion 2: In the post-LLA era, not many HDB heartland GPs will offer H&L injections. H&L Injections will go the way of dodo bird in the heartlands

The expected repartee from people who are out of touch is that this is not about risk premium but about good consent-taking and documentation. If you take a good informed consent and document as such, you should be OK.

Frankly, not many doctors are interested in this spiel anymore. Certainly, after the Eu Kong Weng case, no doctor is really sure what will be deemed effective informed consent-taking under the scrutiny of SMC or the Courts. And if I have to take this kind of risk for a $100 job, I might as well not offer the service and refer to someone else to do the job (and take the risk).

This is probably the outcome that will take place in the next few months, if it has not taken place already. Please do not call this Defensive Medicine. As this Hobbit has said before, it is called Survival Medicine. It’s the only practical way to survive. For me at least.

But it’s not just about H&L injections. How about other simple everyday office procedures like Speculum Examination, Proctoscope Examination or Ear Syringing? The same principle applies and a heartland GP will transfer the risk premium to the public sector or the private specialists by referring to them.

Conclusion 3: In referrals we trust (to avoid taking on insufferable professional risks)

You may ask: How did we get to this situation?

Answer: because everyone behaved in a way that is expected of them

The Judges wanted to move from a doctor-centric to a patient-centric process when medical advice is provided. They promoted patients’ rights to autonomy through promulgating the MM test.

The lawyer wanted to do a good job as SMC’s lawyer by pushing for a deterrent 5-month suspension. He is defending a particular patient’s rights to autonomy as well as promoting patients’ rights in general by going for a deterrent sentence.

The SMC DT wanted to be seen to be defending/promoting patients’ rights as well by accepting Dr Lim Lian Arn’s offer of a maximum $100,000 fine. They also want to send a signal to all doctors that the standards (as they see it) as prescribed by the MM Test are well in force when they promulgated that long list of potential complications and side-effects for a H&L injection.

Dr Lim Lian Arn acted as he should, by offering to pay $100,000 or be suspended for only 3 months (Reasonable speculation: he wanted to avoid a lengthy suspension and also a possible appeal from the SMC lawyer should the punishment be deemed too low).

The patient-complainant is probably satisfied too that the doctor was fined $100,000. Whether she proceeds on to a civil suit or not, we don’t know.

Every party got what they wanted: The Patient, The Doctor, The SMC Lawyer, The Judges, and The SMC DT.

But this Hobbit cannot help but wonder if Singapore society deserves more.

Because the Likely End-Result is collectively, patients will find it either much more difficult to get a H&L Injection from a doctor or will have to pay significantly more for it. And the same goes for other common, cheap and effective office procedures. A situation of either scarcity of service providers and higher prices will result, leading to unnecessary higher healthcare expenditure.

Society will have to pay for this in the long run. Unless the politicians and senior civil servants step in soon with some form of tort reform for medico-legal cases, the practice of medicine, as we knew it, has truly died. And the biggest losers are the patients collectively and society. Not the doctors. I just earn a few hundreds less a month, but I’ll live. Don’t worry.

 

NEHR: A Patient’s Perspective Through A Doctor’s Eyes

Privacy in Your Own Home? Think Again.

Imagine you owned a property you call home. It can be a simple 4-room HDB flat or a sprawling Good Class Bungalow (GCB) in District 10. You receive guests from time to time. Naturally, there are some guests you allow only to sit in the sitting room and maybe you allow them to go to the kitchen so that they can go to guest toilet in the 4-room HDB flat. But certainly, you will not let them go to the master bedroom or use the toilet adjoining it or your children’s bedrooms, unless they are very close relatives or friends. And I mean real close.

If you are staying in a bungalow with many rooms, it gets even more complicated. You may have a family room upstairs or private dining area away from the dining area where you entertain guests. The bungalow may have a study, an attic or a domestic worker’s room which guests are never welcome. In fact, you do not even want anyone other than your immediate family members to know that these rooms exist. These are very ‘private’ rooms not meant for anyone else to enter other that your immediate family members who live in this building or the domestic worker that cleans these areas. You would normally welcome guests in the sitting room or dining room where you entertain. But rarely would a guest be welcomed upstairs where your family and you share private times together.

Now serious problems arise when a bunch of people who now insist that once they enter through the doorway into your sitting room, they have a right to access every single area in the house, including your master bedroom toilet and your wife’s walk-in wardrobe as well as your study and your kids’ study. Not only that, this bunch of people want to rummage through your refrigerator and trash bin to gather information on what foodstuff you have been buying, eating and disposing.

Would you allow that? I wouldn’t. And I guess neither would 90% of people in Singapore.

But that is what the National Electronic Health Record (NEHR) does, in an analogical sense. Actually, the NEHR goes further than this. You don’t even have to allow the person through the front door. Any person who claims he has business or matters to deal with you can walk into your house and every room in your house. He is presumably “authorised”.

This hobbit understands that today, the NEHR has been rolled out in all Restructured Hospitals other than IMH. Any doctor who attends to you has a right to enter into your NEHR and see practically everything there (walk through every room in your house). There may be some small pockets they may not access (equivalent to the small safe in your bedroom) to. He can even go into your fridge or wardrobe and see what you have bought (look at your pharmaceutical record) or eaten.

And you do not even have to allow him in. He just has to claim he is your doctor. Of course, if he isn’t your doctor, that can be tracked, and the doctor will be punished. But that is post-fact. The damage is already done, your house/NEHR has been trampled all over already by the trespasser or unwanted visitor.

Privacy Rights – The Right To Control Who Knows What

The NEHR does not take into account the privacy rights of the patient in a contextual sense. There are some things I will tell Doctor A and there are other things I want only Doctor B to know. I do not want Doctor A and B and C (whom I see for different things and in different contexts) to know everything or have the same information about me.

The fact is, we all compartmentalise our lives. In our families, there are some things we tell certain family members and some things we tell other family members. Each family member often has different information or data-sets of us.  This is even applicable to close family members, such as siblings or children. Do you tell all you siblings or children exactly the same information about yourself?

The same applies in the workplace – certain colleagues know something of us that other colleagues do not. Of course, relatives and colleagues may share information among themselves through interaction but such interaction is usually coincidental, contextual and limited so that it is extremely unlikely that many relatives or colleagues have the same information about us. A simple example would be I would tell my sister certain information and I would tell my brother other information. I will also tell them they must tell no one. I thus retain privacy rights. Of course, if they betray my trust and tell each other the information they possessed without my permission, that is a breach in confidentiality (not privacy). We must not conflate confidentiality with privacy.

This is the essence of privacy rights being applied in our daily lives. As private individuals, we have the right to decide what each person knows about us through the selective disclosure of information to different parties by us. The control lies with me almost all the time, hence it is my right to privacy. It is not a privilege conferred by others. So, the latest reporting that states folks may opt-out of having their information onto the NEHR on a case-by-case basis (subject to approval) is manifestly not good enough. Case-by-case means it is a privilege conferred, not a right possessed. I have a right to privacy, not a privilege of privacy.

Of course, I do not have absolute control over privacy all the time. The elected government with the mandate of the people may take away those rights once in a while through the passing of laws. For example, the Infectious Diseases Act takes away some of these rights. Doctors have to inform MOH when their patients contract certain communicable diseases. The underlying premise is that this limitation of the individual’s privacy rights must be for a greater public good – the prevention and control of an infectious disease outbreak that affects a great many people.

However, what is the “greater public good” justification for the sharing of my medical information as a patient with all my caregivers? I would say that there is little good other than my own well-being or personal welfare. Don’t I get to decide what personal good I intend to achieve with the NEHR? Why can’t I decide what information to give each doctor or caregiver (e.g nurse)? Or even more fundamentally, If I decide to opt out completely of the NEHR, why is my doctor still forced to upload my information onto the NEHR? Yes, when I opt out, no one can access the NEHR, but that is a question of confidentiality, not privacy. My personal well-being arising from participating in the NEHR is not a public good, unlike that of the Infectious Disease Act. The decision to opt-out of the NEHR may be a medically suboptimal decision, but that is my business, not the people who operate the NEHR, as long as I know the consequences of me opting out.

NEHR: Runs Against the Grain Of Current Case Law?

It is even more confusing when you consider this in the light of the direction of medical ethics that our honourable judges are trying to steer us. The Modified Montgomery (MM) Test is now firmly established as case law in Singapore. Essentially, the MM Test firmly puts patient autonomy at the forefront of medical ethics in the country. The Chief Justice has said that patient autonomy is the “first” of the four core principles of medical ethics of beneficence, non-maleficence, social justice and autonomy.

The MM test basically says the patient has a right to decide what he wants, even if the final decision is medically-speaking sub-optimal and that the doctor’s responsibility is NOT to make that decision for the patient but simply to provide all relevant information (from the patient’s perspective) to the patient so that he can make an informed decision. An informed decision from the patient’s perspective may not be the best medical decision from the doctor’s perspective, and if the two do not match, the patient’s decision must prevail (as long as it is not against the law, such as euthanasia, surrogacy etc.). The MM test ensures that patient autonomy is expressed in its fullest sense in our society.

If that is the case with the MM test, then why are the NEHR planners and implementers forcing each patient to

  • share the same medical information with all doctors and nurses when the patient may prefer otherwise?
  • have their medical information uploaded onto the NEHR, even when the patient has opted-out?

Therefore, the NEHR as it now stands, is clearly going down the slippery slope of compromising patient autonomy.

Examples…..

A simple example would be, say, a married, 40 year old, working, female PMET. She would have in all likelihood most or all of the following doctors –

  • a family GP she, her spouse and her children see (who happens to be her old classmate from junior college);
  • a company doctor she sees occasionally at the workplace when she is unwell;
  • a gynae who delivered her kids and does the her pap smears and gynae checkups;
  • a breast surgeon who removed a benign breast lump a year ago and
  • an aesthetic doctor she goes to occasionally for pigmentation treatment as well as for the occasional skin peel.

We haven’t even talked about other doctors she has used whom she hasn’t any recollection of – such as the radiologist, pathologist or anaesthetist, who ALL have “rightful” access to her NEHR records as “authorised” healthcare professionals.

Do you think she wants ALL her doctors to know she has had laser treatment for face pigmentation every six months? (We are not even talking about more extensive “work” like liposuction, filler injection and breast implants, just simple laser treatment for pigmentation)

Or do you think a 45 year-old homosexual man wants all his doctors to know he has had treatment with Dr Y for anal warts excision? (He hasn’t “stepped out” yet)

Or would a 58 year-old woman who is now happily married with adult children want anyone to know she had an abortion when she was 17 (We all make mistakes when we were young, just some mistakes are bigger than others)?

Would anyone want all his or her doctors to know one is on antidepressants or erectile dysfunction drugs? Most men wouldn’t even want most of their doctors they see to know they have prostate problems, let alone be given Cialis or Viagra.

Or that all your doctors now know you have been tested for HIV before (result negative, whew) and the test is not part of a mandatory pre-employment workout?

Or that the radiology results of you, a lady, who had a fractured cheek bone as shown in an X-ray taken at the A&E 10 years ago after your then (now ex-) husband assaulted you, is now known to all doctors and nurses taking care of you now for fractured ribs, whiplash and concussion arising from a road traffic accident? Your current husband loves you, but he is wondering why he gets strange looks when he visits you in the hospital from all the hospital nurses and doctors.

Of that that a well-known 60-year-old CEO of a bank (or Professor) was once admitted to a hospital for observation after a fight and had lost consciousness and fractured his nose 40 years ago?

The list goes on and on.

What NEHR Will Contain….

In case you are wondering if these examples are realistic, well – according to the official NEHR brochure: the following information will be uploaded onto the NEHR:

  • Admission and visit history
  • Hospital discharge summaries
  • Laboratory test results
  • Radiology results
  • Medication history
  • History of surgeries or procedures
  • Allergies and adverse drug reactions
  • Immunisations

So all the above scenarios can happen in real life.

Seriously, from my personal viewpoint, I would like to share only the last two points onto the NEHR without reservation so that all my doctors and care-givers (i.e. who are “authorised healthcare professionals, according to the abovesaid brochure) can know this about me: allergies, adverse drug reactions and immunisations.

This hobbit has serious reservations about the rest, and thinks they should be handled with extreme care.

Security

The last point I would like to deal with is that of security. Security can basically be defined as measures put in place to prevent breaches of confidentiality. How secure is the NEHR? I am confident that the planners and implementers have tried their reasonable best to ensure best practices in IT security have been put in place or are being put in place. After all, the NEHR, being backed by government, has enormous resources to do so.

Even then, no IT system, especially one that is internet-based and cloud-based, with literally unlimited number of entry points (every clinic or hospital computer that is linked to the internet is an entry point into the NEHR) is hack-proof. If it were not so, there would be no need for the government to delink civil servants’ work computers and intranet from the internet last year. It was reported this affected all 143,000 civil servants. That is a tacit admission that no security system is fool-proof or hack-proof. I suppose this shows cyberthreats cannot be wished away, but they can be effectively partitioned away.

This hobbit is sure the NEHR is as secure as can be, but not quite more secure from the civil servants’ work computers before they were delinked from the Internet. In fact, the fact that the NEHR exists must in itself be a very tempting trophy database for hackers from all over the world to try and test and breach.

In the event a breach happens and records and medical information are stolen, what is the liability of the NEHR or  the government with regard to this breach, and what are the rights of the affected patients? Can he seek redress, compensation, damages etc.?

This hobbit is unsure. These are not stated in the aforementioned NEHR brochure. Theoretically, the NEHR is exempt from the provisions of the Personal Data Protection Act (PDPA) as it is a government programme. Today, if there is unauthorised access to your data with say, your mobile phone network operator, the mobile phone network company MUST inform you so, because the company has to comply with the requirements of the PDPA. If your GP record has been hacked into today (Pre-PDPA) or physically stolen, your GP has to inform you too. You can probably sue your GP or the mobile phone network company for civil damages and the regulators can use the provisions of the PDPA to punish the GP, or the mobile phone network company.

If there is a breach of the NEHR and your record is stolen, will the administrators inform you? No one knows. Will the penalties of the PDPA apply? Probably not. Can you sue the NEHR for civil damages? Again, this hobbit really doesn’t know.

Conclusion

In conclusion, is the NEHR a bad thing? No. But a lot of work needs to be done with the NEHR as it now stands; beginning with:

  • We need to discuss openly about the potential downsides of the NEHR as the NEHR currently stands and not just only extol the positives of NEHR.
  • We need to recognize that privacy rights need to be adequately addressed. The patient has to retain the power to give and retain information to the healthcare professionals or settings as he sees fit. It is natural to compartmentalise our lives and our interaction with people, and this compartmentalisation extends to the healthcare realm. You cannot talk about confidentiality and security without settling the issue of privacy rights first.
  • We need to clearly spell out the rights of the patient and the responsibilities and  liabilities of the NEHR owner(s) when there is a security breach. Some sort of a patient charter should extend to the realm of NEHR too.

And we are only talking about looking at the NEHR from the patient’s perspective. We haven’t even talked about the NEHR from the perspective of the people who record and use the information – the healthcare professionals.

A reader of this article may well ask “The typical or average patient in Singapore will in all likelihood not know the issues this article has raised and will not be concerned as such”. It is because this Hobbit is a doctor that he can understand and bring up issues such as privacy, confidentiality and security which dogs the planning and implementation of NEHR.

But that is besides the point. We are actually all in the same boat as “patient advocates”, working for the patient’s best interests and betterment of patient’s well-being: politicians, civil servants, IT experts, healthcare professionals such as doctors, nurses etc., and of course the patients themselves. If we are sincere and serious about being patient advocates, then the questions raised in this article need to be communicated to the public, recognised, considered and addressed by all stakeholders. These issues cannot be ignored, dismissed or simply swept aside if we truly work in the best interests of the patients from a holistic and comprehensive perspective.

The residency rollout was one bad example where those in power then were dismissive of the issues and reservations raised. They steamrolled ahead and adopted the ACGME-I system and the results are for all of us to see now. It is still early days, the NEHR need not go down the same  painful route as residency.

 

Survival Medicine 2: The Modified Montgomery Test

Autonomy as the First Core Ethical Principle of Prime Importance

This column will be a long and serious one. Those regular readers looking for the usual light-hearted banter and vacuous mirth and merriment that is the norm for this hobbit’s writings are well advised to come back after September.

Since the last column “The Petition”, many readers have given feedback that they liked the idea of “Survival Medicine”. This hobbit would like to continue discussing this.

In the latest and 23rd Sir Arthur Gordon Arthur Ransome Oration to the Academy of Medicine, The Honourable Chief Justice Sundaresh Menon said,

“Most theories of medical ethics recognise 4 core principles, which are reflected in the 2016 edition of the SMC’s Ethical Code and Ethical Guidelines and are described in the SMC’s 2016 Handbook on Medical Ethics as “the foundation of medical ethics.

The first is patient autonomy. This means respecting the right of the patient to choose, even (with some exceptions) when the choice seems, or is, unwise. As a corollary, this also requires a physician to supply the patient with the knowledge needed for that choice to be meaningfully exercised. The second and third principles are beneficence and non-maleficence. These require a physician to seek to maximise the good of his patients and to avoid or minimise harm. The fourth principle is justice”.

This hobbit actually looked up the SMC’s 2016 Handbook on Medical Ethics. Under the section of Pages 9 and 10 of the said section “Foundation”, the four values are listed in this order: Beneficence, Non-Maleficence, Respect for Autonomy and Justice. I think they weren’t really listed in any order of importance, but patient autonomy wasn’t listed first.

In the 2016 Ethical Code, (from pages 12 to 14), these headings are listed in this sequence: “Ensure beneficence and non-maleficence”, “Respect autonomy” and “Uphold justice”.

This hobbit, with his very limited intellect, is in no position to disagree with the Chief Justice. If autonomy is proclaimed to be the first core principle of medical ethics, then it must be. But this hobbit has a confession to make. He did not apply to medical school or want to practice medicine with “patient autonomy” as the first and foremost ethical consideration on his mind. And he will bet that most folks did not have patient autonomy on their mind when they applied for medical school too. And he will further bet that most medical school admission interviewers were NOT looking out for candidates who were primarily motivated by ensuring patient autonomy when selecting 19 year-olds for medical school. And in case anyone is wondering, this hobbit is ordinarily not a betting hobbit.

This hobbit reckons that most 19 year-olds aspired to become doctors and applied to medical school “to do good” (beneficence). With the benefit of a medical education and clinical practice, we also learn the axiom of “first, do no harm”. There is a Latin phrase for this: –  “Primum Non Nocere”. Doctors usually take pithy Latin phrases quite seriously. It is the understanding that the knowledge and armamentarium available to a doctor can also have the downside of doing harm: every drug has side-effects; every surgery has risks. So, while most doctors (or aspiring doctors) start off with beneficence as the chief motivating force, non-maleficence becomes a doctor’s guiding beacon as well, to guard against excesses and imprudent exuberance. There is always a healthy tension between these two ethical forces in most doctors: Beneficence and non-maleficence.

A few doctors also start off with social justice as their main motivating force, and sometimes you see these members of the professions setting off in public health, overseas mission work, NGO work etc.

Of course, there are unethical or materialistic doctors who see each patient encounter first and foremost as an avenue to personal financial gain. But let us leave this group out and just concentrate on ethical doctors.

Let us take a breather here and look at the SMC’s Physician’s Pledge:

“I solemnly pledge to: dedicate my life to the service of humanity;

give due respect and gratitude to my teachers;

practise my profession with conscience and dignity;

make the health of my patient my first consideration;

respect the secrets which are confided in me;

uphold the honour and noble traditions of the medical profession;

respect my colleagues as my professional brothers and sisters;

not allow the consideration of race, religion, nationality or social standing to intervene between my duty and my patient;

maintain due respect for human life;

use my medical knowledge in accordance with the laws of humanity;

comply with the provisions of the Ethical Code;

and constantly strive to add to my knowledge and skill.

I make these promises solemnly, freely and upon my honour.”

One can see that this Pledge, which has been in force since 1995, is terribly doctor-centric. It touches more on beneficence and justice than autonomy. One can argue that the references to autonomy are at best indirect and/or vague – “comply with the provisions of the Ethical Code”, “laws of humanity” or when the Pledge demands doctors to safeguard a patient’s right to privacy and confidentiality. What a shame. SMC should insert something like “Make the autonomy and health of my patient my first considerations” to be in line with what our Courts are saying.

To sum up, even though “autonomy” is one of four core ethical principles of non-maleficence, beneficence, autonomy and social justice, autonomy is seldom if ever the starting point for why a person wanted to do medicine. It is also seldom the first consideration in a doctor-patient encounter among ethical doctors. It is there because it is important, but it certainly isn’t there as a first-amongst-equals (i.e. primus inter pares) principle amongst doctors. But now that it is, and I must change and obey accordingly. If I do not change, my very professional existence may be threatened.

The Modified Montgomery Test: Balance between Autonomy and Beneficence

This is because we have to comply with the Modified Montgomery (MM) Test that the honorable five judges have come up with recently. For the avoidance of doubt, in our Common Law system, judges can make case law through judgments and such case law is binding unless it manifestly flies in the face of laws and statues passed in Parliament, of if new case law is created by judges at least as senior or more senior than the judges that created the old case law. And since the MM Test was created by five High Court Judges that included the Chief Justice himself, it will not be anytime soon that the MM test will be replaced by some new case law. Parliament can pass a law that renders the MM test illegal, but that is even a more remote possibility. So, in short, MM test is here to stay for a long, long time.

Many doctors this Hobbit has spoken to are vexed and asking if the MM test is the correct thing to do and whether the MM test is good for patients and for the practice of medicine in Singapore. These are the wrong questions to ask. The MM test is now part of case law. Case law is still law. Doctors in Singapore just have to comply with the MM test, whether you like it or not. Some of my friends have also asked me if I agree with or like the MM Test personally. That is also a wrong question to ask. The law does not require or even ask for my intellectual agreement or emotional affinity, it only demands my full compliance. And therefore, I comply. Or at least try my best to. So, let us get these unhelpful distractions out of the way. The correct question to ask is, “What is the MM test and what must I do to comply with it?”

The Judges have conveniently divided up a typical patient-doctor encounter into third parts: Diagnosis, Advice and Treatment. They took pains to explain that the MM test only applies to the part of “Advice”. They have also said the traditional Bolam and Bolitho (BB) tests still apply “with great force” to diagnosis and treatment phases of the encounter.

The rationale for this approach is that diagnosis and treatment are “doctor-centric” activities while advice has to move from doctor-centric to more a “patient-centric” position, especially with patients becoming more educated and wishing to be involved in the decision-making process. The five judges stated that professional guidelines and societal context of the UK where the Montgomery Test originated, have moved to “recognising patient autonomy as a principle of prime importance”. Singapore has “undergone the same transformation” as the UK (Para. 118).

The five judges also stated in para. 120 that “It is therefore incumbent on us to reconsider the advice aspect of the relationship through the lens of patient autonomy as well as the principle of beneficence and ensure that both principles are upheld. There must be a balance between both principles (as well a balance between the doctor’s perspective and the patient’s perspective); neither should dominate the other”.

That may be the noble aspiration of the judges, to balance autonomy and beneficence with and through the MM test. With all due respect to the honorable judges, they may have placed too much confidence on the capabilities of the average doctor in Singapore. On the ground, the average doctor will, in all likelihood, not be able walk such a fine line (tightrope?). Many will veer towards patient autonomy and not seek to strike a balance. Most psychologists will tell you that over-compensation in the face of a new, uncertain and challenging environment is the usual and therefore expected response of the human race. Doctors are only human.

One cannot argue with the logic for the MM test to be more patient-centric. However, what this really implies to me at the personal level is another matter. The Bolam-Bolitho (BB) test places beneficence and non-maleficence as the first considerations. When I see a patient and take a history, perform a physical examination, and order some tests so as to get a diagnosis, my state of mind is that of beneficence/non-maleficence (“I am trying to do good without doing unnecessary harm/take unnecessary risk”). After I have secured a diagnosis or several differential diagnoses, as it were, I now have to change gears quite abruptly to a “patient autonomy” state of mind and offer advice to the patient that is relevant to the patient’s context and I let him decide (as prescribed by the MM test). “Doing good” takes a backseat to “You, the patient, decide”. After the patient has decided, I now have to switch back to a “beneficence and non-maleficence” mental state at the treatment phase as the BB test comes back into play again and MM test no longer applies.

Let me tell you, I tried doing this and I felt my thoughts and emotions going through two rounds of mental and emotional contortions in each patient encounter. My medical training in the past didn’t quite prepare me for this roller coaster experience and I felt emotionally exhausted, even pained from the encounter. I blame this on the limited plasticity of my thought processes and a small brain that is unable to cope with the flexibility of thought processes. Or maybe I am just a mediocre doctor. But again, I stress, what I feel is irrelevant. The important thing is I must comply with the law which includes the MM test, even when I am emotionally exhausted from trying to do so.

Hence, this hobbit thinks the average doctor will just let the consideration of autonomy dominate beneficence when it comes to the advice aspect of the patient-doctor encounter.  This is already a taxing experience. To move to a higher plane of balancing beneficence and autonomy (i.e. the thinking behind the MM test) will be even more demanding. Perhaps only a great doctor can achieve this. But greatness is rather a rare commodity by any expectations. Having said that, this hobbit certainly hopes that the judges are correct, and that most doctors can balance the two core principles and comply with the MM test. And this Hobbit hopes that over-compensating a little will not amount to professional misconduct. Certainly, from the patient’s interests and perspective, a little over- is better than under-compensation.

Relevant Information and Acting on Relevant Information

The original Montgomery test referred only to risk-related information so that the patient can make an informed decision of give informed consent. The MM test in Singapore covers more. Para. 138 of the Judgment states “will include “other types of information that may be needed to enable patients to make an informed decision about their health”. The broad types of material information include those identified in the Canadian case of Dickson v Pinder [2010] ABQB 269 (“Dickson v Pinder”) as follows (at [68]):

(a)     the doctor’s diagnosis of the patient’s condition;

(b)     the prognosis of that condition with and without medical treatment;

(c)     the nature of the proposed medical treatment;

(d)     the risks associated with the proposed medical treatment; and

(e)     the alternatives to the proposed medical treatment, and the advantages and risks of those alternatives.

Para. 139 further states “As to what exactly it is about the various types of information that would be considered relevant or material, in our judgment, this is largely a matter of common sense”.

As a third-year medical student, a Professor (now Emeritus Professor) of Surgery did tell me quite succinctly that “common sense is not common”. I can only hope common sense has become commoner since then.

Delegation of Decision Making Process

Singaporeans are getting more educated and want more patient rights. That is probably true. But Singapore remains a very heterogeneous society. There remains a large group of patients, especially the older ones, who do not want to decide for themselves. Many patients everyday will tell doctors, “Talk to my spouse/son/daughter etc. I let my spouse/son/daughter decide”. Their only decision is the decision of delegation of decision-making to a loved one.

Do the same standards of MM test apply here? What if the spouse/son/daughter knows or expects something that is different from the patient? Is it going to be the patient’s perspective or the spouse/son/daughter’s perspective? Is delegation of the patient’s rights to a family member or even friend the same as a “waiver” (para. 150 of Judgment)? This hobbit doesn’t have the answers to these questions.

 MM test: Boundaries Already Creeping?

In para. 62 of the High Court Judgment issued by the Court of Three Judges in the Chia Foong Lin case on 27 June 2017, it was stated –

“When the available tests to exclude Kawasaki Disease (KD) are simple to undertake and when the consequences of no timely treatment of KD could be severe, it is not for a doctor to take chances with the well-being of a patient. If there was a need to take chances, that determination should be left for the patient (or his parents if the patient is an infant) to make on an informed basis. We struggle to understand why such exclusionary tests, which were not harmful to the Patient, were not undertaken, or why the parents of the Patient were not informed of their availability. It is here that Dr Chia badly faltered”.

It would appear here that having a patient-centric (or rather in this case, parent-centric) approach to advice given not only applies to treatment but has now also creeped into advice for investigation in order to make a diagnosis as well. Is the MM test strictly limited to advice for treatment, or advice for investigation as well? In the Judgment given by the five judges in May 2017 in Hii vs Ooi, it was stated in para. 96 “where the diagnostic method is routine, non-invasive and risk-free (as in the case of the measuring of body temperature or blood pressure)”, the MM test need not be applied.

So, if you read the two judgments, one could ask: – does the MM test apply to the decision to order “unharmful” blood tests or not? Is the reach of the MM test creeping further already than originally intended? Was Dr Chia guilty of professional misconduct because she omitted ordering the test, or because she did not give advice to the parents so that the parents can make an informed decision whether to have the test or not? Or does the BB test continue to “apply with great force in the diagnostic context” (para. 101) ? This hobbit also doesn’t have the answer to these questions either.

To be on the safe side, this hobbit will be applying the MM Test to all information transfers from doctor to patient, whether the information is for treatment or just ordering an “unharmful” blood test. The patient will have to decide on an informed basis whether he wants a “unharmful” test or not. This change in practice has become an essential part of my Survival Medicine toolkit.

National Electronic Health Record (NEHR)

We move onto something that has happened in the public sector and which will possibly affect doctors in the private sector as well

There is a lot of talk that participation in the National Electronic Health Record (NEHR) will be made a requirement for clinic licensing. In other words, participation in NEHR by hospitals, clinics and doctors will be made compulsory.

The doctor therefore will soon have access to years and years of patient information that may be relevant to the stipulation of the MM test that “other types of information that may be needed to enable patients to make an informed decision about their health” should be given to the patient.

Problems arise when a doctor misses out on information in the NEHR that was recorded a long time ago. Is the doctor truly responsible for taking into account the whole NEHR of the patient from birth till today so as to tailor-make relevant advice for every patient so that the patient can “informed decision”? Is this humanly possible given the constraints of time, resources and simple human frailty?

The MM test more or less says that the doctor is not responsible for not taking into account information if the patient doesn’t give the information to the doctor, and especially if the doctor has made some effort to elicit such information. But does this afford the doctor significant protection when almost all information is already in the NEHR and the NEHR is readily available to all doctors? Must the patient still give the information when the physical consultation takes place? Would the doctor be held liable because of the extensive coverage of the NEHR? The prospect of being guilty of professional misconduct because the doctor missed out on a relevant morsel of information in the cavernous repository that is the NEHR is real and possibly quite alarming.

Defensive Medicine

The judges have opined that MM test will not lead to defensive medicine. No one can really predict the future with 100% accuracy, but this hobbit hopes that the judges are correct. As this hobbit has said in a previous column, the hobbit doesn’t really know what is defensive medicine. The hobbit has to practise “survival medicine” so as to NOT run afoul of SMC requirements and the law and stay registered as a doctor.

 

Resources Required

The first likely consequence of the MM test is that advice (and consent-taking) will take a much longer time than in the previous BB test era. A professional’s time is a precious resource, be it for a doctor, accountant or lawyer. So, appropriate fees have to be charged to reflect the time and resources spent. With the extensive work that the MM Test requires, this hobbit wonders if consent-taking should be made a separate long consultation by itself and therefore is chargeable as a separate encounter between the doctor and the patient?

Since we are on the subject of resources, the private sector actually has it better. The private sector can readily adjust prices or turn away work so as to give each patient better attention and more time so that advice given can be compliant with the MM test.

The public sector will find this more difficult. They can neither turn away work or readily titrate work volume using the price mechanism, since most of their work involves subsidised patients. The end result is that either waiting and appointment times have to lengthen or the system has to employ more doctors. In the distant past, the public  sector can cut some corners, e.g. use junior staff to perform tasks like advice and consent taking. But this is no longer possible, because from another core ethical principle of justice, private and public sector patients must be accorded the same level of protection under the MM test.

Another consideration is that public sectors doctors usually know their patients less well than the private sector. Many patients see different doctors over time, especially in the subsidised classes, and so the chances of missing out on relevant information about the patient is higher, while the MM test demands that the doctor give advice in the context and from the perspective of the patient. You cannot give the right advice when you do not even notice the relevant information. Basically, the MM test requires less effort on the part of the doctor, when there is good continuity of care with the same doctor, which is hardly possible in the public sector due to training and service imperatives.

My Way Forward (Which may not be yours….)

I do not profess to have the solution or “model answer” to complying fully with the MM test. But I shall share with you what I think will work for me to the best of my limited abilities.

The MM test is divided into three parts. This hobbit suggests that advice-giving itself could also be divided into three parts:

  1. Advice to the Reasonable Patient
  2. Advice arising from information from past medical records
  3. Advice arising from information actively obtained from current encounter

The first part deals with a doctor-centric model of the “Reasonable Patient”. The reasonable patent is an artificial legal/ethical construct that does not exist physically. In the BB test era, as long as the doctor gives advice sufficient for “the reasonable patient”, he is absolved of wrong doing. Here, I think standard forms can be designed and used as a checklist to aid both the doctor and patient when the doctor gives advice, especially for common procedures such as a colonoscopy, TURP, removal of breast lump etc.

The second part deals with information that can be gleaned from the patients’ records, such as the NEHR. This is where perhaps Artificial Intelligence (AI) Tools can be designed to automatically screen a patient’s electronic record to highlight relevant and important information for both patient and doctor. I think an AI Tool will be far less error-prone than a doctor scrolling and reading a voluminous patient record quickly. But for now, we still have to just go through the past medical records manually and look for aspects that we think from the patient’s perspective will affect our advice-giving, those aspects that happen to be more than what is required by the hypothetical Reasonable Patient.

In giving advice, both doctor and patient should sign off the standard forms and AI-highlighted information and the advice that is consequently given.

The third part involves the doctor actively eliciting information that is not expected of the reasonable patient or highlighted from the patient’s electronic records and giving relevant advice from the information obtained in the second phase. The doctor can and should ask the patient, “Is there any other information you want to tell me that I already do not know from your past medical records that you think may affect my advice to you from your perspective?”

On top of this, an audio recording, with the patient giving consent to the recording, of the entire three-part advice-giving process should be made. The patient’s decision to give consent or not to an audio recording should be duly documented and acknowledged by the patient in writing (a simple signature in a simple form would suffice, I suppose).

If the patient refuses to even acknowledge in writing that he refused giving consent to making an audio recording, then the doctor can always refuse to carry on with the doctor-patient relationship and stop the consultation in non-emergency situations. (The MM test only applies to non-emergency situations anyway).

I am not advocating this approach to anyone, but it is my personal “best effort” response to complying with the MM test now – which is to make an audio recording. It is useful for both the patient and the doctor when a dispute arises.

Survival Medicine in the Era of MM Test, New SMC ECEG/HME and Deterrent Sentences

Let us now return to Survival Medicine, which is what this Hobbit is trying to achieve to ensure his professional survival. Recently, three unrelated events collectively have affected me greatly.

The first is the new 2016 ECEG and HME which has been in force since 2017. The new ECEG is 65 pages long and the HME is 155 pages long. That’s 220 pages in total and multiples in length of the last version. All doctors must comply with the ECEG. All doctors must also comply with the HME as well, or be prepared to give good reasons why they cannot (and that is not going to be easy). This weighs heavily on this hobbit’s mind – the sheer bulk, comprehensiveness of the ECEG and HME. It’s tough reading going through both documents, and complying with them is even tougher. When the prosecution lawyers “throw the book” at you today when they draft their charge(s), you can bet there is a lot more book to throw at you, 220 pages of book to be exact.

The second is the MM test. The MM test is described in the Judgement on Hii Chii Kok vs Ooi Peng Jin London Lucien dated 12 May 2017 and is over 100 pages long. Every doctor should read this document. It is not easy reading, but essential reading. Some of the implications of the MM test have been described above. Suffice to say that the MM test demands a lot more effort from doctors, because doctors now do not have to just give advice that is relevant to the reasonable patient, but information that pertains to the particular patient’s circumstances and perspective that the doctor should have known.

The third is a little lesser known. It is a High Court judgment delivered on 25 July 2016 on the case of SMC vs Wong Him Choon.

In Para 117 it is stated:

“As can be seen from Lee Kim Kwong and Kwan Kah Yee, we have on at least one previous occasion referred to and, on another, exercised our discretion to depart from precedents that do not reflect the prevailing circumstances and state of medical practice. In our judgment, public interest considerations weigh heavily in imposing deterrent sentences on errant doctors who are found guilty of professional misconduct. In this regard, we expressed at the hearing that we found the sentences imposed in the Dr K case, Dr L case and Dr Amaldoss case (“the Relevant Precedents”) to be lenient. We observed without reservation that these sentences should have in fact been longer. We highlighted to the parties that this court has given fair notice of its intention to recalibrate sentences across professional misconduct cases, and would do so in the present case”.

In other words, in many cases, doctors can expect to face more severe punishments than in the past should they be guilty of professional misconduct, especially in cases where public interest is involved.

Personal Survival Medicine

I cannot claim to speak for anyone but myself, but I do feel anxious about the current and future practicing environment. When I ask questions about certain aspects of the MM test to lawyers, many of the answers come back as “We are not sure, this has not been tested in the Courts yet. We have to wait for the first case”. There is uncertainty in both medical and legal work (The Honourable Chief Justice made this point as well, in the aforesaid Ransome Oration), and we have to accept that.

But still, it is hardly reassuring. I know doctors who would rather have a purulent abscess in his buttocks before he wants to be a test case for the SMC or Courts. An abscess you can drain and treat over a few days; a test case can last for months if not years.

So, again, my response is to practise Survival Medicine: be safe, rather than sorry. I am prepared to over-compensate a little out of prudence.

Is that defensive medicine? Like I said, I do not know what is defensive medicine. I just know I need to practise survival medicine. I need to survive.

 

The Petition

Let’s cut to the chase: more than 1000 doctors signed a petition for a fellow doctor. That’s serious business. 1000 highly individualistic and opinionated doctors. Normally, it is hard to even get three doctors to agree on anything like what to eat for lunch, let alone 1000 on something so complex. And the 1000 included more than a 100 paediatricians. So, history has been made, in a way that well, may well unsettle a few people, as it was meant to be, this Hobbit supposes.

Yes, we are talking about the unsuccessful appeal of Dr Chia Foong Lin to the Court of Three Judges against a SMC judgment and the petition that followed which was signed by more than 1000 doctors.

The petition to MOH stated, “We respect the judgement but we strongly feel the punishment was too harsh”.

The background of the case was that a one year-old child was seen by Dr Chia four times and Dr Chia did not manage to diagnose Kawasaki Disease (KD) on no less than 4 (follow-up) occasions and did not do the necessary investigations to exclude or diagnose KD.

Para. 37 of the Grounds of Decision by the Disciplinary Tribunal (DT) stated “Given the clinical presentations of the Patient and the significant risks of adverse and severe consequences resulting from delayed or missed diagnosis of KD, it would be reasonably expected of the Respondent to order such tests during the course of the Patent’s hospitalisation at Gleneagles Hospital. The Tribunal was of the view that such a failure amounted to a serious negligence on the part of the Respondent”. KD is while not extremely rare, is also not a common disease in Singapore. About 50 to 80 cases are diagnosed in Singapore each year, going by estimates.

Having read the Ground of Decision by the DT and the Judgment by the Three Judges, this Hobbit feels that the management of the patient by Dr Chia was indeed suboptimal. There are a few legal tests and standards in force today in Singapore – the Bolam Test, the Bolito Addendum and now the Modified Montgomery Test are used to see if a doctor is guilty of professional misconduct.

The Hobbit, being totally untrained in the law and also congenitally stupid, uses a simpler test – it’s called the MBBS Final Exam test. If this patient was a long case in the MBBS Finals, would I have passed the final-year student and unleash him to be a house officer had he behaved the way the doctor did?

The short answer is probably “no”. If you are a particularly merciful examiner, you would have at best given a borderline pass to this student. This standard or test would apply to medical officers and GPs. But since this case actually involved a paediatric specialist, the answer is still “no” (held to a higher standard than a final year student taking MBBS final exams or a GP). That’s why specialists are called specialists and are better paid than GPs and medical officers.

But would that alone warrant a 3-month suspension? This Hobbit suspects this is the biggest question that is on the minds of most of the 1000 doctors that signed the petition. This Hobbit doesn’t think it warrants a 3-month suspension either. Maybe a censure and a fine or even a shorter suspension period of say, 2 weeks.

But wait, the Medical Registration Act (MRA) which empowers the SMC DT, doesn’t allow for anything less than 3 months [section 53(2) of the MRA allows for suspension of “not less than 3 months and not more than 3 years”].

This is the problem. And it has been noted to be so since 2011. But nobody who could amend the law did anything about it. Here are the facts: In another unsuccessful appeal case involving Dr Eu Kong Weng against the SMC in 2011, the Three Judges (which included the then Chief Justice) wrote in their Judgement

“We agree that a suspension is called for, and if we had the discretion, we would have imposed a shorter period of suspension. However, the law does not allow us to do that as the 3-month suspension is the minimum mandated by s 45(2)(b) of the Act”.

So, despite the Judges’ statements in 2011 which is on public record, nothing has changed since then. The law was not amended. If a doctor is suspended, it is for at least 3 months. It is noteworthy that in the Grounds for Decision for Dr Chia’s case, the DT did state in para. 65 “Accordingly, the Tribunal ordered that the Respondent be suspended for the minimum period prescribed by law” (emphasis mine). Had the law allowed for a lower minimum period of say, 2 weeks, would the Tribunal have also given the minimum period? And would 1000 doctors have signed the petition if the suspension was just for 2 weeks? All these are of course, speculative and we will never know the answer.

The other issue is with the conviction itself. Many doctors (as does this Hobbit) believed that Dr Chia committed what was essentially cognitive errors which led to suboptimal management of the patient. Should cognitive errors be classified as “serious negligence”? And since there is serious negligence, by logical inference, there must be “non-serious” negligence. This hobbit’s reading of the Grounds of Decision is that Dr Chia had at least 4 occasions to follow up and diagnose or exclude the differential of KD, which she did not. This is regrettable. But a few questions remain:

  • When does cognitive error cross over from “non-serious” negligence to “serious” negligence? What is the legal test for this, to separate the two groups of negligence?
  • Do all cognitive errors equate to serious negligence?
  • Does the disciplinary and appeal process involving the Complaints Committee, DT and Court of Three Judges even recognise this concept of cognitive error?
  • Of even more fundamental importance, is there any room for the realm of honest mistakes, of which cognitive errors is a subset of?

A secondary issue with this case is that of expert witnesses. Expert witnesses called by both sides were noted to be “eminently qualified”, “knowledgeable and objective”.  But the DT preferred the opinion of the expert witness from SMC in the end. The DT noted that the Respondent’s (i.e. the doctor’s) expert witness “took a more sympathetic and charitable view of the case at hand”.

This is a tough one. If an expert was abhorrent of what the doctor had done and was not at least mildly sympathetic and charitable, would the expert even agree to be an expert witness for the defending doctor in the first place? So, if being sympathetic and charitable discounts the expert’s witness weight in the eyes of the DT, then the doctor and his expert witness is already always off to a bad start.

Finally, what are the take-home messages from this case for the doctors on the ground seeing many patients every day? Here’s a few:

  • Investigate and exclude differentials promptly, especially differentials with potentially serious complications, as in KD with cardiac complications.
  • Repeated cognitive errors or repeated honest mistakes may amount to serious negligence.
  • We don’t really know what differentiates non-serious and serious negligence. Better err on the side of caution
  • The fact that the patient did NOT suffer any long-term complications (because the child was diagnosed and treated with intravenous immunoglobulin by another paediatrician a few days later) is NOT a mitigating factor.

Does this mean this Hobbit is advocating defensive medicine? Actually, I am not sure what is defensive and non-defensive medicine. It’s better to say this Hobbit advocates practising “survival medicine”. If my registration as a medical practitioner doesn’t survive, all other points are moot. So first and foremost, if I am to do any further good as a doctor in this country or just put bread on the table, I must first remain a registered medical practitioner. Being unregistered, temporarily or otherwise, is no good at all. Therefore, I just have to do what it takes to stay registered.

 

 

Interview or Interrogation

The purely speculative telephone record of a completely fictitious phone call:

Mr Chin Wu Eng (MOH officer): Hello, may I speak to Ms Seow Kah Chng please?

Ms Seow: Yes, I am Seow Kah Chng

Mr Chin: Ms Seow, I am Chin Wu Eng and I am calling from Ministry Of Health and I would like to ask you a few questions about a recent aesthetic procedure that you went through with Dr Lui Chin Chuay at Ecstatic Aesthetic Clinic at Lorong 38 Geylang.

Ms Seow (in anxious tone): How do you know I went for an aesthetic procedure?

Mr Chin: We are MOH, we know everything. But first, I would like to verify your identity by asking you a few questions. What is your date of birth?

Ms Seow: It’s none of your business.

Mr Chin: We know your birthday is 4 April 1992 and you live near Sims Ave. Is that correct? You also went for a liposuction of your buttocks on 3 May 2015 and 400 mls of fat was sucked out of your left buttock and 400 mls from your right buttock.

Ms Seow: (Nervously): I think so. But the doctor never tell me it was 400 mls.

Mr Chin: (In an authoritative tone) Good. We can now move on. Did Dr Lui Chin Chuay explain to you before the procedure about the benefits, risks and alternatives to buttock liposuction?

Ms Seow: Yes.

Mr Chin: Can you tell me what are some of the benefits, risks and alternatives?

Ms Seow: Yes, he told me that my buttocks will be smaller and look tighter and my husband will like it (giggles)….the “xiao” backside will be very attractive

Mr Chin: And…..?

Ms Seow: And I can also don’t do lor. Can exercise until I become Pioneer Generation then my backside may get smaller a bit. And only a bit…

Mr Chin: Did he mention any risks?

Ms Seow: Yes, he said all operations also got risks, but he said don’t worry, Dr Lui says he is very safe one. He pointed out to all the certificates and degrees hanging on the walls of his clinic.

Mr Chin, I see. Are you satisfied or satisfied with the procedure?

Ms Seow: Actually I don’t know. I suppose so lah. But all my customers say my backside now very tight, firm and small. I now can charge more….. (giggles again). I think now my backside smaller, can go next time to make my top bigger. I want at least a C-cup.

Mr Chin: (swallows some saliva) and your husband that you mentioned earlier?

Ms Seow: I where got husband? Dr Lui anyhow say one lah (giggles uncontrollably). Eh, I stay around Sims Ave and I go to clinic in Lorong 38 Geylang. I also go to DSC clinic every few weeks. You say you are from MOH, you dunno what I do meh???? You don’t know I go DSC clinic meh? Are you sure you are from MOH?

Mr Chin: Thank you for your time, Ms Seow.That will be all. (Click)

The above conversation is unlikely to have ever taken place for the following reasons:

·     There is no clinic called Ecstatic Aesthetics. And if there is, this hobbit will sue for copyright infringement faster than Amos Yee can bust his bail deposit.

·     There are hardly any more locals working in the world’s oldest profession, which together with the banking and academic sectors, are now dominated by foreign talent

·     MOH will definitely know you have gone to DSC clinic. Trust them.

In any case, this recent move by MOH to force patients who consent to an aesthetic procedure to also at the same time die-die (no other description other than the colloquial die-die will do here) consent to be interviewed by an MOH authorised person is nothing short of bizarre, undemocratic and callous in terms of taking into account the aesthetic patient’s emotional well-being.

The vast majority aesthetic patients do NOT want anyone to know that they have “augmented” themselves. This is not like going for an ACL repair or a Lasik job. This is Asia, and people are shy about telling their friends they went for an operation to treat piles, what more a buttock liposuction, for crying out loud. People don’t even want to be seen walking in and out of an aesthetic clinic, let alone talk to a complete stranger about the procedure. MOH may think the term “MOH authorised person” or “MOH officer” invokes feelings of closeness and 100% trust, but you know what? People have privacy needs and talking to a faceless voice on the telephone about his/her buttock liposuction evokes as much empathy, warmth and trust as a dead cockroach rotting in the afternoon sun. Unless you happen to be Caitlyn Jenner, the incredible transsexual Hulk, in which case, you may want to Twitter about it.

This hobbit fails to see what good this approach will do. For one, an effective audit predicated on having interview(s) involves good communication. Good communication that involves highly emotional and confidential information cannot happen between faceless strangers on a telephone call. MOH can learn from the Roman Catholic Church – confessions happen between the believer and the priest in a close private setting and the two address each other as ‘father’ and ‘child’. (No, I am not suggesting MOH officers be addressed as “father” but you get the point).

And to what end? The end is presumably to ensure patient safety and improve standards of aesthetic procedures. Aren’t there better ways to do this? If we are truly concerned that certain doctors are not competent or procedures are unsafe, then either raise the training requirements for doctors, ban the procedure altogether, or at least require the procedure to be done in a safe setting with proper equipment and staff etc. These are all already within the powers of MOH now. Why the need for an interview? An interview is a post-event, “after the fact” intervention. Wouldn’t it be better if we do something preventive, “before the fact”?

We also do not know what really happens in an interview. Could the interview process or the interviewer sow enough doubt and worries in the patient to trigger a complaint or legal action that turns out to be unwarranted or unnecessary? And if so, can the affected doctor seek redress from MOH? Or does MOH guarantee that the interviewer and process is completely neutral in any way and no leading questions are asked in the interview?

Today, it is forcibly bundling MOH interviews with aesthetic procedures? How about tomorrow? Will MOH bundle interviews with health screenings, ECGs and other procedures? Where will this all end? Is this the thin end of the wedge for patient autonomy? Are we killing patient autonomy slowly with each intrusive and forced interview? Where is the right of the patient in all this? Where is his right to consent to the aesthetic procedure but not to the interview? Why are we taking this right to decide whether he wants to be interviewed or not away from him? Can’t the aesthetic procedure patient tell MOH to butt out of his life (pun intended)? Doesn’t the patient have this basic right?

Come to think of it, since the patient doesn’t have the right to decline, maybe we should call this the post-aesthetic procedure interrogation instead

What ever happened to patient autonomy in this country?

Lessons from the Dr Lawrence Ang Case

Background

First, a word from our sponsors.  The ministerial decision to allow the complainant’s appeal in the celebrated Dr Lawrence Ang case did not arise from the current Minister for Health or DMS. It was probably from the previous administration. Hence, calls for the current Minister and/or DMS to commit hara kiri like “in the good old days” is without any basis, merit or even humour. It’s no longer the “good old days” but the “bad present days”, where people who muck up the whole show for 10 years just walk off into the sunset. Life isn’t fair, get used to it.

We now return to the regular programming of the SMC, which now is more gripping than House of Cards, Game of Thrones and Mr Bean all put together.

A recap of the story so far:

• Patient of Obstetrician & Gynaecologist Dr Lawrence Ang complains to SMC alleging that Dr Ang botched her delivery.

• The SMC Complaints Committee throws out the complaint

• Patient appeals to the Minister

• Minister allows the appeal

• A Disciplinary Committee is convened to hear the case and finds Dr Ang guilty of one of the 4 charges. Dr Ang is to be suspended for several months

• Dr Ang appeals to High Court

• High Court rules in Dr Ang’s favour and for the first time in the history of SMC, awards costs against SMC; i.e. SMC has to pay for Dr Ang’s legal costs

• SMC appeals against the High Court ruling

• High Court throws out the appeal on 5 March 2015

The Judgment issued by the Three Judges of the High Court is highly illuminating, but it’s 35 pages long of super-cerebral stuff. To save you the effort of reading through the entire document, this Hobbit has summarised the key comments and findings as listed below:

What The High Court Said

The attempt of SMC (i.e. the “respondent”) to say that the Courts do NOT have the power to award costs against SMC is wrong

“we (i.e. the judges) consider that the power to order costs is an important salutary power for courts and tribunals. The power should be exercised to incentivise appropriate conduct in litigation and, to that extent, to discourage behaviour that impedes the administration of justice. More importantly, it serves as a safeguard against unnecessary financial prejudice being inflicted on a party to the proceedings by the prosecution of unwarranted litigation. This is equally true in the context of disciplinary proceedings instituted pursuant to the MRA. Medical practitioners charged with misconduct already face the prospect of incurring substantial legal fees to defend themselves. If they are convicted, they may face an adverse costs order on the basis that the costs of having to bring such proceedings should be visited upon the practitioner in such circumstances. But there is no reason to assume that the respondent should enjoy absolute immunity from an adverse costs order”. (Para 27 of the Judgment)

This is especially so when the appeal was allowed without giving reasons.  I.e. the decision to grant the appeal was not transparent.

“No reasons were given by the Minister for acceding to the complainant’s appeal despite the conclusions of the Complaints Committee. It is not evident why or how the decision of the Complaints Committee was considered to be unsatisfactory. For the respondent to press for immunity from an adverse costs order in such circumstances seems to us to be indefensible.” (para. 29)

It is questionable if the appeal was even allowed on reasonable grounds

“the determination of the Complaints Committee may be very pertinent in deciding whether to order costs against the respondent. If the Complaints Committee had, as was the case here, dismissed the complaint, and the disciplinary proceedings were instituted pursuant to an unreasoned and unexplained order made by the Minister upon an appeal by the complainant, then the respondent will often be hard pressed to demonstrate a reasonable basis for instituting the proceedings despite the Complaints Committee’s findings”. (para. 56)

The SMC (i.e. the respondent) contributed to some of the errors committed by the Disciplinary Committee by…

“The failure of the respondent to sufficiently particularise the charges and to specify which type of professional misconduct…it was alleging undermined the ability of the Disciplinary Committee to properly evaluate the evidence and safely convict the appellant. Furthermore the Disciplinary Committee’s consideration of extraneous facts presumably arose from the submissions of the respondent as to those facts” (para. 62)

Strange Law

It is time to revisit the law. To put it simply, there are good laws and bad laws.  And then there are strange laws. Section 41  (Section 49 under the current version) of the MRA which allows for this appeal process to the Minister is an example of a strange piece of law. It was strangely conceived and drafted. Interestingly, this section was only put into the MRA very recently – in 2010.

Firstly, this process puts the Minister, a politician, in a very difficult, if not impossible position. Currently, if one disagrees with a Disciplinary Committee decision, one can appeal to the High Courts, where professional judges can examine the case with the help of expert witnesses. It is unclear how the Minister came to the conclusion that the appeal is allowed and a Disciplinary Committee should be formed to try this case. It is most unlikely that any Health Minister in his right mind will decide on his own what to do without consulting anyone. If so, who did he consult? What advice was he given? More importantly, who decided on who advises the Minister? Did the Minister just Google the names up? Or check the Yellow Pages? Or did he consult the ultimate professional advisor to the Government on public health and medical matters – the DMS? And if so, what did the then DMS advise?

The Act should be amended so that appeals go through an expert or technical panel and not to a politician. Indeed, this is exactly what the SMC Review Committee has recommended in 2013, that the appeals go to an independent Appeals Committee consisting of doctors and lawyers, rather than the Minister.

Secondly, the people who wanted this appeals process in 2010 probably don’t really trust the people who sit on the Complaints Committee to judge correctly. If not, why have this appeal process to the Minister? But these members of the Complaints Committee are as the High Court Judges have said, “highly qualified medical professionals”. (para. 28).

The current Appeals Process, when successful, is a fast-track route to the Disciplinary Committee stage. The Minister, or the Appeals Committee (If approved), should have the power to order a new and differently constituted Complaints Committee to re-examine the case instead of just going straight to the Disciplinary Committee stage. And because this “free” appeals process is a potential fast-track, many complainants and their lawyers will think it can used as a free or cheap shot to Round 2 (Disciplinary Committee). It undermines the hard work of the members who sit on the Complaints Committees.

Strange Strategy

It is one thing to argue that based on the circumstances of the case, costs should not be awarded against SMC. And it is an entirely different thing to argue that the Courts have no right to award costs against SMC. What was the SMC thinking? Or rather, what were their lawyers thinking? Such a strategy is at best breathtakingly audacious, at worst, explosively misplaced.

It is no wonder that the Judges devoted some one-third of the Judgment to defending the Courts’ inherent right to award costs. By the way, the word “salutary” implies wholesome; promoting or conducive to some beneficial purpose. I..e the judges are saying that the power to award costs is a wholesome power of the courts that contribute to a beneficial purpose or greater good. And SMC and their lawyers are claiming the Courts do not have any right to award costs against SMC. It is almost “legally embarrassing” all over again.

It is like you could have addressed a problem with a ray amputation (argue on the merits and local circumstances of the case) but instead chose to do an above knee amputation (i.e. argue the courts cannot award damages against SMC).

Humility, Sincerity and Transparency

It has come to this because for a period of time, from 2010 to 2014, no one really knew what happened behind the scenes in SMC in this ‘new’ Appeals Process (since 2010). It is not publicly known why an Appeal is allowed or on what grounds they are allowed. This veil of secrecy has to be lifted. It is against the defending doctor’s interests and now, it is clearly stated that it is against SMC”s interests as well that reasons are not given behind the successful appeal!

The hitherto and misplaced belief that SMC does not ever have to ever pay costs to the defendant has also been a subject of uncomfortable murmurings in many doctors’ tea rooms for a long time. Now the High Court Judgment indirectly acknowledges that this misplaced belief can lead to behavior that does not encourage “appropriate conduct in litigation” and potentially “impedes the administration of justice”.

It is not that these two discomfiting issues are unknown to the people in-charge previously. But such feedback had been brushed aside. Now they are laid bare in this Judgment for all to see.

The next thing is SMC’s lawyers. Clearly, some of them are not up to the mark. Their work had already been described to be “legally embarrassing” previously. Now this. How long must SMC continue to suffer this situation? No one even knows how much are being paid to these lawyers by SMC. They are not cheap, given by what was revealed in the Susan Lim case. Now this is worse, because the profession and the government have to foot not only their bill, but the other lawyer’s bills too (i.e. MPS’ lawyers).

After so many incidents in the last few years, confidence is not just shaken. It is down in the pits. It will take much effort and time to rebuild confidence. Having another Review Committee isn’t going to do much to rebuild or restore confidence. We also do not need another long clarification letter from the President of SMC like the ones dated 16 Dec 2014. So far, the long judgment from the High Court on 5 March 2015 clarifies a lot more than the long SMC letter. Make no mistake, when the SMC suffers on points of law repeatedly, the entire profession suffers; the patients suffer too. And the lawyers get paid (which is not a bad thing if the lawyers do a good job).

We need humility, sincerity and transparency. Only when you are humble can you be sincere. And only with sincerity can there be transparency. Hopefully, the new team in MOH and SMC can demonstrate them.

Interview with Candidate Jiro-Jiro

October 28, 2013 at 7:30pm

Tiffany Halifax-Cumberland (THC):

Hello, welcome to this installment of the interview series of the Syonan Medical Association Newsletter. I am Dr Tiffany Halifax-Cumberland or THC for short and I am the Editor of this august publication. This month, we are very honoured to be given the opportunity to interview Dr Jiro-Jiro, the candidate who has consistently polled the highest number of votes in the last few Conclave Elections.

Konnichi wa, Jiro-jiro-San. Once again, you have performed superbly in this latest Conclave Elections, polling some 38% of the votes cast, more than double the next highest candidate amid a tight field of 5 candidates, excluding your goodself. Congratulations.

Jiro-Jiro:

Thank you, Tiffany-san.

I must say with all modesty I am quite pleased and surprised at this result, considering I did not agree to run, hence I did not even sign the nomination form. And of course, there were no proposers or seconders. I must take this opportunity to thank the Conclave for offering Jiro-Jiro as an option, without which I would not be here.

THC:

If I may say, this is no flash in the pan. You have been outpolling other candidates for quite some time now. Can you tell us what is your secret to success at these elections?

Jiro-Jiro:

Well, the secret is that there is no secret. Take a low profile, don’t do stupid things like twerk in public or queue overnight for a donut and one should be fine. Let the Conclave do the rest.

THC (choking on his donut):

(Cough, cough) Let the Conclave do the rest? Can you elaborate?

Jiro-Jiro:

The Conclave’s record speaks for itself. I do not wish to elaborate, lest I give the wrong impression in any or several ways, or do not seem to be fair to any of the members of the Conclave. But it would be no exaggeration to say that the Conclave is the main factor behind my electoral successes.

Again, in all humility (stands up and takes a deep 90-degree bow), the large number of votes I have received would not have been possible if I had not received strong support from all sectors of the profession: private sector, public sector, specialists, GPs, local graduates, foreign graduates, RI Alumni, ACS Alumni, SCGS Alumni and the NTU-LKC Alumni-to be etc.

I wish to take this opportunity to thank especially the Chief Priest, the President of the Conclave, my parents, my wife as well as all the folks who are waiting for Bus Service 190, which must number in the millions.

THC:

Indeed, the widespread support is quite astonishing. What do you think a vote for you, Dr Jiro-Jiro represents? What were the doctors thinking of when they cast their votes for you?

Jiro-Jiro:

Their votes can represent many things. But I think the common thread is that the status quo is untenable. People do not want more of the same sh*t. People want more transparency on the disciplinary, appeals and administrative processes of the Conclave. People want accountability. This is especially important when the profession bear the cost of running the Conclave. I must say that I am very happy with the Conclave and have no doubt things are humming along under the great leadership of the Chief Priest and his buddies. But it is just that there are lots of fellows are out who want more transparency and accountability. What they want may be right but not possible.

THC:

(Trying to appear disapprovingly of Jiro-Jiro’s comments and failing miserably so) Are you saying the Chief Priest and his buddies are running the Conclave badly? Why, the Chief Priest has been there for eons and he has done an excellent job! He has said he has no part in the disciplinary process and has even set up a Reveal Committee to make sure things are right.

Jiro-Jiro:

And indeed he has. Well, it has been many moons since the Reveal Committee was set up and the Committee has revealed nothing as yet. And I speculate that when all is revealed by the Reveal Committee, it will be status quo. Life goes on, business as usual. (lips pursed, eyes narrow).

THC:

Going forward, how would you try to improve things within the Conclave? You do have a mandate, given the size of the support at the elections.

Jiro-Jiro:

That’s an interesting point. But one must know that a vote for Jiro-Jiro is a special vote. Because no matter how many votes I get, I will NOT sit in on the Conclave meetings or participate in any of the disciplinary proceedings. I think it is precisely of my non-participation that doctors have voted for me: I will never be part of the Conclave even if the Conclave allows me to exist. In a passive-aggressive way, a vote for Jiro-Jiro can be construed to be a vote for apathy, cynicism, and even hopelessness. Even though I must stress again, Jiro-Jiro thinks the Chief Priest and his buddies are doing a great job; its just that many folks do not agree with this view. (Eyes narrow further, chokes on his own saliva)

THC:

That’s a very strange picture you paint there, Dr Jiro-Jiro. Could there be other possibilities, for example – that people out there do not know the candidates that are running and hence cast a vote for you instead?

Jiro-Jiro:

That is a possibility, but a remote one. How big is the Syonan medical profession? Look at the candidates in the last few elections. There are quite a few good and well-known people out there. Surely at least 95% of the doctors will know at least one candidate in each election? One must have been living in a cave to not know any candidate in the last few elections. It’s like saying someone out there does not know any of the members of Big Bang, Super Korea or Girls Generation? Is that possible? Someone check this guy’s vital signs stat!

Another way to look at it is that people will vote when they know they can make a difference. But when they do not believe so, they vote for Jiro-Jiro, which is essentially a non-vote. But I once again say I am a great fan of the status quo (eyes stayed narrowed, breaks into a wide grin). But I cannot change or convince those that think otherwise.

THC:

What of the future?

Jiro-Jiro:

Well, at the rate things are going, I think more people will cast their votes for me. When the situation becomes embarrassing, they will kill off Jiro-Jiro.

THC:

(Looking slightly pale) Kill off Jiro-Jiro?!?! That is terrible! They can’t do that!

Jiro-Jiro:

They can do anything. Remember, we do not control the game and the rules. You know they can and will do anything. Look at how they claimed that everything was just fine when more than 98% of the people voted. Under the threat of a fine of suspension, of course almost everyone voted! Some people say that answer was an insult to their intelligence. But I say hold on. These are edgy times. People are very insecure. After Vettel wins the F1 four times, people now also want to change the rules, yes?

And so the truth is dangerous. And so is intelligence. Veritas mortis parit. That is why in these times, we must always profess our love and loyalty for the Conclave and the Chief Priest and his buddies.

THC:

(looking paler by the minute). Indeed. Hinc lucem et pocula sacra.

Thank you for your time, Jiro-Jiro-san. I wish you well and many years of election success ahead.

Jiro-Jiro:

Thank you, Tiffany-san. Donuts are bad for your health. Shitsurei Shimashita.

(Dedicated to my dear friend Dr Tiffany Halifax-Cumberland, interviewer extraordinaire)

THE CYNIC’S SINGAPORE PHYSICIAN’S PLEDGE

June 21, 2012 at 11:55am

What we swore by publicly once when we first started out –

 

SMC Physician’s Pledge

 

I solemnly pledge to:

dedicate my life to the service of humanity; give due respect and gratitude to my teachers;

 practise my profession with conscience and dignity;

 make the health of my patient my first consideration;  

respect the secrets which are confided in me;  

uphold the honour and noble traditions of the medical profession;  

respect my colleagues as my professional brothers and sisters;

 not allow the considerations of race, religion, nationality or social standing to intervene between my duty and my patient;  

maintain due respect for human life;  

use my medical knowledge in accordance with the laws of humanity;  

comply with the provisions of the Ethical Code; and constantly strive to add to my knowledge and skill.

 I make these promises solemnly, freely and upon my honour

 

 

What I remind myself everyday :-

 

THE CYNIC SINGAPORE PHYSICIAN’S PLEDGE

 

I solemnly pledge to:

dedicate my life to the service of  the clinic rent/loan;

 give due respect and gratitude to my teachers (who did not cover for me and left me out to hang high and dry when I accidentally screwed up);  

practise my profession with what’s left of my conscience and dignity ;  

make the defensive medicine consent-taking of my patient my first consideration;  

respect the secrets which are confided in me which are NOT on the EMRX;  

beware of the  pernicious and internecine traditions of the medical profession

 such as  back-stabbing colleagues  who are professional rivals;

 not allow the considerations of race, religion, nationality or social standing to intervene between my duty and my non-managed care patient only;  

maintain due respect for  lawyers and lawyers’ fees;  

use my medical knowledge in accordance with the  unfathomably wise judgments of SMC;

comply with the provisions of the Ethical Code (out of fear rather than reason);

and constantly strive to add to my knowledge and skill (while sleeping at lunchtime CME talks).  

I make these promises solemnly, unfreely and upon my  defunct copy of the Guideline of Fees

Dragon Flatus

February 24, 2012 at 12:28pm

The Year of the Dragon is off to a very blazing start in terms of juicy news and scandals. For once, Singapore may be outdoing our neighbours to the north on this front. Of course, local healthcare cannot be seen to be left out on the cold either. We have our fair share of dragon flatus, some of harmlessly odorous, while others are plain noxious.

 

Let’s start with the harmlessly odorous – the case of the new Parkway hospital located at Novena, just a few metres away from the Ministry of Home Affairs (which some wise guy has quipped should be renamed simply as Ministry of Affairs) headquarters. Controversy has erupted with it being renamed as Mount Elizabeth Hospital@Novena. Some doctors in the Mount Elizabeth@Mount Elizabeth are unhappy with this and are even considering taking legal action. This Hobbit thinks this is unnecessary. In fact given the exodus of specialists from the public sector (which the Lianhe Zaobao in a recent report has wisely attributed to the residency programme, among other things) as well as this naming precedent set, we can have a slew of new names for existing private hospitals: TTSH GS@Mount Elizabeth, KKH@Thomson, SGH Colorectal@Adam et Paragon etc. The possibilities are endless. We can even have a facility called Nobody@Residency in time to come.

 

More on the residency. It has come to light that some poor ASTs (Advanced Specialty Trainees aka Registrars aka Always Screwed Trainees) and BSTs (Basic Specialty Trainees aka Basically Screwed Trainees) are now forced to pay for and take Residency-related exams. The reason is that by making them pay, they will try their level best to pass the exams. Also, there is claim that they need to take these American exams because the UK exams have changed so much they are no longer good. This logic is astounding. It’s like making a GCE “A” Level student pay for IB exams so that they have a vested interest in passing the IB Exams. Or getting motorists to pay ERP charges even when they have chosen a route from Point A to Point B that hasn’t got any ERP gantries. Or charging hotel guests for room service they didn’t order so that they will order room service anyway. I believe if this was the commercial world where common sense and the law applied, it’s illegal. You cannot charge a person for a good or service he doesn’t need or want. And the geniuses who came up with this really believe that the UK exams aren’t good enough, that’s just too bad. You don’t change things mid-stream and make people pay for it. It’s not the money, it’s the principle. Can you imagine Ministry of Education telling students and parents “Hey, we let you enroll in the GCE system but now it’s not good enough. So now, you have to pay for the IB exams so that you will try to pass it and at the same time, you still have to pass the A levels?” If you messed up by offering a system that is now not good enough, that’s your business. Don’t mess with people in mid-stream. And people only pay for and take exams out of their pockets because they are relevant. Making them pay for the exams matters little to outcome if the exams are irrelevant. In any case, these BSTs and ASTs are already given a raw deal – they have to train junior residents and have heavier workloads to cover up for the residency system. Please don’t make it any worse

 

More disturbing is actually how much hands-on will these residents get. My old Professor of Surgery (arguably the most respected clinical teacher for Surgery in the last 30 years) said quietly to me that he was deeply troubled. He said residents only got to perform simple operations like hemorrhiodectomy as a Year 3 resident and they become qualified specialist surgeons after Year 4 residency! This professor is of the age that he probably won’t ever be operated on by a product of the residency programme. But there is no escape for the rest of us. I think chaps who are promoting the residency programme as a wonderful thing should stand up and be counted and state that they will only be operated on by surgeons who are trained in the residency system. Put your liver/gall bladder/stomach/colon/rectum where your mouth is. That’s intellectual honesty. In case you are wondering, this Hobbit has nothing against residents- these are poor chaps stuck in a situation that offers no way out besides quitting. They are stuck as victims of a cruel monopoly introduced by people with motives best known to themselves.

 

As you are well aware, the SMC has given us a nice New Year present by announcing on 4 Jan 2012 it is raising our annual subscription fees from $300 to $400, because it has been under-recovering and operating at deficit. These are seemingly standard and plausible reasons. For one thing, although SMC is run on our subscriptions, the accounts have never been shown in the SMC Annual Report. There is almost complete opaqueness in terms of SMC’s financial situation to the countless and nameless doctors working on the ground and paying subscriptions to keep SMC afloat.

 

There are two main functions of the SMC – maintaining a registry of doctors (including CME records) and the costs of running investigations and disciplinary actions against allegedly errant doctors.

 

We shall start with the first – maintaining a registry. Anyone who has run something similar to a registry or an association or a club will tell you that it’s all about scale. Except for initial processing costs, unit costs drop dramatically when the size of the membership increases rapidly. And considering that the number of doctors registered in SMC has increased dramatically in the last 6 years, one wonders how come costs have actually gone up for each member. In Dec 2005, when fees were last raised, there were 6748 doctors on full or conditional registrations. Be end of 2010, this number has increased to about 8600, an increase 27%, according the relevant SMC Annual Reports. By now the figure should be about 30%. That’s a lot of doctors in 6 years and a lot of fees paid. Maybe the SMC should why briefly explain why the principle of economy of scale doesn’t apply to the SMC registry.

 

The next big SMC function is that of investigations and disciplinary actions. We don’t have access to SMC records in this area but this Hobbit will hazard a guess that the biggest “customer” of SMC is actually MOH – in other words, MOH is the biggest referral source of cases to SMC. Some of these cases are obviously necessary and the doctor gets disciplined. But one must wonder – how many of these cases could have been unnecessary, in which the doctor is found not guilty? While SMC funds should be used to fund to process complaints from individuals, one must ask should these funds be used to fund complaints from MOH, especially when MOH is so well-funded? Shouldn’t MOH share the costs of such cases, especially for the ones when doctors are not found guilty?

 

Lastly, we really have to look at SMC operating costs. Especially at manpower, which probably forms the largest chunk of costs. One example will illuminate this concern.

 

There are now two executive secretaries in SMC- (link: http://www.sgdi.gov.sg/; accessed on 24 Feb 2012). Executive Secretaries are very senior doctors and they do not come cheap. Let us look at Section 10 of the MRA – “The Medical Council may appoint an executive secretary and such other employees on such terms and conditions as the Medical Council may determine”. That means Section 10 of the MRA states there is only ONE executive secretary at any one time, together with an indeterminate number of other staff. Let’s leave it to Attorney General’s Chambers to advise on the legality of this arrangement of having two executive secretaries since we doctors know nuts about such legal stuff and also the AG Chambers is the government’s legal advisors, but surely this duplication of posts and manpower must lead to increase in costs? Why have two when the law provides for one? No doubt the bureaucrats in MOH will advise the politicians to amend the MRA on this aspect and it will probably be done, but the point is, who is really looking at costs?

 

In case you are wondering if “a” or “an” can mean more than one – Let’s look at the law again – the Medical Registration Act (MRA) that provides for the existence of SMC. Section 18 (1) and (2) of the Act states that “For the purposes of this Act, there shall be a Registrar of the Medical Council. The Director of Medical Services shall be the Registrar of the Medical Council”

 

That means there is ONE DMS and ONE Registrar at any one time and they are one and the same person. Of course, there can be an Acting DMS or Registrar when the DMS is on leave etc. But at any one time, there is only one person holding (and presumably paid for) the two jobs on a long-term basis. In this case, it’s our very esteemed and well-loved Prof K Satku. No one has any problems here with this arrangement or assumes there can be more than one Registrar or one DMS, this Hobbit included. So how can it be that there are two executive secretaries? By the way, if you do go to the online government directory (as given above), in addition to 2 executive secretaries, there are about 36 other staff that of executive level and higher, including one legal counsel. That’s some serious manpower there.

 

This is enough flatus already for 400 bucks. It’s getting kind of hard to breathe in our little shire hut. Gotta go out and get some fresh air. Bye for now.