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


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

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.


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.


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?


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?


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.


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?


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.


(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.


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).


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.


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)


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?


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.


What of the future?


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.


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


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.


(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.


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

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


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 :-




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

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:; 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.

Flaccid Truths to Keep Your Practice Going – The logical and inevitable demise of trust

July 3, 2011

A patient came to see me recently with a painful ingrown toenail. I see ingrown toenails quite frequently in my practice and have become quite adept at removing them. It’s the nature of my Middle-earth practice – Orcs and Ogres have poor nail hygiene and Elves with their long and thin toes are quite prone to them too.


For patient confidentiality purposes, let’s call my elvish patient Johnny. Johnny is a sprightly 340 year old wood elf. He had seen me for the past 20 years or so for various mild ailments. Otherwise, he was fit as a fiddle. Today, he stepped into my consultation room with an expression that was somewhere in between a frown and a wince. You could always tell he was in pain when the tips of his pointed ears turned red.


He showed me his ingrown toe nail. There was some paronychia around the nail with a small collection of pus and it was obvious it had to be excised. I would usually perform a digital block with lignocaine injections at the base of the toe with the help of a rubber band acting as a tourniquet. The whole procedure usually takes about 5 to 10 minutes.


But today was going to different. I started out enumerating the various benefits of the procedure is and the consequences of not going through the procedure. This of course included the piercing pain Johnny was experiencing round the clock as well as the possibility of getting chronic osteomyelitis from letting the infected ingrown toenail persist.. Frankly, from the look on poor Johnny’s face, I didn’t think Johnny needed any convincing.


Next I told him the risks of the procedure and that of the LA as well. Of course, the risks included cardiac arrhythmias and sudden cardiac death from the lignocaine injection as well as me possibly leaving behind tiny bits of my scalpel blade behind in his flesh for the next 400 years (elves can easily live that long and scalpel blade construction is not what it was with these blasted new foreign talent dwarves we are getting nowadays). Even though the chances were remote of these occurring (at least one reported case of retained scalpel bits) , but because of the severity of these possible risks, I thought I should tell him. I also told him about the other usual stuff like chance of recurrence, ugly nails, keloids, infection, fever, pain, allergies to dressings etc.


I also diligently jotted down all these benefits, risks and complications on his card. I then went on to the alternatives. I told him that he could also do nothing. I can refer him to another doctor or to the nearest A&E in Middle-earth. And since his ingrown toenail was not quite life-threatening at this juncture, I told him he could go home to think about it a day or two before deciding on whether he wanted to go through with the excision of toenail or not.


Johnny was flabbergasted and exasperated. The elves are never good with hiding such feelings. He uttered impatiently (trying as much to contain his frustration and anger as much as his otherwise congenial Elvish nature would allow him) “What’s wrong with you today, Doc? Just go through with the procedure and get the blasted ingrown toenail out. It hurts like hell!”


I then asked him with all the equanimity of Sir William Osler to acknowledge on his patient card with his signature that he agrees to the excision and he fully comprehends the risks, benefits, complications and alternatives which had been listed on his patient card to evince his comprehension.


He signs the card quickly. The process had taken 25 minutes. I then took another 10 minutes for the excision (including applying dressing).


He came back the next day for dressing. I could tell he was rather unsettled by something and I asked him, ”Is something wrong?”


“About yesterday. Why did you have to go through with the litany of risks and complications before the procedure, some of which were utterly remote and unnecessarily troubling? For goodness sakes’, it’s just a blasted ingrown toenail. I’m 340 years old and I have seen more than my fair share of ingrown toenails in elves”. He looked completely nonplussed.


“It’s what my medical council demands of me nowadays so that you can be considered to have given informed consent, if not I may run the risk of being found to be guilty of professional misconduct”


He winced a little as I removed the old dressing.


“Does it hurt?”


“Not as much as your bloody longwinded and scary consent-taking process yesterday”. He took a look at what he signed the day before and muttered “bloody stupid and ridiculous”.


I smiled and replied “I have no choice”.


“Of course you do, Doc. I trust you. I have been seeing you for 20 years!”


“It’s not so simple”. I applied the new dressing, gave him a pat and saw him off


It’s really not so simple. A good practice requires a good doctor-patient relationship. We always say it’s important that our patients trust us. But that’s only half the story. It is equally important that doctors trust their patients. But with recent events in middle-earth, I could not afford to. I still want to trust my patients, but my entire practice, my livelihood, and my family’s livelihood depends on me staying professionally alive. And hence I can no longer afford to trust my patients. All it takes is one of them to turn around and say “I did not give informed consent even though I have signed that I did” and I am dead.


Some folks say consent-taking is not a form but a process. That’s true. But consent is also documentation. And it’s pretty obvious some wise guys have decided for all of us that a patient’s signature and a form is no longer enough.


Some folks also say that specific circumstances lead to specific decisions and conclusions peculiar to those circumstances, so the principle of precedence may not hold here. Unfortunately, that is at best an opinion unless it is tested and tried again in the courts and seriously, I wouldn’t want to be that guy to put this to the test.


It’s not just that patients and doctors need to trust one another, but colleagues as well. How can there be trust if I cannot even depend on a relatively senior trainee and colleague to diagnose an acute abdomen? My colleagues in the hospitals now tell me they trust no one now anymore and the workload and decision-making keeps escalating upwards to the senior staff. Private practice seems the only plausible escape.


By all means, promote transparency and accountability. But we all also know that once trust is lost, it is extremely hard to get back. The fact remains that for trust to happen, the system and regulatory authorities must do what it can to foster this trust and not undermine it. The clear and present threat of professional misconduct is enough to radically change how doctors trust patients and colleagues. Call it kiasu-ism, prudent risk management, whatever.


As far as my medical practice goes, I can no longer afford to trust. It’s logical and inevitable, brought on by external events beyond my control.


For the record, my usual charges in the past for excision of ingrown toenail is about 80 to 100 bucks. I charged Johnny 140. That’s for the 25 minutes I needed to get “informed” consent, which I could have spent otherwise seeing another patient. Thanks to some doctors making decisions and setting standards for the whole  profession, Johnny had to pay another 40 bucks which I derived no satisfaction from making. Like most doctors, I have to make rent and pay salaries and there’s only so many hours in a day. So much for healthcare cost-containment and improving productivity.


It’s really not so simple, Johnny.