21 Jun 2011
By: MELISSA PANG
MEDICAL practitioners here want watchdog Singapore Medical Council (SMC) to clarify three areas – including what patients need to know to give informed consent and what doctors can reasonably charge – in the new SMC Ethical Code and Ethical Guidelines.
The other issue concerns the role of specialists and doctors-in-training in team-based management of patients.
The Singapore Medical Association (SMA), which represents 5,300 medical practitioners, wrote to the SMC to seek clarification on these issues in April.
The SMC, conducting its first review of the ethics guidelines in 10 years, had already received suggestions from the SMA in October last year.
In the latest letter, SMA president Chong Yeh Woei noted two recent cases.
Dr Eu Kong Weng, former head of colorectal surgery at Singapore General Hospital, was the first doctor here to be suspended for failing to obtain informed consent from a patient.
His appeal against a three-month suspension was dismissed by a three-judge court.
Dr Eric Gan Keng Seng, a general surgeon, was found guilty of mismanaging the post-operative treatment of a patient. His case reached the Court of Appeal, but his six-month suspension was upheld.
Dr Chong said a number of SMA members have “expressed concerns about the consequences and precedents these two judgments may have set for the profession and the practice of medicine” and are seeking clarification.
The letter asked for the new SMC ethical code to define the level of information a patient would need to be given to constitute informed consent. “For example, would it suffice to note in writing... that the ‘patient has been informed of the benefits, risks, and complications as well as alternatives of a total knee reconstruction’ or must the documentation contain a full list of the actual complications, risks, alternatives and benefits of the said operation?” Dr Chong wrote.
Responding to queries from The Straits Times, an SMA spokesman said yesterday that concerns in Dr Eu’s case had arisen because an informed consent form was signed by the patient, a point which was not disputed.
Yet SMC’s disciplinary committee subsequently stated it believed the testimony of the patient that an informed consent was not obtained, as the case notes did not record any discussion of treatment options, she said.
The spokesman added: “As far as we are aware, it is not the practice of many doctors and hospitals to list out the alternatives and their possible complications in writing when consent is obtained.”
Therefore, the SMA wishes to seek clarity from the SMC on “what level of written documentation is required for a signed informed consent to be deemed effectively informed”.
SMA’s letter also asked for clarity on the matter of team-based management of patients, a common practice in public hospitals. It involves specialists and doctors-in-training working together to treat a patient.
In Dr Gan’s case, the court judgment stated that SMC’s disciplinary committee did not think it was an appropriate case for him to arrive at a clinical assessment based merely on the input of the on-call registrar.
The SMA spokesman said it should be noted that a registrar is a doctor “who is a relatively senior ‘trainee specialist’ (to borrow the court’s term) with several years of working experience”.
She added that the case has opened up questions of what exactly a trainee doctor can be relied upon to make clinical decisions, or “must each and every clinical decision be arrived at after the personal attention and physical attendance of the consultant in charge”.
Such an expectation would be a concern given the large number of patients in the public sector, she said.
In the letter, the SMA also raised the issue of appropriate charging by doctors.
Last August, the Competition Commission of Singapore ruled against having medical-fee guidelines for doctors as they were deemed anti-competitive.
The ruling has left a gap that needs to be addressed, said the SMA spokesman, stressing that it was not in response to Dr Susan Lim’s court case. The prominent surgeon is accused of abusing the trust of her long-term patient from Brunei by overcharging her. The bill for 2007 came to $12 million.
An SMC spokesman said the SMA’s latest letter has been forwarded to the committee for the review of the ethics guidelines. “The working committee will consider all views and recommendations. The review will be thorough and therefore take some time,” she said, noting that the new guidelines are expected to be ready by the first quarter of next year.
Email: melpang@sph.com.sg
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