SINGAPORE – Parliament passed a law on Tuesday (Oct 6) giving doctors a clearer idea of what they need to tell patients, so that they need not fear litigation or resort to defensive medicine by overloading patients with information or exposing them to more tests than they need.
The move would help prevent poorer care and hold down healthcare costs.
Essentially, the change says doctors need to tell patients only what they “would reasonably require to make an informed decision”, said Second Minister for Law Edwin Tong when he earlier presented the Civil Law (Amendment) Bill for debate in the House.
On top of that, doctors have to answer questions patients ask, even if they think it is minor, as what is important to different patients vary.
Noting that the relationship between patient and doctor is one based on trust, Mr Tong said that in recent years, it has been “called into question following several well-publicised medico-legal cases from the Singapore Medical Council (SMC) disciplinary tribunals”.
These include the case of Dr Lim Lian Arn, who was found guilty and fined for failing to obtain informed consent from his patient.
A SMC disciplinary tribunal said he had failed to advise a patient on the risks and possible complications of a steroid injection and some of the side effects subsequently manifested in the patient.
His conviction was later overturned on appeal to the Court of Three Judges, but the case led to many doctors becoming uncertain as to what might be required of them in advising their patients, and saying they would practise defensive medicine to protect themselves.
Questions also arose on whether the case should have gone to the tribunal in the first place, and the court labelled the conviction a “miscarriage of justice”.
“Whenever disciplinary outcomes diverge from well-established practices by doctors on patient care within the medical community, uncertainty follows.
“Doctors start to question their own judgment as to how much information is going to be enough to care for their patients, and there is the constant worry of whether these patients will make a complaint and what will happen to the adjudication of the complaint,” said Mr Tong.
To restore the trust between doctor and patient and the trust of doctors in the medical disciplinary system, another law was amended too – the Medical Registration Act.
This was done through the Medical Registration (Amendment) Bill, which aims to strengthen the medical disciplinary process. Like the Civil Law (Amendment) Bill, it was passed on Tuesday.
A NEW TEST
The Civil Law (Amendment) Bill sets out a new statutory test of a healthcare professional’s duty in giving medical advice to a patient.
The test requires doctors to fulfil two criteria.
One, they must act in a logical manner that is accepted by a body of their peers. This is to assure them that their conduct will be assessed by fellow doctors.
Two, they must provide information that a patient would reasonably require, or that is material to a patient for the purpose of making an informed decision.
This means any question the patient asks must be addressed.
“The patient can be assured that when he walks into a clinic and sees a doctor, there really are no stupid questions. Every question that this patient raises with this doctor, is a valid, relevant question that has to be addressed,” said Mr Tong.
Even when the patient does not raise a concern, if the doctor has access to medical records that show such a concern should have been raised, he must address it.
“This is not intended to impose an obligation on healthcare professionals to review substantial volumes of medical records of the patient, or voluminous medical history in the National Electronic Health Record… The litmus test is that of reasonableness – both in terms of what the healthcare professional has reasonable access to, and also whether the circumstances of the case, the discussion with the patient… creates a scenario where the doctor ought to reasonably review these past records,” he said.
What is reasonable must be assessed in the context of each case, Mr Tong added.
STRENGTHENING THE DISCIPLINARY PROCESS
The Medical Registration (Amendment) Bill aims to strengthen the disciplinary process in four areas.
One, to improve the quality and consistency of processes and outcomes in the disciplinary system.
The Bill provides for the appointment of a disciplinary commission that is independent and separate from the SMC and headed by a senior doctor.
This proposed commission will take over the role of setting up the disciplinary tribunal from the SMC.
This change should address concerns about tribunals not being independent from the SMC, said Mr Tong.
The tribunal must also have a legal professional sitting on it and the SMC is to set up a Legal Advisory and Prosecution Unit.
A new, clear standard on when a case should be referred to the tribunal will also be set out.
Two, the Bill aims to reduce delays and help resolve complaints quicker.
Noting the constant feedback of unreasonable delay in the disciplinary process, Mr Tong said the Bill will have several measures to address the issue.
These include notifying the doctor early when a complaint has been made against him, and requiring relevant documents and evidence to be submitted in a timely manner.
Three, the Bill will protect patients more effectively.
Among other improved processes, investigators will be required to make a report to the SMC if they discover wrongdoing not related to the initial complaint.
This streamlines the current process, which involves a Complaints Committee and is unwieldy and can lead to significant delays, said Mr Tong.
Four, the Bill is targeted at encouraging the amicable resolution of complaints and facilitate a less adversarial disciplinary process.
The Medical Registration (Amendment) Bill will allow an inquiry committee to refer complaints, which are not serious professional misconduct requiring disciplinary action, to mediation.