Singapore Medical Council (SMC)’s recent decision to fine orthopaedic surgeon Lim Lian Arn S$100,000 for failing to obtain consent from a patient before administering an injection into her left wrist has caused much distress in the medical community.
SMC had found Dr Lim guilty of not advising the patient the risks and possible complications that could arise from the H&L (steroid) injection. The patient later experienced swelling and pain at the injected area, a known complication called “post-injection flare” with an incidence rate of about 5 per cent.
She also developed “paper-thin skin with discoloration, (and) loss of fat and muscle” on her wrist, which is an even rarer complication from such an injection.
Pertinently, while both complications cause some pain that can last up to two days, they do not pose any serious danger to a patient.
The SMC ruling has raised many questions which have serious implications for the medical profession and Singapore’s healthcare system.
First, are doctors expected to explain every single possible complication to patients, even if it may be minor or extremely unlikely?
Traditionally, doctors inform patients of common or serious side effects of a procedure.
For steroid injection into joints, these would include infection, damage to nearby nerve or blood vessels, or tendon rupture if repeated injections are given to the same spot.
When I do a colonoscopy, I tell my patients that possible complications are perforation, bleeding, or sedation-related problems. I also tell them they may feel bloated or get a sore throat but both are minor and will disappear within one or two days.
But many other potential complications can occur after a colonoscopy, including piles, spleen laceration, abnormal heart rate, a heart attack and an allergic reaction to the sedation drugs.
The consent process will take a very long time if I have to explain every single possible complication for colonoscopy.
Now, put yourself in the shoe of a doctor who intends to prescribe proton pump inhibitors, a type of drugs that suppresses gastric acid production.
It is generally safe but it can be associated with more than 40 side effects, including dizziness and alopecia (hair loss). Does a patient really need to know all these possible but uncommon side effects?
Confronted with such details, patients may develop information overload, and may tell the doctor not to go ahead with the prescription or procedure. Is that in the patient’s best interests?
It is a standard practice that doctors must warn patients of serious or complications of a procedure or medication, but it is odd if doctors have to warn patients of all possible complications.
Second, is a formal written consent now required for all small procedures at a clinic?
Dr Lim was faulted for not having a formal written consent from his patient for the injection, even though it is not a routine practice.
Are doctors now supposed to do the same for procedures such as vaccination, blood taking, intravenous plug setting, ear syringing, suturing of wounds etc?
If so, wouldn’t this again increase the documentation and time needed for each consultation?
Doctors who used to see four patients an hour may only be able to see two in an hour. Waiting time will be longer and doctors would charge more for the extended consultation.
Is this what we want to see in our healthcare sector?
Lastly, SMC’s asking of a five-month suspension for Dr Lim’s offence has raised eyebrows among doctors, many of whom wonder how it was derived.
Most doctors I spoke with feel that this is rather harsh, given that the patient’s complications were not common nor medically dangerous. What if Dr Lim had caused real harm like nerve damage or infected joints? How long will the proposed suspension then be?
Dr Lim is a senior doctor with an unblemished record of 29 years, and has showed remorse by apologising to the patient and changing his way of records taking.
In addition, Dr Lim has testimonials and character references from independent parties. But the SMC lawyer urged the Disciplinary Tribunal not to give any weight to these mitigating factors in sentencing him.
We then wonder what kind of mitigating factors SMC is looking for when suggesting sentences for errant doctors. We assume if we have been good doctors, that would count as a mitigating factor when we make mistakes.
Since the SMC ruling, an online petition asking the Ministry of Health to clarify its stand on the need for doctors to get “informed consent” from patients for minor procedures such as routine injections has garnered over 6,000 signatures, many from doctors.
MOH and SMC have not publicly responded to the petition or to the questions raised by doctors. The uncertainty is paralysing for doctors.
Informed consent is in itself a useful concept.
But the legal standard the SMC ruling sets — consent for minor procedures and counselling on minor side effects — could drive doctors to practise defensive medicine.
This means over investigation, over treatment or even avoiding administering treatment if possible — something the government had previously cautioned doctors not to do.
Yet, after Dr Lim’s fine made the news, many family physicians who are trained and experienced in doing joint injections have decided not to do any more such procedures and to simply refer patients to specialists.
The fear is not just limited to joint injections, but also in other simple procedures like ear syringing, small lump removal, and suturing of wounds.
The SMC ruling has made many doctors worried, and a common feeling is that “it could have been me instead of Dr Lim”.
Most of us still carry the hope that if we treat our patients reasonably, we will be treated fairly and reasonably by our patients, SMC, and MOH.
And if we make a mistake, we should be dealt with appropriately, according to how serious the mistake is.
SMC and MOH should address the concerns raised by doctors squarely so that there is clarity for all so that Singapore’s healthcare system remains affordable and accessible to Singaporeans.