A recent headline put this topic in the spotlight again.
And a Google search served up this article from a 1992 issue of the SMJ.
Despite being published almost 20 years ago, the basic principles have not changed.
However, when you consider the amount of information involved, and the need to factor in Q&A if the patient has queries, one wonders how adequate this process is, especially in a public hospital setting where consultation times rarely exceed 5-10 minutes.
A detailed explanation alone, even for simple procedures, may take up to 15 minutes if the patient isn't highly educated, if there's a significant language barrier, or if the patient / spouse / relative has additional questions.
And I take serious issue with Prof. Eu's patient's lawyer saying that "the patient is not obliged to seek out further information on the risks, benefits and possible complications of the procedure on his own".
So, in typical Singaporean form, the doctor is expected to shoulder all the blame, even though the patient, Mr. Ang, is a businessman whom I assume is (1) not illiterate, (2) Internet-savvy, and (3) not mute or terrified of Prof. Eu to the extent that he is unable to verbalize his concerns about surgery.
I've always groused about Singaporeans' lack of interest in their own medical care. They seem to expect others to take charge of their health, then get upset when something goes wrong or they're slapped with a hefty bill.
While not all the facts of this particular case are available to the public - and who knows whether the press has presented a truly unbiased view - it looks like Prof. Eu may have gotten the short end of the stick here.
So the next time you're kept waiting 4 hours at a public hospital's specialist clinic, it's probably because the doctors are furiously documenting every consultation.
Thank you, Mr. Ang.
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20 comments:
Well said. I concur on the limitations in public healthcare that precludes the practice of informed consent on its entirety, and further, that Prof Eu (an excellent surgeon and mentor) is hardly at blame here.
Howevever I have to agree with the underlying notion of the verdict that informed consent is important for many reasons and cannot be sacrificed for any reason. Having said that, the physical limitations are there and I'm not saying that doctors should go out of their way to obtain informed consent, but rather that the system should change.
While I agree that informed consent requires different amounts of work when it comes with different patients (factors cited by you are literacy, internet-literacy, ability to talk and intepidity), it is hard to assume.
An article here shows that patients (in an angmoh population by the way, what more s'poreans) don't ask questions. The atmosphere is not conducive, ironically.
so it's a case of the food chain benefitting from the "un-informed" enhanced KPI's until unfortunate doc meets wrong patient at the wrong time, and it's suddenly HIS fault??!
Surgeons should now start having informed consent forms which document the risks & complications of each type of surgery and have the patient sign it. It's better to cover yourself than expose ourselves to patients like Mr Ang. It is small wonder that the patient-doctor relationship is deteriorating when patients are so quick to sue when they get upset.
As for waiting time at public hospitals, let the patients wait more, have new appointments pushed back so that explanation and documentation can be done properly. After all, patients shouldn't mind longer waiting times if they can get "better service" right?
While I sympathise with Prof Eu, Mr Ang should have the worst case scenario explained to him. Like how while taking a consent for colonoscopy, the clinician must always highlight the possibility of perforation requiring laparotomy and stoma. And in this, retroperitoneal sepsis.
Perhaps for routine procedures, a consent form with all the possible complications pre-printed should be available.
Practising extremely defensive medicine is tragic, and should Singapore ever end up like some of the western countries ( videotaping consent taking etc), I cannot imagine the administrative hassle and time wasted. Then perhaps MOHH will need to hire more NTS MOs and this invariably with increase healthcare costs.
Exactly what is informed consent? From the Singapore Law Watch report, 3 risks of the procedure were mentioned - pain, bleeding and infection. I would have thought these are commonly known risks involved in surgical procedures, regardless of whether the surgeon mentions them or not, and considering that the patient is not illerate from the fact that he did check up on the surgeon's reputation before consenting to the procedure. I'm indeed quite puzzled that the surgeon could be guilty of carrying out the procedure without informed consent in this particular case and especially be slapped with a heavy 3-month suspension!
Either you get charged for "failure to take informed consent", or for "over-investigating, wasting resources and practising defensive medicine".... why even bother?
Well, it is SGH's practice to have such forms signed. There are consent forms listing the complications and risk of each procedure being done (individualized for procedure) and in all likelihood, Mr Ang signed one of those.
The problem is now that Prof explained to the patient, patient agreed then after that say he didn't understand what the complications were (can like that reverse after signing play roti-prata one leh!) and that prof was "dismissive".
I have discovered a revolutionary way to download information into people's minds.
What doctors can do is to download the informed consent information to the patient's mind and then get them to take a test to confirm understanding (while the doctor sees the next patient/s).
When they have passed the test, they sign the form and we can proceed with the procedure.
Brilliant eh?
You can order the product at the link below
www.screwyourpatientsmind.com
Hopefully more will be revealed in due course on http://www.singaporelawwatch.sg/legal/ln2/rss/judgment/index.rss.
Perhaps we should defer our private views (expect many, and strong ones too) and public comments till then.
It is MOE fault for not teaching what is pain, bleeding and infection.
When MOE stop teachers from caning students, the students stopped feeling pain and understanding what pain is.
With better design, there are less falls so fewer people bleed since they dont fall so often.
Lastly hygiene has improved such that infection only occurs occasionally.
That is why Mr Ang does not know what pain is, what bleeding is and what infection is.
Blame the system and not the surgeon :(
The morals of this story are:
1) No doctor, no matter how senior or skilled or highly regarded, is safe.
2) Documentation, no matter how time-consuming or tedious, is vital.
3) Always ensure the patient is made aware of the worst-case scenario, and that there is irrefutable proof of this, i.e. witnesses, audio / video recordings.
4) Apparently, even a signed consent form ( including one that lists the common / important complications to expect ) is no longer considered adequate.
5) Go private, where you can spend up to an hour with each patient and live comfortably doing only minor procedures ( e.g. colonoscopy ).
You forgot option 6)
6) Quit medicine
I am not a medical professional. But basic logic tells me that NO 2 humans are identical in the way each would react to medication and/or surgery. No doctor in the whole world can predict that definitively. Only God can.
Add this to any other possible unknown and/or unrevealed underlying medical condition that a patient may have, and it is certain that sometimes, the patient may not get the desired post medication and/or surgery results without complications.
In Prof Eu's case, even the 3 distinguished learned Appeals Judges I am sure realised this and hence said that, if they had their discretion, they would have imposed a shorter suspension. I don't think it takes a rocket scientist to figure out what that points to.
It was all along, Mr. Ang's word against Prof Eu's and, it is most unfortunate that there was a failure to see that it was the system that is flawed and not Prof. Eu's incompetence.
If Singapore is to strive and be a medical hub for Asia, this case is only going to be detrimental in achieving that goal because, instead of admitting the flaw in the system, and correcting it, we have chosen the easy way out of simply finding a 'scapegoat' and running away from the hard truths.
Practising medicine is like having a loaded gun pointed to your head. You do good ok. Something goes wrong. BANG! It is imperative you cover your own backside and take care of yourself to the max BEFORE you take care of others. I know it goes against the out dated hippocratic oath. Anyone who talks about that oath should be asked what the legal system was like in Hippocrates' time. Times have changed. Get real. Unless you like being shot in the head several times.
Obviously, there seems to be a fine line here that unfortunately gave the benefit of the doubt to the patient, even though the doctor did in fact fulfill his rightful obligation. As a result, we saw, and will probably see again, good and brilliant doctors like Prof Eu, being unjustly penalised.
Therefore, the way forward is for ALL practicing doctors, public and private, to unselfishly come together (for their love of and dedication to the profession), and highlight their concerns to the relevant bodies, with regards to the current system on this issue of patient's consent, which is no doubt flawed. You need a united front to convince the relevant bodies that this is a genuine concern.
Hopefully, this will result in a better format that ultimately protects not just the patient but, the doctor as well. A format that is BOTH efficient and fail safe.
After all, medicine is a two way traffic that requires BOTH the patient and doctor to work together in tandem to reach the ultimate goal....health for the patient and a fruitful and meaningful career for the doctor.
I don't think the powers that be bother about "meaningful careers" for the doctor.
To them healthcare is all about cheaper better safer faster.
Doctors are just another cog in the machinery. Nobody gives two hoots about them frankly. Just ask the administrators. What is their KPI? What is the Minister's KPI? Meaningful career for doctors? Please lah. This is Singapore you know.
And as for this "united front" strategy. Sure we always talk about it. But surely this will not bode well for the various KPIs in place. It is much better for the administrators to have a disjointed medical profession. Divided we fall. And anyone who tries to start up a movement like that will be closed down quickly and made a scapegoat for all to see.
Politics.
This is a great topic of major public interest. If doctors don't come together and state in public forums, the downside of encouraging defensive medicine in Singapore, then nobody out there will realize. I am surprised that the SMA has not spoken out on this. The SMC sure does not have doctors or patient interest at heart. With more and more cases like this taking place AND being sensationalized in the press, patients will be encouraged to complain and sue every time there is a dispute, or poor outcome. The only way to practice medicine without complications is to NOT practice medicine. Looks like there is no turning back.. welcome to Singapore, Defensive Medicine!
One of our greatest failings as doctors is that we too often take things at face value.
Is this simply an open and shut case of adequate / inadequate consent? Is it even as simple as one man's word against another?
Perhaps there is more to the matter than we know?
This case involving Dr. Tong Ming Chuan was reported in June last year, but wasn't discussed on this blog. In fact, I don't recall reading about it in the papers either. Interesting...
http://www.topnews.com.sg/content/22554-renowned-surgeon-sued-medical-negligence
A number of similarities between the two, but sadly, one patient did not survive.
This will solve the problem. Before any surgery,
1. Explain all the possible risks that are printed in a 30-page consent form line by line. Get the patient to sign that he is aware and understands it.
2. Get the lawyers to devise a quiz that will test understanding of all pertinent risks of the operation.
3. Get the patient to sit a 1-hour quiz to test understanding what has been explained.
4. Only if the patient gets every question correct will the operation be performed. Otherwise, he will have to go back to studying and re-sit the quiz a week later until he passes or he dies, whichever is sooner.
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