Doctors 'bound by ethics to charge fair fees'

Source: Todayonline  24 Nov 2012

Lawyers for Singapore Medical Council assert that principles of honour and integrity apply to medical profession

Doctors here are ethically bound not to charge unfair and unreasonable fees for their services.

The Singapore Medical Council's (SMC) lawyers made this point, among other things, in a 190-page response to prominent surgeon Susan Lim's appeal against her three-year suspension and S$10,000 fine for professional misconduct.

The council had found Dr Lim guilty of 94 charges, the bulk of which involved overcharging the late sister of Brunei's Queen, whose bills amounted to S$24.8 million for care rendered in 2007.

In her appeal, Dr Lim, 57, argued, among other things, that Singapore does not have any guidelines or a cap on what a doctor can charge a patient.

According to documents submitted to the court - dated Thursday - SMC's lawyers from WongPartnership pointed out that "there is an intrinsic ethical limit prohibiting doctors from charging unfair and unreasonable fees".

"Excessive charging undermines the foundation of any profession based on honour, trust and integrity," they said.

Drawing reference from the legal fraternity, the SMC's lawyers argued that the principles of honour and integrity apply to the medical profession with or without written rules in their ethical guidelines.

Pointing out that Dr Lim's fees are in "an extraordinary class of exorbitance on its own", they also said that the assessment of a practitioner's fee is determined objectively by her peers.

"It is settled law that in assessing whether fees rendered are grossly excessive such as to amount to professional misconduct, the benchmark is an objective assessment of the fairness and reasonableness of the fees charged, having regard to all relevant factors, such as the complexity of the services rendered, and the seniority and skill of the practitioner involved," the lawyers said.

While Dr Lim has insisted that the fees were agreed between her and her patient, the SMC's disciplinary committee ruled otherwise.

Even if there was a fee agreement, "that does not mean that it is ethical … for a doctor to charge excessive fees", the lawyers said.

"As a concomitant, whilst a fee agreement can be valid under general contract law, that does not mean that the agreement is ethical under the rules of professional conduct," they added.

In the legal profession, for example, the courts have also previously ruled that solicitors might be found guilty of overcharging despite having a fee agreement, the lawyers noted.

They reiterated that the case is not one of inadvertence or negligence - Dr Lim knew what she was doing was wrong. Not showing remorse, she continued to assert that there was nothing wrong with her conduct, the lawyers said. They reiterated that "it is not the SMC's intention to make a public example of Dr Lim".

The SMC is charged with the statutory duty to regulate the conduct and ethics of registered medical practitioners, and to uphold the standards and reputation of the medical profession, the lawyers said.

"And it is a matter of fundamental importance in the definition and conception of the medical profession as an honourable profession that practitioners refrain from levying grossly excessive, unfair and unreasonable fees that bring the entire profession into disrepute," said the lawyers.

It is "equally important that medical practitioners maintain the highest standards of integrity in their billing practices", they said.

"That, however, is precisely what Dr Lim has not done."

The court is scheduled to hear Dr Lim's appeal in January.

Healthcare cost in Singapore

There is a saying in Singapore: " you can afford to die but not a long illness in Singapore." It is a common cause why terminally ill patients choose to die without treatment or end their lives prematurely so as not to drag their family into financial difficulties. 

In the early days of Singapore pre-1980s, healthcare costs at the public hospitals and clinics were highly subsidised and healthcare were much more affordable then. The downside were long queues and the poor pays(and thus poor services), but at least the poor still have a cheap alternative to medicine.

Sometime in the 80s and 90s, in the name of restructuring public hospitals, all public hospitals underwent a major overhaul and uplifting, so are the costs associated with healthcare has shot through the roof. The cost difference between public and private hospitals have narrowed significantly despite the formers are highly subsidised by the Government. Many new "public" hospitals such as SGH, KTPH, NUH are newer and more fancied equipment than private hospitals such as Gleneagles, Mount Avernia Hospital. When previous Health minister Khaw Boon Wan decided to publish the healthcare costs on MOH website to force some competitions among the private and public hospitals, it was reported in Straits Times that some operations are more expensive in public hospitals than private hospitals. The difference in costs for many operations are not very different.  A child which have Jaundice and need to warded in ICU will easilyy set you back more than $1500 poorer per night. Someone who is warded in ICU in public hospital need to prepare to fork out at least 15000-20000 for a one week confinement. Many reported cases of cost running into 200k-300k bill for cancer patients have been reported in the press from time to time. 

This is a walking time bomb that this Government needs to solve urgrently given the aging population. Short of create a low cost public healthcare or outsource the treatment to cheaper neighbouring countries, the problem is indeed huge and serious. Healthcare was once affordable in Singapore.

$178.60 medical fee for checking on rashes

Source: Straits Times  20 Oct 2012

MY SON, a reservist, developed a rash after dining on prawns.

He visited Changi General Hospital on Aug 1 and was placed under observation in a ward. Less than 24 hours later, he was discharged as it was nothing serious. The fee: a whopping $178.60.

I am dismayed that the Ministry of Health allows hospitals to charge so much just for consultation and observation for rashes. In Malaysia, it costs no more than RM1 (40 Singapore cents) for consultation and the total bill at a government-funded hospital will cost no more than RM20.

Tan Yan Ren

IVF mix-up

Human error caused IVF mix-up

Source: AsiaOne  24 Nov 2010

INVESTIGATIONS into a botched in-vitro fertilisation (IVF) procedure at Thomson Medical Centre (TMC) concluded that it was due to lapses in procedure and human error.

Investigators found that TMC's IVF centre had deviated from standard operating procedures, said Minister for Health Khaw Boon Wan, who shared his ministry's audit results yesterday.

Earlier this month, it was reported that the Thomson Fertility Centre, a subsidiary of TMC, had wrongly used another man's sperm to conceive a child for a couple - a Singaporean Chinese woman and her Caucasian permanent- resident husband.

After the incident, the Ministry of Health (MOH) ran a check on nine other assisted reproduction centres here.

Besides TMC, two other centres were found to have deviated from international best practices.

Mr Khaw revealed three key lapses that led to the mix-up:

Firstly, the embryologist was processing the semen specimens of two individuals at the same workstation, and at the same time.

Best practice requires an embryologist to work on the specimens of only one individual or one couple at a time.

Secondly, the pipette used to transfer the specimen was reused instead of being discarded.

To prevent contamination and a potential mix-up, the disposable instrument should have been discarded after each step.

Mr Khaw said: "Even though it was reused only for handling the specimens from the same individual, it unnecessarily raised the risk of human error."

Finally, the third major lapse was the absence of a second operator to counter-check that the specimens were transferred to the correct receptacles.

"This incident has no doubt impacted the reputation of Thomson Medical Centre IVF Centre and also indirectly affected Singapore's reputation as a regional medical hub," said Mr Khaw.

He also addressed queries by Dr Lam Pin Min, a Member of Parliament for Ang Mo Kio GRC, about the rights of the unintended father in the case.

He said that TMC has a duty towards every individual involved in this incident and that the baby's "rights should take priority".

"If the donor asks, then TMC will have a duty to inform but TMC should not volunteer information, taking into account the impact it might have, especially on the baby," he said.

He added that the Health Ministry is not aware of any other mix-ups in recent years.

NUH apologises to late patient's family

Source: AsiaOne  May 12, 2012

The National University Hospital (NUH) has apologised to the family of a late heart patient for failing to pay 'close attention' and give 'reassuring care' to her.

Admitting that Madam Heng Choon Noi was shortchanged, NUH waived the $40,000 hospitalisation bill and paid out a compensation to her family.

In a statement, NUH said it "accepts that it failed to give Madam Heng and her family the close attention and reassuring care that they deserved and has apologised unreservedly to the family for this."

In October last year, Mdm Heng had undergone a heart-valve surgery at the National University Heart Centre, part of the NUH, as a private patient. 

She was moved out of the intensive care unit to the general ward when she was showing signs of recovery.

However, it was there that her condition began deteriorating again. Her sons, who were keeping vigil overnight, said they tried to alert the doctors on duty from 1am to 6am, but to no avail.

They claimed that the two junior doctors - a medical officer and a registrar - did little and would not call in the senior doctor despite their repeated requests.

When her surgeon, Dr C. N. Lee, came to see her that morning during his ward rounds, he immediately moved her into intensive care, but it was too late.

Mdm Heng died at the age of 74 from slow bleeding in her brain, according to a coroner's finding.

Her three sons told the Straits Times (ST) that they were appreciative of the hospital's 'care and concern' and the briefing they were given on the results of the investigation into the circumstances leading to their mother's death.

They also said the hospital apologised but the two doctors involved did not.

Complaints from her sons that there had been a 'serious lapse of due diligence by the doctors at the ward' led to a full-scale inquiry into the case by NUH.

However, the registrar Tay Jia Sheng, who was training to be a heart surgeon, resigned even before the investigations were completed.

The medical officer, Dr Ng Hui Chong, is now at Tan Tock Seng Hospital.

NUH said that steps will be taken 'to ensure that the lessons learnt from Madam Heng's case' will be used to prevent a recurrence of what had happened. However, it did not elaborate on what steps it intends to take and how it will go about it.

According to ST, Mdm Heng's sons have expressed a wish to return the money as a gift to the NUH in their mother's name, for it to be used for future training of its doctors to improve patient care.

S'pore medical tourism needs careful rethink

Letter from See Leong Kit

Source: Todayonline  May 14, 2012

THE timely report "India's medical tourism could cause superbug to spread globally" (May 9) referred to a new superbug that has emerged from India, partly because of medical tourism, with scientists saying there are almost no drugs to treat it.

As more people travel to find less costly medical treatments, it is feared this superbug could spread across the globe.

First detected in 2009 in New Delhi, cases of the bacteria code-named NDM-1 have since emerged in Britain, the United States, Europe, Australia, Hong Kong and Japan.

In 2010, six NDM-1 cases were detected here. The first was a resident who had sought medical treatment in India. The second was a Bangladeshi who had visited Singapore for medical treatment.

Of the remaining four cases, three were elderly patients but the fourth was in his 30s. As they had not travelled abroad, it is likely they had caught the superbug here.

Back in 2007, a Vietnamese who came here for medical treatment was subsequently found to be infected with extensively drug-resistant tuberculosis (XDR-TB), over which global concern is also mounting, as it kills in three in four cases.

In March last year, the Annals, Academy of Medicine, Singapore, published an editorial co-written by Dr Catherine Ong and Dr Paul Tambyah with this thought-provoking conclusion:

"The commercial forces promoting medical tourism in our country need to be regulated at a national level to curb the transmission of potentially lethal infectious diseases within our borders, lest we pay the price. It is simply not worth it."

Indeed, with a hot, humid climate and being densely populated, Singapore is particularly vulnerable to the spread of infectious diseases. The Health Ministry should provide detailed assurances on its proactive measures to tackle such public health threats.