The outcome of a recent disciplinary hearing by the Singapore Medical Council (SMC) raises a number of questions, not least about how much patients can count on the watchdog body to protect their interests.
The case involved United States Merchant Marine Michael Balensiefer who decided to get some aesthetic treatment done while recuperating from a knee treatment here in March 2009.
He went to Dr Kevin Teh Tze Chen at the Singapore Lipo, Body & Face Centre at Novena Medical Centre for Vaser LipoSelection of his lower back. The $1,926 treatment liquefies fat before extracting it.
But things did not turn out well. Although he didn't know it then, the doctor wrongly gave him amoxicillin, a common antibiotic he had told the clinic he was allergic to.
As an antidote, the doctor gave him an injection in his right hand that made him react immediately. Mr Balensiefer, now 37, remembers shouting "Hot! Hot! Very hot!"
After the treatment, his hand was swollen. Two days later, the swelling had extended almost to his elbow.
A week later, he was in severe pain and his thumb and the part of his hand where he had been injected were turning black. He went to the emergency department at Tan Tock Seng Hospital (TTSH) where doctors warned he might lose his thumb and a finger as 15 cm of the artery in his arm was blocked.
Mr Balensiefer asked Dr Teh for his medical notes for the TTSH doctors, but Dr Teh did not mention that he had given the patient an injection of promethazine to counter the amoxicillin. The TTSH doctors were left puzzled as to the cause of the injury.
Dr Chia Kok Hoong, then head of vascular surgery at TTSH, operated and managed to save Mr Balensiefer's hand, but told him he would have to avoid exposure to cold and recommended that he not continue in his job as a rescue swimmer.
Mr Balensiefer said changing jobs resulted in a 23 per cent drop in pay.
In a case that stretched all the way to this year, Mr Balensiefer first turned to the SMC in 2009, but his complaint was dismissed. It was only last year that the medical watchdog began a disciplinary hearing, and only after being directed to do so in 2011 by the Minister of Health, to whom Mr Balensiefer had appealed.
Dr Teh, a general practitioner offering aesthetic treatments, faced six charges:
- Wilful neglect in allowing Mr Balensiefer to be given amoxicillin, a drug he was allergic to.
- Failure to act in his patient's best interests when he proceeded with the Vaser LipoSelection treatment despite realising the patient had been given a drug he was allergic to.
- Failure to tell the patient he was being injected with promethazine to treat a potential allergic reaction to the amoxicillin.
- Gross mismanagement of the care of the patient after treatment.
- Falsifying, or causing to be falsified, the patient's medical records to say the promethazine was diluted, when it was not; and
- Falsifying, or causing to be falsified, the patient's medical records to say his allergy was known on March 12, when it was only discovered on March 17, the date of the procedure.
Dr Teh was found guilty of four charges - the first three and the sixth - and fined $10,000. He was also slapped with the usual censure and asked to provide a written promise not to repeat the offence.
When one considers what the doctor did, and why he was found guilty, his punishment appears too light and sends the wrong signals of acceptable practice by doctors.
The three doctors on the SMC panel, Professor Lee Eng Hin, Dr Raymond Chua and Associate Professor Paul Thng Leong Keng, and the lay member, Mr Chan Kok Way, said they chose to be lenient in penalising Dr Teh and gave their reasons.
They felt that the first three offences were not serious enough for him to be suspended from practice.
The first was that he failed to ascertain if the patient had allergies. Mr Balensiefer had told the clinic nurse and she failed to record that information. But a doctor is expected to verify this for himself.
The second was that after discovering he had wrongly given Mr Balensiefer a drug he was allergic to, Dr Teh continued with the treatment. The panel felt that "given that the procedure was elective and cosmetic in nature, Dr Teh ought to have refrained from taking any risk".
They found him guilty of professional misconduct and said he should have told the patient about the mistake and given him the option of proceeding or returning on another day for the procedure.
The third offence was that Dr Teh gave the patient an antidote without telling him about it.
While many might agree the first offence was not so serious - accidents do happen - Dr Teh's subsequent actions, and especially his failure to come clean to his patient, appear to be cause for concern.
How can patients trust doctors who try to cover up their errors like this?
As the professional watchdog, the SMC has to look after the interest of the doctors it oversees. But surely it also has a duty to the public to ensure that errant doctors are not let off too lightly.
Dr Teh was found guilty of the sixth charge - of falsifying his patient's record, or causing it to be falsified. The panel felt that this was his most serious offence, yet did not feel it merited suspending him from practice.
Its reasoning: "We consider that as a young doctor just starting out in private practice, Dr Teh made a clinical mistake which caused him to panic. This, in turn, led to Dr Teh making a series of misjudgments which ultimately culminated in him dishonestly trying to cover his tracks."
Dr Teh is 40 years old, and at the time of his offences, had been practising for 11 years. If a doctor is considered sufficiently qualified to run his own practice, he should be held accountable for his actions.
He was cleared of two other charges - that he grossly mismanaged the care of the patient; and that he gave undiluted promethazine but falsified the records to show it had been diluted. On the latter, the panel noted that although his "record-keeping left a lot to be desired, there was a certain amount of uncertainty surrounding Dr Teh's administration of the undiluted promethazine".
The facts remain that this doctor gave his patient the wrong drug, failed to tell him about it, tried to cover up by giving him another drug - possibly undiluted, as Mr Balensiefer complained of pain when it was given, a common reaction when it is undiluted - then tampered with the case notes so "it diverted the blame to the nurses and cast them in a bad light", the SMC panel found.
And yet, he was merely fined $10,000.
It had to be clear to the panel that Mr Balensiefer's condition was worrying - especially when the TTSH specialists warned he might lose his fingers.
Dr Teh continued with his cover-up even when he knew his patient risked amputation. The TTSH doctors were trying to save the patient's fingers, but he did not tell them about the promethazine.
The committee said it noted that Dr Teh had since reformed much of his clinic's standard operating procedures with regard to the administration of medications.
But it also appears that the doctor showed little remorse as he steadfastly denied the charges, and the hearing took place over seven days between July 18 last year and Aug 19 this year. He even tried to blame his nurses, but one of them had recorded two conversations with him and that helped to prove his guilt.
During a recent parliamentary session, Health Minister Gan Kim Yong said the SMC should not be held back from getting the legal help it needs in its disciplinary hearings, simply because of lack of funds, or it would not be able to properly carry out its duty of regulating the medical profession.
"There will be a loss of confidence in its ability to safeguard the interests of patients and in the integrity of the medical profession," he said. He was referring, in part, to the high-profile, long-running dispute between the SMC and surgeon Susan Lim, and the costly legal fees incurred.
In the relatively low-profile case against Dr Teh - one that the SMC had initially decided had no merit to be investigated - it held a disciplinary hearing only after being told to do so by the minister.
After the panel concluded the case this year, Mr Balensiefer tried to appeal against its decision, but was told by the SMC that only the doctor had the right of appeal.
The law was amended in 2010 to allow complainants to appeal against SMC findings, but Mr Balensiefer's case had started in 2009.
This case also raises the issue of whether the SMC is consistent in dealing with errant doctors.
In 2011, a doctor was suspended for three months for not telling his patient that there was an alternative treatment. The decision was upheld by the High Court when the doctor appealed.
Last year, another doctor was suspended for nine months (reduced to five months by the High Court on appeal) and fined $10,000 for beginning a caesarian operation on a patient before the sedation took effect, and amending the notes to indicate the epidural was given 10 minutes earlier than it actually was.
The case against Dr Teh appears to be as serious if not more, yet his penalty was considerably lighter.
The SMC needs to ensure more consistency in the penalties it metes out to be seen to be fair to both doctors and their patients.