Avoid practising defensive medicine, docs told

Doctors were urged yesterday not to overreact to a recent case in which a paediatrician was suspended for failing to diagnose that a child had the rare Kawasaki disease.

Senior Minister of State for Health Lam Pin Min reminded them that it is part of their work to exercise "good clinical judgment" when treating their patients.

They should avoid practising defensive medicine, which would raise healthcare costs unnecessarily, he added.

Dr Lam was replying in Parliament to Dr Lim Wee Kiak (Sembawang GRC), who had asked if there were guidelines for doctors to "send all cases for detailed diagnostic tests to avoid misdiagnosing rare medical conditions".

Dr Lim cited the case of the paediatrician, whose suspension led more than 1,000 doctors to sign a petition to the Health Ministry and the Singapore Medical Council (SMC), saying that the punishment was too severe for misdiagnosing a rare disease.

Dr Chia Foong Lin, who is in private practice, had appealed against the disciplinary tribunal's judgment, but the Supreme Court upheld it.

  • Timeline of events

  • Feb 25, 2013

    A one-year-old child suffering from red eyes and high fever for three days is hospitalised at Gleneagles Hospital.

    Dr Chia Foong Lin diagnoses him as having a viral infection.

    Feb 27

    The child is fretful, his lips turn bright red and he develops a rash.

    Dr Chia considers Kawasaki disease, but does not do any supportive tests for this (there is no specific diagnostic test for Kawasaki disease), nor does she tell his parents.

    Feb 28

    The boy's fever spikes in the morning and his lips are red and cracked.

    March 1

    His fever appears to have settled and Dr Chia discharges him. His red eyes have improved and he has no rashes, but his lips are still red and cracked.

    March 3

    He is reviewed by Dr Chia as an outpatient at her clinic. His parents say the child's fever has continued in the past two days.

    March 4

    The boy's parents seek a second opinion from Dr Lee Bee Wah, another paediatrician in private practice.

    Dr Lee notes that the boy is irritable, has a rash on his upper body, redness on his palms and soles, prominent lymph nodes on the right side of the neck, and a heart murmur.

    She orders blood tests and an echocardiogram, which shows that the blood vessels of the heart are already affected.

    She treats the boy for Kawasaki disease and he responds well.

    Salma Khalik

Dr Lim asked whether the ministry would issue guidelines, if none exists, for diagnosing potentially rare illnesses.

Dr Lam said internationally accepted guidelines for Kawasaki disease have been in existence since 2004. They state that a prolonged fever, with two other symptoms, warrants checking for the disease.

The one-year-old boy Dr Chia was treating had fever and three other symptoms: red eyes, a rash, and lips that were red and cracked.

The tribunal found that "Dr Chia fell short of the reasonable standard expected of a senior paediatrician by not ordering tests to support the diagnosis or discussing with the parents this possible diagnosis which she had considered", said Dr Lam.

It judged her actions as "serious negligence", he added.

Kawasaki disease, if untreated, results in 15 per cent to 20 per cent of children - usually under five years old - developing serious medical problems including heart disease, or dying.

Between them, National University Hospital and KK Women's and Children's Hospital see 160 to 190 cases of Kawasaki disease a year.

Ms Tin Pei Ling (MacPherson) had asked about the basis for Dr Chia's suspension.

Dr Lam said that in deciding on the three-month suspension, the tribunal took into account her 23 years of experience as a paediatrician, and her unblemished record.

It also looked at eight precedents of doctors missing or giving a wrong diagnosis. Six of them were suspended.

Ms Tin also asked whether studies had been done on defensive medicine and potential implications if it was practised here.

Dr Lam said that there is no such local study, but when a doctor deviates from sound medical practice for fear of a malpractice suit, it adds unnecessarily to healthcare costs, he added.

"As part of their work, doctors are expected to exercise good clinical judgment to manage patients appropriately," he said.

Dr Lam added that doctors need to keep abreast of medical knowledge and international guidelines. That is why the SMC requires all doctors to have mandatory continuing medical education.

He said he was aware the case has caused concern among many doctors. He urged them "to stay calm and not overreact", and to read the tribunal's rationale for the penalty.

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A version of this article appeared in the print edition of The Straits Times on August 02, 2017, with the headline 'Avoid practising defensive medicine, docs told'. Print Edition | Subscribe