Parliament: MPs ask about defensive medicine after doctor is suspended for not diagnosing rare illness

Dr Chia Foong Lin, a paediatrician of 23 years, was found guilty by an SMC disciplinary tribunal of failing to diagnose a one-year-old with Kawasaki disease, that could potentially cause heart problems.
Dr Chia Foong Lin, a paediatrician of 23 years, was found guilty by an SMC disciplinary tribunal of failing to diagnose a one-year-old with Kawasaki disease, that could potentially cause heart problems. ST PHOTO: KEVIN LIM

SINGAPORE - Doctors should not practise defensive medicine. Doing so is not good clinical practice and it would raise healthcare costs unnecessarily, said Senior Minister of State for Health Lam Pin Min in Parliament on Tuesday (Aug 1).

He was responding 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 recent case where a doctor was suspended for three months for not diagnosing a child who had the relatively rare Kawasaki disease (KD). 

More than 1,000 doctors had signed a petition to the ministry and the Singapore Medical Council (SMC), saying that a suspension was too severe a penalty for misdiagnosing a rare disease.

Dr Chia Foong Lin, a paediatrician in private practice, had appealed against the disciplinary tribunal's (DT) judgment, but the Supreme Court upheld it.

Dr Lim asked if the Ministry of Health could issue guidelines for diagnosing potentially rare illnesses, if no such guidelines exist.

 
 

However, Dr Lam said that in that particular case, there have been internationally accepted guidelines for the disease since 2004.

He said: "Based on these international guidelines, the child presented with signs and symptoms which should be investigated further for KD."

The child had a high fever that had lasted more than a week, red eyes, red cracked lips and a rash.

KD is a disease that, if untreated, would result in 15 per cent to 20 per cent of children developing serious medical problems, including heart disease, or dying.

  • What happened to the boy with Kawasaki disease

  • Timeline of events:

    Feb 25, 2013: The year-old child suffering from red eyes and a 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 KD), 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, 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 parents seek a second opinion with 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 KD and he responds well.

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

Dr Lam said: "The DT concluded 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.

"The DT judged that this amounted to serious negligence on her part."

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

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

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

Dr Lam said defensive medicine, which happens when a doctor deviates from sound medical practice for fear of being sued for malpractice, results in unnecessary healthcare costs. There has not been any local study on this.

He added: "As part of their work, doctors are expected to exercise good clinical judgment to manage patients appropriately."

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