Mike Griffiths, regional director of healthcare at Howden Insurance Brokers, talks through the implications of one of Asia’s most infamous malpractice suits last year
Gambling is not really encouraged here in Singapore. The founding father, Lee Kuan Yew, long resisted proposals to build casinos as he feared the promise of easy riches would undermine Singaporeans’ famous work ethic. It was not until 2010 that the first of our two casinos was finally built, and even now there is a US$100 entry fee to deter locals (and sadly, permanent residents as well) from visiting them too often. With a rigour and efficiency that is uniquely Singaporean, devoted gamblers who stay at the tables for 24 hours receive an SMS instructing them to head to the exit or pay a further US$100.
But just this once I will go against the wishes of Mr Lee, and invite a wager. What would you bet was the cause of Singapore’s highest-profile malpractice case in 2019?
There are some obvious candidates. Brain injuries from difficult obstetrics cases are typically the largest malpractice payouts. Spinal surgery complications would also be at short odds given the risk of permanent paralysis. Cosmetic surgery also comes with some high risks, and in fact, Singapore’s largest malpractice award ever of S$5m stemmed from liposuction complications.
Putting your money on any of these would demonstrate a good understanding of where serious malpractice claims normally arise, and in most years would give you a good chance of winning. In 2019, however, you would have lost your shirt.
Singapore’s most-discussed malpractice case of 2019 stemmed from a cortisone injection.
Have you ever heard of a cortisone injection? Yes, of course, you have – it is such a common procedure for relieving pain and inflammation of the joints that almost everyone is familiar with it. Cortisone is an effective treatment for arthritis, tendinitis and other common ailments. It has a few minor side effects – the pain and inflammation often get a little worse for a couple of days before improving – but is in most cases a safe and effective treatment.
Now, can you guess how a cortisone injection became a high-profile malpractice case? No, you can’t, because the series of events that took place is so improbable it reads like the plot of a Pink Panther movie.
Dr Lim Lian Arn is an orthopaedic surgeon with more than 20 years’ experience and is, by all accounts, well-regarded within his speciality.
In February 2019 however, Dr Lim found himself before the disciplinary arm of the Singapore Medical Council (SMC), charged with failing to warn a patient of all risks and possible complications before administering a cortisone injection.
The patient, who had seen Dr Lim almost four years earlier, complained that she had developed ‘paper-thin skin’ with loss of fat and muscle at the wrist. I do not wish to trivialise this patient’s complaint but these are hardly life-threatening injuries, and there was no suggestion that the cortisone injection was an incorrect treatment for the patient’s condition.
Dr Lim, no doubt hoping for a speedy resolution with a minimum of fuss pleaded guilty to failing to obtain proper consent. The SMC disciplinary tribunal, in its wisdom, elected to levy on Dr Lim the maximum possible fine of S$100,000 (around US$74,000). Had Dr Lim wrongly amputated the limb instead, the fine could have been no higher.
The Singapore medical community greeted with disbelief the news of a maximum fine against one of their number for an apparently minor oversight. They quickly united behind Dr Lim and raised a 4,000-signature petition expressing dismay at the decision and concern over its implications for medical practice.
This turned into much stronger demands for reform of the Singapore Medical Council disciplinary process itself when, one month later, a S$50,000 fine was handed down to Dr Soo Shuenn Chiang, a psychologist who had been tricked into releasing confidential patient details to a family member who purported to be the patient’s husband.
Letters were written to the Ministry of Health and to newspapers, criticising the heavy handed approach of the disciplinary tribunal and its failure to recognise the realities of modern medical practice. Poor Dr Lim, who had wanted only a quiet resolution of the complaint, became perhaps the best-known medical practitioner in Singapore.
At this point, events began to tend toward the surreal. The Singapore Medical Council came to the slow realisation that the mounting criticism of these two cases required them to take some kind of action.
One can imagine the meeting of the Singapore Medical Council board considering how to resolve the issue without admitting that any mistakes had been made, and someone blurting out ‘Why don’t we appeal to the courts against our own decision?’
A stunned silence, and then gradually heads start nodding.
No better ideas emerged, apparently, and so it was that in June 2019 the Singapore Medical Council appealed to the courts seeking a reduction in the fines imposed on the two doctors by its own disciplinary tribunal.
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The Singapore courts quickly demonstrated that they had a far better grasp of both community expectations and the realities of medical practice. The Court of Appeal first overturned the conviction and fine imposed on Dr Lim and pointed out that not every departure from accepted medical standards amounted to professional misconduct.
The unanimous judgment was critical of the Singapore Medical Council’s disciplinary tribunal for too readily accepting Dr Lim’s guilty plea.
Next, the conviction and fine imposed on Dr Soo was quashed with the courts finding that the allegations against him were not made out. In this case, the courts did note that Dr Soo might have defended the original allegations rather than simply plead guilty in the hope of a speedy resolution.
Singapore efficiency being what it is, these two judgments do not quite represent the end of the story.
The Ministry of Health has now instituted an enquiry into the powers of the Singapore Medical Council’s disciplinary tribunal. A betting man would say that reforms are on the way!
And so, as we head into the new year, we look back on 12 months with a great deal of activity in the regulatory arena, but a pleasing absence of high-profile malpractice claims.
Despite occasional arguments to the contrary, Singapore remains one of the more benign environments for litigation against doctors. The main beneficiary of this environment is, of course, the Singaporean patients who receive treatment from doctors not intimidated into practice defensive medicine.
Long may it remain so!