Disturbing Case

I nearly missed this news article, which is too lengthy to reproduce in full. Here are the opening paragraphs and the accompanying commentaries by some lawyers.


A First: Doctors applied to court for permission to amputate patient's legs as she was in coma
A Twist: Order cannot be carried out as patient wakes up

By Karen Wong
January 26, 2006

IT is a legal first that comes with a medical twist.

The High Court has handed down an unusual order to allow doctors to amputate a diabetic patient's legs in order to save her life.

The order was sought by the woman's doctors because she was in a coma and her only kin here, her 16-year-old son, was too young to sign the consent papers.

Earlier, she would not agree to the amputation.

And here's the twist: after the court passed the order, but before the operation could be carried out, the 51-year-old woman woke up from her coma.

Now, as long as she remains lucid, doctors have to keep aside the court order and go by her wishes.


Lawyers: Case is significant

THIS is the first time that a hospital here has gone to court seeking such a declaration.

And, the court's landmark decision means that in future, doctors may not need to go running to court for such a declaration, when faced with a similar situation, lawyers say.

When contacted by The New Paper last night, Ms Kuah Boon Theng, a lawyer who advises doctors and hospitals, commented: 'We now know that Singapore has adopted the English law position, which is that in situations where a patient is not competent to decide, and when the procedure is in their best interest, doctors can proceed to provide the treatment.'

What is the effect of this court judgment on doctors and hospitals?

She said: 'In future, there may be no need for doctors to scurry to court every time they are faced with this same situation, to seek a court declaration.'

When contacted, Mr Christopher Chong, the hospital's lawyer, commented: 'If a comatose patient has not previously said anything, this decision confirms that doctors would have to treat the patient according to the best interest of the patient medically.

'But in unusual cases where there is uncertainty as to the patient's consent, there is now a procedure by which the lawfulness of the proposed treatment can be determined by the court.'

Although it remains to be seen whether the amputation will be performed in Madam LP's case, lawyers seem to be unanimous in saying that Justice Choo Han Teck's ruling will be relevant in similar medical cases.


Now you may think that angry doc will be jubilant at the fact that the court has essentially ruled that 'doctors know best', but I am actually very disturbed by the ruling. Again, it is difficult to judge what the doctors did with just the information provided in the article; the doctors who did what they did must have their reasons, but it seems to me this case violates the concept of patient autonomy.

I have previously been in medical teams managing patients whose lives were threatened by a gangrenous limb or perforated gut, but who refused life-saving surgery.

It was frustrating to watch them deteriorate day by day and sink into a febrile delirium when you know that we have the means to save the patient's life and all we needed was for him or her to say 'yes'.

Sometimes they changed their minds. Sometimes it was too late by the time they changed their minds.

But we never forced the issue. We knew that just because the doctor knew best, it didn't give him to right to do what he thought was best.

I think this court ruling actually made it harder for doctors from now on, rather of easier.

Will the doctor who genuinely wants to respect the wishes of a patient face a lawsuit from the patient's family if he would not apply a court order to over-rule the patient?

Will the doctor really be immune from a lawsuit from the patient who lived because of the court order, but now suffers 'a fate worse than death'?

How will you feel if you wake up from a coma to find a part of yourself removed against your expressed wish? Will you ever be able to trust your doctor again?

W.W.H.D.

Here’s one they will never ask during the Final M.B.B.S. MCQ paper.


"You are a colorectal surgeon in a restructured hospital.

Two weeks ago an old man was admitted to your team for bowel obstruction.

He was initially seen by his GP, who correctly judged that the case was urgent and the patient had to be seen at the A&E. He referred the patient to a Government Polyclinic, in the mistaken belief that if the patient was referred by a GP he would not be entitled to government subsidy. The patient was seen at the polyclinic and given a referral to the A&E, where the doctor decided to admit the patient.

At the Admission Service, the patient’s family decided to opt for B1 Class for the patient, hoping to let the patient have better service during his stay, not realising that all subsequent follow-up will be at non-subsidised rates.

The patient underwent surgery that same night. The diagnosis was an obstructive cancer. The patient will need follow-up at your clinic (as a paying-class patient) and also expensive chemotherapy. The full cost of his treatment now becomes clear. The family hope that you can help them reduce the medical costs by downgrading them to subsidised-class."

What should you do?

A. Nothing
Continue seeing the patient as a paying-class patient – you're a doctor, not an accountant. Besides, they should have known better when they chose a paying class for the patient.

B. The correct thing
Refer them to the hospital Medical Social Worker for Means Testing since you can't make a decision on the downgrading. The MSW will then assess the family's income and make a recommendation, a process which may take weeks, during which the patient will undergo further investigations and treatment at non-subsidised rates.

C. Exploit the loophole in the system
Discharge the patient from your clinic and ask them to go back to the polyclinic for a referral to the subsidised clinic on the day that you will be there so you can continue to see the patient. There may be some time lag between due to the long waiting list, but at least the family will save some money. Well, a lot of money.

D. Abuse the system
Discharge the patient from your clinic and make the patient to go to the A&E faking severe abdominal pain, so that he will be admitted to the ward (this time as a subsidised patient) where he can have his treatment continued.


What would Hippocrates do? What would you do?

Anatomy of a Complaint Letter

I like reading complaint letters.

For two reasons:

First of all, I believe in the complaint letter as an avenue of feedback to let us know how we are doing.

It is also interesting to try to discern the intention behind the complaint letter, and how the writers had tried to craft the letter in such a way to make their complaints seem more justified, and the crime of the person/institution complained against more heinous.

Take for instance this one from today’s ST Forum. Bear in mind, as usual, that the letter may have been edited.


Why is KK Hospital keeping my son's x-ray films?

My seven-year-old son accidentally swallowed a paper clip recently. He was rushed to KK Children's Hospital where we were told to get an X-ray.


‘where we were told to get an X-ray’ instead of ‘where an X-ray was done for him’. Note the subtle difference?


To add to my anxiety, the radiologist proceeded with the request form routinely as she hummed to a song and teased my son 'you Superman ah?'

She showed no sympathy and was certainly oblivious to our distress. She also did not ask whether I required a copy of the X-rays.


Now, if you were the radiologist (who I assume was really the radiographer), how would you try to put the child at ease? Behave in a similar state of anxiety as the patient or his mother? In a quiet, clinical manner which might be interpreted as ‘uncaring’? Or try to be friendly and joke with the child?


An emergency procedure removed the paper clip lodged in my child's esophagus.

When the discharge summary came, it not only wrongly stated my son's gender as 'female patient' thus making my insurance claim more tedious,


It is customary when writing a complaint letter, it seems, to pad the primary complaint with other minor inconveniences experienced, which in this case would have been easily remedied by the clerical staff. And the primary complaint is?


... the hospital also refused to give the X-rays to me.


Right there.


Instead, it said that I did not make known my intention to the radiologist to have a copy before the X-ray was done. Isn't it the responsibility of the hospital staff or the radiologist to explain beforehand the policies and procedures to the patient before the X-ray was taken?


Actually, it doesn’t really matter whether her request for a copy of the X-ray was made known before or after the X-ray was taken, since one can always print extra copies, like with photographs.

It is the duty of the radiographer to explain the procedure before taking the X-ray; but to explain the policies? When she was already in a state of ‘distress’? What would she have said about the radiographer who was taking her time explaining the policy for requesting a copy of the X-ray film when her son was suffering from a medical emergency?

Still, her not having asked for a copy earlier on is no reason for not giving her a copy when she asked for it later...


Why is the hospital retaining the X-rays for non-chronic cases, which are eventually discarded, instead of scanning them into its system for future referral? Aren't we entitled to our own medical records and diagnosis?

I need the X-rays to remind and educate my children as well as for their personal medical record.


I think by the time a child is old enough to read an X-ray, he or she would not be swallowing paper clips. I know I stopped swallowing paper clips when I entered medical school – they were just too expensive at the CO-OP.

But seriously, this isn’t the first complaint letter concerning the release of X-ray films; there were a couple just these past couple of weeks? If memory serves, the hospital should be storing their X-rays electronically by now. Nevertheless, the process of obtaining a duplicate copy of an X-ray would still entail some signing of forms, and I suspect a payment, which was not mentioned in the letter.

I think the writer has a legitimate complaint (they almost always do), but again I take exception to the fact that she had chosen to implicate a healthcare worker (the radiographer/radiologist), who seem to have done her job safely and effectively, when her primary dissatisfaction was with the policy on release of X-rays.

It is no easy task to get a child to lie still enough for an X-ray, and it seems that despite the humming and 'superman' joke, the radiographer nevertheless managed to get a film done so that the child could have his emergency scope.

Equally interesting, of course, are the replies to complaint letters. Let’s see how the hospital reply to this one.

Free at the Point of Delivery

The term 'NHS' is often used locally as a sort of a bogeyman, to represent how bad things can become if healthcare became universally free and is fully paid for by taxes.

I must admit I don't really have any first-hand experience with the NHS, so I am glad Dr Crippen has decided to give us an insider's view at his blog.

And the winners are ...

The winners for the 2005 Medical Weblogs are born!

You can see the results at this site.

Thank you all for your support.

Warning - Smoking may cause dyscalculia

angry doc: Do you smoke?

Patient: Ya. Actually I managed to stop for two months while I was on this medicine from my GP, but then I stopped the medicine and started smoking again.

angry doc: Why? Wasn't the medicine effective?

Patient: It was, but it was expensive.

angry doc: How much did it cost you each month?

Patient: Hundred-over dollars.

angry doc: How much do you smoke a day?

Patient: One pack a day.

angry doc: How much is a pack these days?

Patient: About ten dollars.

angry doc: ... so how long have you had difficulty doing sums?

Bad Docs

In last night’s episode, Doc Martin managed to antagonise almost all the townsfolk, and was thought to be uncaring, incompetent, and an all-round nasty person. By the end of the episode, however, everyone is reconciled when they realise that even though he may not be friendly on the outside, he was a professional and a caring person at heart. All they needed was to come to an understanding and accept how each other worked.

While watching the episode, my sympathies (and I suspect those of most doctors who watch the series) were with Doc Martin. I wonder how laymen feel watching him, or for that matter House.

The way I see it, doctors see ‘bad doctors’ as being of the following types:

1. Bad bedside manners
Exemplified by Doc Martin and Dr House, or in the local context perhaps that GP who made the news a few years back when it was reported that he had put up a sign outside his clinic stipulating that patients had to adhere to a few rules before they would be seen. Rules like (if memory serves): speak only when a question is put to you, don’t ask too many questions.

I remember thinking that this doctor was ‘weird’, but after a few years in the practice you kind of understand why he might have done that. Not that I would do that myself or advise any doctor to do so, but really I don’t think what he did was ‘wrong’; afterall, in a non-emergency situation, a doctor has the right to decide to end a patient-doctor relationship if there was a ‘serious personality conflict’, and of course the doctor might have reasoned that refusal to adhere to those rules constituted a personality conflict between him and the patient.

I think doctors are usually unwilling to think of another doctor as a bad doctor based on accounts of ‘bad bedside manners’, because we all had that experience of having one patient end the consult with ‘You are such a good doctor and I want to see you the next time I am here.’, and the very next saying ‘I have never seen such a terrible doctor like you and I never want to see you again!’. At the end of the day, the patient-doctor relationship is a relationship between two persons, and as in all relationships, some people click, and some don’t.

2. Incompetent
Recently a doctor was reprimanded for failing to diagnose a case of appendicitis in a boy. And that’s not the first time a doctor got into trouble for something like that.

It is of course impossible for most of us to decide if he was indeed incompetent because we do not have all the facts at hand, but again I suspect most doctors will not be too hasty to condemn him.

We all know how difficult it can be sometimes to diagnose an early case of appendicitis (and a great number of other conditions). Sometimes you just can’t tell yet.

That’s why we tell the family to bring the patient back ‘if he gets worse’.

But why would anyone need to be told that? If the patient did get worse, would they really rather take the risk that the doctor might have been wrong, or that the disease had progressed, than to bring the patient for a second consult or a second opinion and be told off because ‘the last doctor already said he was OK’?

I don’t know the answer to that, but I was once rebuffed when trying to tell a mother what signs of appendicitis to look out for in her child with “I do have general knowledge, you know?”

And of course none of the TV doctors are incompetent.

3. Unethical
My pet peeve. Doctors who sell habit-forming drugs for profit, abuse steroids, and put patients through unnecessary investigations and surgery to fleece them.

They seem to be the ones that doctors, patients, and the Medical Council are most ready to condemn.

Good.

4. Weird
The ones that I don’t talk about ‘because it would be gossip’.

While the doctors in the other categories may be considered ‘bad doctors’, it would probably be more appropriate to call these doctors ‘bad co-workers’ or ‘personality disorder cases’. Some of them are actually ‘functional’ as doctors, but you don’t want to go on-call with them.


I guess both Doc Martin and House would be Types 1 + 4.

I find that comforting.

Big Doctor is watching you

As I promised andrew, here's the link to the SMC Newsletter 2005.

The article I was referring to is Prof Chee's article, titled "Medicine 2010".

Regarding the use of computerised medical records, he has this to say:

"So by 2020 with our IT infrastructure in place... information would flow seamlessly. That which is confidential would be guarded by the patients (with access granted to the providers only when they give permission) and other information available would be for education, training, research and quality or performance indicators."

and

"... as regards the clinical competency, clinical outcomes and practice patterns of doctors, the Ministry of Health would be in a very good position to access all necessary data warehouses available when Medicine in Singapore is fully computerised... All will be done once doctors key in patient data into their computers, which would be nationally linked. From these data, the SMC will know more about the clinical practice and patient care of its doctors. Frightening? No. Just becoming more transparent which is what patients and the public expect."


I am a little disappointed he didn't address the issue of patients' responsibility. I doubt patient expectations will change drastically over the next five years or so. Come the time when every doctor's every move is under scrutiny, patients may find their doctors becoming less willing to accommodate their every wish/request/demand. How will patients come to terms with this new paradigm where doctors aren't really truly free to do what they want anymore?

We live in interesting times.

The Doctor is Beng

angry doc welcomes Blinkymummy to this blog.

Click on the convent girl on the right-hand panel to go to her blog.

See you there.

Move over, Dr House...

angry doc's new favourite medical TV series for the year is.... no, not Grey's Anatomy, but Doc Martin.

A British series about a socially-inept surgeon (as rude as House, not as witty, but immaculately dressed) who switches career-path to become a GP in a small Cornish town. The architechure and scenery!

In the first episode we see Doc Martin's brusque style clashing with the laid-back attitude of the townsfolk, with disastrous results.

I'll be following this series.

Down but not out... yet

Like Dr Oz Bloke, I too have been feeling low, from a combination of factors.


1. My stethoscope broke.

It's been with me through dark times, dire emergencies, and dirty toilets, but it's heard its last heart sound. I have never had this happen to me before, and I don't quite know what to do with the remains of what had literally been an extension of my professional self for so many years. I limped along the rest of the workday until I could acquire a 'loaner', but it's just not the same.

It's a stark reminder of my own mortality, and also of the number of years I have been in this profession, and how I am still angry after all these years.

2. You win a few, you lose many.

The other day I had a patient lose his temper after I challenged his immature thinking pattern. But a few minutes after storming out of the clinic, he returned, apologised for his behaviour, and we had a long talk about his problems.

But compare that with the number of patients who persist in being 'clueless', I am still on a deficit here.

3. For some people, the new year is definitely NOT going to be better.

The 'big picture' means very little when you are looking at individuals with very real problems which they cannot hope to solve on their own. It breaks the heart to see human dignity obliterated by a combination of incurable illness and crushing poverty. And more so when you realise that you yourself cannot see a viable solution for them.

It makes me want to cry 'Enough!' and wonder if there is a way I can better the world we live in more efficiently than doing what I am now doing.


But unlike Oz Bloke, I remain convinced that I am worth more alive than dead. I'll be back, fighting tooth and nail.

I just need some time to lick my wounds.

Vote Early, Vote Often

Never understood how that worked... but voting for the 2005 Medical Blog Awards has opened.



You may cast your vote here.

Voting closes at midnight on Sunday, January 15, 2006 (PST), and the results will be announced on Wednesday, January 25, 2006.