Angry Doctor

Tuesday, February 28, 2006

A rash of letters

I count a total on nine letters on the medical 'incidents' which we discussed over the past weeks in today's ST Forum.

Six of them touched on the issue of doctors refusing to see patients near to the closing time posted, and all of these argued on the subject of patient-doctor relationship and what the expectations of each side should be. Their arguments move from the specifics of the case to the general, and some are well-argued and others less so, but it is nonetheless interesting to see the view from both sides of the divide.

The letters I want to highlight today, however, are the ones relating to the use of 'Elidel'.

The
complaint letter (emphasis mine), published 23 Feb, reads as follows:


Doctor prescribed unsuitable rash cream

I AM writing to highlight a very unpleasant experience I had with Thomson Paediatric Centre at Thomson Medical Centre.

On Feb 1, I brought my then four-month-old baby to see the pediatrician for a rash on his cheeks. The consultation with the doctor was over in about five minutes as he had to rush off elsewhere.

The doctor prescribed Elidel (pimecrolimus) cream 1% for the rash and told me to apply it twice daily on the affected area. Although this cream cost me $50, I did not mind as I thought it should be good for my son. But this was not the case.

Imagine my shock when I found out through the Internet that Elidel is not approved for use for children below two-years-old.

The possibility of carcinogenicity of Elidel aside, our Health Sciences Authority (HSA) and the US Food and Drug Administration concur in the recommendation against the use of Elidel for children younger than two-years-old.

In addition, both authorities recommend that Elidel should be used only if other creams have not worked.

It was my baby's first visit to the doctor concerning the rash on his face. Yet he was given a cream that is not meant for babies of his age. The doctor also did not caution me on the use of the cream.

I e-mailed Thomson Medical Centre my complaint on Feb 11. To date, it has not responded.

I am disturbed by the lack of consideration in prescribing Elidel for babies against the HSA's recommendations and the medical centre's slow response in this matter.

Are there any measures to ensure that such strong medication is not prescribed carelessly? I hope the relevant authorities can look into this matter to protect other babies and parents who may be none the wiser about this.

Ruth Tan Yueh Herng (Ms)


The reply is published today (again emphasis mine).

Safe to use rash cream on young infants

I APPRECIATE Ms Ruth Tan Yueh Herng's vexation over her child's skin condition in 'Doctor prescribed unsuitable rash cream' (ST, Feb 23). But her letter contains a few misperceptions.

First, this was not the first time Ms Tan had visited our clinic for her child's eczema. It was their third visit for the same condition.

A steroid cream prescribed in a previous visit was obviously ineffective. In fact, Ms Tan had mentioned that the rash was not responding to treatment elsewhere.

As the eczema was severe, a second line medication like Elidel 1% or Protopic 0.03% is in order. This was a considered prescription and not a careless one as mentioned.

The question is: Is Elidel safe in the dosage and duration prescribed? Elidel is an approved drug in Singapore, USA and other countries.

When the US Food and Drugs Administration approved the drug in 2001, the studies were based on children two years and older. Since then, there have been published studies showing that Elidel is safe for use as a topical skin medication in children three months and older.

As a result, the following countries have approved Elidel for use in children three months and older: Australia, Hong Kong, Indonesia, Malaysia, New Zealand, Pakistan, Philippines, and Thailand.

In Singapore, a multicentre trial involving the National Skin Centre, Changi General Hospital and National University Hospital has been initiated to establish the efficacy and safety of Elidel 1% cream in infants.

Perhaps this is why the Health Sciences Authority has not yet updated its recommendation for the use of Elidel 1% in young infants.

Both steroids and Elidel work by suppressing the immune system. Theoretically, both could cause cancer.

Indeed, oral and injectable steroids and Elidel have been implicated in studies to be carcinogens.

However, the topical forms of these drugs have been found to be very safe in large-scale use.

Topical steroids have been in use for decades while there are over seven million users of Elidel 1%. Studies have shown that such creams have minimal penetration beyond the skin and are not well absorbed into the body.

I understand Ms Tan's frustration when her email went unanswered. But she had chosen to email Thomson Medical Centre instead of our clinic.

We could have clarified the matter and saved her unnecessary worry. We would also have told her that I was called to attend to an emergency Caesarean section immediately after the consultation.

It was unfortunate but my patients who have further queries will wait for my return, which takes up to 15 minutes. If this had upset her, I apologise.

Dr Ang Poon Liat


I believe that despite what we read on the ST Forum (and what you read on this blog) most clinical encounters are mutually-satisfactory ones. By making an issue of a single unsatisfactory episode on a public forum, the complainant gives a one-sided and sometimes inaccurate picture of what a doctor and his practice is like. To defend himself against an unfair accusation, the doctor is put in the unenviable position of having to breach patient-confidentialty, and having to expose the complainant as ignorant or being a liar - again certainly not the sum of who that person is.

I wonder how many times incidents of this kind must happen before the ST Forum stops publishing unverified accounts from complainants without referring them first to the parties complained against. That would seem to me the more professional and responsible thing to do, even if it means fewer 'controversies' for us to blog about.

Labels:

9 Comments:

  • I think Straits Times published these letters because it makes for good readership.

    Just look at the number of letters they printed today in relation to doctors. Imagine the number of letters they received!

    From the look of it, there's going to be more of these letters. It's good for ratings and sales!

    By Blogger Dr Oz bloke, At February 28, 2006 5:43 pm  

  • Do sales of the ST actually fluctuate a lot, or enough for them to reap a significant profit?

    In any case, their Forum page is the only part of the newspaper that is available free on the internet.

    By Blogger angry doc, At February 28, 2006 5:49 pm  

  • Aiyah angry doc, I have already made my case that we are singled out by the ST for attacks, and why ST has no problems in doing so

    But dryvlee reminded me why we can do nothing about it.

    As to WHY ST wants to do it.....well if not for money/sales...then WHY?!!

    By Blogger Dr Oz bloke, At February 28, 2006 6:21 pm  

  • I'm just thinking.. if it's really her 3rd visit, why did she specify it was the 1st? Did she think the rash was different?

    I'm a bit concerned also about the 5 minute consultation. In that case, the doctor should have just left without seeing her. But you know what? I believe it's always hard to please everyone. To give both parties the benefit of the doubt, I believe both acted best in accordance to both their circumstances, just maybe that others may not understand the motive that's all.

    I think I sound a bit incoherent now. Hahaha. I hope you guys understood what I meant..

    and angry doc - you're doing good =)

    By Blogger The Rational Neurotic, At February 28, 2006 8:35 pm  

  • I believe that for any complaint directed at a public healthcare institution with regards to a specific case, TPTB have "requested" (*ahem*) that the ST publish the complaint letter TOGETHER with the reply from the institution being complained against. Too bad that this does not apply to private docs & institutions as well...

    By Blogger aliendoc, At February 28, 2006 9:24 pm  

  • I too note the letter by the doc today makes the second time another doc has to breach patient-doc confidentiality in a public media forum to correct misrepresentations by the patient's relatives.

    which brings up a interesting issue. Will the Singapore Medical Council censure both the docs by doing so? Not being from the medical field, I'm not too sure about the mitigating circumstances that allow such revealing of confidential information, especially in a public forum. Can the docs here shed light on this?

    By Blogger phelan, At February 28, 2006 10:33 pm  

  • phelan, the issue of confidentiality was discussed at Mr Wang's blog:

    http://www.blogger.com/comment.g?blogID=12908820&postID=114085512077803548

    I believe in this case "qualified privilege" can be claimed by the patient as immunity against a counter-suit by the doctor rather than as a defence by the doctors.

    By Blogger angry doc, At February 28, 2006 11:06 pm  

  • Sounds like Ms. Ruth Tan Yueh Herng has a serious problem: interpreting limited info with her limited experience. If I use the internet, I can prove Nutra-Sweet causes cancer. I can also prove that time-tested treatments such as heparin for heart attacks really have no true studied data to support it. Many, many FDA-approved drugs are used for "off-label" aka non-FDA approved uses, but most people don't know this fact either. She needs to stop this mentality of "I'm smarter than the doctor because I read some stuff on the internet."

    The facts are some treatments don't work, and some medical problems can take multiple tries, usually because (among other reasons): 1) the issue is not life-threatening and 2) why not start with more benign treatments than more potentially dangerous ones.

    If she doesn't like her doctor, she should go get a new one, preferably one that can spend more than 5 minutes with her, because there is a lack of communication between these two. I find it disgusting that she takes her issue into such a public forum to disparage someone who sounds like has made an effort to treat her child, and has put some thought into it.

    By Anonymous Anonymous, At September 17, 2008 11:27 am  

  • This is a tricky issue because Elidel does still has a question mark over it's head and should be used with caution.

    However, in young children unresolved eczema can have disastrous consequences. A few years ago I read of an infant who died unnecessarily because her parents refused to use conventional medicines on her eczema; she got a secondary skin infection and died. I don't think I am in a position to advise on Elidels use for infants however It seems that the doctor was trying to act cautiously for this reason.

    Here's my two cents on the use of Elidel for adults~
    http://www.parkitweb.com/skinsavers/2010/04/06/elidel-pimecrolimus-1-cream/

    By Anonymous Amandap, At May 20, 2010 5:29 pm  

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