There was an outcry among medical professionals when orthopaedic surgeon Lim Lian Arn was fined the maximum S$100,000 for failing to tell a patient of the possible side effects of an H&L (steroid) injection that he gave her.
Some doctors felt that the ruling could gravely impact how medicine is practised in Singapore and potential lead to rising costs for patients. A petition, started by another orthopaedic specialist Dr Kam San Tho, argued that if doctors were to outline every side effect and secure detailed informed consent for every single minor procedure, that would take a very long time and could ‘paralyse a busy accident and emergency ward’.
The petition, which called for the Ministry of Health (MOH) to clarify their stand on informed consent for minor procedures, has garnered just over 6,000 signatures online.
In the case of Dr Lim, his patient developed ‘paper-thin skin’ with discolouration and loss of fat and muscle on her wrist as a result of the injection. While H&L injections are a common procedure, this side effect is less common.
In his mitigation plea, Dr Lim admitted that he did not tell his patient of any risks or complications at all from the injection. But he also explained that this was an “isolated incident and wholly uncharacteristic of his usual clinical practice”.
He said he normally outlines all treatment options, including possible complications, to his patients. To prove this, he provided anonymised case notes of other patients he saw before and after the incident in which he did indeed provide them with more information about procedures and possible complications.
The tribunal that ruled on Dr Lim’s case said that it is not uncommon for doctors to get specific written consent for H&L injections. However, the author of the online petition disagrees, saying that “the majority of the medical professionals performing these injections do not routinely take or document a detailed informed consent, as stated by the SMC’s own expert witness”.
The petition also highlighted that “it had never been a professional standard of practice to routinely inform patients of minor side effects of medications given for procedures or as prescriptions, especially if they are also uncommon.”
Following the launch of the petition, the SMC said “It should be emphasised that Dr Lim was charged for wholly failing to inform the patient of any possible complications and not for failing to inform the patient of all possible complications that could arise from the H&L injection.”
They clarified that the SMC does not mandate the practice of getting informed consent for minor procedures but that it “would be good clinical practice to document in the case notes that a patient had been informed and was agreeable to the injection, a proposition which no doctor would reasonably disagree with”.
SMC also said that doctors need only to convey ‘relevant and material’ information to their patients and do not need to inform them of all possible complications of a treatment or procedure. They added that remote risks with minor consequences will generally be deemed immaterial, and do not need to be disclosed.
The courts have also clarified in a previous case that an “information dump” would not be appropriate and that a reasonable patient would not need or want to know every iota of information before deciding whether to undergo a proposed treatment, the council noted.
As such, SMC said that the tribunal’s decision serves as a reminder for doctors to document that they have explained the treatment or procedure as well as the patient’s consent – not that doctors must take written consent for every minor treatment or procedure.
Dr Lim’s lawyer had asked for the maximum S$100,000 fine or the minimum three-month suspension, while the SMC had sought a five-month suspension. The tribunal eventually decided to impose a fine and forgo a suspension as they felt there were sufficient mitigating circumstances, said the SMC.
In response to the petition to MOH to clarify their stand, the a ministry spokespersons aid that the MOH understands doctors’ anxiety and shares their concern that healthcare cost should remain sustainable for patients.
She added, “MOH welcomes feedback from stakeholders and we will continue to engage the medical community to see if we can refine our system further to provide greater clarity and certainty for doctors and patients.”
One netizen seems unimpressed with SMC’s vague response to the petition, calling out the absurdity of asking doctors to only disclose ‘relevant information’ but failing to consider that to a medical professional, everything is relevant.
Another netizen pointed out that if a doctor only presented common side effects to their patients but it somehow transpired that their patient experiences the incredibly rare but serious side effect which they were not told about, the responsibility would still be on the doctor’s shoulders for failing to disclose all ‘relevant’ information.
