Guidelines to Minimise Misdiagnosis by Doctors

Ms Tin Pei Ling asked the Minister for Health with regard to a recent case where a paediatrician was suspended for professional misconduct after she failed to properly diagnose and treat a young patient for Kawasaki disease, whether the Minister can explain the basis for the decision and the duration of the suspension in comparison to other cases involving disciplinary actions.

Ms Tin Pei Ling asked the Minister for Health what safeguards are there to prevent misdiagnoses and to ensure good health outcomes within the public and private healthcare systems in Singapore.

Ms Tin Pei Ling asked the Minister for Health (a) whether there are studies made as to the countries where defensive medicine is practised; (b) whether he can share the findings from these studies; and (c) what are the potential implications if it happens in Singapore.

Mdm Speaker, Kawasaki disease is a childhood disorder affecting the blood vessels with an incidence of approximately 32.5 per 100,000 children less than five years old per year. KK Women and Children's Hospital and NUHS see about 160 to 190 Kawasaki disease cases per year. Kawasaki disease is also the most common cause of acquired heart disease in children in developed countries. If left untreated, about 15%-20% of cases develop coronary aneurysms and ectasia, and the risk of ischemic heart disease and sudden death.

The background facts to the case are as follows. On 25 February 2013, the patient, a one-year-old child, was hospitalised at Gleneagles hospital with high fever for three days and red eyes, besides other symptoms. The paediatrician who was on call at the hospital, Dr Chia Foong Lin, attended to the child and diagnosed the case as a viral infection.

Two days later, on 27 February, or the fifth day of the child's fever, the child was noted to be fretful, had red lips and developed a rash. On 28 February, the following day, he had a spike of fever in the morning and red and cracked lips. Dr Chia considered the possibility of Kawasaki disease and looked for the full features of Kawasaki disease. However, she did not conduct any supportive tests for Kawasaki disease and did not share this with the parents. Dr Chia's diagnosis remained as viral infection as there were no full features of Kawasaki disease.

On 1 March, the fifth day in the hospital and the seventh day of the child's fever, the child was discharged by Dr Chia as the fever appeared to have settled. According to Dr Chia, the red eyes improved and no rashes were seen but his lips were still slightly red and cracked. The diagnosis by Dr Chia was again viral infection.

On 3 March, which was the ninth day of the child's fever, the child was reviewed by Dr Chia as an outpatient at her clinic. Dr Chia was informed by the parents that the fever had continued in the two days after discharge although, according to Dr Chia, the red eyes and the rashes had resolved and the child's lips had improved. The history of the progression of the child's symptoms and signs, including prolonged fever, red eye, rash and red lips were suggestive of Kawasaki disease which should have prompted Dr Chia to carry out supportive tests, but Dr Chia still maintained that it was viral fever and did not order any supportive tests.

The next day, on 4 March, the child's parents decided to seek a second opinion and went to consult another paediatrician as the child continued to have high fever. On examination, she noted that the child was irritable and had a rash on the upper body. The second paediatrician also noted redness in the child's palms and soles, prominent lymph nodes on the right neck and discovered a heart murmur. All these were signs suggestive of Kawasaki disease. She ordered the blood tests which supported the diagnosis of Kawasaki disease and an echocardiogram which showed that the blood vessels of the heart was already affected. Fortunately, the child responded well from the treatment for Kawasaki disease and the fever settled.

The child's mother then filed a complaint with the Singapore Medical Council (SMC). In accordance with the Medical Registration Act, the SMC convened a Complaints Committee. After conducting its own investigations, the Complaints Committee concluded that a formal inquiry by a Disciplinary Tribunal (DT) was necessary.

A DT was convened comprising two senior doctors and a lawyer. During its inquiry, the DT also considered the opinions of two expert witnesses. The DT noted that there were already well accepted international guidelines for the diagnosis of Kawasaki disease since 2004. Based on these international guidelines, the child presented with signs and symptoms which should be investigated further for Kawasaki disease. 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 about this possible diagnosis which she had considered. The DT judged that this amounted to professional misconduct on her part.

In deciding on the sentence, the DT considered eight precedents relating to doctors who had missed or given a wrong diagnosis, failed to provide adequate advice and/or failed to provide adequate and timely treatment to patients. The DT noted that six of the precedents were dealt with by a suspension instead of a fine. The DT also took into account the seniority of Dr Chia and that she was an experienced paediatrician of 23 years' standing. After considering all the relevant facts and circumstances, including the aggravating and mitigating factors, such as Dr Chia's unblemished record, the many testimonials and character references and her contribution to society, the DT ordered a three-month suspension, which is the shortest suspension under the Medical Registration Act.

Dr Chia appealed to the High Court against the DT's decision. The High Court noted that Dr Chia had not pleaded guilty to the charge and that the disease faced was not uncommon. Taking these factors, as well as the precedents into consideration, the High Court found the order of three months' suspension to be appropriate. The appeal was then dismissed by the High Court.

Dr Lim asked if MOH advocates doctors to send all cases for detailed diagnostic tests to avoid misdiagnosing rare medical conditions. The answer is no. Such defensive medicine practice deviates from good clinical practice. It will also unnecessarily increase healthcare costs. Dr Lim also asked if the Ministry should issue standard practice guidelines on diagnosis for all potentially rare illnesses. It is neither possible nor practical for MOH to issue guidelines for all rare diseases. Doctors would have to exercise their clinical judgement in such situations. However, in this particular case, there were already existing international guidelines which warranted further investigations to diagnose Kawasaki disease, given the symptoms and signs of persistent fever, red eyes, red cracked lips and a rash.

Ms Tin asked if there have been international studies on defensive medicine, which is defined as a deviation of sound medical practice that is induced mainly by a fear of medical malpractice action. There have been a few international studies, mainly comprising surveys of doctors, which noted the high prevalence of defensive medicine practices overseas, resulting in unnecessary increases in healthcare costs. Other international studies have also suggested that a substantial fraction of malpractice claims are a result of failure of doctor-patient communication. There has been no local studies on defensive medicine.

As part of their work, doctors are expected to exercise good clinical judgement to manage patients appropriately. Clinical judgement is dependent on the seniority of the doctor, the area of practice and experience, clinical presentation of each patient and the facts and circumstances surrounding each case. For cases which are complex or for which the treating doctors are unsure, they can also discuss with other colleagues on the most appropriate management of the case. In addition, medical knowledge is constantly evolving. It is important for doctors to keep abreast of medical knowledge and international guidelines based on the recommendations of medical experts.

Hence, SMC requires all doctors in the public and private sectors to have mandatory continuing medical education. Our hospitals and institutions also have teaching, training and peer review to enable doctors to maintain and upgrade their skills.

Let me just thank the Senior Minister of State for the very long account that he has just given. I would like to ask the Senior Minister of State regarding the blood test he referred to for diagnosis of Kawasaki disease. What is the exact blood test he is referring to? Because, as far as I know, there is no specific blood test for Kawasaki disease in the first place. Last of all is that it is very common. I mean, for all parents here who have children, to find a child with fever, with a rash. Does it mean that every single child with rash and fever has to be sent for a cardiac scan in future? I think that is the fear that we have now.

What is the impact of this verdict on current healthcare costs? Frequently, we hear complaints from our residents, from our patients that the investigation costs are going up − tests are very expensive. In fact, every single blood test, every single scan, every single MRI you do, is expensive. Every single headache could be a brain tumour. Are we going to investigate every single headache with a scan as well? I think these are the pertinent questions that we are asking.

Is MOH monitoring whether there are signs of defensive medicine being practiced in Singapore? Currently, if you look at the outpatient bill, what proportion of the outpatient bill is investigation cost versus consultation and medication cost? Is the investigation cost portion increasing over the years? These are the things that I think MOH should be looking at as well.

I would like to thank Dr Lim for the also very long and comprehensive comment, and the many supplementary questions. With regard to the first question, which is on the type of blood test that can be used in the diagnosis of Kawasaki disease, we are referring to C-reactive protein which is the inflammatory marker for any form of inflammation. Though non-specific for Kawasaki disease, it is a supportive investigation that helps in the diagnosis of Kawasaki disease. And, of course, in cases where Kawasaki disease is highly suspected, there is also a need to order echo-cardiogram to assess the coronary vessels to look for any aneurysms or dilatation.

The American Heart Association has come up with international guidelines in the management of Kawasaki disease as well as the evaluation of incomplete Kawasaki disease. If you look at the literature, incomplete Kawasaki disease is more common in children who are of a very young age, which was what this child had in this case − incomplete Kawasaki disease.

If doctors were to follow the international guidelines issued by the American Heart Association, the definition of incomplete Kawasaki disease is defined as persistent fever with at least two signs that are suggestive of Kawasaki disease. So, in this case, the patient does have persistent fever, the patient has skin rash, bilateral sore eyes as well as cracked lips. So, this patient actually had more than two signs; he had three signs. Based on the international guidelines, supportive tests, such as C-reactive protein and echo-cardiogram, should have been ordered.

As to the Member's second comment on whether every child with fever or rash should therefore be investigated for Kawasaki disease, the answer is obviously no. But it is important for doctors to have the enhanced awareness that should the patient develop other symptoms or signs that point towards Kawasaki disease, further investigation would be warranted.

I also understand that there are many doctors who are concerned with the verdict and judgement of this case. My advice to doctors is that they should stay calm and not overreact. Secondly, do read and understand the proceedings of the DT and appreciate the rationale and considerations of the judgement. Because, very often, when doctors read the headlines, they will jump to the conclusion that, "Oh, if I miss a fever and therefore miss a Kawasaki disease diagnosis, I will be suspended for three months". That is actually not the case.

One of the common questions that Dr Lim had alluded to is: "Should I investigate every child who presents with fever or a rash for Kawasaki disease?" Of course, like I mentioned previously, the answer is no. That would actually be tantamount to very poor clinical judgement and defensive medicine.

The advice to doctors is that we should fall back on basics first. Getting a good history and a thorough and proper clinical examination is critical in the practice of medicine. Consider any international guidelines available in the evaluation and management of the condition at hand. In the case of Kawasaki disease, the international guidelines on the evaluation of suspected incomplete Kawasaki disease and the diagnosis of management of Kawasaki disease from the American Heart Association is internationally well-known and accepted and has been there since 2004.

If the doctor is unsure or if the case is complex, please do not hesitate to discuss with other more experienced colleagues on the most appropriate management of the case. And last but not least, I would like to remind doctors to participate actively in continuing medical education and to continue to build strong trusting relationships with the parents, with the patients, with the family members through clear communication and informed shared decision making.

And to the Member's last supplementary question on whether there is any increase in unnecessary investigations, I think the trend is towards that. MOH is monitoring this very carefully and, like I mentioned, if doctors were to practise good clinical judgement, we do not have to go towards defensive medicine.