CASE 1

A student attended a medical examination in a busy group practice clinic to apply for a student visa to travel abroad for further studies. In the process, the student’s passport was lost in the clinic. The doctor had to make a statutory declaration, lodge a police report to enable the student to apply for a new passport.

Considerable amount of money was expended by the doctor. Meanwhile, the clinic has installed CCTV and minimized the handling of passports by the staff.

Member wrote in to enquire:

1. for advice
2. whether MDM Bhd will reimburse the expenses?

Comments

1. Clinic is commended for installing CCTV;
2. A passport should be in the possession of the owner; it is to be produced for verification;
3. Loss of important documents is an administrative and security problem and not medical negligence. Reimbursement for expenses incurred cannot be entertained.

CASE 2

General Practitioner gave medical leave to a patient for one day. The employer wrote to the doctor to confirm whether one day or two days medical leave was given. The employer suspects the patient has altered the (1) to (2) days.

COMMENTS

1. The doctor was advised to send a photocopy of the duplicate M.C. to the employer – this will confirm whether the employee has altered the M.C.
2. All M.C.’s and important documents should have double carbon paper. This will prevent erasure or addition.
3. M.C.’s should be in the safe possession of the doctor.
4. The doctor should also inform the patient to avoid an allegation of breach of confidentiality. The doctor owes the patient a duty of care but does not owe the employer anything.

CASE 3

Principal partner of a clinic attended to a diplomat for an ailment. In the proceedings, the diplomat mentioned that one of his staff needed medical attention for “depression”. The doctor suggested that the staff attend for consultation and if necessary he will refer her for a psychiatric opinion.

When the principal partner went on leave the diplomat brought the staff for consultation with the locum doctor. The diplomat impressed on the locum that the principal partner has agreed to give the staff a month’s medical leave. The locum complied.

Subsequently, the office of the High Commission queried the principal partner on why one month’s medical leave was given.

The diplomat, when contacted, denied that he had misrepresented the facts to the locum.

The “depressed” staff came to the clinic with the mother accusing the doctors of misconduct and used unpleasant words.

COMMENTS

1. It is unusual to grant one month’s medical leave. It will be more prudent to grant a week’s medical leave, review the patient and extend the leave or if necessary refer to a specialist.
2. The locum should not have given a month’s medical leave on hear say.

CASE 4

A fifty year old female diabetic patient consulted a physician for neck pain, left shoulder and left arm pain at 10.30am in 2003. She was examined and provisionally diagnosed to have cervical spondylosis with C3.C4 radiculitis. This was explained to her. She was advised to have an M.R.I. of the cervical spine.

Her symptoms were not relieved with inj.Voltaren and Vioxx. Hence the physician prescribed inj. Nabulphine Hydrochloride, 10mg I.M. The M.R.I. appointment was scheduled for 11.30am; and she was observed at the Accident & Emergency Dept. whilst waiting for the M.R.I. scan.

She developed reaction to the Nabulphine inj. (generalized numbness, giddiness and nausea). She requested the nurse to ask the physician to check on her. He prescribed inj. Metoclopramide 10mg I.M. and he saw her two hours later. In view of the reaction to Nabulphine the M.R.I. scan was rescheduled for 2pm. By 2pm, she was still unwell and she declined the M.R.I scan. Instead, plain x-rays of the cervical spine were done.

At 5pm the physician reviewed her. Being still unwell she was advised to be admitted for treatment and observation. Initially she declined. Subsequently, she agreed to be admitted. She was started on I.V. drip of dextrose-saline, I.V. pantoprazole 40mg B.D. as well as inj. Metoclopramide 10mg I.V. p.r.n. Her blood sugar was monitored regularly. She was referred to the orthopaedic surgeon for the cervical spondylosis

By the next day, the side effects from the inj. Nabulphine have subsided. But the neuralgic pain in the left upper limb persisted. She again declined the M.R.I scan.

The orthopaedic surgeon examined her and confirmed the diagnosis. By 2pm she was reviewed by the physician and she was discharged. The patient lodged a complaint against the physician to the Malaysian Medical Council.

The Preliminary Investigation Committee (P.I.C.) of the Malaysia Medical Council (M.M.C) held hearings in 2006 and the physician had to answer three charges:-

1. ‘not warning (the complainant) on the side effects of the medication”
2. “neglecting (the complainant) when she suffered violent reactions” and
3. “acting in an abusive and threatening manner”

The physician attended the P.I.C. with a legal counsel. The P.I.C. dismissed all the three charges.

COMMENTS

1. The treatment rendered by the physician was correct although if more compassion had been shown the complainant would not have lodged her dissatisfaction to M.M.C.

2. At no time her condition was life threatening and she was monitored throughout.

3. Patients nowadays, especially very demanding ones, wants immediate attention to their complaints. They will not hesitate to file complaints with the M.M.C. Good communication with patients and being sensitive to their needs at all times will help in avoiding complaints and/or litigation.

4. MDM Bhd will always provide a legal counsel to its member for such hearing. Practitioners with insurance indemnity are disadvantaged. Insurance companies do not provide its member with legal counsel at such hearings. These practitioners will have to engage their legal counsels.

5. When a practitioner faces the P.I.C. he/she will need to take leave, produce witnesses and if from outstation there will be expenses for board and lodging. At times, the P.I.C. hearing cannot be completed in one hearing. There is a substantial loss of income and incurred expenses in addition to the mental anguish.

6. Practitioners are advised to bear the above factors in mind when treating difficult patients to avoid patients complaining to the M.M.C.

CASE 5

An obstetrician & gynaecologist attended to a 40 year old female with secondary subfertility, when she was 18 months pregnant. She was regularly followed-up in the ante-natal clinic. At 27 weeks gestation ante-natal blood screening was to be done. Patient said this was done at another clinic. At 38 weeks gestation she still could not produce results of the blood screening. This was done immediately as she was having contractions. She was transferred to the labour room for observation.

Haemoglobin, blood grouping, screening for infectious disease (rubella, hepatitis B, syphilis and HIV) were done stat. At this juncture, HIV1 and HIV2 blood test were presumptive active. The doctor informed the patient and the husband (in cantonese).

The doctor suggested to the patient that she be transferred to a University Hospital which has a dedicated infectious disease unit, where the expertise is available to handle babies born to women who are HIV carriers. She agreed.

The repeat blood tests for HIV at the University Hospital were negative. The patient delivered a healthy boy per vaginam.

Subsequently, the medical centre received a letter from the patient’s lawyer demanding an explanation on the episode:

1. Wrongly diagnosing the patient’s HIV status
2. Stigmata to the husband
3. Severe estranged marital relationship
4. The abuses and embarrassment the husband endured from members of the wife’s family
5. The mental anguish and shock on being transferred to another hospital

COMMENTS

1. Letter of apology from the doctor should be given. This will alleviate the situation. Undoubtedly the doctor’s reputation will be affected.

2. False positives must be considered in infectious disease blood tests. Confirmatory tests must be done to rule out false positives.

3. In this instance, the delivery could have been done at the private medical centre after taking all the necessary precautionary measures. This would have avoided the transfer and the inconveniences.

4. Communicating HIV results to the patient will need a lot of skills, more so when the patient cannot understand English. If one cannot speak the dialect then an interpreter may be required, to avoid misunderstanding. Good communication with patients and being sensitive to their needs at all times, particularly in such clinical situations, will help in avoiding complaints and/or litigation. Patients should be informed of what to expect from investigations and their limitations.