In an unprecedented move, more than 1,000 doctors have petitioned the Director of Medical Services to revoke the three-month suspension of a paediatrician for failing to diagnose a serious childhood disease in a toddler.

The decision by the Singapore Medical Council (SMC) on Dr Chia Foong Lin, a private practitioner on call at Gleneagles Hospital for that case, was upheld by the Supreme Court last month.

The petition, started on July 4, was sent yesterday to Associate Professor Benjamin Ong, who as Director of Medical Services at the Ministry of Health, is the top medical official in the country.

In it, the doctors expressed their "grave reservations" with an SMC disciplinary tribunal's decision to suspend Dr Chia, a paediatrician of 23 years. They said: "We respect the judgment but we strongly feel the punishment was too harsh."

Dr Chia had been found guilty by the tribunal of failing to diagnose a one-year-old with Kawasaki disease (KD), an acquired illness that could potentially cause heart problems. It suspended her from practice for three months, the minimum suspension possible for gross negligence in not diagnosing and treating the child correctly.

She appealed to the Court of Three Judges, which upheld the tribunal's decision.

It is believed that this is the first time so many doctors have come out in support of a colleague. The petitioners said they were concerned by the severity of her punishment and argued a censure or warning would have been more appropriate to raise awareness and vigilance among doctors.

Medical council defends tribunal's judgment

The Singapore Medical Council has defended the judgment of its disciplinary tribunal in suspending paediatrician Chia Foong Lin for three months for failing to diagnose a child with the rare Kawasaki disease, and said the decision of the Court of Three Judges is final. The disease can cause significant heart problems. It told The Straits Times that Dr Chia, a specialist with 23 years of experience, had "at least three occasions of serious lapses" involving the patient. The first was when she failed to consider the possibility of Kawasaki though the child, who was a year old, had had a fever for five days, a maculopapular rash, which is a combination of both flat and raised rash, conjunctivitis and red lips. The second lapse was to discharge the child while he still had a fever. The third was when she reviewed him two days after discharge, and retained her diagnosis of a viral fever even though he had had a fever the preceding two nights. As a result, Dr Chia "fell short of the reasonable standard of due care and attention expected of her". Her appeal to the Court of Three Judges also failed. In upholding the disciplinary tribunal's decision, the court had said: "It is crucial for a paediatrician to maintain a high index of suspicion in relation to KD." It added: "If she had kept an open mind and maintained a proper appreciation of the symptoms related to KD or incomplete KD, and not been consumed by her own initial diagnosis of viral fever, she would not have failed to undertake the requisite tests to exclude KD. "It was not simply an error of judgment but a serious oversight." As to the petition by the doctors, the SMC said under the Medical Registration Act, "there is no appealing the High Court's decision, and therefore, the disciplinary tribunal cannot consider withdrawing the order of suspension".

RISK OF DEFENSIVE PRACTICE The suspension imposed in this case is likely to prompt health practitioners to lean towards defensive practice, resulting in over-diagnosis of KD, and leading to unnecessary use of intravenous immunoglobulin (a costly blood product). THE DOCTORS, in their petition to the Director of Medical Services.

The doctors said the missed diagnosis was human error and not negligence. "The suspension imposed in this case is likely to prompt health practitioners to lean towards defensive practice, resulting in over-diagnosis of KD, and leading to unnecessary use of intravenous immunoglobulin (a costly blood product)," they wrote.

Kawasaki disease is an uncommon childhood illness occurring in 0.0325 per cent of children younger than five years old here. This works out to about five cases a month. It is not known what causes it but the disease is not infectious.

The doctors noted that there is no test to confirm it, and the child in question did not have all the symptoms - known in medical parlance as incomplete KD.

"Diagnosing KD in young children can be challenging as the clinical signs may evolve with time", said the petition. "Incomplete KD is even more difficult to diagnose conclusively. This is an inevitable and inadvertent limitation of clinical practice."

During the court hearing, expert witnesses for the SMC and Dr Chia had agreed it is not easy to diagnose. But the SMC argued that as it is the most commonly acquired severe cardiac condition, it is reasonable to expect a paediatrician to diagnose and treat it competently.

Its expert witness, Associate Professor Chao Sing Ming, a senior consultant at KK Women's and Children's Hospital, had said Dr Chia's treatment of the child amounted to serious negligence and was wholly unacceptable.

The baby's condition was diagnosed and treated correctly when the parents sought a second opinion with another paediatrician in private practice. They later made the complaint.

The specialist, Dr Lee Bee Wah, said the patient had come to her later, with more symptoms. She was one of 180 paediatricians, including prominent teachers like Professor Quak Seng Hock and Associate Professor Marion Margaret Aw, both of the Yong Loo Lin School of Medicine, who signed the petition. The other 840 are from other specialities.

Two doctors have also written to The Straits Times Forum in support of Dr Chia. One of them, Dr William Yip, said he was trained by Dr Tomisaku Kawasaki himself and has treated children with the disease for 40 years. He said the disease can be "confidently diagnosed only after the first week of illness". He added: "Unnecessary referral and erroneous diagnosis of KD results in significantly costly investigations and inappropriate treatment."

In upholding the tribunal's decision, the court had said it would be "slow" to interfere with its findings unless they were "unsafe, unreasonable or contrary to the evidence".

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