18th March 2018
CASE REPORTS FOR 2013
A 58 year old lady presented with recurrent bilateral dislocation of the patella with mild osteoarthritis of the knees. Bilateral total knee (computer aided) replacement was done.
In addition to the joint replacement the orthopaedic surgeon claimed for bilateral osteotomy of the knees and bilateral synovectomy of the knees.
The patient was presented with a total bill of RM25,000.00 which she settled. The hospital overlooked the billing of RM11,000.00 for the "navigated mobile bearing total knee package". She was asked to settle this sum after she was discharged.
The orthopaedic surgeon's professional charges were:
i) Computer Aided Surgery RM3,150.00 includes 5% levy by the hospital
The total sum of RM14,132.75 included the 5% levy on the doctor's fees.
The children were upset with the demand to pay the RM11,000. They lodged a complaint with the Ministry of Health.
i. The orthopaedic surgeon was advised to settle the issue amicably. The patient should not be asked to pay the RM11,000 due to the fault of the Hospital Administration.
iii. The osteotomy was not specific and the question is raised was this done or indicated?
vi. She presented with recurrent subluxation of the patellae with mild osteoarthritis. A total knee replacement is not indicated.
v. "Computer Aided Surgery" - there is no "fee schedule for such a procedure in the PHFS Act 1998. In the event computer aided surgery was used the orthopaedic surgeon should not charge this fee. This fee has been factored in the invoice for "navigated mobile bearing total knee package".
vi. The osteotomy and synovectomy would have been done through the same incision for the total knee replacement. Quoting the PHFS Act 1998 and Regulations & Order, Regulation 433, Part A - Medical Fee 2 - "when two procedures are performed through the same incision, the fee chargeable for the lesser procedure should not exceed 50% of the fee charged for the lesser procedure.
vii. The hospitals 5% levy on the orthopaedic surgeon is unethical - it amounts to "fee splitting". The hospital may levy the 5% under "administration but should not lump it with the orthopaedic surgeon's professional charges.
CASE NO. 2
An anaesthetist gave anaesthesia to a patient with an intra-orbital abscess. The abscess was drained by the ophthalmologist, who also gave an intravitreal injection of antibiotics. The patient has sued the ophthalmologist. The patient's solicitor served a subpoena, with RM300, on the anaesthetist to be a witness. The solicitor also requested that the anaesthetist give a detailed account of her involvement.
Member asked whether she has to attend court.
1. The anaesthetist has to attend court as a subpoena has been served. She can charge a witness fee.
2. The detailed account amounts to a medical report. Consent must be obtained from the patient (via the solicitor) and a fee can be charged for writing the medical report.
3. Please refer to the attached sheet on Subpoena and Witness Fees.
CASE NO. 3
An Obstetrician & Gynaecologist treated a lady with second degree prolapse uterus with a cystocoele. Under spinal anaesthesia while attempting a vaginal hysterectomy the patient sustained a two centimetre bladder tear during the dissection.
After discussing with the patient and the patient's husband the doctor did a total abdominal hysterectomy. The bladder was repaired from the vaginal approach. A continuous bladder drainage was instituted.
Two days postop, urine leaked from the vagina. The patient was examined under G.A. and a one centimetre bladder tear was noted. This was repaired in two layers. Again continuous bladder drainage was done.
She was discharged on third postop day. On the ninth postop day she was reviewed. There was no urine leaking. The continuous bladder drain was removed. On the fourteenth postop day the patient returned with urine leaking.
The obstetrician and gynaecologist referred her to a urologist. The urologist delayed the repair to three weeks later to get optimal result. The bladder repair was successful.
The obstetrician and gynaecologist received a Writ of Summons one day before the expiry of the statute limitation!
1. On lacerating the bladder the member should have asked for help from a urologist.
2. If no urologist was available the obstetrician and gynaecologist should have completed the hysterectomy. The bladder should be drained continuously. The obstetrician and gynaecologist should refer the patient to the urologist as soon as possible.
3. In today's setting unless the obstetrician and gynaecologist is urologically trained lesions of the kidney, ureter, bladder and urethra should be managed by a urologist.
4. The case could not be defended. It was settled out of court for a sum without admission of liability.
5. Had MDM Bhd exercised the exclusion clause - "Any claims arising out of a specific liability assumed by the member under contract which goes beyond his duty to use such skill and care as is usual in the exercise of the member's activities stated in the Application Form", the member would have had to fund his defence.
CASE NO. 4
A partner of a General Practitioner Group Practice, is a member of a bank's panel treating its staff. The group were requested to conduct medical examination on staff with frequent medical certificates and furnish the bank with a medical report on such staff.
The bank staff has requested a copy of the medical report of the medical examination. The Group declined the request. The staff is a member of the bank union. The Union of the Bank Employees requested the Group to provide the medical report to its members, otherwise the Union will lodge a complaint with Malaysian Medical Association and other authorities complaining that the Group has not complied with the doctor-patient confidentiality. The Group requests for legal advice.
1. The doctor has a duty of confidentiality to his patients.
2. The medical examination of the employee must be done with his consent, and he must be made aware of the purpose of the examination.
3. Since the medical report is about the staff he is entitled to a copy.
4. Staff taking too much M.C.'s will come under the purview of the Human Resource Department of the
5. Malaysian Medical Association has no jurisdiction to take actions against the Group.
6. Doctors are reminded to refer to -
i) Malaysia Medical Council's CODE OF PROFESSIONAL CONDUCT
ii) M.M.C.'s GOOD MEDICAL PRACTICE
iii) M.M.C.'s CONFIDENTIALITY
5. Disclosure of Information Without the Patient's Consent
CASE NO. 5
In October 2006 a 42 year old female was diagnosed as grade II infiltrating, ductal carcinoma of the breast - T4 cm node, 6axillary nodes out of 24 involved, ER (estrogen receptor) / PR (progesterone receptor) negative, HER 2 (human epidermal growth receptor type 2) negative.
Right mastectomy and axillary clearance were performed in October 2006.
She underwent a course of chemotherapy from November 2006 to February 2007.
She also had a course of radiotherapy to the right supraclavicular fossa and the right chest wall from March 2007 to April 2007.
In March 2008 she presented with pain in the left sternoclavicular area. C.T. Scan of the area reported nothing abnormal.
In June 2008, during follow up she yet complained of pain in the left sternoclavicular area. An ultrasound of the abdomen revealed multiple liver secondaries.
A re-staging C.T. Scan confirmed metastatic disease in the liver and medial end of the left clavicle. She was advised to undergo a course of chemotherapy.
A meeting between patient, oncologist and radiologist was held to discuss the missed findings of the C.T. Scan of March 2008.
She lost confidence in her doctors in Malaysia and sought chemotherapy overseas.
The oncologists and radiologists overseas have confirmed that the metastases were present at the medial end of the left clavicle in the C.T. Scans of March 2008.
The patient succumbed to her illness in June 2009.
In March 2012 the oncologist and radiotherapist and the hospital received a letter of demand for general and special damages of RM462,416.00.
The oncologist, MDM member, requested for assistance.
1. Oncologist and radiologist should have admitted the error in the interpretation of C.T. Scans of March 2008 and apologized immediately.
2. Giving an apology is not an admission of liability. In many incidents an immediate apology has diffused the situation. In this instance a letter of demand was issued to the radiologist, oncologist and the hospital because of the delay in tendering the apology.
3. The radiologist has missed the findings in the C.T. Scan of March 2008. He bears the responsibility of the error, but the oncologist cannot be exonerated as he had the clinical advantage of examining the patient and correlating the clinical findings with the C.T. Scan findings.
4. The deceased's estate has not continued to pursue the matter. If the matter is pursued, an out of court settlement should be considered with the radiologist bearing the bulk of the damages.
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