By Mak Yuen Teen

The saga involving the two doctors accused of sharing patients for sex continues to put organisations and individuals in the spotlight and raises important issues such as whether the listing of healthcare companies is compatible with medical ethics; the effectiveness of the Singapore Medical Council (SMC) in protecting patients; and the role of stakeholders such as medical insurance providers in promoting high ethical standards and protecting its customers and beneficiaries.

On April 14, I posted my first article about the saga titled “HC Surgical Specialists: From Medical Ethics to Corporate Governance” on this website. One of these doctors, Dr Julian Ong, had lost his defamation suit against the woman who had made the accusations, with the District Court judge finding her comments justified and not defamatory. News media reports on the case, together with screenshots of What’s App messages allegedly sent between the two doctors which have appeared online, raise serious issues of possible professional misconduct. Even if their conduct did not involve patients, there is extremely poor judgement and issues of personal ethics and morality which I believe many patients will find unacceptable in doctors who look after very personal areas of their health.

HC Surgical Specialists (HCSS), listed on the Catalist board of SGX, has been embroiled in the saga because Dr Ong is an employee of the group, and HCSS owns 70 percent of the practice started by him, Julian Ong Endoscopy & Surgery Pte Ltd (JOES). HCSS bought 51 percent in February 2017 and another 19 percent in October 2019, with the additional stake bought some 16 months after a complaint had been made against Dr Ong and the other doctor to the Singapore Medical Council (SMC).

The company has since been queried several times by SGX, and its responses showed that it was aware of the complaint to SMC when it bought the additional 19 percent stake. It relied on Dr Ong’s side of the story that there was no basis to the allegations, without undertaking any independent investigation on the matter.  This raises questions as to whether commercial considerations trumped ethical ones.

The CEO is now the subject of a section 216A action by the woman at the centre of the saga, who happens to own 100 shares in HCSS. I believe that HCSS will continue to face not just legal and regulatory risks, but also reputational ones which will continue to harm its business.

An online petition started at change.org two weeks ago to bar the two doctors from practice has garnered nearly 1,600 signatures as of May 10. The Parkway Group has disallowed Dr Julian Ong from practising in any of the Parkway group hospitals, a stark contrast to the stance taken by HCSS. At least one major healthcare insurance provider appears to have dropped Dr Ong from its updated list of approved panel of specialists released this month. I would expect other insurance providers to take steps to ensure that they only work with doctors and healthcare providers that uphold high standards of professional and personal conduct among its doctors and staff.

The SMC has also faced criticism in its handling of this case.

The woman concerned first complained to it in June 2018, and Dr Ong was formally notified about the complaint some eight months later, in February 2019. It has been about 23 months since and there is no indication as to when the investigations will be completed.

SMC issued a media release on April 22 saying that it is already investigating a complaint against the two doctors. It also said that when the judgement from the defamation suit was brought to the SMC’s attention in April 2020, it had acted immediately to secure undertakings from the two doctors “to refrain from contacting female patients for purposes outside the scope of their medical practices, pending the completion of the disciplinary processes against them”.

Letters to the Forum page of The Straits Times were critical of SMC. One  from AWARE questioned why the SMC only secured the signed undertakings after it learnt of the outcome of the defamation suit.

According to the SMC website: “Investigations by the CC [Complaints Committee] usually take at least nine months. For more complex complaints, investigations may take more than a year.” A Straits Times report on April 16 also said: “Improvements on the SMC’s disciplinary processes are under way with the aim of concluding all cases within 18 months, with some resolved as early as four to six weeks. This is after a work group appointed by MOH recommended changes to improve the SMC’s processes.”

I have looked at 31 decisions made by the Disciplinary Tribunal (DT) of the SMC published on its website from year 2017 to last week. They comprise 11 decisions made in 2017, 11 in 2018, and nine from 2019 until last week. I excluded interim orders by the Interim Orders Committee (IOC) of the SMC which are usually made when a doctor has been charged or convicted of a serious criminal offence. These are usually made expeditiously given the seriousness of the offences and the information available.

From these 31 reports, I extracted various key dates such as date of initial complaint, date the doctor was notified of the complaint, date of notice of inquiry, date of conviction/dismissal of final appeal for cases involving criminal charges, date of DT meetings, date of DT decision, and key details about the cases. Not all the information on dates is available for all cases.

For the complaint against Dr Julian Ong, it has been reported that he was formally notified about eight months after the woman lodged her complaint with SMC. How typical is this? Based on the 15 cases where this information was available, eight months was actually a little faster than average. The shortest time between initial complaint and the doctor being notified was four months, and the longest was 46 months. The median was nine months and the mean was about 13 months. This begs the question as to why it typically takes so long to notify the doctor of a complaint.

SMC also said that investigations by the CC usually take at least nine months. Since the average time it takes to notify the doctor of a complaint is already nine months or more, it seems unlikely that investigations can be concluded within nine months. It also said that it is hoping to conclude all cases within 18 months. So how long does it typically take to complete investigations?

Based on the 22 DT cases where the date of the initial complaint is known, the mean number of months from the time of the initial complaint to the date of the decision of the DT was 53 months, with a median of 51 months. The shortest time was 34 months and the longest 75 months. In other words, none of these cases took 18 months or less.

In the other nine cases, there was no date of initial complaint noted in the DT report. Often, they involved cases where there were criminal convictions. For these nine cases, I took the date of the conviction or dismissal of final appeal as the date of initial complaint and added to the other 22 cases.  The statistics look better in this case. The mean was 47 months, median 49 months, minimum 16 months and maximum 80 months.

There may be a downward bias to the above statistics because there may be long-standing cases that have not been concluded yet (information on ongoing cases is not available).

I would caution that the 31 cases may not be representative of all the cases decided by the DT or convey the efficacy of the current disciplinary process, given that SMC has indicated that it recognises the problem and has sought to improve. So how has the SMC fared more recently?

Therefore, I looked at the most recent cases that have been decided for alleged misconduct that occurred between 2015 and 2017 (these are the most recent cases, even though I looked at all DT decisions published from 2017 to last week), and calculated the difference between the date of DT decision and date of initial complaint/date of conviction/date of final appeal. The mean was 30 months, median 28 months, minimum 16 months, and maximum 54 months, for these nine cases. Only one case was concluded within 18 months.

Therefore, it would appear that SMC still has much to do to achieve its 18-month target.

The protracted disciplinary process has affected the penalties imposed in a number of cases . Of the 31 cases, the doctor concerned was found guilty in 30 cases, which would suggest that only clear-cut cases are considered by the DT. Of the 30 cases where the doctor concerned was found guilty, the delay in the disciplinary process was pleaded as a defence in 10 cases – or one third of all the cases – to reduce the penalties imposed (the term “inordinate delay was often used).  In nine of these cases, the penalties were explicitly reduced on account of the delay, often through the reduction of the suspension period by up to half and/or a reduction of the financial penalty.

There were a number of cases where I felt the protracted process may have exposed patients to clear and present harm. One case was particularly disturbing. This was a case where a doctor was convicted on two charges of outraging the modesty of a patient and sentenced to ten months’ imprisonment. His final appeal was dismissed in November 2015. In January 2016, he was also convicted on a charge of knowingly making a fraudulent declaration to the SMC in an attempt to procure a practising certificate. He was sentenced to a penalty of $3,000 or two weeks’ imprisonment in default for this latter charge. At the DT hearing on March 21, 2018,  he was struck off the register and ordered to pay costs.

The DT made the observation that “no IOC was appointed by the SMC shortly after [the doctor] was charged or at the latest after his appeal was finally disposed of, to consider whether any interim orders (such as interim suspension of registration or making registration subject to conditions or restrictions) was necessary for the protection of members of the public or was otherwise in the public interest”. The failure to do so meant that the doctor “was able to locum carte blanche on a full license since his release in August 2016. Considering the pattern of deception [the doctor] practised on the Patient above, it was only fortunate that [the doctor] did not reoffend during this period. If he had, this would have been a matter of grave concern”. I would add that if he had, SMC would have much to answer for.

SMC should assess whether its current disciplinary process is in good health. The current case involving the two doctors is almost certainly going to put that to a stern stress test.