Singapore Medical Council v Wong Him Choon  SGHC 145
Significance: The Court of Three Judges reversed the decision of the Disciplinary Tribunal (DT) on appeal by the Singapore Medical Council (SMC) and held that the medical doctor, a consultant orthopaedic surgeon from Raffles Hospital, had breached his ethical duties to the patient, a migrant construction worker, by issuing inadequate medical leave (MCs) in disregard of the patient’s interests and having regard instead for extraneous interests such as those of the worker’s employer.
Medical Professional Misconduct, Singapore Law, DIsciplinary Proceedings, Doctors, Migrant Workers
As a summary of the facts, the patient was a PRC construction worker who fell 3 metres and fractured his hand which he used to break the fall. The doctor conducted surgery and gave him only 2 days medical leave or MC for the time the migrant worker was hospitalised. He gave the worker “fit for light duties” for the remaining days. Jolovan Wham from H.O.M.E. called the hospital subsequently and was informed by a nurse that this was the arrangement between the company, the worker’s employer, and the doctor. Jolovan Wham filed a complaint to SMC on behalf of the worker, bringing up the fact that the company’s “collusion” with the doctor was because of trying to circumvent the regulation that workplace injuries resulting in 3 or more days of MC had to be reported. The worker was returned to work but was not paid his salary for not working, obviously being unable to work given his fractured hand, and because he was not given MC.
: “This case also – as we shall also elaborate upon below – concerns the important issue of perspective. In particular, the doctor must also be cognisant of the patient’s position and welfare. And this entails placing himself or herself in the shoes of the patient, so to speak. In this regard, the following oft-cited advice from a father to his daughter in a famous novel ought to be noted (see Harper Lee, To Kill A Mockingbird (William Heinemann Ltd, 1960; reprinted in the New Windmill Series, 1966) at p 35):
First of all, … if you can learn a simple trick, Scout, you’ll get along a lot better with all kinds of folks. You never really understand a person until you consider things from his point of view – … until you climb into his skin and walk around in it.”
Of significance is a submission made by the doctor’s lawyer / legal counsel, Mr. Selvaraj that the doctor did what he did in relation to the patient because the doctor had “dealt with foreign workers, he had some knowledge about them”. The Court rebuked the party, stating that “this was an illegitimate and outrageous submission that should never
have been made before this court”: .
Regarding the substantive issue, the Court applied the two limb test in Low Cze Hong v Singapore Medical Council  3 SLR(R) 612 (“Low Cze Hong”) for the determination of “professional misconduct”:
(a) where there is an intentional, deliberate departure from standards observed or approved by members of the profession of good repute and competency (“the first limb”); or
(b) where there has been such serious negligence that it objectively portrays an abuse of the privileges which accompany registration as a medical practitioner (“the second limb”).
The Court then referred to the analytical framework set out in Ang Pek San Lawrence v Singapore Medical Council  1 SLR 436 (“Ang Pek San Lawrence”): see . The DT has to make the following findings before it can hold that the SMC has proven the charge against the allegedly errant doctor:
(a) In relation to the first limb of Low Cze Hong:
(i) what the applicable standard of conduct was among members of the medical profession of good standing and repute in relation to the actions that the allegation of misconduct relates to;
(ii) if the applicable standard of conduct required the said doctor to do something and at what point in time such duty crystallised; and
(iii) whether the said doctor’s conduct constituted an intentional and deliberate departure from the applicable standard of conduct.
(b) In relation to the second limb of Low Cze Hong:
(i) whether there was serious negligence on the part of the doctor; and
(ii) whether such negligence objectively constituted an abuse of the privileges of being registered as a medical practitioner.
In assessing the facts of the case, the Court referred to two medical experts. The expert SMC relied on was Associate Professor Aymeric Lim, the Chairman of the Medical Board of the National University Hospital (“NUH”), a Senior Consultant of the Department of Hand & Reconstructive Microsurgery in NUH. The central strand that ran through A/P Lim’s evidence was that it was incumbent on Dr Wong to ensure that there were adequate conditions for the Patient’s rest and rehabilitation when issuing light duties to the Patient. His ultimate point, however, was that light duties should have never been issued in the present case and was in favour of prescribing at least two weeks of medical leave: .
The doctor relied on Dr Bose, a Consultant Orthopaedic Surgeon at the Mount Elizabeth Medical Centre and a Visiting Consultant (Department of Orthopaedic Surgery) at the Singapore General Hospital. Dr Bose’s evidence was that he did not “find the management of the case by [Dr Wong to be] wanting in any way”. In this regard, as noted by the DT, he was of the view that it was not the normal practice to give medical leave to a patient who had gone for surgery for a distal radius fracture: .
The Court accepted both experts’ common view that the applicable standard required the doctor to establish that there
were adequate conditions for rest and rehabilitation before light duties were given: .
In relation to the appropriateness of certifying a patient fit for light duties immediately after the surgery for a distal radius fracture instead of two weeks of medical leave, the Court, following the DT, preferred A/P Lim’s evidence over that of Dr Bose. A/P Lim’s evidence was preferred as it was supported by academic literature that states that during the immediate postoperative period, the patient would have required immobilisation of his affected limb: .
The Court also found, based on the experts’ common view, that the duty of the doctor to discuss with the patient whether there were adequate conditions for rest and rehabilitation crystallised and was to be discharged before the doctor decides on the type and duration of medical leave to be administered on the patient: .
The Court then held that the DT’s decision was contradictory to its findings on the evidence. The Court held that there was “a fundamental disconnect between the DT’s finding … on the one hand and the actual (as well as objective) evidence which it took into account in holding that Dr Wong fell below the applicable standard… the DT made all the findings that were necessary to establish an intentional, deliberate departure from the applicable standard by Dr Wong and thereby convict him of the Charge but then decided not to convict him of the same by focusing on an issue that was entirely irrelevant to the Charge…”: .
The Court stated that the applicable standard would have required the doctor to establish that there were adequate conditions for rest and rehabilitation if medical leave for two days after the surgery followed by light duty was to be given: .
The Court found that Dr Wong did not ascertain the existence of light duties during his initial consultation with the Patient, and that he had relied on his previous experience with Kajima, the patient’s employer, and had assumed that such duties would be available. Because the applicable standard would require him to establish adequate conditions for rest and rehabilitation vis-à-vis the Patient, the Court found that these were assumptions that Dr Wong was not entitled to make: .
The Court found at  that “Dr Wong did not make any adequate inquiries of the Patient’s conditions of work or rest”.
The Court found at  that Dr Wong’s subsequent “backdating of the MC therefore supports the view that Dr Wong was attempting to cover up his mistake of failing to ensure that there were adequate conditions for rest and rehabilitation for the Patient before certifying him fit for light duties on [the initial consultation]”.
It was further found that Dr Wong knew of the applicable standard that was required of him, that is to establish the existence of light duties and the patient’s conditions first before certifying a patient fit for the same. The Court referred also to para 188.8.131.52 of the SMC’s Ethical Code and Ethical Guidelines–“A doctor is expected to have a sense of responsibility for his patients and to provide medical care only after an adequate assessment of a patient’s condition through good history taking and appropriate clinical examination”. As the Code and Guidelines represent so fundamentally the most basic aspects of clinical practice, the Court opined that an errant practising doctor would be hard put to argue that he has no knowledge of matters which are covered by the said Code and Guidelines. On the contrary, there would be a strong presumption that he has knowledge of the matters contained therein: .
The Court further opined in obiter dicta and not as a reason for its decision that based on the findings of the DT, “Dr Wong would, in any case, have been liable for gross negligence under the second limb of Low Cze Hong: .
On sentencing, the Court found that there were aggravating factors in the case.
At , the Court found that “Dr Wong’s failure to provide a MC to cover the Patient for even the period between 5 to 7 September 2011 demonstrated a wilful disregard for the patient’s welfare and interests, and in particular, his need for proper rest and rehabilitation“.
The doctor’s argument was that “he did not give the Patient medical leave as he wanted the Patient to have “supervised rest””: . At , the Court condemned the reasoning and argument. It said Dr Wong “appeared to be concerned that he would not be able to supervise the Patient to ensure that the Patient was not abusing the medical leave if he were to grant the MC. If this was truly his reasoning, then it would seem to suggest that he thought foreign construction workers were somehow to be treated differently from other patients. Indeed, this appeared to emerge also from Mr Selvaraj’s submissions (see above at ). We wish to emphasise in no uncertain terms that this is utterly wrong. The doctor’s first priority is to ensure the patient’s care and welfare”.
The Court then harshly said at : “Dr Wong’s evidence also exhibits an indifference to the welfare of the Patient. In this regard, he was content with giving the Patient, a foreign construction worker, light duties and letting the employer decide the extent to which the Patient should rest. He appeared to also be keen in maximising the value that the employer could extract from the construction worker“.
The Court then stated that “Dr Wong’s main concern was not the patient’s welfare and interest – he was, instead, advancing the interests of the employer and wanted the Patient to return to work as soon as possible“: .
“The evidence also demonstrated that Dr Wong possibly did not give the Patient medical leave, as he was suspicious of the circumstances surrounding his accident. As noted above at , Dr Wong checked the expiry of the Patient’s Work Permit upon seeing him. Dr Wong was cross-examined on why this was done. He responded that this was because, inter alia, he observed an “increased frequency” in foreign workers getting injured before their Work Permits expired”: .
At , the Court stated “Dr Wong was unremorseful and sought to pin the blame on the Patient for his own failure to adequately manage his post-operative recovery”.
The Court opined at  that “[i]t should not be the case that a patient has to “kneel and beg” (as the Patient in fact did, according to Dr Wong) for medical leave that he was in any case entitled to on proper clinical grounds. This was what happened to the Patient. All in all, in our judgment, the evidence revealed that Dr Wong chose not to give the Patient medical leave for a multitude of extraneous, less than proper, as well as non-medical considerations”.
In conclusion, the Court sentenced “Dr Wong [to] be (1) suspended for a term of six months with effect from the delivery of our judgment; (2) censured; and (3) required to furnish a written undertaking not to repeat such professional misconduct. Dr Wong was to bear the costs of the inquiry before the DT and the appeal”: .