Kawasaki Disease

Name and Constituency of Member of Parliament

Dr Lim Wee Kiak
MP for Sembawang GRC

Question No. 1288

To ask the Minister for Health in light of the recent case of misdiagnosis of Kawasaki disease (a) whether there are guidelines for doctors to send all cases for detailed diagnostic tests to avoid misdiagnosing rare medical conditions; (b) if there are no such guidelines, whether the Ministry can issue standard practice guidelines on diagnosis for potentially rare illnesses; and (c) if so, how will this impact on the cost of healthcare.

Name and Constituency of Member of Parliament

Ms Tin Pei Ling
MP for MacPherson

Question No. 1291

To ask the Minister for Health with regard to a recent case where a paediatrician was suspended for professional misconduct after she failed to properly diagnose and treat a young patient for Kawasaki Disease, whether the Minister can explain the basis for the decision and the duration of the suspension in comparison to other cases involving disciplinary actions.

Question No. 1292

To ask the Minister for Health what safeguards are there to prevent misdiagnoses and to ensure good health outcomes within the public and private healthcare systems in Singapore.

Question No. 1293

To ask the Minister for Health (a) whether there are studies made as to the countries where defensive medicine is practised; (b) whether he can share the findings from these studies; and (c) what are the potential implications if it happens in Singapore.

Oral Reply

1.     Kawasaki Disease (“KD”) is a childhood disorder affecting the blood vessels with an incidence of approximately 32.5 per 100,000 children less than five years old per year.  KKH and NUHS see about 160 to 190 KD cases per year.  Kawasaki Disease is also the most common cause of acquired heart disease in children in developed countries. If left untreated, about 15-20% of cases develop coronary aneurysms and ectasia, and risk of ischemic heart disease and sudden death.

2.     The background facts to the case are as follows.

(i) On 25 February 2013, the patient, a one-year-old child, was hospitalised at Gleneagles hospital with high fever for three days and red eyes, besides other symptoms. The paediatrician who was on call at the hospital, Dr Chia Foong Lin, attended to the child and diagnosed the case as a viral infection.

(ii) On 27 February, or the 5th day of the child’s fever, the child was noted to be fretful, had red lips and developed a rash. On 28 February, the following day, he had a spike of fever in the morning and red and cracked lips. Dr Chia considered the possibility of KD, and looked for the full features of KD.  However, she did not conduct any supportive tests for KD and did not share this with the parents. Dr Chia’s diagnosis remained as viral infection as there were no full features of KD.

(iii) On 1 March, the 5^th day in the hospital and the 7^th day of the child’s fever, the child was discharged by Dr Chia as the fever appeared to have settled. According to Dr Chia, the red eyes improved and no rashes were seen but his lips were still slightly red and cracked. The diagnosis by Dr Chia was again viral infection.

(iv) On 3 March, which was the 9^th day of the child’s fever, the child was reviewed by Dr Chia as an outpatient at her clinic. Dr Chia was informed by the parents that the fever had continued in the two days after discharge although according to Dr Chia, the red eyes and the rashes had resolved and the child’s lips had improved. The history of the progression of the child’s symptoms and signs including  prolonged fever, red eye, rash and red lips were suggestive of KD which should have prompted Dr Chia to carry out supportive tests, but Dr Chia still maintained that it was viral fever and did not order any supportive tests.  

(v) The next day on 4 March, the child’s parent decided to seek a second opinion and went to consult another paediatrician as the child continued to have high fever. On examination, she noted that the child was irritable and had a rash on the upper body. The second paediatrician also noted redness in the child’s palms and soles, prominent lymph nodes on the right neck and discovered a heart murmur. All these were signs suggestive of KD. She ordered the blood tests which supported the diagnosis of KD and an echocardiogram which showed that the blood vessels of the heart was already affected. Fortunately, the child responded well from the treatment for KD and the fever settled.

3.     The child’s mother then filed a complaint with the Singapore Medical Council (“SMC”). In accordance to the Medical Registration Act, the SMC convened a Complaints Committee. After conducting its own investigations, the Complaints Committee concluded that a formal inquiry by a Disciplinary Tribunal (“DT”) was necessary.

4.     A DT was convened comprising of two senior doctors and a lawyer. During its inquiry, the DT also considered the opinions of two expert witnesses. The DT noted that there were already well accepted international guidelines for the diagnosis of KD since 2004.  Based on these international guidelines, the child presented with signs and symptoms which should be investigated further for KD. The DT concluded that Dr Chia fell short of the reasonable standard expected of a senior paediatrician by not ordering tests to support the diagnosis or discussing with the parents about this possible diagnosis which she had considered. The DT judged that this amounted to professional misconduct on her part.

5.     In deciding on the sentence, the DT considered eight precedents relating to doctors who had missed or given a wrong diagnosis, failed to provide adequate advice and/or failed to provide appropriate and timely treatment to patients. The DT noted that six of the precedents were dealt with by a suspension instead of a fine. The DT also took into account the seniority of Dr Chia and that she was an experienced paediatrician of 23 years’ standing. After considering all the relevant facts and circumstances, including the aggravating and mitigating factors such as Dr Chia’s unblemished record, the many testimonials and character references and her contribution to society, the DT ordered a three month suspension which is the shortest suspension under the Medical Registration Act.

6.     Dr Chia appealed to the High Court against the DT’s decision.  The High Court noted that Dr Chia had not pleaded guilty to the charge, and that the disease faced was not uncommon. Taking these factors as well as the precedents into consideration, the High Court found the order of three months’ suspension to be appropriate. The appeal was then dismissed by the High Court.

7.     Dr Lim asked if MOH advocates doctors to send all cases for detailed diagnostic tests to avoid misdiagnosing rare medical conditions.  The answer is no. Such defensive medicine practice deviates from good clinical practice. It will also unnecessarily increase healthcare costs. Dr Lim also asked if the Ministry should issue standard practice guidelines on diagnosis for all potentially rare illnesses.  It is  neither possible nor practical for MOH to issue guidelines for all rare diseases. Doctors would have to exercise their clinical judgment in such situations.  However, in this particular case, there were already existing international guidelines which warranted further investigations to diagnose KD, given the symptoms and signs of persistent fever, red eyes, red cracked lips and a rash.  

8.     Ms Tin asked if there have been international studies on defensive medicine, which is defined as a deviation of sound medical practice that is induced mainly by a fear of medical malpractice action. There have been a few international studies, mainly comprising surveys of doctors, which noted the high prevalence of defensive medicine practices overseas, resulting in unnecessary increases in healthcare costs. Other international studies have also suggested that a substantial fraction of malpractice claims are a result of failure of doctor-patient communication. There has been no local studies on defensive medicine.

9.     As part of their work, doctors are expected to exercise good clinical judgement to manage patients appropriately. Clinical judgement is dependent on the seniority of the doctor, the area of practice and experience, clinical presentation of each patient and the facts and circumstances surrounding each case. For cases which are complex or for which the treating doctors are unsure, they can also discuss with other colleagues on the most appropriate management of the case. In addition, medical knowledge is constantly evolving. It is important for doctors to keep abreast of medical knowledge and international guidelines based on the recommendations of medical experts.

10.    Hence, SMC requires all doctors in the public and private sectors to have  mandatory continuing medical education. Our hospitals and institutions also have teaching, training and peer review to enable doctors to maintain and upgrade their skills.