Are junior doctors behaving badly in Singapore?

The frequency of unprofessional behaviour among junior doctors in Singapore is considerably low, making up about 4.1 percent of the disciplinary tribunal proceedings, a recent study has shown. Most complaints against physicians involve systems issues and human factors within the workplace environment.

Furthermore, “[u]nprofessional behaviours related to fraud and dishonesty need special attention in medical school,” the researchers noted.

Two screening levels were used to examine annual reports of the Singapore Medical Council from 1979 to 2017 and published grounds of decision from 2008 to 2017 to identify cases involving junior doctors. Cases were grouped into five outcome categories: professional misconduct, fraud and dishonesty, defect in character, disrepute to the profession, and acquitted.

Of the 317 cases identified, only 13 (4.1 percent) involved junior doctors. There were four cases (30.8 percent) of professional misconduct, four cases (30.8 percent) of fraud and dishonesty, three (23.1 percent) acquittals, and one case each of defect in character and disrepute to the profession. [Singapore Med J 2020;doi:10.11622/smedj.2020021]

In the cases of professional misconduct, a need arose to differentiate medical errors due to systems factors from those due to individual culpability. This could be addressed by applying instruments such as root cause analysis and the Unsafe Act Algorithm. [Patient Educ Couns 2010;80:288-292]

“Disciplining the individual alone does not help prevent the recurrence of similar medical errors,” the researchers said. “We found that fraud and dishonesty was an important category of unprofessional behaviour among junior doctors.”

Incidents of fraud and dishonesty occurred outside the doctor-patient relationship, which could be explained by the doctors’ ignorance and failure to recognize that behaviours outside of professional work would affect their medical professional standing and career.

“Hence, it is vital that medical students are made to recognize from the beginning that a doctor’s work requires the public’s trust and that they are held to higher ethical and legal standards compared to the rest of the population,” the researchers said. [www.annals.edu.sg/PDF/SundareshMenon/LectureCJMarch2018_2.pdf]

Medical errors are caused by a combination of active failures of the healthcare professional and latent conditions of the system. [Reason J. Latent errors and systems disasters. In: Reason J, ed. Human Error. Cambridge University Press: Cambridge, 1990]

Active failures are defined as human errors such as slips, lapses, fumbles and procedural violations committed by those in direct contact with the patient. Latent conditions refer to system design decisions made at different levels from builders to management, which generate an error-prone environment. [BMJ 2000;320:768-770]

“Malicious and reckless behaviour of individuals that is intentional and deliberate require an appropriate disciplinary process,” the researchers said. “Taking appropriate measures to correct systems issues, instead of a merely punitive approach, helps to prevent medical errors.”

For junior doctors, the researchers recommended the implementation of better support networks to address personal and mental health issues.