The SMC has recently updated their ethical codes and guidelines after 14 years. The six year process included extensive consultation with the medical community and that the publication was based on principles including adapting to the complexities and variations of medical practice, relevance to modern medical practice and protecting the interests of patients' but at the same time, being fair to doctors by regulating behaviour rather than imposing empty prohibitions.

The updates include changes to the fees for services, aesthetics, doctor-patient conduct and the issuance of medical certificates (MCs) as well as additions on new areas of focus such as alternative medicine, telemedicine and end-of-life care. Changes are effective as of 1st January 2017.

Fees for services

The issue of fees has been a longstanding problem since 2007. Patients have claimed to be overcharged, and now the document states that "doctors must not charge fees of a level that would bring the profession into "disrepute". The appropriateness of fees is also subject to peer review". However exact amounts are not laid out. This could lead to a repeat of history resulting in disputes between patients and doctors as what constitutes as "overcharging" would be different for both parties.

As such, the SMC suggests in the guideline that "fees or range of fees the doctors set must be transparent and made known to patients in advance, But patients’ acquiescence to fees does not absolve doctors of the responsibility of charging reasonable fees".

As such, it can be appropriate to say that the doctor decides what is fair and reasonable, taking into account of the opinions of other doctors in the same speciality and of the same seniority, according to respiratory physician Dr. Ong Kian Chung from Mount Elizabeth Hospital.

"I usually try to explain to the patient beforehand, and if he or she still wants to go ahead, then there are less chances of dispute thereafter,” he said.

Dr. Chia Shi-Lu, an orthopaedic surgeon and MP said that it was a balanced decision as it is like asking wha a fair and reasonable price is for any commodity, except that in this case, if patients feel that they value the services and are told about the fees beforehand, it is free will.

The guidelines also state that doctors "must not take additional fees for if they have not provided any part of the services to a patient by other doctors".

Aesthetics

The updated guidelines for aesthetics include the responsibility of doctors to take reasonable care "to ensure patients do not have psychological or psychiatric illnesses involving self and body image before performing procedures". Afterwards, when consent is obtained from patients, "doctors must disclose risks "beyond those that are more common", compared to that required of conventional medicine".

An anonymous surgeon who works at a public hospital said that these guidelines were too open for debate and to interpretation that it would be hard to hold any practitioner accountable as the guidelines could be twisted to their advantage. Cosmetic procedures come with varying risks and side effects but the guidelines address them as a whole, he added.

Another addition to the guideline included a reasonable "cooling off" period that must be given to patients between the time of treatment and time of consent. However, what constitutes a "reasonable 'cooling off' period for each procedure is not spelt out, he highlights.

Doctor-patient conduct

The SMC advises against social media relationships with patients as it is a breach on professional boundaries. It reasons that patients may be put in a position where they would feel obliged or pressurised to engage with practitioners. However should the patient initiate the relationship, doctors are allowed to choose to accept such relationships however they cannot compromise the relationship by sharing anything that would expose patient confidentiality or through verbal assault such as 'punishing' patients for their lifestyles or habits that they do not approve of.

It is also understood that doctors are active on social media, however they must ensure that they "do not diminish their professional standing, or bring the profession into disrepute". 

Complementary and alternative medicine

In a new area of focus, the SMC states that the guidelines only apply to modalities that are approved by the SMC such as needle acupuncture, however doctors must provide medical reasons to the patient and the SMC for offering complementary and alternative medicine (CAM) services to the patients. There should also be no medical contradictions that the patient would suffer.

It is also stressed that CAM cannot be used as a substitute to treat the patient when their medical needs are better met through conventional or modern medicine. Patients should also only be sent to certified CAM practitioners.

Telemedicine

In this new field, general practitioner Dr. Leong Choon Kit mentioned that the guidelines were formed in mind that the practitioners and the medical industry are not restricted, rather would help them adopt to new technologies and advancements. However, doctors are to ensure that they have sufficient training and information themselves in order to manage patients through telemedicine options such as a simple phone call or video call. Otherwise, they should state the limitations of their opinions to the patient.

Patients should also be knowledgeable and capable of operating their telemedicine equipment from their locations.

Doctors are also to retain responsibility for overall management of a patient, for example, who undergoes robotic procedures even if they were performed by other doctors. Medical information on digital platforms should also be confidential

Read more:
Raffles Hospital surgeon suspended for six months due to professional misconduct
Doctors in Singapore hit a new high of 13,936
Cancer specialist Dr Ang Peng Tiam of Parkway Cancer Centre fined by SMC

Sources:
http://www.straitstimes.com/singapore/new-smc-guidelines-doctors-shouldnt-start-social-media-relationships-with-patients
http://www.todayonline.com/singapore/doctors-not-initiate-social-media-relationships-patients-smc
http://www.todayonline.com/singapore/some-practitioners-fault-new-code-not-being-precise-enough
http://www.businesstimes.com.sg/government-economy/revised-guidelines-on-middlemen-fees-emphasises-patient-care-comes-first-moh
http://www.todayonline.com/singapore/council-stops-short-setting-fees-lays-out-general-principles-instead
http://www.todayonline.com/singapore/whats-new-smcs-ethical-code-doctors
http://www.healthprofessionals.gov.sg/content/hprof/smc/en/topnav/guidelines/ethical_code_and_ethical_guidelines.html