Are doctors abusing patients; or patients abusing doctors; or both?
Are doctors abusing patients; or patients abusing doctors; or both?
Last week I spent two days in London participating in a conference on media education. It was a valuable experience. On my return home I found welcoming me a form with the logo of Medicare Services Ltd. It informed me that a doctor (name and registration number supplied) had called at my house on May 16, 2008 and that no one answered the door. No great surprise since I was in London and I do not employ the services of a full time Russian maid.
The name of the "principal" - I guess that stands for the employer - was not listed. So I asked myself at whose behest the visit was made. Could it be that the Archbishop asked Medicare to check on my state of health? Since recent times - i.e. the arrival of St Paul to our shores - I don't think than any Archbishop ever sent a doctor to check whether a priest was sick or just wanted to skip work. So that possibility I counted out. Could it the University Rector - the head of the institution where I lecture - sent the doctor. Unlikely, since I am one of those who always fill in the relevant form to ask permission for special leave, The approval form duly signed and stamped was, in fact, on my desk.
So I guess it was a mistake; and these do happen. It's human nature after all! This means that the employers of someone who reported sick now have a note saying that he/she was not at home when the doctor phoned. Some explaining to do then, I guess.
Company doctors and your rights
This is one of the problems tied to the institution of company doctors. You are in but if they go to the wrong house they will say you were out. But there is a much larger ethical question tied to the procedures of this work practice which many do not know about. Read the following sitting down: You, as a patient, have rights and these are, many times being ignored or trampled on by the system.
The following extract from the code of Ethics of the Medical Profession is ample proof. This code is published by the Medical Council which regulates the profession.
Paragraph 11 (iv) "When it becomes the duty of a practitioner occupying an official position to see and report upon a case of illness or injury, he should communicate with the patient informing him that it is his right to ask his practitioner to be present during the examination. The practitioner seeing the case officially shall scrupulously avoid interference with, or remarks upon, the treatment or diagnosis that has been adopted.
(see also circular MC/145/93 of 22.3.1993 and MC/180/99 of October 1999 clarifying the procedure to be adopted in such visits) remarks upon, the treatment or diagnosis that has been adopted."
The circular of 1999 makes it clear that this refers to those who are known as company doctors. The circular of 1993 says, among other things, that:
- doctors must always act in the best interest of the patient;
- when there are doubts these must be interpreted in favour of the patient;
- doctors should show utmost courtesy and consideration to the patient.
In relation to paragraph 11 (iv) it further states that "while it may not be practicable for the patient's practitioner and the doctor acting in an official capacity (company doctor) to meet when the complaint is trivial, in other cases where difference of opinion exists it is expected that consultation between the two practitioners should take place."
The above are not optional wishes. They are mandatory. Company doctors have the duty to inform the patient of his right to ask his practitioner to be present during the examination. Those doctors who do not give this information are acting unethically. A possible exception to this presence is considered when it is a trivial matter. This is not a light or laughing matter. The Medical Council - whose powers include striking a doctor off the register - said in the same circulars that "the Council will take a serious view of any lapses in this regard."
How many company doctors observe these ethical norms?
If company doctors ignore their ethical duties you should not. If you are employed and your company sends it company doctor remind him of his ethical obligations and your rights.
You and the Medical Council
I have been a member of the Medical Council for the past four years. I am one of the representatives of the public on the Council. All those who from time to time use the service of a doctors or a dentist should know of their rights. The Medical Council is there to safeguard them. Many do not know of these rights or are afraid to seek their rights thinking that since the Council have a majority of professionals i.e. doctors and dentists, it will support the professionals come what may. This perception is not a correct one. I can vouch that the other members now serving on the Council take their duty seriously. There is no let's hush this complaint culture.
Over the years complaints varied from allegations of sexual abuse to arrogant behaviour. There was a very slight numerical increase in the last years but their number is still very small.
I have spoken to several persons who served on the Council in different time periods. It seems that a common concern was shown about the length of time taken to reach decisions when inquests are instituted. In spite of all the good will of the there have been many cases when the complainant and the accused had to wait for years to get a result one way or the other. There were also cases when a decision was taken but it took whoever was responsible more than five years to write and communicate the decision. This is not right as justice delayed is justice denied.
Doctors have rights as well
Patients should also remember that doctors have rights as well and they should have regard for these rights. They should remember that also doctors have rights and these should be respected. There are after all even offending patients; and this is not right. After all the vast majority of our medical professionals care and respect their patients and most go the extra mile trying to help them.
How to complain
The website of the Medical Council is http://www.sahha.gov.mt/pages.aspx?page=87. the postal address is 181 Melita Str., Valletta CMR02. The phone number is 21255540.
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John Schembri
May 30th 2008, 19:38
Some Decisions of the Medical Council :
"The Director of Corporate Services in the Ministry of Education, Youth and
Employment referred a press report concerning a facilitator who while on
sick leave was in fact attending a training course with Air Malta. The
Director also referred to various medical certificates issued by a medical
practitioner and eventually submitted to the Department by the facilitator in question. The Medical Council after having received an extensive report bythe medical practitioner concerned came to the conclusion that the
certificates were issued in good faith and any abuse was committed by his
patient. Case considered closed"
"The attention of the company doctor was drawn to the fact that he should
scrupulously avoid interference with, or of any remarks upon the treatment
or diagnosis that has been adopted by his colleague.
The Medical Council considered this warning was sufficient in the
circumstances and that no further action was necessary.
"The Education Division raised a complaint on a Medical Practitioner
claiming that he issued sickness certificates to an employee with the same
date and consecutive numbers."
Thanks Father Joe.
John Schembri
May 30th 2008, 17:24
@ Dr Francis Saliba : "a very objective diagnoses I must say".
In my opinion , if a doctor falsely certifies someone as not being fit for work ,and is caught by the authorities he should have his warrant suspended or withheld and the 'patient' fired from his job.
Same should apply the other way round when a worker is really sick and the (company) doctor insists on sending the patient to work , if proven without a shadow of doubt, the doctor's warrant should be withheld or suspended.
As things stand today , if a malingerer is caught , he gets punished but his doctor runs away scot free , and is left certifying more workers who "abuse the social services, their employers and fellow workers"
I repeated my questions because they were never answered . I feel I am being very objective. After all it takes two to tango, in abusing the system the doctors are accomplices with the malingerers.
Dr Francis Saliba
May 30th 2008, 07:00
@ John Schembri
Your refusal to utilise the Medical Council to examine your slanderous insinuations and irrelevant rhetorical questions prove conclusively that your real aim is not to improve relations between patients and doctors or between official doctors and family doctors. Your comments are destructive and further the interests of a notorious minority of shirkers who would like to abuse the social services, their employers and fellow workers for purely selfich reasons. Your repetitive comments do not merit reply
John Schembri
May 29th 2008, 17:14
As far as I know people have rights in the form of of the Data Protection Act . This is not a question of malingering . I do not want the wages clerk to know from what I had suffered. Should this Act be bypassed?
I compared the doctors to the much despised wardens and Dr Saliba , rightly , called it it a "Flippant suggestion", I exaggerated on purpose to drive home my argument.
Are family doctors and company doctors different from each other ?
Can workers afford paying their doctor two times to confirm that they are sick as you are suggesting?Shouldn't the company doctor call the patient's doctor when not in agreement?
How does Malta fare with other countries as regards sick leave by private sector workers ?
We should adopt what other European countries have been using for ages.
Should anyone take a 10% commission on the medicine s/he prescribes/pushes?
Malingerers should be severely punished ,together with their doctors , BUT when certified by doctors who are independent from the employers.
I hope I am sounding fair . Where are my wild accusations?
Dr Francis Saliba
May 29th 2008, 10:44
@John Schembri
You make yourself clear enough in spite of obvious contradictions.
You use the plight of genuine patients to sabotage the current system of checking malingering. Your suggestions, imprecise and impracticable, would open the gates for flagrant abuse.
You insist on the confidentiality of medical records but would transfer the checking on sick persons from doctors to lay persons (wardens).
Because the present system has not erdicated malingering you recommend that the use of doctors be abandoned. By the same argument the service of judges and policemen should be abolished because they have not succeeded to eradicated crime.
You do not consider the advice of Fr Joe Borg in this blog to utilise the service of the Medical Council to check cases of alleged abuse. You prefer to slander the profession in the media by wild unsubstantiated allegations.
You do not make one single constructive and practical suggestion to reduce the antisocial evil of feigning illness and getting paid for it.
Your slip is showing.
John Schembri
May 28th 2008, 16:51
@Dr Francis Saliba , perhaps I did not explain myself clearly enough.
1) Medical records are a very personal matter. People under oath should handle them.
2) Doctors allowed themselves to be used to control malingering,because there is money involved.
3) Because of some malingerers a lot of honest workers are suffering. If malingerers are not being controlled than the system has failed its purpose and company doctors are not the solution.
4) Dr Saliba makes a difference between family doctors and company doctors as if the former are less honest than the latter when both types of doctors took the same oath and follow the same code of ethics .
5) Workers cannot afford paying their doctor two times to confirm that they are sick .
6) I do not have a magic solution , but workers who never take sick leave on routine bases should not even be visited by a company doctor , it shows trust by their employer.
7) How does Malta fare with other countries as regards sick leave by private sector workers .As far as I know this system exists only in Malta.
8)Should doctors take a 10% commission on the medicine they prescribe?
Dr Francis Saliba
May 28th 2008, 11:53
@ J Schembri
It is flippant to suggest local wardens, rather than doctors, to control malingering. This was attempted in the past. Sick leave certificates were issued without medical examinations and were issued from local police stations at the request of a relative, Absenteeism skyrocketed and doctors became embroiled without being asked if they accepted or not.
The genuinely sick have nothing to fear from a visit by an oficial employer's doctor especially if the family doctor can afford the time to accompany him.
The question of confidentiality of medical records is too complicated for this blog but it most certainly cannot be solved by involving the local wardens.
John Schembri
May 28th 2008, 05:23
I do not think doctors ,should take the role of policing workers , it's more a job of a local warden especially when many workers hardly take any sick leave.
Dr. Saliba is confirming that their are people who are suffering , and he is blaming the workers who are abusing the system and still are not being caught.I think doctors should not have accepted to be "embroiled" in this system at all.
A question which I would like to be answered is wether the ailment of the patient/worker should be divulged on the certificate to third parties (the employers and Social security personnel)). Isn't this in breach of the data protection act? Why should for example a sick worker suffering from mental depression have his condition written on a certificate accessible to everyone?
Dr Francis Saliba
May 26th 2008, 09:56
@ John Schembri
People rarely "suffer" because of "bad judgement and no diagnosis". They suffer because there are too many shirkers who insist on receiving a wage without giving a day's work in return, whenever they feel disgruntled. The sufferers are their honest fellow workers, their employers and the family doctor who becomes embroiled unwillingly.
In my role as an official doctor I am not sure that there was a single instance when a family doctor accepted my regular invitation to be present during a surprise visit. He would be too busy treating the genuinely sick.
In my other role as a family doctor I recall only one instance when a patient of mine on sick leave received a surprise inspection from a doctor/politician who was informed of my desire to be present, challenged my diagosis without examining the patient and left without waiting for me at all. The subsequent medical board confirmed my certification. I duly reported this unethical behaviour to the employing department of health which took no action at the appropriate time but advised me belatedly, after many weeks, to report the matter to the Medical Council myself. We live in more normal times now.
John Schembri
May 25th 2008, 10:47
"Malingering" that was the word. For the bad judgment and no diagnoses of a doctor people suffered and are still suffering.
How about taking the word of the family doctor, doesn't he know the patient more then the company doctor? Aren't they both professionals who took the same oath ? As far as I know certifying (pigeon holing) patients as being sick is not their true vocation.
Victoria Grech
May 24th 2008, 17:02
In the Old Testament, especially in Proverbs 8, Wisdom is personified as a woman - Lady Wisdom. She provides a godly worldview and offers insight for living.The Hebrew word for divine wisdom is 'hokhma' (which is feminine). The roots h-k-m are the same for 'hakem/hakma' in Maltese for one requires wisdom to be a good ruler. In recent years some feminist Christians have sought to retrieve Hokhma as a female image of God. They say nothing about her counterpart Lady Folly in Prov 9! Further to what Fr Joe said about the God as 'She' in Isaiah, there are at least four references to God in this way esp Isa 49, 15; 66, 9 ;but there are other references in the OT, even in the Book of Psalms 22, 9-10. The Bible likens the Lord to many different things in order to illustrate the relationship with human beings. God is usually represented in a masculine form: bridegroom, king, husband, warrior, father, tradesman. For the softer side of God the Bible resorts to feminine imagery, to illustrate two different aspects of our relationship with God.
For all you doubting Thomases out there go check.
Fr Joe Borg
May 23rd 2008, 13:52
Dr Soler is not only one of the longest serving members of the Medical Council. He is one of the most valid member. Thorough, fair, well informed, hardworking are just few of his qualities. I think that there are several reasons why very few people refer to the Medical Council. Let me me list few that i got from a kind of straw poll i made: some people don't know of the Council; others believe that you would never get it right; others think that the Council is just a front; others are afraid to challenge a doctor , most of the doctors do a very good job ..... Just a few reasons. I think that we should study more into the issue. The public face of the Council is very subdued. It should be higher.
Fr Joe Borg
May 23rd 2008, 13:46
I am very sorry if my reference to God as She led to some scandal. But Isaih refers to God as a mother and i guess that that's a "she". I don't suggest getting Isaih struck off the biblical list of books. So i guess till them my way of referring to God is correct.
victor deguara
May 23rd 2008, 12:33
There MUST be some plausible reason why you use the pronoun when refering to God of the christian faith. In Church documents and other literature the has been used for millenia. When refering to His Father, Jesus instructed us to call Him < OUR FATHER>. Could you, please, explain the philosophy behind this choice of yours?
Dr Francis Saliba
May 23rd 2008, 11:11
Fr J Borg
Underlying the problem of possible reciprocal patient/official doctor abuse is the scourge of rampant malingering which is not only anti-social but which is also the cause of conflict between the certifying family doctor and the official doctor who is expected to check on that abuse. I have been on both sides of that equation and can speak from experience. The problem is further accentuated by the intrusion of a political element when the habitual malingerers during one political administration suddenly become paragons of good health when their political party is in power.
There are sound rules which govern the ethical behaviour of doctors towards each other and towards patients. They should be enforced equitably, and without fear or favour, irrespective of whichever political party happens to be in power. The intrusion of non-medical persons, of politicians and worst of all of doctor/politicians with a hidden agenda will only create bad blood between doctors and their patients.
Joseph Attard
May 23rd 2008, 00:49
Dear Father Joe,
Well taking this a bit further I am told that employees of HSBC Uk Limited, at Swatar Call Centre are made to sit for a "back to work interview" once they are back to work from sick.
You see HSBC UK Limited does not send out a doctor to see for your well being if you're sick.....thats costly...so they have an high level manager who takes the liberty of asking you....
.what was wrong with you these last days......where did it hurt most.... did you visit your own doctor......did you have a migraine .......going as far as your private parts.............amazing isn't it..!
A bank manager asking about your health and coming up with.....you are taking too much sick leave...youre on my bad books...don't do it again etc...........So this goes to even higher level......
HSBC UK Bank not to send a real professional doctor and spend Lm 10 on your well being and leave some money in the pockets of local doctors.
In 2008, this is not acceptable. It is even more not acceptable because HSBC claim that they have created the "place to work" .
John Schembri
May 22nd 2008, 22:25
Some ten years ago I had a visit from one of these doctors , his conclusion was that I abused the system , hence a warning was issued by my employer and a day's wage was deducted , two days later I had to go urgently to a clinic to have my wisdom tooth extracted . By the way ,the doctor who came to visit me was a government employee and was supposedly on duty at St Luke's when he paid the visit.
May I pose a question to the readers of this blog: is it ethically correct for medical doctors to be paid hefty commissions on the medicines they prescribe to their loyal patients ? Doctors are also sent for 'seminars' abroad with their spouses in luxurious hotels . Who is really paying for these holidays.
Should not doctors be obliged to prescribe medicines with their real pharmaceutical name e.g. codeine , and then leave the Pharmacist to offer the client various options of the medicine prescribed including the 'generic' version on which no commission is paid.How many doctors prescribe 'dynamite' to crush a small 'stone'?
Dr. Denis Soler
May 22nd 2008, 19:39
I have been a member of the Medical Council, on and off, for 20 years and can safely state that of the many thousands of of doctor - patient encounters that occur in Malta every day, the number of complaints that come to light are too insignificant to mention. Is this because patients don't know their rights or because they have not heard of Medical Council? I very much doubt that knowing the litigious characteristic of the Maltese.
Steven Calascione
May 22nd 2008, 15:25
Dear Fr. Joe,
Would you be so kind so as to refrain from referring to God the Father as "She" in future. Twelve year old children do read the Times.
Thank you.
Steven
Dr Anthony Dalli
May 22nd 2008, 12:11
Personally I have great respect for doctors and people in the medical realm (nurses, bacteriologists...). My experiences with them were always very positive. Sometime ago I had to go through a heart surgery some time ago, I remember that I was treated beautifully at St Lukes.
My only complain about doctors is related to the fact that a number of them ask for huge fees, and then they do not even handover a VAT receipt. If you ask for it, as I do, they would simply increase the amount that was previously asked. This does not affect me. I consider myself a person of substance and of principal. However, I know many who would not ask for a receipt either to not irritate their doctor, lawyer…, or to not get a higher price.
I really believe the government should try to control more the fees of doctors, lawyers and other professionals! It’s a shame that some of these people, because they know that their service is indispensable, ask for such unreasonable amounts without contributing to taxation, and without considering that in front of the they have fellow human beings.
Dr Anthony Dalli, M.A. (Milan), D.Phil. (Oxon.)