Last month was a month for changes and for celebrations. Two events, the HKMA 90th Anniversary Charity Concert and the Public Education Day (Beat Drug Stars Brighten the Community) were successfully held. Both events were beat drugs activities related to the new Beat Drugs Action Committee. Another event was the Annual General Meeting with the announcement of results of the HKMA Council Election. Dr. CHOI Kin was elected President (again). Dr. CHAN Yee Shing and Dr. CHOW Pak Chin were elected Vice-Presidents (again). Dr. LEUNG Chi Chiu was elected Honorary Treasurer (again). The six elected Council Members were Dr. IP Wing Yuk, Dr. LO Chi Fung, Dr. SHEA Tat Ming, Dr. SHIH Tai Cho, Dr. WONG Yee Him and myself. I have to thank everyone for their support so that I can continue to serve on the Council. I was also appointed the Editor of the News again in the first Council Meeting. (Dr. LEE Fook Kay was appointed Honorary Secretary.) In this issue, I continue to share with you some important observations concerning decisions of the Medical Council. It is about the use of steroid again.
Last month, a doctor was found
professional misconduct “… in that he
prescribed to the patient systemic corticosteroids without informing the
patient of the nature, anticipated actions, and possible side effects of such
medication.” Another case decided
early this year was looked upon as the precedent case. The charge in that case was that “the doctor prescribed to the patient celestamine
that contained steroid without informing the patient of the fact that
celestamine contained steroid.”
In the recent case, the judgment
stated that: “The Council has repeatedly
emphasized that it is a duty upon all registered medical practitioners who
prescribe steroids to inform patients of the nature and the side effects of the
medication.” The judgment was very
strict and was very broad as it caught all steroids and not just
systemic steroids, and the dosage or duration was not taken into consideration.
For example, the judgment also stated
that: “By failing to inform the patient
that Dexamethasone is a steroid, the Defendant’s conduct has fallen below the
standard expected amongst registered medical practitioners.” It was also ruled that the specific Chinese
term 類固醇 had to be mentioned. “The
term 消炎、消腫藥 is too ambiguous as it can refer to many
other drugs, and is not an acceptable substitute for類固醇.”
Naming it “properly” was not
enough, the nature and side effects had to be explained. In this case, “The Defendant only advised the patient of the potential side effect of
gastro-intestinal upset. No mention was
made of other significant side effects of steroids, such as susceptibility to
infection and mental disorder. In this
respect, the Defendant’s conduct has fallen below the standard expected amongst
registered medical practitioners.” It
was debatable whether Dexamethasone 0.5mg QID for two days could cause these
side effects. Even for informed consent,
failure to volunteer rare side effects might not render the doctor guilty.
The appropriate provision in the Code for warning patients about side effects of
medications is Section 9.6. It stipulates that: “Where a drug is commonly known to have serious side
effects, the doctor has the responsibility to properly explain the side effects
to the patient before prescribing the drug.” The non-judicial use of steroids should be
discouraged. However it is neither a
good law nor a good practice to make it necessary to have informed consent for the
use of steroids disregard of the indication, the duration or the dosage.
Below is the summary of my
observations and thoughts:
- Whenever steroid is use, the patient has to be informed.
- The doctor has to volunteer all the information. He would be found guilty of misconduct if he does not do so. It does not matter whether the patient asks about it or not.
- Steroids have to be referred to as 類固醇.
- Detailed potential side-effects have to be mentioned.
- This is not limited to systemic steroids.
- The indication, the dose and the duration are not taken into consideration.
- Strict liability has been introduced for the use of steroids.
- I still doubted that the prosecution had failed to prove that the use of a few days of low dose steroid could cause serious side effects to the extent that professional misconduct was involved.
- It is not clear whether this strict liability is limited to the use of steroids (and whether it is limited to systemic steroids) or to all drugs commonly known to have serious side effects.
- The strict requirement of informed consent for the prescription of a drug is more complicated than you can expect. It can develop into the need to prove that there has been consent; that the patient understands the information given; that the patient agrees to the use of the medication with the specification of everything including the dose, the duration, the correct diagnosis and each and every details; and that there should be explanation of other options of treatment.
(Source: HKMA News August 2010)
