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香港醫務委員會病人投訴機制 急需根本性檢討

2017/2/17 — 2:06

港島區公營醫院瑪麗醫院(資料圖片)

港島區公營醫院瑪麗醫院(資料圖片)

【文:高德禮(香港民主促進會)】

(See below for the English version)

操守、醫術、或健康欠佳的醫生均會對公衆的安全構成風險。香港醫務委員會(下稱「醫委會」)的一個職責就是保障公衆免受這些不稱職醫生的傷害。醫委會這一職責至為重要,因為它是香港唯一獲賦予權力撤銷或暫停醫生行醫資格的法定機構。某醫生即使在民事訴訟中承認醫療失當,除非醫委會同時吊銷其行醫資格,這醫生依然能夠繼續行醫,並繼續對公衆的安全構成威脅。

廣告

醫委會透過其投訴及紀律機制行使撤銷或暫停醫生行醫資格的權力。在這機制下,假如某醫生被裁定犯了「專業上的失當行為」,視乎失當行為的嚴重性,醫委會可以向該醫生作出公開警告或譴責、暫停該醫生的註冊、或甚至將該醫生在醫生名冊上除名。

因此,從投訴及紀律機制的功能看,假若醫委會未能適時地處理病人投訴,醫委會實際上已經未能有效地履行其保障公衆的職責。拖延提供保障實際上就是拒絕提供保障(protection delayed is protection denied)。假若病人投訴的處理延誤一年,這就等同將公衆置於不稱職醫生的風險中多一年。從這角度看,病人投訴處理的長時間延誤,除對相關的病人及醫生不公外,也對公眾安全構成嚴重的威脅。

廣告

根據醫委會最新的推算,處理一宗病人投訴所需的時間可能長達72個月。這不單顯示投訴機制實際上已經失效,更揭露醫委會容許病人投訴個案長時間的累積這一忽略公眾安全的失職行為。因此,最近為檢討及改革醫委會而成立的「三方平台」只是一遲來的亡羊補牢改革嘗試而已!改革早就應該推行了!

為確保「遲來」的改革確實能「亡羊補牢」,從而使得投訴機制更能保障公眾安全,我們必須清楚明白「處理投訴的速度」只是眾多決定機制整體效能的因素之一。假如機制本身在其它方面均有缺陷,單單增加處理投訴的速度並不會提高機制保障公衆的整體效能。效率與效能並不相同。固此,「三方平台」必須對醫委會的投訴及紀律機制作徹底的檢討。機制內的出問題的地方涉及多個層面;改革的焦點不應只則重於加快處理投訴這問題之上。

機制的第一個問題涉及「專業上的失當行為」這一概念。由於投訴機制建基於這概念,因此對「怎樣的行為才構成失當行為」及「失當行為何等的嚴重會被判處何種的紀律處分」有清晰的理解和指引至為重要。除非失當行為的各類性質及判處各種紀律處分的準則都有明確的界定,失當行為的裁決很大機會不一致。「裁決不一致」意味著某些裁決會較寬鬆。這不但對某些投訴者及被投訴的醫生不公平,更導致投訴機制未能為公眾提供足夠的保障。

就著何謂失當行為的指引,醫委會表示公眾及醫生可參考其出版的《香港註冊醫生專業守則》。可是,守則只非常概括地列出醫生應有的操守和責任。守則並沒有較具體的指引說明醫生的行為偏離這些標準有多嚴重才構成「專業上的失當行為」。除不具體外,守則更根本的問題卻是它的內容其實並不完整。根據醫委會的年報,醫委會在2014年接納的投訴個案中,有超過40%是涉及欠佳的醫療質素,例如,治療╱手術無效或效果不理想,及處方藥物不當等。年報將這些個案歸類為「罔顧對病人的專業責任」的失當行為。令人感到困惑的是,在守則中「對病人的專業責任」這一條目下卻找不到任何與醫療質素相關的參考。再者,從公開的資料看,醫委會似乎也沒有制訂判處各種紀律處分的指引。由於以上種種的不清晰,醫委會是否一貫都以一致和明確的準則作紀律裁決是需要認真檢討的課題。

機制的第二個問題是關於公眾向醫委會作出投訴所遇到障礙。我們要緊記,投訴機制的保障功能在接受投訴後才會被啟動。因此,高的投訴門檻必然會削弱投訴機制的保障功能。

醫委會表示,投訴是否會被接納取決於投訴者所提供的證據。換句話說,投訴者有責任搜集足夠的証據去說服醫委會接納他們的投訴。醫委會這樣的要求似乎並沒有意識到搜集証據本身需要一定程度的專業訓練;而一般普羅大眾根本不可能受過這方面的訓練。另一方面,醫委會也沒有體諒到一般市民索取在醫療報告、病歷、及其它相關的醫學資料時會遇到的困難。我們憂慮,歷年來,究竟有多少真確的專業失當個案,因為投訴者提供不了足夠的証據或提供了並不相干的証據,而被醫委會拒絕受理?另外,又有多少個案,因為投訴門檻過高,投訴者自己放棄提出申訴的權利?這些沒有被處理的個案,究竟又已經為公衆造成多大的安全風險?

第三個問題涉及醫委會接納投訴作正式調查及公開聆訊的決策過程。投訴個案若要被醫委會接納作公開研訊,它需要經過一兩階段的挑選程序:1)篩選階段;2)初步偵訊委員會(Preliminary Investigation Committee)階段(下稱「初步偵訊階段」)。兩階段的功能及法定決策原則都不同。「篩選階段」的功能是篩除那些瑣碎無聊或毫無根據(frivolous or groundless)的個案;挑選的重點並不是個案是否最終能確立,而是個案是否真的瑣碎無聊或毫無根據。挑選的法定原則是:除非個案是瑣碎無聊或毫無根據,否則個案一般都應該轉介給初步偵訊委員會審議。「初步偵訊階段」的功能則是篩除那些沒有機會被確立的個案(have no real prospect of being established)。挑選的法定原則是:假如個案有機會被確立(即,個案表面證據成立),個案應轉介給醫委會作正式研訊。由於正式研訊並未開始,因此這兩個階段絕不能就已有的証據最終是否能確立投訴作出任何判斷,或對那些証據較為可信作出任何判斷(to resolve conflicts of evidence)。

「兩階段挑選程序」在整個投訴機制中扮演著樞軸的角色;它決定那些個案有「資格」被接納作正式聆訊。固此,我們對醫委會在2015年一宗司法覆核案中承認在「篩選階段」曾引用了錯誤的法律原則去篩除個案感到非常震驚!醫委會承認,在決定某個案應否轉介至「初步偵訊階」段時,它們曾對那些証據較為可信作出判斷。在案中的供詞中,也有証據顯示醫委會在「初步偵訊階段」也犯了同樣的錯誤(註:「初步偵訊階段」並非案中覆核的對象)。這宗司法覆核案揭示,醫委會似乎不太理解應如何履行自己的法定職責!司法覆核案的法官對醫委會有這樣的意見:被委任處理投訴的人仕似乎沒有明確理解自己的角色和功能;這可能是由於他們缺乏培訓和指導所引致。醫委會這個錯誤意味著它在「兩階段挑選程序」中引用了更嚴格的挑選原則。因此,我們憂慮,歷年來,究竟有多少應該被接納的個案因為醫委會錯誤地引用了更嚴格的挑選原則而被它駁回?又有多少不適合行醫的醫生由於醫委會這錯誤能繼續行醫?

第四個問題出現在投訴機制的人事安排。這問題有兩個層面。首先,按現時安排,初步偵訊委員會的主席及副主席同時負責「篩選階段」的工作。根據法例規定,只有當主席及副主席均同意下,投訴才可被駁回;假若任何一方不同意駁回,投訴個案就必須轉介「初步偵訊階段」繼續審議。主席及副主席這雙重角色帶出一連串公平的隱憂。主席或副主席能否繼續以開放的態度在「初步偵訊階段」重新審議自己曾經認為瑣碎無聊或毫無根據的個案?主席或副主席有多大可能改變自己的立場,並支持將個案轉介醫委會作公開研訊?主席和副主席可以時刻分辨清楚自己在「篩選階段」及「初步偵訊階段」中不同的角色和功能嗎?主席或副主席會否有可能潛意識地錯誤將「初步偵訊階段」中較嚴格的挑選個案準則引用在「篩選階段」呢?

另一層面的人事安排問題在於所有參與投訴機制決策的人仕都同時是醫委會的成員。這人事安排也同樣帶出公平的隱憂。從被投訴醫生的角度看,負責檢控的和負責審判他們的都是同一機構。醫生會否認為醫委會這雙重角色對他們不公呢?醫生會否認為投訴機制剝奪了他們接受公平審訊的權利 -- 當其權利與義務涉訟須予判定時,有接受獨立及無私之仲裁機構公正公開審訊的權利?

對公衆而言,由於一半的醫委會成員是由醫生選舉產生,而另一半的委任成員則大部份都是醫生界別業內人仕,公衆會否感到醫委會成員跟醫生一樣都是來自同一個「業內俱樂部」呢?再者,由於那一半的由選舉產生的成員很有可能需要向他們的醫生選民問責,這批成員會否視自己為業界的代表多於視自己為公衆的僕人呢?當對被投訴的醫生作出的裁決時,醫委會成員會否潛意識地感受到壓力要以自己「業內同事」及「選民」的利益為先呢?

對醫生而言,基於醫委會現在組成方式,他們會否視醫委會是代表自己的機構,而非規管自己的機構?這會否引致這樣一個惡性循環 -- 當醫生認為醫委會為一代表機構時,醫委會就更會視自己為業界代表及更傾向以醫生利益為先,而公衆就更會對醫委會的公正性失去信心?

我們憂慮,上文提及司法覆核案中醫委會所犯的錯誤究竟有多少是受到醫委會以自己「業內同事」及「選民」的利益為先這傾向所導致。

機制的第五個問題涉及紀律處分的罰則。如上文所述,假如醫生被裁定犯了「專業上的失當行為」,他們可能面對的紀律處分包括:1)從醫生名冊除名;2)從醫生名冊除名一段時間;3)遭受譴責;4)緩刑 -- 暫緩執行以上1)、2)、或3)的處分一段時間;5)收警告信。就著這些罰則,我們必須特別注意的是,犯了專業失當的醫生,除非被判處「從醫生名冊除名」,否則的話,縱使他們是不稱職的醫生,他們依然能夠繼續行醫,或在某一段時間後能夠繼續行醫。換言之,他們依然對病人構成安全風險。因此,除非專業失當醫生,在判處紀律處分外,還需同時接受再教育以提升他們的操守或醫術,判處紀律處分本身對保障公衆而言是沒有意義的。要有效地保障公衆,我們認為「除名」以外的其它紀律處分罰則都必需同時附帶「再教育」的要求。

可是,從公開資料看,醫委會似乎並沒有一套完整的專業失當醫生再教育方案。根據我們理解,那些犯上「沒有妥善備存危險藥物」失當行為的醫生,醫委會會要求他們接受同胞核查以改正他們的錯誤。但對那些因為醫術欠佳而被裁定專業失當的醫生,醫委會卻似乎沒有相關的再教育要求以提升他們的醫術。假如我們的理解正確,醫委會投訴及紀律機制的保障公衆安全功能實在有很大的缺陷。

本文提出的問題都是投訴及紀律機制內根本的問題。因此,對機制作完全而徹底的檢討實屬刻不容緩。指出這些問題的重要性並不代表我們認為現時關於「投訴處理的延誤」及「業外人仕參與不足」等問題的討論是焦點誤置。我們要指出的是,只集中處理這些問題並不一定能加強投訴機制保障公衆安全的效能。

最後,我們想強調,即使以上提及的所有問題都能妥善地解決,投訴機制能為公衆提供的保障依然是有限的。因為投訴機制本質上始終是被動的(reactive)。在一個以「投訴推動」的規管制度下,醫生只要能避過病人的投訴,他們就會被制度假定為「好」或「稱職」的醫生。這個假設當然是完全不真確。為了更有效地保障公衆,與其等待受害病人揭發醫生的失當行為,我們有需要建立一個更積極主動(proactive)的機制去查找不稱職的醫生。在這方面,一個可行的方法是對醫生作定期的重新甄審(periodic re-validation)以確保所有正在行醫的醫生都是稱職的。我們促請「三方平台」在檢討投訴機制度的同時,考慮建立「醫生定期重新甄審制度」。

作者按:本文的簡短版本原刋於信報;以下為本文的英文版,原刋於 ejinsight

One duty of the Medical Council of Hong Kong is to protect the public from dysfunctional doctors, who, by reason of their misconduct, poor performance or ill health, put the public at risk of harm.

This duty is of paramount importance because the council is the only statutory body in Hong Kong with the power to suspend or remove a doctor’s right to practise medicine. A doctor admitting malpractice in civil proceedings can continue to practise unless the council suspends or removes the doctor’s practising right.

The Medical Council exercises its power to suspend or remove a doctor’s right to practise through its complaints and disciplinary mechanism.

Under this mechanism, if a doctor is found guilty of “misconduct in a professional respect”, and depending on the seriousness of the misconduct, the council may subject the doctor to a public warning or reprimand, suspension of registration for a period of time, or removal from the register.

If the Medical Council fails to handle patient complaints in a timely manner, then apparently it is not doing a good job in its duty to protect the public.

Protection delayed is protection denied. A one-year delay in handling complaints, for example, means putting the public at risk of dysfunctional doctors for a year.

In other words, apart from the issue of fairness to the complainants and doctors concerned, inordinate delay in dealing with complaints poses a serious patient safety issue.

The latest projection says that the delay in processing a complaint can be as long as 72 months. This indicates not only that the current complaints mechanism is not working but also that the council is failing in its duty to protect the public in tolerating such delays.

It is appropriate therefore that a tripartite platform involving all stakeholders has recently been established to review systemically the operations of the council. Reform is long overdue indeed.

To secure meaningful reform and better protect the public, we have to stress that the capacity to handle complaints timely is only one of many aspects affecting the effectiveness of the council’s complaints mechanism.

If there are defects in other aspects of the mechanism, increasing speed in handling complaints alone will not necessarily increase the mechanism’s overall effectiveness in protecting the public.

Efficiency and effectiveness are distinct. Therefore, the platform has to undertake a thorough review of the council’s complaints and disciplinary mechanism. Problems inside the existing mechanism are multifold. Reform emphasis should not be focused mainly on speeding up the handling of complaints.

The first problem has to do with the phrase “misconduct in a professional respect”.

Since the council’s complaints and disciplinary mechanism is founded on this phrase, it is vital to have a clear understanding of what kinds of conduct amount to misconduct and what degree of seriousness warrants which type of disciplinary sanction.

Unless the nature of different kinds of misconduct and the thresholds for different disciplinary sanctions are well defined, disciplinary decisions on misconduct risk being inconsistent and being unfair to some doctors and some complainants.

One likely consequence of inconsistency and unfairness is inappropriate leniency in some cases, resulting in a failure to provide adequate protection for the public.

For its guidance on what professional misconduct is, the Medical Council refers the public and doctors to its Code of Professional Conduct.

The standards of conduct expected of doctors are laid out in the code in very general terms only.

The code does not say how serious a departure from its standards has to be for a doctor to be considered to have committed misconduct.

In addition to unspecificity, a more fundamental issue with the code is its incompleteness. In 2014, according to the Medical Council’s yearbook, more than 40 percent of the complaints taken up by the council were of the nature of substandard clinical practice, such as unsatisfactory results of treatment/surgery and inappropriate prescription of drugs.

These were categorized as “disregard of professional responsibility to patients”. Surprisingly, however, there is no reference in the code to clinical practice under “professional responsibility to patients” whatsoever.

From the perspective of the general public, there also seems to be no guidance on the imposition of sanctions. In view of such obscurities, questions arise as to how far disciplinary decisions are made based on consistent and well-defined criteria.

The second problem with the complaints and disciplinary mechanism relates to the hurdle of lodging a complaint against a doctor with the council.

The complaints mechanism’s function of protection will be initiated only after a complaint is accepted. If the mechanism itself poses an undue barrier to the lodging of a complaint, its protective function will to that extent be undermined.

The council says whether a complaint is accepted depends on the evidence provided by the complainant. In other words, it is the complainant’s responsibility to assemble the necessary evidence against a doctor and to convince the council that misconduct has occurred.

In adopting this approach, it seems the Council takes no account of the fact that gathering relevant evidence in this regard requires considerable expertise and is in most instances beyond an ordinary citizen.

Nor does the Council appear to appreciate the difficulties confronting an ordinary citizen in obtaining medical-related evidence.

For the general public, the hurdle for lodging a complaint with the council is thus disproportionately high.

We are concerned how many genuine misconduct cases might have been lost to the complaints mechanism over the years because the evidence provided by complainants is deemed irrelevant or insufficient or because aggrieved patients have simply been discouraged by the system from the outset, and how much patient risk this loss has resulted in.

A third problem concerning the complaints and disciplinary mechanism is about the decision-making process on accepting a complaint for formal inquiry and adjudication by the council.

For a complaint to be formally taken on for full inquiry, a two-stage filtering process is involved — the screening stage and the preliminary investigation committee (PIC) stage.

The functions and the legal approaches to decision-making of these two stages are different.

The function of the screening stage is to screen out complaints that are frivolous or groundless; the focus is not on whether the complaint can eventually establish a case of misconduct. The legal approach of this stage is: a complaint should normally proceed to the PIC stage unless it is frivolous or groundless.

For the PIC stage, the function is to filter out complaints that have no real prospect of being established. The legal approach here is: a complaint ought to be referred to the council for full inquiry if it has a real prospect of being established (i.e., if the prima facie evidence supports the case going forward).

At both the screening and the PIC stages, no attempt is to be made to assess whether the available evidence can eventually substantiate the complaint or to resolve conflicts of evidence because formal inquiry into the complaint has yet to start.

Given the pivotal role of the two-stage filtering process in determining whether a complaint is “qualified” for inquiry, it is shocking that the Medical Council admitted in a 2015 judicial review that it had adopted a wrong legal approach at the screening stage.

It admitted that an attempt was made to resolve conflicts of evidence at the screening stage when deciding whether a complaint should proceed to the PIC stage.

There is also evidence in the related testimony that the council made the same mistake at the PIC stage (although the PIC stage was not the subject of the judicial review).

It seems that the council was rather confused as to how to discharge the duties required of it by law. The judge of the judicial review commented that “[t]here … appears to be a lack of appreciation of the precise role and functions by persons designated to handle complaints which could be due to inadequate training and supervision”.

Given the confused and mistaken legal approach adopted, rendering the two-stage filtering process a very high threshold for accepting a complaint, we are concerned how many complaints might have been dismissed over the years by the council that should not have been, and as a result of which, how many doctors who present a risk to patients might have not been dealt with who should have been.

Besides the issues outlined in the first part of this column, another problem related to the Medical Council’s complaints and disciplinary mechanism has to do with its personnel aspect.

At present, the Chairperson and the Deputy Chairperson of the preliminary investigation committee (PIC) are also responsible for screening complaints at the initial stage; that is, they are screeners at the same time.

Under the current system, a complaint can be dismissed only if both the Chair and the Deputy Chair of the PIC concur. If one of them disagrees that a complaint should be dismissed, the complaint has to proceed to the PIC stage.

This dual role of the Chair and the Deputy Chair raises a concern about fairness. Would a Chair or Deputy Chair who has dismissed a complaint at the screening stage look upon the same case with a sufficiently open mind and consider it afresh at the PIC stage? How likely is it that the person involved will change his/her mind at the PIC stage and support referring the complaint to the Council inquiry stage? Would the screening and investigation personnel be able to keep their separate roles in the screening stage and the PIC stage distinct? Could it be possible that the more stringent standards for assessing cases at the PIC stage have been subconsciously or mistakenly adopted for the screening stage?

Concerns of fairness also arise from the present personnel arrangement under which almost all persons involved in the decision-making of the complaints and disciplinary mechanism are members of the Council. This arrangement suggests that the Council performs the functions of prosecution and adjudication at the same time. The prosecutor and the judge of a doctor charged of misconduct are of the same organization. Would accused doctors consider this dual role of the Council unfair to them? Would they perceive this arrangement as depriving them of the right to a fair trial – the right to a fair and public hearing by an independent and impartial tribunal in the determination of their civil rights and obligations – which is protected by human rights laws?

For members of the public, given one-half of the Council is elected by doctors while most of the other half also comes from the medical professionals, wouldn’t it appear in the eyes of the public that council members are actually all “members of the same club”? Furthermore, as half of the council is elected and thus very likely beholden to their doctor electorate, wouldn’t this group of council members see themselves more as representatives of the profession than as servants of the public? Would council members feel under some subconscious pressure to lean towards protecting the interests of fellow members of the same club and their electorate when making “judicial” decisions on accused doctors?

On the part of doctors, given the way the Council is currently constituted, would doctors perceive it more as an organization representing rather than regulating them? Would there also be a danger of a vicious circle in that the more doctors perceive the council as a representative body, the more the Council really takes on this role and puts doctors’ interests first, resulting in further public mistrust of the Council’s fairness?

We are worried about how much the mistaken legal approach uncovered by the judicial review mentioned above was influenced by the Council’s inclination to protect doctors’ interests.

A further issue in need of review relates to disciplinary sanctions. As mentioned before, if a doctor is found guilty of professional misconduct, one of several sanctions may be imposed: 1) removal from the register, 2) removal from the register for a period of time, 3) reprimand, 4) suspension of the application of 1, 2, or 3 for a period of time, subject to certain conditions, 5) warning letter. It is important to note that doctors sentenced to sanctions other than removal from the register can continue to practise or resume practice after a certain period of time despite blemishes in their practices. In other words, such doctors remain a risk to patients. Thus, unless doctors guilty of misconduct are also required to undertake remediation or re-education so that they improve their practices, sanctions other than removal from the register are meaningless in protecting the public. To effectively protect the public, sanctions other than removal from the register must carry a requirement of remediation or re-education.

From publicly available information, however, the Medical Council does not seem to have a comprehensive remedial program for doctors guilty of misconduct. While a requirement of peer audit is normally imposed in cases of failure to keep dangerous drugs properly, there appears to be no mandatory re-education requirement for offences relating to substandard practice. If this is really the case, the complaints and disciplinary mechanism is severely inadequate in its capacity to protect the public.

The issues we have raised are of a fundamental nature. They call for a fundamental review of the complaints and disciplinary mechanism. When highlighting the importance of these issues, we are not suggesting that current concerns about delays in the handling of complaints and insufficient participation of lay persons in the Council’s decision-making are misplaced; we are saying that focusing on these alone is unlikely to increase the mechanism’s effectiveness in protecting the public.

We would like to emphasize that even when all the aforementioned issues have been properly addressed, the protection that a complaints mechanism can provide to the public remains inadequate because it is essentially a reactive system.

Under a complaint-driven regulatory system, so long as doctors can avoid getting into trouble with the regulator, they are assumed by the system to be “good” or “competent”. This assumption is obviously untrue. In order to protect the public adequately, instead of waiting for someone to make a complaint, a more proactive approach to identify under-performing doctors is needed.

To this end, one possible approach is periodic re-validation of doctors’ skills and competence. In addition to reviewing the current complaint mechanism, we urge that an introduction of a system of periodic re-validation be also considered.

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