Patients ‘clearing MCs’ or taking sick leave for holidays: Doctors speak out about telemedicine abuse

SINGAPORE: Telemedicine doctors have spoken up about the challenges they face on the job, especially when it comes to dealing with malingerers and patients who get upset when denied a medical certificate (MC).
The health ministry said last month that it intends to revoke MaNaDr Clinic’s licence. It also said 41 of the clinic’s doctors have been referred to the Singapore Medical Council for alleged professional misconduct.
These arose from potential breaches – short teleconsultations, repeated issuance of MCs to the same patient over a short period of time, and questionable and poor documentation.
Two doctors, who requested to remain anonymous, said some patients would get frustrated if they tried to get further clarification about their medical history, or if they asked about their recurring occurrence of taking MCs.
“(I have even seen) cases where they straight out say that they are ‘clearing MC’,” said one of the doctors, who has worked part-time on several telemedicine apps including Doctor Anywhere, MaNaDr and WhiteCoat. 
“There were also cases where the patients are obviously overseas – whether it’s the geotag or the physical location – but they’ll claim they’re sick and in Singapore.
“When we end the consultation without providing an MC, we risk getting complaints.” She would have to respond to these complaints, and they might even result in “low” ratings that could affect her pay.
One repeated-visit patient got upset and abruptly hung up on her after she asked to see his medicine and sought updates on his symptoms. The patient had asked for his MC to be backdated and for another two days of medical leave.
“I had emphasised that it’s difficult to provide him an MC if his symptoms are persistent or worsening since he should see a doctor in person,” she said. 
“After he hung up, both backend staff and I tried calling him multiple times (but there was) no response. I then got rewarded with a complaint email a few days later, which was full of untrue statements.”
If doctors “void” such calls, they do not get paid. But this is not fair to the doctors as calls with such patients typically take longer “because they’ll be arguing about their right to take MC”, she said.
“It builds a mentality that (patients) don’t have to pay if they don’t get what they want, which isn’t right since they did consume health services and should pay for it, regardless if they got their wish of an MC or not.”
Another doctor said some patients would try their luck to get an MC on the app so they do not have to use their annual leave. 
“They would actually ask me if I can give them an MC so that they don’t have to touch their annual leave,” said the doctor, who works full-time at a private clinic but uses the MaNaDr app to provide teleconsultation services outside her office hours. 
She estimated that malingerers – where a person pretends to be ill to escape duty or work – made up 10 to 15 per cent of her patients.
“Most of the time, I would still charge them because a consultation was done,” she said. “I know some doctors might feel sorry and would waive the fee but to me, I’ve already done the consultation and I reached the conclusion that you’re not eligible for MC so you still have to pay.”
Caseloads for teleconsultations can also be very high, resulting in nonstop calls for hours.
“Calls will be coming in all the time, making it such that you’re just sitting for hours catering to the nonstop calls – without even a short break for toilet,” said the first doctor. 
“It’s even harder if you’re already trying your best but the (administrative team) comes in to question why certain calls were missed or why there’s a wait time before calls were picked up.”
In the wake of the MaNaDr incident, some telemedicine apps and healthcare providers told CNA they are stepping up checks on their doctors and patients to prevent abuse.
Digital healthcare provider Speedoc, which offers house calls by doctors and telemedicine, said it has implemented additional checks and audits on how its doctors issue MCs.
This is to ensure that the MCs are granted appropriately and align with regulatory standards, said the company’s chief executive officer Dr Shravan Verma.
Dr Verma added that if a patient visits repeatedly for video consultations, they may recommend an in-person consultation to ensure that no underlying conditions are overlooked.
Similarly, Fullerton Health, which also offers teleconsultations, said it has an alert for repeated-visit patients who undergo three or more consultations within the calendar month. 
“These metrics will help doctors advise such patients to go to a physical clinic for a thorough assessment of unresolved or frequent health condition,” said its spokesperson, adding that its platform also summarises the dates and duration of MCs issued for each patient.
Last year, CNA reported concerns about certain telemedicine apps issuing MCs after extremely brief consultations. In one instance, a CNA reporter obtained an MC from MaNaDr after a remote consultation that lasted only 43 seconds.
Dr Zeng Zhi Yong, a resident doctor at BCH Clinic @ Pasir Ris, said he conducts about two to three consultations per week, which usually take around five to 10 minutes.
“It would be difficult to go through everything in one minute because there are other things to go through besides asking them about their symptoms. We also need to look at possible red flags. For instance, if they say they have a headache, we might ask them to take their temperature to see if they are having a fever too,” he said. 
Dr Zeng said his clinic only conducts teleconsultations for patients who have visited the clinic in person before. 
Besides protocols to prevent malingering, telehealth providers CNA spoke to said their doctors have to undergo a vetting process before they are allowed to conduct teleconsultations.
Telemedicine app Doctor Anywhere said it requires all doctors to provide information on their current employment, licensing and telemedicine experience, including proof of completing the health ministry’s mandatory telemedicine e-training. 
It does not employ doctors working in public healthcare or those with potential conflicts of interest.
Similarly, Raffles Medical said all teleconsultations are conducted by trained family physicians and general practitioners. All doctors on its teleconsultation platform are employed full-time and it does not hire external locums. 
Similarly, Dr Zeng said locum doctors at his clinic are not allowed to conduct teleconsultations. 
“We do this because we would want our patients to see a familiar face, so that it’s a bit more comfortable,” said Dr Zeng.
However, the private doctor who works part-time on telemedicine apps remained sceptical about how effective these measures are in guarding against telehealth abuse. 
She pointed out that repeat-visit alerts only work if patients use the same platform.
If a patient uses a different telemedicine app, the doctor would not be aware of their previous consultations on other platforms unless the patient disclosed this.
Setting a minimum duration for teleconsultations may not work too, she said, as some conditions do not require much time to diagnose.
“These measures are more for the doctors to be able to protect themselves,” she said.
“Honestly, the patients who abuse telehealth, or the whole MC system, will continue to do so. They should also be held liable for their behaviour.”