Consequences of medical negligence and litigations on health care providers - A narrative review.

Medical professionals face high stress due to the type of work they do and the prolonged working hours. Frequent burnout results due to the challenging nature of their work. Added to the stress of work, malpractice lawsuits add to their burden. In India, most doctors work in compromised settings with poor infrastructure and manpower but are expected to follow the best practices. In court, they are judged with the Bolam and Bolitho tests being essential considerations. Several tragic incidents have been reported, including depression, anger issues, and even suicide deaths of healthcare professionals (HCPs) after accusations of negligence and subsequent inquiry. Such incidents demonstrate the multitude of challenges an HCP faces in day-to-day practice. It is crucial to find ways to tackle these problems and enhance the capacity of HCP to handle such demanding circumstances. Malpractice litigation can significantly impact the mental health of HCPs. It is common to experience emotional turmoil when faced with a lawsuit. Second victim syndrome (SVS) is a term used to describe a set of symptoms experienced by HCPs who make an error leading to injury to a patient. However, it also happens if he is traumatized by the consequences of violence during healthcare services or a lawsuit or defamation article in newspaper/social media. Following a litigation crisis in their career, many HCPs go through various stages of grief, including shock, denial, anger, bargaining, depression, and acceptance. At times, death by suicide of the HCPs is well known. SVS is known to profoundly affect the personal, family, economic, professional (defensive practice), and social life of HCPs. HCPs should accept the allegations of negligence as an occupational hazard and prepare for the eventual litigation at least once in a lifetime by knowing about the medical laws, HCP's rights, becoming aware of the emotional turmoil of the lawsuit, preparing to cope with the lawsuit, and seeking help from colleagues and indemnity insurance. Frequent training of the HCPs is strongly recommended to know about the changing laws and also to undergo periodic professional competence enhancement to reduce the incidents of errors amounting to medical negligence. Medical and hospital administration should debrief after any incident and conduct internal investigations to identify systemic flaws and prevent future recurrence, resolve issues within their control at their level, and manage media (mainstream and social media) appropriately. If established, a reporting system with online and offline services will ease the internal administrative investigation process and take appropriate, timely actions. During the crisis, HCPs should have adequate and appropriate insurance or indemnity coverage and mental health support systems.

Violence against Health Care Professionals and Facilities-Local Insights about a Global Malady.

Acts of violence against health care professionals (especially doctors) as well as facilities are a growing global problem. In our country, it has taken an unfortunate dramatic turn of the involvement of a mob-a ragtag group of persons who organize and perpetrate the crime based on community, caste, religion, or political affiliations. This crucial factor is the fundamental difference in what we face as compared with the so-called Yi Nao phenomenon of China. In India, the mob gathers and indulges in acts of violence, intimidation, and blackmail at the behest of its "leader," often having no direct relationship with the deceased patient. It is premeditated and systematic vandalism. Often it is also associated with financial gain to the perpetrators through extortion and blackmail, adding to the woes of the health care professionals and hospital facility. We discuss what is the primary goal and what is a byproduct in this cycles of violence against the people who are doing their best to save the lives of patients. Unless the governments and the courts take this matter seriously as well as follow-up with corrective measures, the future looks bleak for all stakeholders.

When the ophthalmologists turn blind.

The cost of technology is high in ophthalmology but given the increasingly competitive environment and the social demand, there is a pressure to progressively lower the costs to the consumer. To keep costs down there is a tendency to do as many surgeries as possible in an assembly line fashion both in hospitals as well as in the charitable camps. This article provides ophthalmologists an insight into the legal pitfalls in practice of ophthalmology in India and the dangers of the constant lowering of costs of surgery as well as of free service. This lowering of costs would have been ideal in a Utopian world, but times have now changed and there is cost to be paid even for providing free service. In India the prevalent tradition of providing free service, has also resulted in a lowering of guard by the eye surgeons. These mass eye surgery assembly popularly called "free eye camps" has seen millions of people benefited. But recently there is an increase in number of cases where exorbitant penalty has been imposed by the courts, on these philanthropic surgeons for any deficiency in service, and this has destroyed the careers of many ophthalmologists. Time has now come to introspect and to factor the cost of litigation and compensations into the cost of surgeries so that we not only benefit the patients but also safeguard the ophthalmologists and help them fulfill their responsibilities towards their own dependents.

Incidents of violence against doctors in India: Can these be prevented?

Violence against doctors is on the rise all over the world. However, India has a unique problem. Meagre government spending on healthcare has resulted in poor infrastructure and human resource crunch in government hospitals. Hence, people are forced to seek private healthcare. Small and medium private healthcare establishments, which provide the bulk of healthcare services, are isolated, disorganized and vulnerable to violence. Violence against health service providers is only a manifestation of this malady. The Prevention of Violence Against Medicare Persons and Institutions Acts, which have been notified in 19 states in the past 10 years, have failed to address the issue. To prevent violence against doctors, government spending on healthcare must be increased and the Indian Penal Code should be changed to provide for a tougher penalty that could act as a deterrent to violence against doctors.

Should Advertising by Aesthetic Surgeons be Permitted?

Cosmetic, aesthetic and cutaneous surgical procedures require qualified specialists trained in the various procedures and competent to handle complications. However, it also requires huge investments in terms of infrastructure, trained staff and equipment. To be viable advertising is essential to any establishment which provides cosmetic and aesthetic procedures. Business men with deep pockets establish beauty chains which also provide these services and advertise heavily to sway public opinion in their favour. However, these saloons and spas lack basic medical facilities in terms of staff or equipment to handle any complication or medical emergency. To have a level playing field ethical advertising should be permitted to qualified aesthetic surgeons as is permitted in the US and UK by their respective organisations.

Legal hurdles for gastroenterologists in India.

Litigation and compensation claims have started occurring with increasing frequency against gastroenterologists in India. A study of few such cases decided by Indian Courts shows that commonest reason for allegations of negligence being upheld by Indian Courts is an improper consent being taken. Professional organisations need to focus on these issues more aggressively than has been done in the past. Judgments which do not appear to be in conformity with standard medical practices need to be challenged in higher courts, failing in which they would become precedents for future similar judgments.

Do Legal Issues Deserve Space in Specialty Medical Journals ?

Physicians and Internists in India have tended to brush under the carpet legal issues affecting their profession. Of concern to all Physicians is the judgment in a recent case where the NCDRC has stated that if MD Medicine Physicians write Physician & Cardiologist on their letterhead it is Quackery. What is MD Medicine degree holder in India qualified and trained to treat ? These are issues which need debate and that can only be initiated once we recognize that there is a problem. Either an MD Medicine is a cardiologist or he is not. If he is then it is the bounded duty of the Association of Physicians of India to challenge this judgment in a higher court of law and seek clear guidelines from MCI as well as Supreme Court on the issue. Editors of Specialty journals have a responsibility of selecting the best articles from those which are submitted to them to be published. Ultimately space in these journals is limited and hence the responsibility to select is enormous and simultaneously reason for rejection of an academic paper also has to be substantial. The question is "do issues which are not core to the specialty concerned deserve space in these?" Physicians and Internists in India have tended to brush under the carpet legal issues effecting their profession. Surgical specialties specially obstetricians and their associations have to some extent recognized the problem and taken steps to address the issue specially as regard PCPNDT Act.1 Physicians are more complacent and regard the Consumer Protection Act (CPA) 19862 and problems associated with it to primarily concern the surgical specialties. What is forgotten is that the maximum penalty of 6.08 crore plus interest of 5.5 cr has been awarded in case involving a patient treated primarily by a physician and on whom no surgical procedure was performed.3 It has also to be realized that there is no limit on the amount of compensation which can be asked for under CPA.2 Compensations have been awarded by National Consumer Dispute Redressal Commission (NCDRC) in a case where patient had fever with low platelet count for not doing LFT and ultrasound as patient later died of fulminant hepatic failure. Decisions have been given in complicated medical cases like GI Bleed in which the issue has been what modality should be chosen (balloon tamponade vs sclerotherapy),4 whether peritoneal lavage should have been done for acute pancreatitis. Trials in Consumer Fora being inherently Summary in nature and are meant to provide speedy redressal of greiviance of a consumer. These quasi judicial bodies are not exactly the place where complicated medical issues can be debated satisfactorily. Of concern to all Physicians is the judgment in a recent case where the NCDRC has stated that if MD Medicine Physicians write Physician & Cardiologist on their letterhead it is Quackery and also a clear case of negligence if he treats Rheumatic Valvular Heart Disease.5 The Honorable Supreme Court has already in 2009 decided that "if representation is made by a doctor that he is a specialist and ultimately turns out that he is not, deficiency in medical services would be presumed.6 An advisory has been issued by NCDRC in 2013 "to Medical Council of India and Health Ministry to initiate steps to strike down such practices of medical professionals who are posing as a specialist or misrepresenting as a superspecialist without any approved qualification by statute or controlling authority. In other words it is quackery, that is treating the patients in absence of a valid degree. Our questions are simple; 1) What is MD Medicine degree holder in India qualified and trained to treat ? 2) Is MD Medicine degree holder a qualified specialist and if so what is he specialist of ? Resolving this issue is extremely important in a country where quack AYUSH (BAMS, GAMS, BUMS, BHMS), MBBS doctor and even Physiotherapists are all qualified "Physicians". Given the substantial patient population which is uneducated and / or non-discerning, those with specialized training (MD Medicine) use terminologies like Heart Specialist, Cardiologist, Gastroenterologist, Endocrinologist, Specialist in Diabetes, Neurologist in addition to the Consultant Physician on their letterheads and nameplates. In absence of adequate number of qualified DM, DNB superspecialists in the country, it is MD Medicine doctors who work in various super-specialties in which they are trained and competent. Despite this well known fact no Association or Organization deemed it fit to challenge a judgment which discredits this practice and is logically out of sync with reality in a country like India. There is also the issue of differential liability for doctors while working in Government Hospitals and those working in private hospitals. If MD Medicine doing echocardiography is outright negligence in private sector it would also be so in Government Sector. In absence of DM Cardiologists most district hospitals and civil hospitals have MD Medicine doctors who are the official cardiologists doing echocardiography and other non-invasive investigations, reporting them and treating cardiology patients. The Goyal Hospital judgment had also stated that among "rampant unethical medical practices in India it is most common that nursing homes and hospitals provide facilities like diagnostic laboratory, radiology or sonology units without a specialist like Radiologist and Pathologist". Even under PCPNDT Act the requisite qualification to do ultrasonography is not only "MD Radiology". An MBBS doctor with required training or even a gynecologist is competent to do ultrasonography under the Act.1,2 No Government civil hospital or even General Hospitals in any state / UT has Radiologists or Pathologists, Anesthetists, Neurologists, Psychiatrists and more. If an MBBS degree along with training in required discipline is adequate qualification in a Government Hospital how can it not be in a Private Hospital. If however an MD Medicine doing echocardiography is negligence in a private hospital then it also has to also be so in a Government one. Most Government Hospitals including ESI hospitals7,8 are today covered under Consumer Protection Act hence differential liability is unacceptable. Training program and study curriculum of MD Medicine includes cardiology and the residents are posted in cardiology wards and ICCUs in all teaching institutions despite being only MBBS at the time. Though some institutions do not encourage active involvement in clinical care to be done by residents (who are as yet only MBBS) but most hospitals use the resident doctors as cheap workforce in various departments including cardiology. If in an institution the MD student is qualified to treat a cardiology patient under nominal supervision if at all, then a MD (Medicine) degree holder specially if has received further training should be able to perform routine functions of a cardiologist like doing an echocardiogram. Either way these are issues which need debate and that can only be initiated once we recognize that there is a problem. An ostrich-like attitude will not solve any conflict. Each conference of Association of Physicians of India has workshops on echocardiography, live demonstrations of difficult percutaneous interventions and talks on newer techniques in treatment of heart failure. If MD Medicine doctors are not specialists capable of treating cardiology patients, why burden them with knowledge they do not need. Their Association should focus on providing them knowledge and updates in their field of work of which they are specialists. Either an MD Medicine is a cardiologist or he is not. If he is then it is the bounded duty of the Association of Physicians of India to challenge this judgment in a higher court of law and seek clear guidelines from MCI as well as Supreme Court on the issue. Whether this challenge is done or not is also secondary to the question, whether these are issues important enough to be raised in speciality journals, to stimulate discussion and generate consensus.

Usage of betel quid, areca nut, tobacco, alcohol and level of awareness towards their adverse effects on health in a north Indian rural population.

AIM: To assess the overall prevalence of betel quid, areca nut, tobacco and alcohol use in the rural population of Muradnagar tehsil of Ghaziabad district and their awareness level towards adverse effects of these habits on general as well as oral health. METHODS: A total of 422 persons from 63 households of four (4) villages were enrolled for the participation in the study. A preformed, pretested questionnaire was used to collect the information on prevalence of risk behaviours of chewing tobacco, areca nut, betel quid, smoking and alcohol consumption. RESULTS: 72.5% of respondents reported indulgence in one or more habits of chewing areca nut, betel quid, tobacco, smoking and alcohol consumption. Smoking tobacco was the most common type of adverse habit in males while chewing tobacco in females. 26% of respondents believed that the community residents would quit the habit only if they personally experience any health problem due to the habit. CONCLUSION: In spite of being aware of risk of having multiple health problems, a major proportion of respondents were using betel quid, areca nut, tobacco and alcohol.