Diagnosing Medical Negligence
As long as the doctor is sincere, he works very hard to get at the diagnosis, taking into account all the available data; if he still fails to arrive at the correct diagnosis, it is nobody’s fault
 
Medicine is a serious business, and a noble profession. We have certain obligations to society for the exalted position we enjoy. Having said that, one must try and understand the practice of medicine in India against the background of a Supreme Court judgement which stirred up a hornet’s nest. I am happy that Dr Kunal Saha’s loss has been adequately compensated—a record Rs16.96 crore for the death of his wife attributed to medical negligence. 
 
But I am a bit concerned that this judgement might further escalate the already sky-high corporate sickness industry’s bills and might make it extremely difficult for ordinary people. Now, the doctors’ indemnity insurance will go through the roof and many doctors will not be able to afford it unless they join the corporate juggernaut.
 
There are many different professions. Each one tries to offer services and get paid. Why should only doctors work in the villages, look after the poor and the downtrodden, and work round the clock without any time of their own? A lawyer charges lakhs of rupees per hour of his/her time, but the doctor is not supposed to charge like that. IIT, IIM and MBA graduates—most of them at least—leave the country immediately after their studies, to work abroad. Nobody bothers about them; but, if a doctor wants to do that, people find fault with her/him. 
 
The taxpayer pays for their education equally anyway, except for the ones who pay through their nose to get admission and degree in many of our (in)famous private universities. The under-the-table ‘fees’ might run into crores of rupees these days.
 
No human being is infallible; but why does society, and the courts, find fault for a wrong diagnosis? If my interpretation of the law is right, we are supposed to exercise due care to see that we do OUR best for the patient. Diagnosis in medicine is not as easy as it is made out in the press. There are no black and white areas in human physiology. Imponderables abound in the diagnostic arena. Even at the best centres in the world, where they pool the wisdom of many people in difficult cases, 12% of the patients’ diagnoses could only be made on the post-mortem table. 
 
No patient’s death can be predicted, or prevented, by any doctor, however good s/he is. It is very difficult even to give a correct prognosis as the future is an imponderable in science. The future is yet to be born. No doctor can predict the unpredictable future of the patient, although we have been doing that to pander to our pleasant self-image. 
 
We are, to a great extent, responsible for this exponential growth of consumer cases against doctors. Firstly, we deified ourselves and assumed greater powers than we really have and, many a time, claim to do wonders. We are no longer humble enough to state that we only dress the wound and nature (God) heals. We have taken medicine to the marketplace, to make big money. That has brought, in its wake, the market forces to our area also. 
 
In truth, the medical world revolves round faith of the patient in his doctor. It is the coming together of two human beings, one who is ill or thinks he is ill, and comes to seek the advice of another, in whom s/he has confidence. This confidence works wonders even in healing. Unfortunately, today, in the corporate hospitals set-up, this holy relationship between those two human beings no longer exists. It is like the assembly line work. Modern medicine, in this century, has become a corporate monstrosity, according to a study done in London by Hillary Butler.
 
As long as the doctor is sincere, he works very hard to get at the diagnosis, taking into account all the available data; but if he still fails to arrive at the correct diagnosis, it is nobody’s fault. But the doctor should document all these efforts to show that he has done all that was needed to be done for ‘reasonable care’ of the patient. 
 
Of course, in all these, there should be no wanton negligence at any stage. Communication skills are a great help in keeping the patient, and his near and dear ones, in the picture through the time that the patient is in the hospital or clinic. That would go a long way in avoiding unnecessary litigation. Where needed, a second opinion is another safeguard against litigation. In hindsight, one might be able to do better; but, in an emergency situation, there is the added element of urgency to intervene which will not be there for the reviewing doctor, court or a witness that the primary doctor was denied. 
 
Another reason due to which the problem gets compounded is the jealousy of our own brethren who might inadvertently create a situation where the patient’s relatives become suspicious. If the patient gets worse and is then shifted to another hospital, someone there might inadvertently say: “If only you had come early, we would have been able to do lot for the patient.” This single sentence, though not the complete truth, is the single most important abettor of consumer complaints.
 
These days, the huge bills of most corporate hospitals work as seeds for litigations to grow. In some cases, the grievances are genuine. Keeping dying (and dead) patients in the intensive care units (ICUs) with tubes stuck into all possible orifices, or wheeling dead patients from operating tables into ICUs, to be kept there for some hours on ventilators before they are declared dead, admitting apparently healthy people for all sorts of tests and scans, removing the appendix for every minor pain in the abdomen, abdominal deliveries where normal delivery was feasible, operating on the wrong side or wrong limb, leaving operating instruments inside the patient’s body or administering dangerous wrong medications, the list of genuine consumer complaints is growing. But complaints, regarding the competence of a fully qualified and licensed doctor, fall in the grey zone.
 
The patient and the relatives must always be kept in the picture and documentation of all that is done kept meticulously will be the best insurance against consumer court cases.
 
(Professor Dr BM Hegde, a Padma Bhushan awardee in 2010, is an MD, PhD, FRCP (London, Edinburgh, Glasgow & Dublin), FACC and FAMS.)
Comments
Hemlata Mohan
7 years ago
Agreed Dr Hegde. India suffers from lack of doctors because of the very high cost of medical education and lack of faculty. We are unwittingly getting into a situation where we would never be able to even "see"a doctor without paying the fees. An d Insurance companies are waiting for precisely this situation . If medical education is made affordable, more youngsters would join and be happy to serve the public, But this is a very distant dream..
Meenal Mamdani
7 years ago
As a physician, I agree with Dr. Hegde. This article describes the problems in making a diagnosis and assuring optimal treatment.

The main problem I feel is inadequate communication by the doctor. Doctors either do not wish to spend the time to explain to patients or lack the skill to do so.

If the problem is the former, it could be rectified by having a well trained nurse or physician assistant on the staff who can decode the cryptic doctor notes, give enough time to the patient to ask questions, suggest resources to get better informed and be available to answer doubts that may arise after the patient has left the clinic/hospital.

A second opinion is valuable only if the referring physician has no conflict of interest with the second physician.

I am afraid that the only way to force the doctors and hospitals to change their behavior is through litigation. And yes, this will hurt the honest MDs but that is unavoidable.
Narendra Doshi
7 years ago
Dr. Hegde,
Well clarified and detailed.
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