The medical 'negligence' myth

01 October, 2014

The medical ‘negligence’ myth

The medical ‘negligence’ myth
Doctor-patient trust is disappearing fast today
Errors in judgment happen to the best of us. But which doctor would willfully harm a patient?

One of the fieriest debates doing the rounds these days is on medical negligence. I still fail to understand why a doctor would be willfully negligent, as his practice depends on word of mouth. My own understanding of the situation is that often the expectations of the patient or their relatives outweigh the doctor's capacity.

The concept that is prevalent in this country is that doctors can deal with any disease effectively. But that is not true. However, the doctor should always weigh all decisions carefully and explain the various modalities of therapy and their advantages and disadvantages to the patient and his relatives -- ensuring that they are a part of the clinical decision- making.

Medical malpractice is professional negligence by a healthcare provider, wherein the treatment falls below the accepted standard of practice of the medical community, resulting in injury or death. Many such cases involve medical error. In such cases of malpractice, the litigant must establish that the doctor owed a duty to the patient and that duty was breached by substandard treatment. The breach of duty must result in an injury or a tangible damage. This damage may even be emotional.

In this context, I remember a colleague who had a good suburban practice as well as a town practice at a well-known city hospital. He was called out of his practice chamber in the suburbs to deal with a young patient apparently suffering from vertigo. He could find nothing wrong and the ECG reports were normal as well. It seemed like an obvious case of vertigo. In such a situation, usually there would be no need for admitting the patient. On the insistence of the relatives he admitted the patient to a city hospital. Three hours after admission, he received a phone call conveying that the patient had become critical, at which point he asked for the patient to be shifted to the ICU. Leaving behind his busy suburban practice chamber almost immediately, he drove to the city hospital, but it was hours before he could arrive. On his arrival, he found the patient to be in a vegetative state in the ICU. Apparently, this patient had an unapparent cardiac rhythm abnormality, which resulted in diminished brain circulation, making the patient comatose.

Subsequently, the colleague was sued, and he came to me to seek advice. On looking at the situation, I could easily determine that on the face of things there would be no apparent need to admit the patient. If one admitted every giddy patient -- considering the one-in-a-million chance of there being something amiss with the initial thorough evaluation -- then hospitals would be overflowing, patients unattended, and doctors richer for no good cause. My friend went thought a traumatic time, having to spend large amounts on lawyers in consumer courts in the city and in Delhi. Imagine the mental trauma, of working with a sword of Damocles over your head, trying to deliver not just good, but approved healthcare. He did win in the end -- but stories like this push doctors to practice defensive medicine and admit patients more often than necessary, at a large economic cost.

Reports of violence against doctors and hospitals in this country are well documented. In a recent incident in Tiruvallur district, a 30-year-old woman, admitted for a gynaecological procedure, died, leading her relatives to agitate and block roads. Similar situations have occurred in Mumbai as well, where hospitals have been damaged and physicians beaten up, despite the laws that exist to prevent such acts.

From a normal standpoint, surgery is safer today than it was a decade ago and the risk involved for the patient depends largely on the general health of the patient as well as the procedure. Yet, however safe a procedure might be, there remains a minuscule, but certain, risk of death from anaesthesia. This is very unfortunate, especially in cases where the patients want to undergo cosmetic procedures with no real medical benefit. I therefore do not recommend surgery unless absolutely necessary. Even when the patient opts for any surgical procedure, they should be adequately counseled, along with their family members, about the risk involved.

The other problem in an Indian situation is that much of the advice offered and options discussed are verbal as compared to the West. This sounds reasonable, considering that the Western consultant sees three to four patients in the time that we see 12 to 16 patients. Even the outpatient departments of hospitals in the West are usually by appointment, in contrast to the Indian situation where a walk-in is acceptable. During the training phase of a resident, he sometimes turns over 30 patients in an hour, which comes to to 90 to 100 patients over the morning in the OPD. This requires a degree of expertise the West has never seen. Not only that, but in such diagnoses they are correct most of the time.

With the problem of growing litigation for negligence, physicians now note their advice on or behind the prescription, and the more enterprising make out a detailed report. This is time consuming and unnecessarily ups the price of consultation and fees. That means that legal expenses are usually more than what one would obtain from consultation or simple surgery. With litigation against doctors regularly appearing in the press, also disappearing is the element of trust, which was the point of the doctor-patient relationship.

In conclusion, the cost of protecting oneself against litigation involves many other time-consuming and expensive investigations. I would be happy the day the courts remove negligence from consumer courts, which treats the profession no better than a trader's, but gives it the dignity it deserves by passing negligence issues back to medical councils. Which doctor in his right senses would willfully harm a patient? Errors in judgment do happen to the best of us. Everyone is wiser in hindsight; after the boat has sunk somehow everyone knows why.