Hospital, Doctors fined for unfair trade practices: Doctors “ be clinically and legally correct so as to save themselves”


 

Since Hannurabi times  1750BC, medical profession or health care has been regulated. For thousands of years, attempts  have  been made, laws enacted  to regulate or control medical treatments or doctors. It has never been perfect.  In today’s time, where medico-legal issues have become as important as much as treatment, it is strange to find such practices, where transplant was done without valid license. More importantly, it was done in a well known hospital in Delhi and not in unknown location.

Going by the news item,  Jaipur Golden Hospital New Delhi conducted renal transplant without having a valid license for the same in 2006. It could have gone unnoticed, in case  everything had gone well. But  in today’s scenario, no one accepts even small and routine  complications. So doing a procedure like transplant without license  is asking for trouble.

Medical fraternity is clear that there are no treatments without complications.  Even simple procedures can get complicated. Therefore, doing anything which is   legally not correct, can be a blunder.  Consequences of even little mistakes can be disastrous in current environment, which is not very supportive to doctors.  Temptation  for  doing procedures without being legally correct  can be many, like holding  a license previously, or just to maintain a continuity of performing a special surgery. Money generated may  or may not be a great incentive in such circumstances . Reason can be as simple as to continue doing procedure while license is awaited and take  temporary invalidity of licensing requirements lightly.

Legalities should be taken in correct perspective always.  Doctors can save themselves by just following well laid protocols and  legal requirements. This is not right  for doctors   doing  procedures against the law or without legal permissions. Because  no one, including patient will not support the doctor in adverse circumstances.

Doctors  can save themselves by   doing procedures, which are clinically and legally correct.

Aberrant Evolution of medical profession: will it help the patient?


With advances in medical science, simultaneously there has been aberrant evolution of medical profession, education, regulation and medical industry. By provoking controversy about doctors for varied reasons, medical industry and law has been positioned between the doctor and  patient and  taken a center stage in health care. Till now, doctor patient interaction was the central point of the health industry, a core around which medical industry revolved. But now   this interaction, treatment and  almost everything is controlled by industry and regulated in some manner. There have been technical advancements to promote better treatment and diagnosis but these, at the same time, increase the cost of treatment, involvement of industry and hence dependence on investors.

 There has been advancements, but are they in right direction?

Discouragement  of medical fraternity:  The adage “To err is human” probably does not apply to the doctors anymore. Doctors are definitely regarded different from rest of the humans and are not supposed to have privileges that other persons of humankind are guaranteed. Hence they are harassed often for any adverse clinical outcome even though it may be because of poor prognosis of patient. They work under continuous fear and stress and are punished for each small or big error.

Commercial evolution of medical education: medical student are now forced to pay exorbitant fee with lower standards of education.  

Evolution in medico legal  procedures:  extensive and complex communication, technical advancements and legal interactions has taken a toll on the doctors. But more importantly, how that has improved the patient care or  doctor patient relationship? I feel, it has created fear in mind of doctors and deterioration of doctor patient relationship.

 Evlution of Doctor patient relationship and Trust :In all the complexity, trust between doctor patient has taken a hit. A good paternistic relationship, now has been converted to more of a legal one. Trust has been replaced by  mutual fear.

Evolution of Complex medical regulation and documentation: There has been overzealous regulation of medical profession. Time and resouces which should have been utilized for treatment of patients,  has to be used for complex documentation.

Evolution of media and social media: Painful retrospective analysis of work of doctor by media, courts and public contuse. Decisions which doctors has to take in moments are analysed retrospectively by everyone with wisdom of hindsight over years, without understanding complexities involved.

Evolution of Insurance sector: increasing cost of treatment and  medicolegal component has made both patients and doctors paying to insurance companies.

            This kind of aberrant evolution of medical profession has increased the problems of doctors and patients and it is not helping anyone. Ultimately it will help everyone except doctor and patient. Ultimately discourage the excellence in medical care.

 

21 occupational Risks to doctors and nurses, while performing their duties


 

Doctor save the patient, but save yourself also.

Working of a doctor and nurses is not free from risk to themselves. The risk is generally underestimated, although it often involves major  risk  to life and may be frightening. Problem is that  majority of people, society and governing bodies  and even doctors themselves do not perceive or acknowledge it many times  the risks seriously.  But since  these risks are increasing exponentially everyday, because of changing scenario, they should be known to students, who want to take medicine as a profession. They need to take an informed decision. There are lesser set procedures, lack of awareness, not protective equipment or supportive society, governance and  laws, at most of  the places globally, and  doctors continue to work  in danger zones. These risks can be of varied types. Contracting the diseases is just one of them.

Even when doctors and nurses contact the diseases, there may or may not be proper support for further treatment, compensation and rehabilitation. Most of the time, they  have to fend for themselves. Because quite many of them , in government and private sector work on adhoc basis, temporary posts and on contract. Doctors  may have following risks, readers can add, if I have missed few:

Occupational health hazards

1.Tuberculosis: Common among health care  workers

2.Hepatitis B, Hepatitis C

3.HIV

  1. Influenza, Swine flu and other viruses of similar type.

5.Chicken pox

6.Rabies

7.Patients some times comes with unknown viral illnesses, which can not be tested. At the time, when treatment is going on, even diagnosis is not known. Doctor can contract these bacteria or viruses. There can be many more.

 

Risks related to stress and overwork

8.Depression, suicide, hopelessness

  1. Burnout.

10.Restricted social life

11.prone to alcohol/ drug abuse/ drug exposure.

Stress of balancing Family life: Kind of work and night duties effect family life very adversely. 12. Specially  female doctors. Completing  family will effect their careers, most of time.

13.High rates of divorces

14.Stress related diseases

 

15.Life style diseases: mainly sedentary work and long hours of working, makes them prone to life style diseases like ischemic heart disease , hypertension etc.

16.Exposure to radiations: specially in radiology and oncology. female doctors are more affected.

17.Lack of exposure to sunlight: effects bones , deficiency of vit D and predisposes to depression

 

  1.   Risk of catching resistant infections and sometimes there is risk that they carry these deadly bacteria to their homes. So their family members and children are at risk.
  2.   Risk of  working in disaster area and transport of sick , floods, earthquakes. Accidents of    ambulances .
  3.   Change in natural bio flora  of doctors and nurses. It is replaced by hospital bio flora. If they get infection, it is difficult to treat.
  4.  Risks because of legal problems and violent patients:  adds to stress Patients may not have favourable prognosis. But it is common for doctors to be blamed  even for naturally poor prognosis of the  disease. Legal trouble adds to further stress.

    –verbal abuse and threatening is very common. So spoiled mood unnecessarily.

– fear of  physical   assault can really harm doctors and family members.

– excessive and unilateral regulation puts doctors at the receiving end of the discontent.

Worst part is that our systems are not defined to prevent, treat or compensate or even acknowledge for these big disasters, if it happens to healers. These problems are not known to students, when they decide to take medicine, nor they are taught in medical school. Most of the time they have to fend for themselves, if problems occur.

Administrators and regulators refrain to study data that would establish and quantify the occupational hazards of being a doctor and nurses. Some of these hazards may be known, but there is no comprehensive analysis of workplace risk for physicians and nurses, like those that have been done for other professions. As physicians, we have a sense of the risk, and yet we remain engaged, continuing to care for our patients as we know  “these things” happen. Perhaps society prefers to remain blissfully ignorant of the sacrifice and risk their doctors take on, comforted by the fantasy of the serene  hospital. Perhaps we  all despise to let reality and data shatter the illusion.

Everyday globally, the doctors and the nurses  greet the new day and return to their work of taking care of their patients, knowing well the risk  involved.

Maybe it is time that we are little more aware  and acknowledge that even doing everything in best manner and honestly , we are in a  conflict zone and  we are all in harm’s way. Just be careful and be mindful that  doctors, nurses, and healthcare workers,  may get  sickened, injured, disabled, or can be dragged to court or harassed even  as they care for their patients in best manner.

Doctor save the patient, but save yourself also.

Artemis doctors, CEO booked for negligence: how to save medical lawsuit in case of post operative complications?


Doctors save the patient, but save yourself also.

News of this kind brings tsunami of fear in minds of doctors all over. Not only doctors, but patients also fear that something like this should not happen to them. In general, it will also create a negative impact on trust of patients, because it reflects that harm is a result of blunder done by doctors.

Artemis Hospital Gurgaon, its CEO, medical director, medical superintendent, and three other doctors of the hospital were booked on  Sunday, based on the complaint of the husband of a patient who died in the hospital in August last year after undergoing treatment in it for two months. (link)

http://timesofindia.indiatimes.com/city/gurgaon/artemis-docs-ceo-booked-for-negligence/articleshow/59008481.cms

Reality and impact of this scenario may be a bit different from what is usually conveyed and is suffocating medical profession as a whole, all over the world, in some form or the other. Loss to the patient is immense and with sympathy wave against the doctor, everybody will cry for harshest punishment for the doctors. For a human error (which is called negligence), an unintentional harm and failure to anticipate a difficult situation has landed doctors in a soup. The   situations, which are detected by retrospective analysis along  with wisdom of hindsight are challenging and are real trouble. Real time diagnosis  may not always be possible to anticipate and often difficult.

As a doctor, I am forced to ponder whether by punishing the doctors in harshest way for unintentional errors, especially for one incident is the solution to the problem.

  • Can treatment and surgeries be made complication free anywhere? Unless everything is done by a Robot and computers.
  • If consequences of one mistake are such horrifying, will doctors be able to do work, especially in difficult situations free of fear? Or really should they opt for being in such situations?
  • If lots of doctors do not want difficult situations, what will happen to patients?

Difficult scenario for doctors, as even simple surgeries can lead to big complications in certain situations.  Not frequently, situations are unpredictable. So, what should doctors do to avoid to be in such difficult scenario?

How to survive medical lawsuit in post operative complications: Reality is that complications are part and parcel of treatment and surgeries. There will always an element of unintentional harm, whatsoever treatment is being done.No doctor can guess, which patient is going to have complications and give saviour the lifetime pain and shame. It is like a bad lottery. Only improvement can be made is to decrease the number of complications and timely recognition.  How to avoid such problems?

  1. Just be extra careful, extra conscious. Always have in mind that something can happen. It may lead to defensive practice, but that may be the need of the hour.
  2. Due to irony of present era, the preparation of saving yourself, the doctor has to start from the time the preparation of surgery starts. Most important part is consent. Doctor cannot predict, which patient will have what kind of complications. Detailed consent with detailed list of complications have to be mentioned and told to patient and relatives and duly signed with witness. Complications, although rare must be mentioned.
  3. Separate consent for anaesthesia to be obtained along with complications.
  4. Must check for coagulation profile and presence of infection in body.
  5. Risk to be assessed besides actual surgery, for other factors.
  6. Simple surgeries become high risk because of malnutrition, infections, low albumin levels and presence of other medical illness like diabetes, cancer, cardiac ailments. In presence of other factors, high risk consent to be taken.
  7. Never ever risk is to be understated, for the thought that patient will not agree, in case he is told about all the possible complications and risks.
  8. Careful surgery, with high index of suspicion for possibility of complications is required. Never be overconfident. Complication can happen in hands of most experienced people also.
  9. Post operatively : maintain a good record of vitals and pain. If patient is having problem, go to every detailed investigations to rule out your worst fears. Investigations will cost some money and people may accuse you temporarily of getting extra investigations. But it is better not to be accused later for criminal charges and losing all your peace of mind and reputation.
  10. Never discharge a patient, while problems are unresolved. May get a CT scan done and let people accuse you again for getting extra investigation . Time is such that doctors will be blamed and accused for something or the other by retrospective analysis. Let us take a smaller accusation. Later there no body will be forgiving.
  11. If you are not convinced or patient is unable to understand the risk, opt out of surgery. Doing few less procedures will not harm you.
  12. Upgrade quality assurance program of hospital and your department. With aim to minimize complications and early detection.
  13. Periodic audit of medical records.
  14. Medical Indemnity insurance: importance of indemnity insurance is immense these days. Be careful of not disclosing the medical indemnity insurance coverage, because litigant lawyer or patient may exploit it for litigation purposes.

 

Not infrequently, whole scenario becomes a story of revenge against the doctor, even for routine complications and naturally poor prognosis of disease. Therefore, Doctors – save the patient, but save yourself also.

 

 

How to survive medial lawsuit for central venous line insertion


 “ doctor- save the patient, but save yourself also”.

Consent must before invasive procedures: consumer panel  

National Consumer Disputes Redressal Commission has said that doctors must take consent of a patient or his family members for any invasive procedure during treatment. (11.5.2017 Times of India link below).

I really feel sad for the doctors, who sometimes due to overwork or zeal to do things  find themselves in a soup, because of lack of paperwork.  But they are learning the lessons the hard way. Law and media call them a mistake but I think the errors in documentation are due to lack of proper training and poor understanding of legal requirements of profession in consumer’s era. The ignorance is about necessity to save thou self, when we try to save the patient. These documentation have become all the more necessary in current scenario because of the non-acceptability of even common complications. If a complication occurs during treatment, prolonged retrospective analysis goes on at leisure by lawyers with an intention to find fault. They are driven by money as an incentive, and with the wisdom gained on the hindsight, they may find some fault almost always in some way. Thus, doctors are at great disadvantage on this issue. choosing medical career a disadvantage to doctors.

It is high time for doctors to learn how to save themselves. It is important to have a thorough documentation. I am mentioning certain aspects which should be taken care of, while putting a central line .

  1. As already in news “consent” is very important. Take care to write patient identity, age sex and all other relevant columns. Explain and write all benefits and possible complications of procedure. Get signature of patient, relative and a witness. Put doctor’s signature with date and time.
  1. Always try to use ultrasound to help you to locate lines. Patient can be obese, having short neck and it may be difficult anatomy. Ultrasound will help you in differentiation of artery and vein and avoid arterial puncture as in above case.
  1. Be sure before dilatation that you are in vein. Sometimes it is difficult to differentiate between artery and vein. Do everything to prove that you are in vein before dilatation.
  1. Take suitable precautions for to prevent sepsis, air embolism
  1. If it is not emergency always check coagulation profile.
  1. Make sure doctor who is doing the procedure is well trained for it.
  2. Upgrade quality assurance program by keeping record of adverse events during procedures.

These are simple steps, although documentation is cumbersome. But it is worth because it can help the doctor from future litigation, harassment and so many problems. This is need of the hour. Bottom line is “save the patient, but save yourself also”.

http://timesofindia.indiatimes.com/city/delhi/consent-must-before-invasive-procedures-consumer-panel/articles how/58618137.cms

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