Apollo Hospital fined 5 lakh: “Doc, Talk less, write more”.Doctor save yourself by “documenting the communication”


Doctors are trained to treat patients and  that is they keep on  doing. But in today’s era that is not enough. They are expected to examine, investigate, diagnosis , treat correctly   and communicate to the family or patient. Everything should be speedy and  financially suitable to the patient’s expectations. Even if that is done, the things do not end here. Doctor need to document, what has been  communicated to the family.  It is hard to believe that  doctor at a hospital like Apollo,  who really did well to diagnose a disease like SLE and still did not communicate. Yes, news item mentions that in file that  there was no evidence of communication. Doctors still behave like doctors and do not treat patient as consumer. Usually , doctor trust their patients  and there is lot of verbal communication takes place. Verbally they sympathize, communicate  and  tell many things which are not documented as a routine.

The Delhi State Consumer Commission, in its judgment, made it essential for a hospital to disclose to the patients or their attendants, the line of treatment and the potential risks involved in it.
The judgment came in connection with the death of a 23-year-old student, who died during a treatment at  Indraprastha Apollo Hospital in 2004.

Many times patients are sincere enough to admit to  verbal  communication. But sometimes when  during ongoing  medico legal lawsuits, a feeling  of revenge prevails  or as guided by lawyers, patient  may not admit  to the verbal communication.  Specially if verbal communication is not documented in file.

How to  save yourself  by  “documenting  the communication”

  • examine, investigate, diagnosis , treat correctly and communicate
  • Make a note of plan of treatment and prognosis, and communicate to patient or attendants.
  • Sign yourself and ask the patient or nearest relative to sign.
  • It is not uncommon that relative will refuse to sign. In that case just write a note and mention that attendant refuses to sign.
  • It is also a common issue that after listening to everything, relative will say that he does not understand or will ask his uncle or aunt. These are difficult moments and commonly happen. Just make a note of everything. Besides it wastes crucial time.
  • Can use camera for communication in difficult cases.
  • Never rely on verbal communication. It has little value.  Commonly people refuse to admit verbal communication, and will say that they were not told anything.

As time for everything is limited in life, be it treatment, communication, consent or documentation. So message is clear for doctors. “Talk less and write more”. You will be judged by documents after many years. Therefore,  do save the patient, but save yourself also.

 

 

Two doctors from Fortis Hospital arrested – How doctors may save themselves by learning from such cases.


Doctor,  do save the patient but save yourself also.

Doctors continue to treat and save  many patients in the years they work. But present law and regulatory system does not take into account those years of  good and hard work. It does  treat doctor as a petty criminal for some single mistake or unfortunate incident. Law just deals with it in a harshest possible manner.  Patient may have died because of disease, but when in side the hospital, it is very easy to relate death with actions or inaction of doctors.  Specially because inquiries are always done  with  retrospective analysis, with wisdom of hindsight. Although there is a feeling among doctors that what is really happening these days, something may not be very appropriate, but there is no room  for leniency here.

News of this kind brings tsunami of fear in minds of doctors all over. It can be anyone in such situation, where  it is just   that a particular doctor did not have that eye for danger in that moment. The  doctor did  not realize or anticipate the gravity of  the consequence and outcome of the patient in real time. It may be difficult to pick up or just not take the situation very seriously. That can simply be poor training or working without good application of mind. But  looking retrospectively, situation becomes clear.

Two senior doctors of Fortis Hospital in Haryana’s Gurgaon were arrested on Friday for a “delay in administration of emergency medicines” to a 51-year-old woman, who died of cardiac arrest last year, police said.

 

      Lessons to be learnt:  What options doctors have at present? Because they are at receiving end always. They have to learn from such cases and do something in their routine to prevent disasters. How can they save themselves?

  1. All patients to be seen by primary consultants or someone from concerned unit at the earliest. It is important as emergency doctor may  not be equipped to deal with specialty  problem.  Prompt diagnosis by specialty doctor and written findings are important.
  2. Initial assessment should be quick and with in minimum time.
  3. Good communication and documentation of the problem.
  4. Assess the patient and make a note of treatment to be given.
  5. Document the plan of action, that is investigation and management.
  6. Avoid phone call consultations and leaving treatment loosely. Well thought documented plan should be in place.
  7. Situation may be different for smaller nursing homes. Treatment of an emergency will remain same, whether patient goes to bigger or smaller hospital.   Nursing homes may not be equipped for all the emergencies. So challenge before the smaller hospitals will be to identify the problem and diagnose them quickly  and  if required send them to proper  hospital, rather risking themselves in today’s times.
  8. Aspiring doctors can have a cue about what they are getting into. So as to adapt to prevalent adverse circumstances for doctors, if they aspire to be one.

 

Doctor, do save the patient but save yourself also.

 

Dr Hazida Bawa-Garba case: sacrificial lambs “The doctors” and not health administrators? Dangerous precedence for doctors worldwide


Dr Hazida Bawa case is of importance worldwide in many ways, an (lost)opportunity  for learning some hard and truthful lessons, as it touched upon various crucial aspects involved in treatment, especially in difficult situations , for doctors.  At the time of death of patient, a constant and  universal last link is only the doctor, that is visible. This visibility of doctor at the time of  declaration of death  or while treating the patient on his bedside, makes him vulnerable to all kinds of accusations. By application of an average wisdom,  all deaths can be easily attributed or linked to fault of the doctor. Subtle presentations of severe disease, rapid deterioration, multi organ complexities, under staffing and sub optimal systems, equipment and  other innumerable shortcomings of the whole system may not be visible or not given consideration in the  haze, as compared to  publicity and attention  given to only doctor’s faults. This is specially so when the wisdom is applied retrospectively, with knowledge  of hindsight,  and by the people who have never treated emergencies or have never been in such difficult situations  themselves.

Analogy to  Dr Hazida Bawa case

        Imagine a situation where during a bad sea storm, large number of people are trapped and are in mortal danger. The coast guard on the duty tries his best in the emergency situation with his limited resources and saves a large number of people. There were only a few coast guards present, equipment were inadequate and sub optimal.  However the guards manage to salvage the situation by doing the best possible in the circumstances. There were instances, where they decide, act, communicate and document events simultaneously, in an instant.  Those who could not be saved were exposed to risk of death as resources allocated by authorities were limited.  The near and dear ones of those who died were unhappy and revengeful with the services. Inquiry is done to find out the cause of failure in preventing those deaths. Rather than appreciating the facts that greater proportion of victims were saved in those difficult circumstances, the guards are blamed for those who could not be saved. Guards who are already apologetic for not been able to save the few, are blamed for doing their duty shabbily after careful fault finding analysis of the event. The administrators  who are responsible for allocating the inadequate number of guards and equipment, who actually failed in their duty, also participate in pointing fingers at the guards.

  The saddest part was that courts also were  unwilling to apply wisdom to look beyond the guard faults and  reach beyond the fog in present hazy circumstances. Systems and administrative lapses and inadequacy of number of coast guards was not raised as a concern. The responsibility of the deaths is thus fixed on the persons who struggled to save the lives of many. Every one has great sympathies for the deceased, but there is another angle for doctors in such  difficult situations.

This is an analogy to Dr Hazida Bawa case, but similar unfortunate incidents are happening to medical professionals worldwide, more so in developing countries. The new regulated system of medicine has an aberrant evolution and   chooses to hang their own wounded soldier for not putting up the best fight, rather than accepting the limitations of medical science or errors in the supporting systems.  Was  she an easy scapegoat for some obviously non- admissible reasons prevalent?

Why is it always necessary to punish a doctor, and  conveniently overlook errors of the sub optimal  system in cases of unfavorable prognosis, especially in sick patients. Why a sub optimal system or unsafe working conditions  like  all other registrars were on leave simultaneously, or only one registrar in place of three and that too a trainee. There was no consultant or registrar covering her?   Why is a single doctor stuck in a difficult situation  not  treated as  just another human being in an emergency situation, especially in cases of very sick patients? Why administrators or managers are not punishable for putting doctor and patients at risk and unsafe condition ?

If a doctor is supposed to raise concern (may be at cost of his career), then what is the role of managers, management and administration?  Are they inefficient or incompetent  to anticipate the situation? A new doctor coming on duty can not anticipate the deficiency of system. He will not have time to assess the managerial deficiencies. Therefore raising a concern by doctor on duty is something, which is expected but at the same time not feasible always, in true sense.  This expectation to raise  a concern  may be  used to later implicate the doctor as to why he or she did not raise a concern.  At the same time it takes responsibility off, from the  administrators whose  duty was to raise concerns.

NHS is looked upon in the world as one of the better organized health care organization in terms of uniformity. If such an organization has to sacrifice its working hands in the form of scapegoats to prove its quality, deliberately overlooking its system errors, then it is a sad state for doctors all over the world. This would set a precedence for governments and health administrators, world over to be  fearless in  putting errors of sub optimal system under the carpet by punishing the doctors instead. Since there will always be a doctor in the end who will declare the death, is the last and common link in all deaths. Other circumstantial issues would be overlooked  because of sheer unwillingness to do so.

Irony of the situation is that generally people who have been invested with the power to decide on these issues of medical negligence  may  have  never faced  such situations themselves.  They may be the people in administrative positions who have never treated a single patient, leave aside emergencies.  They do not even  know, what it takes to deal with emergencies of life and death, that too multiple ones, with limited resources. The court takes years to decide on these issues discussed retrospectively with wisdom of hindsight, on issues which the doctor had to decide in a jiffy.  A person who perhaps can only imagine such a situation, or  never handle it himself, even in his wildest dreams is the one who decides what went wrong merely based on how the situation is placed and presented before him.

         If there is unsaid immunity to governments and administrators for providing a suboptimal systems, then the doctor should be the first person to get this immunity. But unfortunately nobody seems  to be willing to find out who is responsible for putting  the doctor  in such  a difficult situation, making everything error prone.

       If in such system a doctor is punished, then the administrator, manager or trust should be an automatic accomplice to the doctor’s punishment. Firstly   for providing an unsafe and  suboptimal system, and secondly for not raising a concern as management . Thirdly for putting it’s doctor in difficult circumstances. If it was an understaffed system, then disaster was bound to  happen sooner or later. This is a perfect example how management lapses contribute to death but doctors are the only ones who are entirely blamed and punished in isolation.

  Another sad part is the unwillingness of judiciary system to look at the larger picture and the fault in the system, which has led to mass demoralization of the doctors. The doctors are denied the true justice in many such cases.  They are being used as sacrificial lambs. Health administrators are obviously at an advantage enjoying the invisible immunity and perks, at the cost of medical professionals.  By crucification of the doctors, vengeance of the society is fulfilled and everyone feels  satisfied  with false sense of justice.  But does this give any advantage to the society? Definitely not. In fact  the society is thus raising a  demoralized force to be their care providers, who under duress, will definitely not perform to their very best.  If this is quality of justice for saviours, this demoralized force may also not be available in future.

Doctor’s assault at D Y Patil Medical College: incident hits doctor’s compassion and trust towards patients


unwillingness or failure of government  to prevent such attacks on doctors will have deep ramifications on future of medical profession. Silence of authorities, human right commission is really appalling.  Role of doctor associations, parent institutes have been spineless and not encouraging.  Role of media, celebrities, film stars in spreading the hatred against the medical profession and creating an environment of mistrust is unpardonable, where stray incidents were portrayed as normal routine just to earn money and fame. Ultimately doctors have been left to fend for themselves individually or with friend groups.

 Discussion always revolves around the trust of the patients on the doctor. But in reality, situation is getting opposite gradually. Empathy, sympathy, compassion and trust  of the doctor towards the patient, will definitely get a hit after these incidents. Everyday  the news of assaults on doctors, court cases against doctors, negative projection of the medical profession   in the media are viewed  by doctor’s community anxiously. Recent senseless attack  on doctor  at

D Y Patil Medical College Pune  is another example. 

A resident doctor was assaulted with a scalpel and a few paramedics were roughed up by relatives of 26 -year-old man after he suddenly died following a cardiac arrest at D Y Patil Medical College and Hospital in Pimpri late on Friday evening.
The resident doctor suffered a deep cut on his face and some blunt injuries in the assault.

 

        Merely taking some token  action and showing  protest will not solve the problem. It does not compensate for the  damage done to medical profession. Sympathy, compassion and trust of the doctors towards patients will definitely reduce. Who will be  the ultimate sufferer, does not need a Einstein brain to predict.

          Formal and informal discussions among medical professional at various forums  have taken a center stage about the changing scenario. It  gives a perception that patients are loosing faith in doctors. That perception is not incorrect. But what remains hidden is that every incidence of verbal, legal, and physical assault  brings some kind of feeling of insecurity in minds of all doctors, who deal with patients.

                    This insecurity or fear of the uncertainty tends to affect the thinking process of doctors and the way they practice medicine or deal with the patients. Many will like to be defensive in practice, or try not to treat very sick patients.  Why would someone try complex surgeries with risk involved? Few will limit themselves to follow protocols. Going extra mile with risk, which not everyone will like to take. Many will become health managers or  do something else than do active clinical work. Who should risk his life while doing routine work?

  Every incidence of verbal, legal, and physical assault is a trust breaker. It is not only erosion of patient’s trust on doctors but the vice versa is also true.  As  a rule of nature, as violence increases, compassion decreases.

    Patients might get their revenge for the  naturally occurring disease, but they will lose compassion and trust of doctors in the long run. If that is the way to impart justice in this era, doctors will have to find some way to save themselves.

 

Supreme Court judgement on End of Life & Living Will: Partaking moral and ethical dilemma of doctors and relatives


A welcome, long awaited judgement, where law has come to help the doctors and relatives of terminally ill patients. Doctors are often accused of over treatment, without realizing that law does not permit them the termination of treatment as desired by patients or relatives. commonly  doctors come to face these difficult situations, where moral and ethical dilemma  is larger than treatment itself.

The Supreme Court ruled on Friday that individuals have a right to die with dignity, in a verdict that permits the removal of life-support systems for the terminally ill or those in incurable comas.

The court also permitted individuals to decide against artificial life support, should the need arise, by creating a “living will”.

 Living will

A ‘living will’ is a concept where a patient can give consent that allows withdrawal of life support systems if the individual is reduced to a permanent vegetative state with no real chance of survival.

It is a type of advance directive that may be used by a person before incapacitation to outline a full range of treatment preferences or, most often, to reject treatment. A living can detail a person’s preferences for tube-feeding, artificial hydration, and pain medication when an individual cannot communicate his/her choices.

In its verdict on Friday, SC has attached strict conditions for executing “a living will that was made by a person in his normal state of health and mind”.

The US, UK, Germany and Netherlands have advance medical directive laws that allow people to create a ‘living will’.

 Active and passive euthanasia

Active euthanasia, the intentional act of causing the death of a patient in great suffering, is illegal in India. It entails deliberately causing the patient’s death through injections or overdose.

But passive euthanasia, the withdrawal of medical treatment with the deliberate intention to hasten a terminally ill patient’s death was allowed by the Supreme Court in Friday’s landmark verdict.

The court also laid down guidelines on who would execute the will and how a nod for passive euthanasia would be granted by a medical board set up to determine and carry out any “advance directive”.

In cases where there is no “advance directive”, the patient, family, friends and legal guardians can’t take the decision on their own, but can approach a high court for stopping treatment .

 Terminally Ill Patients (Protection of Patients and Medical Practitioners) Bill

In 2012, the union health ministry posted a draft of the Terminally Ill Patients (Protection of Patients and Medical Practitioners) Bill on its website and invited public reactions.

The Bill is popularly referred to as the Passive Euthanasia Bill although its draft did not use the emotive word “euthanasia” to skirt complications around the term, a health ministry official told HT in 2016. It says every advance medical directive (also called ‘living will’) or medical power of attorney executed by a person shall be taken into consideration in matter of withholding or withdrawing medical treatment but it shall not be binding on any medical practitioner.

 Misuse of law

A major concern is the misuse of the law. If it is legal to passively allow or hasten death, what’s to say an aged parent won’t be hastened in favor of an inheritance, or a spouse have treatment withdrawn for the sake of a hefty insurance payout? That is why there are legal provisions  in the judgement  by Supreme court, to safe guard the patients.

The bench also stipulated strict conditions for the execution of the living will, which includes the setting up of two medical boards and certification by the judicial magistrate. It also directed high courts to maintain a record of all living will documents prepared within the state.

 Euthanasia in other countries

Euthanasia and physician-assisted suicide have been legal in The Netherlands and Belgium since 2001 and 2002. In the US, Switzerland and Germany, euthanasia is illegal but physician-assisted suicide is legal. Euthanasia remains illegal in the UK, France, Canada and Australia.

Source- Hindustan times

LNJP hospital doctor’s assault: Role of Doctor’s Associations and Parent Institutes, human right commissions?


The  impunity with which attendant easily and brutally assault doctors is really appalling, that too in bigger institutes like LNJP Delhi , should be shameful to law enforcing agencies. Are we a lawless society? More problematic is the government apathy and silence of human right commission. Here comes the point that what is the role of our doctor’s organizations and parent hospital and institute, where the incident happens.

         Why  in each and every case of doctor’ s assault, doctor’s bodies and organization do not file a case in the court against the  responsible  authority for security. Non action by Doctor’s Associations, bodies and organizations, not able to take a stand for their children is  most disappointing.

     Another issue is with the parent institute, where such incident happens. Institutes as a unit or a parent  should file cases, rather than few suffering doctors running here and there for help.

 Role of Government, Doctor’s Associations and Parent Institutes is akin to a “father”, who is wining and dining, whereas  his  working and brilliant children are being beaten black and blue.  This is certainly  a poor advertisement, if society wants good doctors.  At least  it should not rue about extinction of good doctors. 

doctor assault CMC Ludhiana

Beti padhao beti bacchao

assault of female doctors

Doctor’s assault (CMC Ludhiana): Every incident hits doctor’s compassion towards patients


Discussion always revolves around the trust of the patients on the doctor. But in reality, situation is getting different gradually. Empathy, sympathy, compassion and trust  of the doctor towards the patient  are important factors during the treatment.  Everyday  the news of assaults on doctors, court cases against doctors, negative projection of the medical profession   in the media are viewed  by doctor’s community anxiously. Recent senseless attack  on doctor in Christian medical college Ludhiana is another example. Merely taking some action after protest will not solve the problem. It does not compensate for the  damage done to medical profession. Also it erodes the trust and compassion of doctors towards patients.

          Formal and informal discussions among medical professional at various forums  have taken a center stage about the changing scenario. It  gives a perception that patients are loosing faith in doctors. That perception is not incorrect. But what remains hidden is that every incidence of verbal, legal, and physical assault  brings some kind of feeling of insecurity in minds of all doctors, who deal with patients.

                    This insecurity or fear of the uncertainty tends to affect the thinking process of doctors and the way they practice medicine or deal with the patients. Many will like to be defensive in practice, or try not to treat very sick patients.  Why would someone try complex surgeries with risk involved? Few will limit themselves to follow protocols. Going extra mile with risk, which not everyone will like to take. Many will become health managers or  do something else than do active clinical work. Who should risk his life while doing routine work? Brilliant students  will not be inspired to be doctors.

  Every incidence of verbal, legal, and physical assault is a trust breaker. It is not only erosion of patient’s trust on doctors but the vice versa is also true.  As  a rule of nature, as violence increases, compassion decreases. Patients might get their revenge for the disease, but they will lose compassion and trust of doctors in the long run.

 

MEDICAL LAWSUITS FOR COMPENSATION: ARE DOCTORS SOFT TARGETS ?


Doctors save the patient, but save yourself also.

In an era, when family members, brothers and sisters fight for money among themselves, it will be naive to think that idea of extracting money from the doctor does not exist. With courts giving millions in compensation, lawyers are ready to fight cases on zero fee and divide the booty later. There may be many relatives, lawyers who are ready to try their luck, sometimes in vengeance and sometimes for the  money received in compensations. This encouragement and instigation of lawsuit against doctors is becoming a major disadvantage to doctors. Here is a news from a paper showing the problem.

Dentist accused of botching up an implant, produces video of complainant feasting at gurudwara langar: Senior citizen claims Rs 35 lakh from her dentist saying her implant was botched up and she was unable to eat; the doctor produces a video of her feasting at a gurudwara langar; cops close case.

In this case the doctors was really smart and lucky. The doctor was able to generate some evidence .  but  most of the time, things lie in grey zone and it becomes very difficult for the doctor to defend. Unfortunately  sympathy of the court and public sentiments runs against doctors . Thanks to media and celebrities for the  negative and  campaign against medical profession.

Many a times problems are just part of genuine poor prognosis or just bad course of disease or simply complications of the treatment.  Public has failed to realize that during treatment of  human body, complications  are inevitable and will always happen.  Retrospective analysis and wisdom of hindsight, always throws better light. But during treatment all this luxury is not available to doctor. Genuine complications can be easily labeled as mistakes of the  treating doctor. Unfortunately, if there is a lawsuit against a doctor, he will be wasting all his time with lawyers and courts, which will takes years to sort out.

Problem is that, there is no deterrent for patients to put cases on a doctor. Even when  case is  just with a intention to harm, revenge or extortion. Harassment of the doctor is full and permanent, even if he is not at fault. Lawyers and patient’s  relatives can always have a field day, at the cost of doctors. Society may be slow to anticipate their long term loss at present.  Till that time, doctors will have to  find ways to save themselves, as this doctor did!

 

 

Misdiagnosis of health care, wrong and misdirected treatment of real problem


       Yesterday, there was a painful news in paper about the death of a child due to rabies.  It is really painful  loss of life due to a preventable disease. Every one sympathizes with child and parents. But equally strange was the suggestion  that action will be taken  against the  doctor.  Newspaper also  fails to raise a point that,  why at all a preventable disease should happen?  Similar trend we always see in media, when some death occurs due to diseases like dengue and malaria, it is a doctor, who treated the patient or trying to fight with the advanced complications is punished or made a scapegoat and projected as a villain in the story by media.

  No one including administration,  government, courts or media raises a point, that why at all the diseases which  are  completely preventable,  should happen and  keep on happening.  In my previous article, I mentioned the misplaced priorities of media about the same.  At least public, who is suffering should understand that dog bite and mosquito bite is preventable. Therefore more emphasis should be on preventing these bites. That should be made a priority. If  that bite is not prevented and no action is taken to prevent that, these diseases will keep on happening in  a large proportions.  Beds  and doctors are limited in number and will be unable to treat it, specially in advanced stage. So we need really good people to make a proper diagnosis  of our health care. Every time such cases happen and these are preventable disasters, doctors are sacrificed as scapegoats.  Some one sensible need to do a root cause analysis of preventable deaths.  Media people will  have to  find the correct remedy  and demand for it. Otherwise it is not going to help and treat sufferings of common people.

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