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Presentation on theme: "CONSUMER PROTECTION ACT FOR MEDICAL PROFESSION IN INDIA"— Presentation transcript:

Dr. Bipin Pandit MD.DGO.DFP Hon. Gynaecologist at Dr. Balabhai Nanavatii Hospital, V Parle Hon. Gynaecologist at Dr. L.H. Hiranandani Hospital, Powai Hon. Gynaecologist at Municipal Maternity Hospital, Marol Hon. Gynaecologist at L & T Welfare Center Andheri. Chairman Medico-legal committee MOGS Past President of Association Of Medical Consultants Mumbai Committee Member of Indian Education Society. Past President Andheri Medical Association (E & W)

2 Time line Guidelines for good medical practice across the ages :
The Code of Hammurabi ( 2000 B.C. ) Park’s textbook of PSM,16th edition

3 Time line…. The Hippocratic Oath (460-370 B.C.)
“I swear by Apollo the healer, by Asclepius, by Health, by Panacea and by all the gods and goddesses, making them my witnesses that I will carry out to the best of my ability and judgment this oath and this covenant (horkos kai syngraphe)…” Park’s textbook of PSM,16th edition

4 Time line….. CHARAK’S OATH (200 A.D.) “Thou shalt be free from envy, not cause another’s death, and pray for the welfare of all creatures. Day and night thou shalt not desert a patient, nor commit adultery, be modest in thy attire and appearance, not to be drunkard or sinful, while entering a patient’s house, be accompanied by a person known to the patient. The peculiar customs of the patient’s household shall not be made public. " Park’s textbook of PSM,16th edition

Time line ….. ARABIC CODE OF MEDICAL ETHICS ( AD) Adab al – Tabib Park’s textbook of PSM,16th edition

6 Time line ….. The Declaration of Geneva 1948
The Indian Medical Council Act 1956 The Consumer Protection Act 1986 The inclusion of medical services in CPA 1995

7 Medical Dilemma A profession in retreat. Professional dissatisfaction
Fuzzy science, awkward art. Doctors give hope, not perform miracles. THE WOUNDED HEALER. Abigail Zuger . Dissatisfaction with medical practice. NEJM Vol 350, 69-75, Jan. 2004

8 WHERE TO GO ? Consumer Dispute Forum Civil Court Criminal Court
Medical Council

9 WHY CPA? MCI Delay Biased Expensive Can’t award damages
THE COURTS Delay Expensive The answer – Alternate dispute resolution system – Easy, quick, accessible, cheap and effective Sec 3A, 12, CPA 1986

10 Consumer Protection Act, 1986
Empowers the consumer with the Right to : Safety Information Choose Heard Redressal Consumer education Sec 4 to 8 of The CPA ( Amendment ), 2002

PERSON : Complainant / Representative PLACE : Consumer Dispute Redressal Fora FEE : Nominal TIME LIMIT : ≤ 2 yrs FATE : Accepted Dismissed Sec 12 CPA 1986

12 Consumer Disputes Redressal Agencies DISTRICT FORUM
Jurisdiction Upto Rs. 20 lakhs Composition President + 2 Members Powers Examines complaints Issues notices Orders analysis / tests Conducts hearings Award damages Sec 9 to 15 of THE CPA ( Amendment ), 2002

13 Consumer Disputes Redressal Agencies STATE COMMISSION
Jurisdiction From 20 lakhs Up to 1Crore Composition President + ≥ 2 Members Power Similar to district forum + Hearing of appeals Sec 16 to 19 of The CPA ( Amendment ), 2002

14 Consumer Disputes Redressal Agencies NATIONAL COMMISSION
Jurisdiction > Rs. 1 Crore Composition President + ≥ 4 members Powers Similar to State forum + Hearing of appeals Sec 20 to 25 of The CPA ( Amendment ), 2002

15 Professional Negligence:
Definition: Absence of reasonable care or skill or willful negligence on the part of the medical practitioner in the treatment of the patient whereby the health or life of the patient is endangered. Parikh’s Textbook of Medical Jurisprudence, Forensic medicine.

16 Types of Professional Negligence:
Civil Negligence: Malpractice, Deficiency in Service Criminal Negligence: gross lack of competency, gross inattention reckless behavior

17 In general a doctor's innocence is presumed
The complainant has to prove negligence.

18 Proof of Negligence 4 D’s The essentials of negligence are four "D"s:
There was a Duty towards patients; There was Deficiency in duty This Directly resulted in (causa causans ) Damage which may be physical, mental or financial loss to patient or relatives. Tiwari S.K, Baldwa M Medical Negligence. Indian Pediatrics 2001; 38:   

19 Res Ipsa Loquitur “The thing or the fact speaks for itself.”
Error is so self evident that the doctor has to prove his innocence. E.g., Amputation of right instead of left leg.

20 Vicarious Liability Liability for another’s act.
A doctor is responsible for not only his own negligence but also for the negligence of his employees, if such an act occurs under his direct supervision, by the principle of Respondent Superior.

21 A patient’s journey through the realm of medical malpractice
Quality of care A patient’s journey through the realm of medical malpractice Commitment of medical error A Doctor’s Defense Lets take a trip through time as though we were a patient and explore the medical malpractice process, from the initial patient-physician encounter, to medical error, to pursuit of litigation, and finally, legal outcomes. We will also focus on the malpractice situation in California and briefly discuss strategies in effect now and proposed solutions and where they fit into this difficult journey. Outcome: judgment and awards

22 Patient - Doctor Relationship
Quality of Care Patient - Doctor Relationship ( Implied contract ) Good afternoon every one . Myself Dr.bel

23 The Sacred Patient-Doctor Relationship – A thing of the past
Recent studies show that a positive patient perception of the doctor-patient relationship significantly reduces the likelihood of a patient filing a medical malpractice claim. Caring and healing.

24 Patient - Doctor Relationship ( Implied contract )
An implied contract between patient (consumer) and doctor( service provider) for a consideration ( fee ). Not established : While giving first aid in emergency Pre-employment medical examination Examining a patient under court order Parikh’s Textbook of Medical Jurisprudence Forensic medicine

25 Requirements of Doctor Patient Relationship
Reasonable skill An average degree of skill possessed by his professional brethren of the same standing Reasonable care Such care and attention for the safety of the patient as their mental and physical condition may require Communication

26 Common Patient Complaints
Too little time for patients Does not listen Does not explain well Shows no sympathy Neither understands the patient nor his family Hey, DOC! Harris Poll, Roper Center Polls, 2000

27 How well do you understand it?
“Informed” Consent How well do you understand it?

28 Informed Consent IMPLIES: Understanding by the patient
Natural history of the disease. Nature of proposed treatment. Anticipated prognosis of the proposed intervention. Expected side effects. Unexpected hazards. Any alternative and potentially successful treatment. Consequences of no treatment at all. Bailey and Love’s Short Practice of Surgery, 24th Edition

29 Types of consent Implied : inferred from actions
Express : actively stated Proxy consent : on behalf of others

30 Why is Consent Necessary
Willing patient, better outcome defense against a charge of assault / battery

31 When is Consent Necessary
Everything in the Doctor - Patient Relationship is CONSENSUAL

32 Express Consent is expected..
Surgical/Invasive Procedures Chemotherapy / Radiotherapy Radiological / Investigational Procedures Medical Research Teaching - intimate examination

33 Competence/Capacity in Informed Consent
Competent Adult ( > 18 yrs ) In case of Minors ( < 12 yrs ) – Parent or legal guardian( Loco Parents ). Emergency ( the law implies consent ) (Sec.92.I.P.C.)

34 Rules Of Consent: Consent - in the presence of a disinterested third party, e.g., a nurse. Consent should not be a blanket permission. In criminal cases the victim/assailant cannot be examined without his/her consent. Consent given for illegal acts is invalid. When an operation is made compulsory by law, e.g. vaccination, the law provides the consent. The law of Medical Negligence – Dr. H. L. Chulani, 1996.

35 Why do patients sue? “Original injury is not enough.”
Prime concern: perceived lack of caring 3 reasons for litigation Altruism – protect others Expose the truth Financial restitution. Lack of communication. Over 1/3 would have opted out of litigation with explanation, apology Vincent, Young, Philips, “Why do people sue doctors?” Lancet, 1994

36 How does fear of lawsuits alter patient care?

37 Defensive Medicine – the use of costly diagnostic efforts of medical treatments for the sole purpose of avoiding potential litigation definition Litigation has decreased quality of care More tests than medically needed More specialist referrals than needed More invasive procedures than needed More medicines than needed Fear of Litigation study, Harris Interactive, Apr 2002

38 Fear of the patient !! Altered patient-doctor relationship
Bernard Lown, MD, in the world-renown, cardiologist who invented the defibrillator and cardioverter. He teaches at the Harvard School of Public Health. With the organization International Physicians for Prevention of Nuclear War, we won the Nobel Peace Prize in 1995 on behalf leading physicians against nuclear proliferation. He says: “Docs who worry about being sued probably will be. Fear of litigation, when in the front of one’s mind sets the stage for it. Every pt becomes a potential adversary. When a pt is more surly and dissatisfied, a doc increasingly suspects possible litigation. Pts have no qualms in suing a perfect stranger. Litigation against docs who invest time w/ pts is rare. Even small overtures of kindness are long remembered Docs are human.” Potentially adversarial relationship Each patient a potential plaintiff Each question a possible source of angst “Doctors who worry about being sued probably will be.” Lown, Bernard, MD, “The Lost Art of Healing: Practicing Compassion in Medicine,” 1999

39 IOM - “To Err Is Human” The American health care system is not as safe as you might think
So just how safe is the American health care system. For most physicians, the core value of medicine “Do no harm” persists. Still, mistakes to happen, but just how often do medical errors take place? The American health care system is not as safe as you think. Take a look at some of the more common and most feared causes of death in the US per year. If we look at deaths caused by AIDS, breast cancer and car accidents, we see more deaths than all of these due to errors committed by usually well-meaning physicians in hospitals each year, even when using the LOWER figure for deaths (44,000/yr). Not to mention the human toll are the financial costs associated with medical error, including the expense of additional care necessitated by the error, lost income and household productivity of the pts, and resulting disability. Physicians also pay with loss of morale and frustration from not being able to provide the best care. As a result, we see diminished satisfaction in both pts and docs. #1 – deaths by medical error #2 – motor vehicle collisions #3 – breast cancer #4 – AIDS 44, ,000 deaths by PREVENTABLE medical errors in hospitals each year Institute of Medicine, “To Err is Human: Building a Safer Health System,” Nov 1999 Harvard School of Public Health, from Testimony of Harvey Rosenfield, FTCR, Feb 2003 Jrnl of Health Care Info Management, “A System Approach the Error Reporting,” Vol. 16, No. 1

40 To err is human : Building a safer health system, IOM, 2000

41 ALLEGATIONS THE SURGEON Consent not taken prior to operation.
Articles left in patient’s body. Consent not taken prior to operation. Operation on wrong side. Failure in diagnosis or Not operating in time.

42 Allegations… ANAESTHESIOLOGIST Excessive anesthesia
Injury to eyes/skin Injury from mask/mouth gag

43 Allegations… Electrical shock & burns Injuries to vision Pigmentation
RADIOLOGIST Electrical shock & burns Injuries to vision Pigmentation Loss of hairs

44 GYNAECOLOGIST Consent not taken before abortion Failed tubal ligation
Injury to uterus Operation causing sterility

INTERPERSONAL LEVEL Courteous and polite if any mishap ACADEMIC AND TECHNICAL UP GRADATION Attend CME,Workshops and Conferences

MEDICAL Reasonable skill and care SOCIAL Exhibit skill to patient: body language LEGAL Document in legible handwriting Record of failure

Forum to discuss acts and cases fought Never talk loose of your colleague MEDICAL ETHICS Thorough knowledge is a must PROFESSIONAL INDEMNITY Insurance

Listen attentively Maintain privacy Face patient Start afresh if distraction Ask questions intelligently Give time to the patient

49 HISTORY TAKING DON’TS Don’t discriminate.
Don’t assume all what patient says as correct Don’t smoke Don’t look overconfident

Thoroughly examine the pt. Oblige again if patient considers examination incomplete Review next day if patient is examined hurriedly

Don't examine if you are: sick exhausted intoxicated NEVER examine a female patient in the absence of a female nurse or an attendant especially during genital or breast examination

Qualification/training/experience/designation (Indian Medical Degree Act’1916) Date and timing of the consultation Age and sex of patient Precise history of illness/physical finding Diagnosis under review if unsettled

MENTION : Refusal for investigation/administration in local language with proper witness H/O drug allergy Names/dosage/route of administration of drugs clearly with precautions like ac/pc.

MENTION : If patient is pregnant/lactating Side effect/interaction of drug Emergency treatment in chronic illness Not to stop drug suddenly if tapering required If a particular drug/equipment unavailable

MENTION : Reasons for deviation from standard care Prognosis explained Where patient should contact if you are unavailable Review SOS.

56 PRESCRIPTION DON’ TS Don’t prescribe : without examination/ banned drugs/ for experimental reasons. Don’t write : multiple drugs/instructions on separate slip. Don't allow substitutions.

57 INVESTIGATIONS DO’S Analyse cost benefit ratio
Read reports carefully and interpret results of tests/X-rays properly Rule out pregnancy before subjecting uterus to X-ray Consent-invasive invest.

Never order an investigation unless result is likely to help direct treatment Don’t allow modern diagnostic test to substitute your clinical judgment Don’t inform patient has HIV till confirmatory test is done

59 MANAGEMENT DO’S Update with latest management by attending CME and conferences Employ qualified assistants Update facilities and equipment Obtain legally valid consent before any procedure

60 MANAGEMENT DO’S(contd..)
In case of MTP/sterilization, follow guide lines issued by Govt of India Ensure proper post - operative care Relieve pain specially in cancer patients

61 MANAGEMENT DON’TS Don’t perform procedures in agitated patients eg. broken needle can be a cause for law suit Don’t forget to count swab and instruments when ending operation Don’t hesitate to take senior’s or colleague help if in trouble Don’t deny medical care to HIV positive NEVER AVOID EMERGENCY CALLS

62 OTHER DO’S Extend your sympathy to bereaved family
Label a condition as functional only when other causes are ruled out Issue certificates only when full verification is done

63 OTHER DON’TS Don’t refuse leave against medical advise
Don’t withhold information however harsh and difficult(sensitive communication) Don’t refuse patient’s right to examine and receive an explanation about your bills

64 Outcome: judgment and awards

65 “Litigation lottery” and frivolous law suits?
Award designated Just what are patients getting out of the medical malpractice process for their “frivolous” claims? Is the US liability system really working on behalf of injured patients? Only 1.5% injured file a claim Only 8 – 13% cases filed go to trial Only 6.7% trials receive court verdicts (others thrown out in favor of defense) Only 19% verdict in favor of plaintiff and award designated. Then, only % (3 out of 10,000,000) of all reported medical injuries result in any type of verdict in favor of the patient 14x as many negligent acts as successful claims HH Hyatt et al “A study of medical injury and med mal: an overview,” NEJM, 1989 Only 30% claims settled in pt’s favor (doesn’t necessitate a payment) 57 – 70% of claims result in no payment. PIAA, 1987 Verdict for plaintiff 19% Court verdict 7% 81% Case to trial 8-13% 93% “Litigation lottery” and frivolous law suits? Claim filed 1.5% 92-87% Patient injured 98.5% Hyatt, et al, “A study of medical injury and med mal: an overview,” NEJM, 1989

66 Doctor’s Indemnity Why do doctors need insurance anyway?
Peace of mind

67 Insurance does not cover
Any Criminal act Services rendered while intoxicated Any procedure under GA outside hospital Use of miracle drugs Cosmetic surgery

68 Other Problems With Insurance
High premiums Do not pay whole of the damages Lot of running around Defense lawyer in the insurance co.panel lacks adequate medico-legal knowledge Patients are encouraged to go in for litigation

69 The Best Insurance Policy
THE 3 C’s: CARE CONCERN CONSIDERATION Faith is the only currency between a doctor and a patient ( Dr. K. C. Mahajan FRCS)



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