Presentation on theme: "CONSUMER PROTECTION ACT FOR MEDICAL PROFESSION IN INDIA"— Presentation transcript:
1CONSUMER PROTECTION ACT FOR MEDICAL PROFESSION IN INDIA Dr. Bipin PanditMD.DGO.DFPHon. Gynaecologist at Dr. Balabhai Nanavatii Hospital, V ParleHon. Gynaecologist at Dr. L.H. Hiranandani Hospital, PowaiHon. Gynaecologist at Municipal Maternity Hospital, MarolHon. Gynaecologist at L & T Welfare Center Andheri.Chairman Medico-legal committee MOGSPast President of Association Of Medical Consultants MumbaiCommittee Member of Indian Education Society.Past President Andheri Medical Association (E & W)
2Time line Guidelines for good medical practice across the ages : The Code of Hammurabi ( 2000 B.C. )Park’s textbook of PSM,16th edition
3Time 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
4Time 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
5ARABIC CODE OF MEDICAL ETHICS (800-1300 AD) Time line …..ARABIC CODE OF MEDICAL ETHICS ( AD)Adab al – TabibPark’s textbook of PSM,16th edition
6Time line ….. The Declaration of Geneva 1948 The Indian Medical Council Act 1956The Consumer Protection Act 1986The inclusion of medical services in CPA 1995
7Medical 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
8WHERE TO GO ? Consumer Dispute Forum Civil Court Criminal Court Medical Council
9WHY CPA? MCI Delay Biased Expensive Can’t award damages THE COURTSDelayExpensiveThe answer – Alternate dispute resolution system –Easy, quick, accessible, cheap and effectiveSec 3A, 12, CPA 1986
10Consumer Protection Act, 1986 Empowers the consumer with the Right to :SafetyInformationChooseHeardRedressalConsumer educationSec 4 to 8 of The CPA ( Amendment ), 2002
11LODGING A COMPLAINT FORMAT: Written PERSON : Complainant / RepresentativePLACE : Consumer Dispute Redressal ForaFEE : NominalTIME LIMIT : ≤ 2 yrsFATE : AcceptedDismissedSec 12 CPA 1986
12Consumer Disputes Redressal Agencies DISTRICT FORUM Jurisdiction Upto Rs. 20 lakhsComposition President + 2 MembersPowers Examines complaintsIssues noticesOrders analysis / testsConducts hearingsAward damagesSec 9 to 15 of THE CPA ( Amendment ), 2002
13Consumer Disputes Redressal Agencies STATE COMMISSION Jurisdiction From 20 lakhs Up to 1CroreComposition President + ≥ 2 MembersPower Similar to district forum+Hearing of appealsSec 16 to 19 of The CPA ( Amendment ), 2002
14Consumer Disputes Redressal Agencies NATIONAL COMMISSION Jurisdiction > Rs. 1 CroreComposition President + ≥ 4 membersPowers Similar to State forum+Hearing of appealsSec 20 to 25 of The CPA ( Amendment ), 2002
15Professional Negligence: Definition:Absence of reasonable care or skill or willful negligenceon the part of the medical practitioner in the treatmentof the patient whereby the health or life of the patient isendangered.Parikh’s Textbook of Medical Jurisprudence, Forensic medicine.
16Types of Professional Negligence: Civil Negligence: Malpractice, Deficiency in ServiceCriminal Negligence: gross lack of competency,gross inattentionreckless behavior
17In general a doctor's innocence is presumed The complainant has to prove negligence.
18Proof of Negligence 4 D’s The essentials of negligence are four "D"s: There was a Duty towards patients;There was Deficiency in dutyThis Directly resulted in (causa causans )Damage which may be physical, mental orfinancial loss to patient or relatives.Tiwari S.K, Baldwa M Medical Negligence.Indian Pediatrics 2001; 38:
19Res 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.
20Vicarious 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.
21A patient’s journey through the realm of medical malpractice Quality of careA patient’s journey through the realm of medical malpracticeCommitment of medical errorA Doctor’s DefenseLets 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
22Patient - Doctor Relationship Quality of CarePatient - Doctor Relationship( Implied contract )Good afternoon every one . Myself Dr.bel
23The 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.
24Patient - 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 emergencyPre-employment medical examinationExamining a patient under court orderParikh’s Textbook of Medical Jurisprudence Forensic medicine
25Requirements of Doctor Patient Relationship Reasonable skillAn average degree of skillpossessed by his professionalbrethren of the same standingReasonable careSuch care and attention for thesafety of the patient as theirmental and physical conditionmay requireCommunication
26Common Patient Complaints Too little time for patientsDoes not listenDoes not explain wellShows no sympathyNeither understands the patient nor his familyHey, DOC!Harris Poll, Roper Center Polls, 2000
27How well do you understand it? “Informed” ConsentHow well do you understand it?
28Informed 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
29Types of consent Implied : inferred from actions Express : actively statedProxy consent : on behalf of others
30Why is Consent Necessary Willing patient,better outcomedefense against a charge of assault / battery
31When is Consent Necessary Everything in the Doctor - Patient Relationship is CONSENSUAL
33Competence/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.)
34Rules 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.
35Why do patients sue? “Original injury is not enough.” Prime concern: perceived lack of caring3 reasons for litigationAltruism – protect othersExpose the truthFinancial restitution.Lack of communication.Over 1/3 would have opted out of litigation with explanation, apologyVincent, Young, Philips, “Why do people sue doctors?” Lancet, 1994
37Defensive Medicine – the use of costly diagnostic efforts of medical treatments for the sole purpose of avoiding potential litigationdefinitionLitigation has decreased quality of careMore tests than medically neededMore specialist referrals than neededMore invasive procedures than neededMore medicines than neededFear of Litigation study, Harris Interactive, Apr 2002
38Fear 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 relationshipEach patient a potential plaintiffEach 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
39IOM - “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 – AIDS44, ,000 deaths by PREVENTABLE medical errors in hospitals each yearInstitute of Medicine, “To Err is Human: Building a Safer Health System,” Nov 1999Harvard School of Public Health, from Testimony of Harvey Rosenfield, FTCR, Feb 2003Jrnl of Health Care Info Management, “A System Approach the Error Reporting,” Vol. 16, No. 1
40To err is human : Building a safer health system, IOM, 2000
41ALLEGATIONS THE SURGEON Consent not taken prior to operation. Articles left in patient’s body.Consent not taken prior tooperation.Operation on wrong side.Failure in diagnosis orNot operating in time.
42Allegations… ANAESTHESIOLOGIST Excessive anesthesia Injury to eyes/skinInjury from mask/mouth gag
43Allegations… Electrical shock & burns Injuries to vision Pigmentation RADIOLOGISTElectrical shock & burnsInjuries to visionPigmentationLoss of hairs
44GYNAECOLOGIST Consent not taken before abortion Failed tubal ligation Injury to uterusOperation causing sterility
45MEASURES PREVENTION AT PERSONAL LEVEL Qualification Communication INTERPERSONAL LEVELCourteous and polite ifany mishapACADEMIC AND TECHNICALUP GRADATIONAttend CME,Workshops andConferences
46PREVENTION AT PRACTICE MEDICALReasonable skill and careSOCIALExhibit skill to patient: body languageLEGALDocument in legible handwritingRecord of failure
47OTHER MEASURES PEOPLE SUPPORT GROUPS Forum to discuss acts and cases foughtNever talk loose of your colleagueMEDICAL ETHICSThorough knowledge is a mustPROFESSIONAL INDEMNITYInsurance
48DO’S AND DON’TS FOR DOCTORS HISTORY TAKING DO’S Listen attentivelyMaintain privacyFace patientStart afresh if distractionAsk questions intelligentlyGive time to the patient
49HISTORY TAKING DON’TS Don’t discriminate. Don’t assume all what patient says as correctDon’t smokeDon’t look overconfident
50EXAMINATION OF PATIENT DO’S Thoroughly examine the pt.Oblige again if patient considers examination incompleteReview next day if patient is examined hurriedly
51EXAMINATION OF PATIENT DON’TS Don't examine if you are:sickexhaustedintoxicatedNEVER examine a female patient in the absence of a female nurse or an attendant especially during genital or breast examination
52PRESCRIPTION DO’S MENTION: Qualification/training/experience/designation (Indian Medical Degree Act’1916)Date and timing of the consultationAge and sex of patientPrecise history of illness/physical findingDiagnosis under review if unsettled
53PRESCRIPTION DO’S(cont..) MENTION :Refusal for investigation/administration in local language with proper witnessH/O drug allergyNames/dosage/route of administration of drugs clearly with precautions like ac/pc.
54PRESCRIPTION DO’S(cont..) MENTION :If patient is pregnant/lactatingSide effect/interaction of drugEmergency treatment in chronic illnessNot to stop drug suddenly if tapering requiredIf a particular drug/equipment unavailable
55PRESCRIPTION DO’S(cont..) MENTION :Reasons for deviation from standardcarePrognosis explainedWhere patient should contact if youare unavailableReview SOS.
56PRESCRIPTION DON’ TSDon’t prescribe : without examination/ banned drugs/ for experimental reasons.Don’t write : multiple drugs/instructions on separate slip.Don't allow substitutions.
57INVESTIGATIONS DO’S Analyse cost benefit ratio Read reports carefully and interpret results of tests/X-rays properlyRule out pregnancy before subjecting uterus to X-rayConsent-invasive invest.
58INVESTIGATIONS DON’TS Never order an investigation unless result is likely to help direct treatmentDon’t allow modern diagnostic test to substitute your clinical judgmentDon’t inform patient has HIV till confirmatory test is done
59MANAGEMENT DO’SUpdate with latest management by attending CME and conferencesEmploy qualified assistantsUpdate facilities and equipmentObtain legally valid consent before any procedure
60MANAGEMENT DO’S(contd..) In case of MTP/sterilization, followguide lines issued by Govt of IndiaEnsure proper post - operative careRelieve pain specially in cancer patients
61MANAGEMENT DON’TSDon’t perform procedures in agitated patients eg. broken needle can be a cause for law suitDon’t forget to count swab and instruments when ending operationDon’t hesitate to take senior’s or colleague help if in troubleDon’t deny medical care to HIV positiveNEVER AVOID EMERGENCY CALLS
62OTHER DO’S Extend your sympathy to bereaved family Label a condition as functional only when other causes are ruled outIssue certificates only when full verification is done
63OTHER 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
65“Litigation lottery” and frivolous law suits? Award designatedJust 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 claimOnly 8 – 13% cases filed go to trialOnly 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 patient14x as many negligent acts as successful claimsHH Hyatt et al “A study of medical injury and med mal: an overview,” NEJM, 1989Only 30% claims settled in pt’s favor (doesn’t necessitate a payment)57 – 70% of claims result in no payment.PIAA, 1987Verdict for plaintiff19%Court verdict7%81%Case to trial8-13%93%“Litigation lottery” and frivolous law suits?Claim filed1.5%92-87%Patient injured98.5%Hyatt, et al, “A study of medical injury and med mal: an overview,” NEJM, 1989
66Doctor’s Indemnity Why do doctors need insurance anyway? Peace of mind
67Insurance does not cover Any Criminal actServices rendered while intoxicatedAny procedure under GA outside hospitalUse of miracle drugsCosmetic surgery
68Other Problems With Insurance High premiumsDo not pay whole of the damagesLot of running aroundDefense lawyer in the insurance co.panel lacksadequate medico-legal knowledgePatients are encouraged to go in for litigation
69The Best Insurance Policy THE 3 C’s:CARECONCERNCONSIDERATIONFaith is the only currency between a doctor and a patient( Dr. K. C. Mahajan FRCS)