According to media reports, there are around five million cases of medical malpractice in India each year and the number is increasing day by day. This could be due to increased medical knowledge and medical technology, greater expectations of both patients and doctors and the cost involved in rendering the services. Malpractice usually has three characteristics- proven lack of standard care, proven iatrogenic injury and significant disability or damage.
A distinction must be made between medical practice and untoward results occurring in the course of medical care and treatment that is not the fault of the physician. An injury occurring in the course of medical treatment which could not be foreseen and was not the result of any lack of skill or knowledge on the part of the treating physician is an untoward result, for which the physician should not bear any liability.
Most of the surgeries are done to relieve the pain, to restore the function of the gland or organ and at times for an aesthetic reason. Here we would like to cite two examples. One related to slipped disc surgery and another a total joint replacement surgery. Usual presentation of the slipped disc is the pain of variable severity and rarely a neurological deficit. Usually, slipped disc symptoms are relieved with the rest along with the anti-inflammatory medicine commonly known as painkillers but it takes a long time and hence the patient suffers longer. Reviews of literature reveal that in the first attack of slipped disc, 90 per cent of the patients get relief with rest and painkillers, 50 per cent after second attack and only 10 per cent after third attack. In any way the slipped disc pain can be relieved immediately after surgery.
Similarly, in case of total joint replacement surgery, the surgery is indicated mainly to relieve pain, to correct deformity and to regain the joint motion. Here again there is a grey area regarding the timing of the surgery. There is an ongoing debate about the type and timing of the surgery. A patient of joint pain can have a relatively good life with the pain or in other words surgery can be delayed for years but the aim of the surgery is to improve the quality of life which is a relative condition in our diverse society. Similarly, explanations can be given in case of many elective surgeries like gallbladder removal, cardiac stent surgery, correction of deformity or even cosmetic surgery. Litigation is usually seen after the surgeries.
There are many syndromes which cannot be treated by one specialist or one therapy in certain patients as in polytrauma and cancer patients and in patients with many lifestyle diseases like diabetes, hypertension, atherosclerosis and many more syndromes. The incidence of cancer is increasing along with the awareness about cancer, its complications and treatment. Cancer needs a multi pronged approach like surgery, hormonal, chemo and radiotherapy which are delivered by a team of specialists. Each has pros and cons. If there is recurrence or distal spread after the surgery, the surgeon and surgery usually bear the blame. In our opinion, it should not be so because the recurrence and distal spread is a characteristic feature of cancer.
It is difficult to differentiate between ignorance and connivance. There are many such cases which are well documented in mass media and in scientific literature. We would like to cite some of the incidents. An incident which was well documented in mass media was regarding the uteruses of all women of a village being removed by a single surgeon with the understanding that all uterus problems are cancerous problems.
Almost a half of all surgeries performed in India are unwanted or unnecessary, according to a mass media report. On detailed analysis it was found that 55 per cent of heart, 48 per cent of uterus, 47 per cent of cancer, 45 per cent of caesarean and 48 per cent of knee replacement surgeries were unwanted or unnecessary. It was concurred by the Parliamentary standing committee on health in 2016.
Few of the medical errors like hospital acquired infections, unsafe surgical procedures, diagnostic errors, unsafe transfusion practices, radiation errors, surgical procedure in the wrong limb or site are the common errors in medical practices not only in developing countries but also in developed countries. Because of these errors in practices, the nation is losing crores of rupees every year. The quality of work depends upon the quality of the worker and quality of the worker depends upon the quality of learning. We have given a DRAFT principle that means, Do it Right at the First Time (DRAFT) because repair and redo are costly affairs.
It has been noticed that the malpractice virus is spreading in the insurance sector as well, whether it be the public insurer or private. The senior author had written earlier about the misuse of Ayushman Bharat Yojna by doctors and patients. It has been brought to the authors’ notice that people are using the insurance benefit by changing the name, manipulating the facts of the disease, timing of the injuries and hiding known comorbidities because of fear that the doctor may refuse further treatment or raise the cost of treatment if he agrees to the treatment.
Medical care involves both medical services related to the care and comfort of the patient. The general public cannot differentiate between the degree of quality of standard involved in them. Doctors in the small hospitals are not only dealing with their hospital’s problems like the diagnosis and treatment but also other services of the hospitality like food and lodging. In addition to that it has the component of the service sector dealing with people in stress. There is a fair possibility that patients and relatives have high hopes which sometimes cannot be met in all areas. Therefore, there is a fair possibility of conflict or altercation between the service provider and service taker sometimes which may lead to litigation.
The medical profession is a noble profession based on honesty, trust and faith among doctors, patients, their friends and family. We personally feel that one of the culprits is prevailing practice of commission. Initially it was confined to the blood tests but now it has spread to all investigations, drugs, implants and even surgeries and in other hospital activities.
We think that there is a deterioration of overall ethical values in the society as a whole. We need to practice ethical values in all walks of life but more so in the medical profession because the medical profession is still considered to be a noble profession and the fundamentals of this profession are based not only in service to the man but also to mankind.
(The authors are orthopaedic surgeons based in Dehradun. The views expressed are personal)
