 Hello and a very warm welcome to our third episode in the series, Manipal Hospitals Presents Changing Face of Medicine. The medical community has the hardest of all jobs, doctors, nurses and other paraprofessionals in the field work tirelessly so you and me can feel better. But sometimes things go wrong and various kinds of complications occur leading to legal and ethical problems. In today's episode, we will throw some light on such complex cases and how they can be handled effectively and compassionately, always keeping the best interest of the patient in mind. Joining us for this discussion are Dr. Nagendra Swamy, President of Manipal Health Enterprises and Chairman of Quality Council of MHE, Dr. Sudarshan Balal, Chairman Medical Advisory Board and Medical Director, Manipal Health Enterprises, Private Limited and Dr. Jogarao. Dr. Jogarao is our medical legal expert at the panel today. As a doctor, one always tries to do their best and there is actually no room for being responsible, Dr. Balal. But how as a doctor would you define medical negligence? I think this is a very, very important topic that you have brought up because the definition of negligence depends on who is at the receiving end. The perceptions are very, very different from the patient's angle, from the family's angle and certainly from the doctor's and the legal angle. To me, what is negligence is sort of willful disrespect to the patient's care. This could be like operating on the wrong patient, which has happened not only here, but also in the U.S., operating on the wrong organ. That has again happened many times here and abroad. And of course, leaving some instruments behind when you do surgeries are something that's very, very grossly negligent and which can be proven by law. Let us not accept any untoward incident or a complication of the procedure as negligence. Let us not equate poor outcome with negligence. The negligence constitutes a triangle of situation. One, there has to be a relationship of obligation between the doctor and the patient. The second is there has to be a omission or a commission by the doctor. The third is there has to be a repercussions of this omission or a commission resulting in an injury or a death. Unless all these three points of the triangle are there, it cannot be constituted as a negligence. But unfortunately, most of the situations, as Dr. Balal rightly mentioned, it is a utter expectation mismatch. I think that is where we need to create awareness, education between the complication, poor outcome and the right outcome, and what is humanly possible by a doctor to give it. Dr. Rao, the same question to you but from the legal aspect. What is medical negligence as per law? I had worked into what Dr. Balal and Dr. Swami said. By and large, from a public perception wise, what they have stated constitutes medical negligence according to them. But when it comes to law, quite categorically has been stated that under no circumstances, a poor outcome constitutes negligence. No circumstances, a complication leading to any adverse impact is not negligence. According to law, supported by several judicial decisions, in a given context of doctor-patient relationship, if the doctor fails to exercise the warranted standard of care, and as a result, if the patient is subjected to some kind of injury, then the conduct can be labeled as negligence. A lot of times, things and treatments do not work and things don't go as they have been planned by the doctor or the family isn't denial, Dr. Swami, about the outcome. At that point in time, how do you talk to them or how do you make sense of what has happened? See, normally what really requires is the denial comes from the patient and also from the patient's party. When a terminal illness or a prolonged treatment is suggested, the first and foremost that comes to their mind is, is this right? Why it should be with me? Why am I suffering from this? So it is a bound duty of the doctor to give that comfort and the rationale why he thinks what he is telling and also to suggest the patient alternates that are available for this treatment, along with also to conform it with another set of doctors or thing so that he gets completely aligned to the suggested method. I want a person to challenge the decision, ask the right questions, rather than blindly living it, Dr. you do what is right. And the moment something goes wrong, blame it all on the, that is where the medical profession has to rise up to say, listen, if somebody says, do what you deem fit, you better watch out, you need to educate him whether he likes or not, what I said. Dr. Rao, law pertaining to medical negligence are quite defined abroad, but in India there is a lot of ambiguity around issues like compensation. What are the deciding factors here in the country? When it comes to medical negligence, I think we have come a long way. In creating relevant benchmarks with a view to quantify what is the appropriate compensation in a given case of medical negligence. But I think off late the popular mood is slowly changing, that is on account of couple of judgments. Now there is a very important debate that is going on, whether there can be a cap on compensation that can be awarded vis-a-vis either doctors or hospitals. I think to that effect there are benchmarks to be looked into to consider what is the appropriate quantification. But whether there can be a cap on the maximum level also is being considered, which I personally feel I think is a very important point to be looked into. Dr. Balal, how do big hospitals like yours deal with issues of negligence, lawsuits, compensations? As always in life, I think an ounce of prevention is better than a ton of cure. So I think the theme is to try and prevent these lawsuits or these allegations of malpractice, negligence, rather than try to fix it later. So I think we should take extraordinary measures to prevent it. And in my opinion, there are three major factors. One is honesty. You have to be honest to your patient and to the family, speak the truth, don't try to hide things, do things that are not necessary, speak the truth, take them into confidence and only then go ahead with the necessary treatment. Second is an excellent patient-doctor relationship. I have rarely in my 30, 35 years of practice seen patients who are doctor, where they have had extraordinary faith and good communication with the doctor. The third, I think, which is very, very necessary in the Indian context is documentation. As all lawyers would say, what is not documented means that we have not done it. So and we as Indians are very, very poor. In medical records. In medical records. We hardly and most of the times doctors don't write anything and whenever they write something, no one understands what they've written. So I think that's a serious problem. But if and when there is a negligence that happens, we have a set protocol to deal with this. First, we seek an explanation from the reading doctor as to what is the reason why the patient has felt that there was negligence. Obviously, that's documented. Second, we get an internal opinion from people of the same fraternity who are not involved in the care. And rarely, we might also take an external opinion. And then of course, based on all this, we take a call whether we think it is negligence or whether it was just a complication or a poor outcome of the procedure. And the further dealing with the case would depend on what our judgment is. Dr. Swamy, the next question is about when do you choose to play human? And when do you choose to play a doctor? So when a patient's family comes to you and requests you to not disclose anything to the patient, how do you decide what to do then? There is something called as patient right. Patient right and responsibility is one of the important charters of medical care. Imagine there is a cancer patient. We are not supposed to tell him the cancer, but we are supposed to start a chemotherapy on a well healthy, mentally alert patient. When a patient is sound mentally alert, it becomes a bounded duty of the doctor to explain to the patient, taking him into confidence. Otherwise, legally, however morally, we would like to justify that it is on the request of the patient's party we would like to do. The patient writes, demands that he should know what he is going through. At the most, you may play it down a little bit to what is at the end of the day. You need to give him a hope. If that hope is well justified on giving without diluting the seriousness of the issue, I think the doctors need to play. Let me take a short break here. But when we come back, we talk about damage control in case of medical negligence, patient safety and the importance of ethical practice in modern day medicine. Stay tuned. Welcome back to Manipal Hospital presents changing face of medicine. We are broaching upon some sensitive issues here pertaining to medical negligence and ethical practice in the field of medicine. And I take the discussion forward talking about preventive steps now. Dr. Swami, what are the measures that are taken to prevent even the smallest occurrence of medical negligence and to actually make the system foolproof? See, primarily the preventive steps could be put in primary steps and secondary steps. Primary steps are as per the care is concerned. You need to have a standard practices that are established in the hospital. The main, one of the most important issues is there is famous nine hours or letter R, nine hours. They say if you follow this nine hours very religiously, you are mostly you will stay away from getting into a medical litigation or an illigency problem. First star is rapport. How is your rapport with patient, patient party and fellow team members? Second is rationale. What you are going to do to the patient should be based on a sound sound scientific rationale. Why you have chosen that path to that stream of investigation or that stream of treatment to this patient? Next is respect, mutual respect to the patient and to the doctor. You need to exhibit though the patient has come to you surrendering for illness, you need to give his patient rights the values for him. That's the right is another one is the right of the patient to be honored. Next is as Dr. Balal said, record. Your recording should be appropriate, right time and complete as far as the sequencing concern. The next is remarks. You shouldn't pass loose comments in front of the patient about another system or another colleague without understanding. This can have a huge impression on. So that remarks is another thing. Next R is you put that Rx, that prescription. Next last but not least is the rest is pa liquidar. That means the things speaks for itself. If you are supposed to do a right hand surgery, if you do on a left hand, you don't need a judge to give the judgment. It's quite obvious that things speaks for itself. These are primary preventive steps. The secondary preventive steps are like you put a good grievance addressal system within that. Most of the times in my experience, probably 30 years as administrator, I can boldly tell you if you empathize with the patients or his relatives anxiety and put in a transparent system to address the grievance, grievance addressal system is a very important part. The last but not least is having a sound legal cell, having your indemnity insurance properly done. Before going into insurance, it's important something called as credentialing and privileging of the doctors, right doctors to be appointed. There are things to be done so that we are not into the thing. Then there are statutory obligations which we should honor in the country because suppose there is a PNDT act, we should honor what the law says that. As long as these three steps are taken, we should be. While supplementing to what has already been stated, let me slightly change the focus. Can we preempt a potential midco legal case within an institution? I want to focus on that. Dr. Swami mentioned about the patient redressal grievance. Is there a mechanism that can be provided? In my opinion, in majority of the cases of medical negligence, the most significant problem that comes in the way is there is no communication between the doctor or the treatment doctor and the patients. As a result, the relationship gets snapped. But in my opinion, if we can establish an institutional mechanism within the hospital where you pay heed to what the patient is saying, that is the reason why in institutional like Manipal hospitals, in perfect sense, we encourage as much as possible patient feedback. I think these are the steps which inculcate confidence and faith into the minds of the patients and patient families. Dr. Bilal, if I can briefly get into the importance of second opinion, as a doctor, when do you recommend it? I think second opinion has a huge role to play in appropriate medical care. Even as a doctor, you would recommend it? Yes, yes. And in fact, a lot of my juniors say, sir, why do you ask for a second opinion? I said it's what the patient needs and also for the safety of the doctor treating the given patient. But in general, when do we ask for a second opinion is a million dollar question. And to me, the answer is fairly simple. Any illness that is prolonged is not going the way it should have gone. There's a disconnect between what you thought the patient should have and what has actually happened to the patient. So the family obviously will be irate, upset. So in these instances, you offer the patient the second opinion. You tell them this is what I thought would happen. However, the things have turned out to be very different and you are very open to get a second opinion. I even tell them suggest names and I tell them we'll facilitate a second opinion. So when the outcome is not as planned, second is an extremely complex patient. There are medical instances where the patient may have a very complex illness. That's not in the realm of day-to-day medicine and where you're not able to come to a definitive diagnosis after enough workup of the patient. There you tell them, see, look here, I've done everything possible, but we still have not reached any conclusion. And we are open to have a second opinion. Third is when you see that the patient is getting upset about the way the care is being given. And then proactively you tell them, I get a sense that you are not very happy with the way things are going. So please feel free to get a second opinion. But I also would urge that whenever there's a second opinion given, the treating doctor also has the choice of not following that second opinion if he doesn't agree with it. All right. If you agree with that opinion, fine, you can go ahead with it. But if you don't agree, then you can give the patient the choice of moving out to someone else's care. Or if you agree with it, you follow the care opinion that's been given. I'm absolutely running out of time, but I do have one very important question that I wanted to put to your doctors for me, which is we are living in a very challenging times and doctors are mistreated. Sometimes they're even manhandled. Instances of manhandling doctors are now at a rise. How do you keep your sanity? What do you tell your doctors? No doctor intentionally will ever, ever will try to harm a patient. I am, by no stretch of imagination, I am not telling that there is no wrong that has been done in that. There may be. There will be wrongs. They are human beings. When that wrong happen, there are systems to address that. By going and hitting the doctors, you are making doctors shy away from taking difficult cases. You will come to a situation where the doctor will very comfortably say, sorry, this is all I can do. He doesn't want to even give a try to that case, because he is morbidly scared about fearlessly practicing the medicine. To that extent, my appeal to the public is you are damaging your own health by doing this. We all should collectively sit together and prevent certain things. I think the country has put in law in certain states, but it should become across the country that this is not answered. Well, on that note, we end our special discussion here. Thank you, gentlemen, for taking our time for us and coming to the studios. Medical negligence remains a critical subject, and so does the legal system around it. While hospitals are making a consolidated effort in maintaining transparency and zero tolerance for negligence, there is a growing need for compassion-based medical practice, a strong legal system to handle such issues, and a more evolved system of counseling patients and their families. Thanks for watching.