There are many diseases which afflict medical profession in India today some of which are due to external causes like quackery, violence against doctors, litigation under Consumer Protection Act, poor image in society, bureaucratic control through PCPNDT (Pre-Conception, Pre-Natal Diagnostic Technique) Act and CEA (Clinical Establishments Act), licensing through Drugs and Cosmetics Act and Biomedical Waste Management Act/Rules, lack of budgetary allocation to health by successive governments. There are other diseases, which are not extrinsic in origin like erosion of ethics, selfishness, ego, turf war, lack of unity and many more.
The king of all maladies, which afflict the medical profession today, however, is jousting; the habit of doctors frequently criticising the previous doctors directly or indirectly. This may be done by gesture, comment, outright statement and occasionally even in writing in medical records and create a legal problem for their colleagues. This is done out of misplaced ego, perverse pleasure, professional jealousy or sheer insensitivity.
When one provider criticizes another, both are at increased risk of legal problems. When a patient hears a physician criticize another physician or healthcare provider, the patient suddenly feels that the care he or she received was inappropriate. This feeling — fuelled by the physician’s spoken criticism or even nonverbal hints — sends the patient to an advocate to find out ways to extort money out of the previous doctor. In India before approaching the lawyer a patient usually gathers a mob and threatens the doctor or in rare cases assaults him, especially in small and medium healthcare establishments. The jousting doctor is frequently at equal risk because he will also be summoned to give evidence against a professional colleague and cross-questioned about his criticism. Situation may arise when the jousting physician may actually need to defend his actions legally.
What we forget is that hindsight is always superior. Pathologists consider themselves the best doctors because their diagnosis is always right but then they have reached the diagnosis after a post mortem examination. Jousting doctors being the second line have the advantage of hindsight but frequently do not have the entire clinical information of the time when the first physician was consulted but still they rush to criticise. Some actually go to the extent of instigating patients to sue the previous doctor and even guide them about the process.
Minor errors are blown out of proportion sometimes to gain misplaced importance but mostly however to justify and magnify their own work done for the patient. A simple pack removed from a patient’s nose or vagina put in by previous physician is exaggerated to give impression of a supra major surgery to save the patient’s life. This does help the jousting physician to charge exorbitantly for otherwise a minor procedure just because the gauge was left by the previous physician and not removed within 24-48 hours either by oversight or because the patient did not go back to him. Even photographs of such gauge are given as trophies to the patient’s relatives and operative notes written in graphic detail and provided to the relatives. The trophy is sent for histopathology examination so as to make the case against the previous doctor foolproof.
A surgeon who has left a gauge in abdomen while controlling torrential bleeding while operating and in process saving a patient’s life should be rewarded not penalized. Unfortunately, key Supreme Court judgments have labelled this as outright negligence in same league as operating on wrong side of patient. More sadly none of the associations of surgeons and gynaecologists has made any attempt to rectify this erroneous impression of the judiciary. But more importantly none of these associations has taken action against the “trophy hunters” the surgeons who videograph removal of a mop or gauge and provide it to the patient’s relatives to be used as evidence against the doctor and splashed in newspapers and TV news.
Jousting in medical records needs to be curbed severely. In the case of Dr Reeta Bharwal vs Kishan Singh the doctor did not come and telephonically gave instructions to staff for management of retained placenta and bleeding who later died. The staff recorded the refusal of the doctor to come to the hospital along with some damaging comments. This medical record proved damaging for the doctor in court even though it was done by paramedical staff. In another case a resident’s notes mentioned Dr X did not come despite being called a number of times (as usual). When tertiary hospitals receive patients treated outside inadvertent discussion during teaching rounds may also sometimes make a patient realize that he has been a victim of negligence.
The practice of medicine is scientific data balanced with clinical instincts and experience. Every time a medical decision is made there may be opinion to the contrary or an alternative line of management. Even Standard Practice Guidelines keep changing nearly yearly which in itself is evidence that medicine cannot be rigid or black and white. It is constantly evolving and to straightjacket an individual approach will smother development. When this smothering is done in form of jousting specially by a senior colleague or in a tertiary institution it has a very damaging effect on the doctor’s psyche besides the violence and litigation faced by him. It is not to say that reverse does not occur. In attempt to show yourself in superior light institutional errors may occasionally be highlighted by small nursing homes and hospitals. However, I must give example of Sadbhavna Hospital in Patiala where a mop left in abdomen by gynaecologists at PGIMER was removed. This case went to court and was dismissed purely because doctors at Sadbhavna Hospital did not testify against PGIMER.
Dr Neeraj Nagpal
Medicos Legal Action Group