It is often said that 50 per cent of the practicing lawyers at any given time are delinquents because they work against truth and justice and try to build a fort of lies to win a case (assuming that only one can be right in a dispute) unlike doctors who have to search for truth in every case to win that. Sometimes the lawyers bend the thin twig of law so much so that they could make it touch their side of the fence even though they are wrong.
This malady has spread to the Supreme Court judges too nowadays. Some of the judges are venting their personal prejudices in the judgments instead of staying above prejudices while pronouncing judgments. But this is not complete death of court — as for every Ajit Nath Ray, there was a H R Khanna (During Emergency in 1975) and for every Altamas Kabir there is an A R Dave (during NEET Verdict). But their voice is getting weaker day by day.
The first fiasco happened few months back with the NEET Exam where the verdict surprised everyone including the judiciary. It didn’t require extreme degree of intellect to interpret what went behind the scenes and why the judgment was leaked.
The second fiasco pertains to the exorbitant fine imposed by the court. The judges had taken the existing knowledge about the condition and fixed the fine for a problem that happened in the pre-internet and communications revolution era. The doctors were definitely guilty — no doubt about it — but the amount of compensation is way too heavy.
Hypothetically, it is true that every life is priceless and we cannot measure its value. But for practical purposes while announcing compensation, the court has to take into consideration the social impact of its verdict. The court definitely knows that if a social price is fixed, it will never come down in the future. This will also embolden the lower courts to put hefty fines in the future. After all, most of the people are greedy and will try to find loopholes in the treatment, not out of love for the patient but for the love of the money in connivance with or coerced by the lawyers — the classic American malady.
The indemnity insurance costs will increase along with the distrust between the doctor and the patient, which will indirectly be passed to the patient. Under the CPA (Consumer Protection Act, 1986), there is no cap on the amount of compensation — it is the earning capacity and hence the loss to the consumer, which is the deciding factor. So, no small hospital can afford rich patients and only big hospitals can afford them and they will also increase the fee citing the Supreme Court ‘tax’.
I am not trying to protect the doctors but only trying to emphasize the fact that the fine imposed was outrageous because the court increased the fine by almost 1100 per cent (the last highest amount was 1 crore rupees) because it would have widespread social ramifications. Society would not notice gradual changes but sudden changes are definitely noticed. The sudden drastic increase in fine will make doctors more defensive and the patients’ attendants greedier. Every action of a doctor would be scrutinized under microscope, which would not augur well for the doctor-patient relation.
Normally courts follow precedents to fix the compensation. We need to compare the present case (which happened in 1998) to a similar but more ghastly incident — the Uphaar theatre fire tragedy (June 13, 1997) in which 59 people died of severe burns. I had personally treated some of these patients when they arrived in the AIIMS casualty and I was outraged at that time (it was the nearest movie theatre to AIIMS and we used to go there frequently). For the administrative negligence, the court awarded Rs 6.5 crore compensation for the 59 people dead and 103 people injured. How different were both incidents? Why the compensation differed in both incidents?
The Supreme Court lost a great opportunity to act in a responsible way and chose the easy way out by putting a hefty fine, which is more than an honest doctor can acquire in his lifetime. We cannot go back to the days of Hammurabi for fixing the fines. No doctor is God and every doctor including honest people must have made at least one mistake unknowingly — sometimes it is called complication and sometimes it is negligence. Many times, there is a very thin line of separation between a complication and negligence. The only doctor who can confidently say that he didn’t commit a mistake is the one who stopped medical practice.
The court said that this would improve the medical care of the patients. This is a ludicrous statement because the court itself tried to promote mediocrity in medical field by quashing the NEET exam. The government is also trying its bit to promote mediocrity by selling medical seats for money by colluding with private medical college establishments.
The court said that “Failure to use due skill in diagnosis with the result that wrong treatment is given would be negligence”. The honourable court should note that the human body is not a fixed circuit like a machine. We are still miles away from deciphering the human body and human code. Although we found out the genetic code, it’s on and off switches and its interaction with the environment is not fully known. For many diseases, there is no single ideal approach. Even evidence based medicine talks about statistics but not what is required for an individual patient. Ultimately the burden of choosing the treatment falls on the patient and the doctor acts only as a facilitator. When a patient survives, they praise medicine as a noble occupation and if the same doctor makes a small mistake they burn his reputation at stakes.
There was a statement about Mr Manmohan Singh few days back in The Hindu Editorial — “Guilty on many accounts but not corrupt” which applies absolutely to the current medical profession. Many people started treating medicine as business since the Supreme Court judgment 20 years back. But most of us didn’t treat it like business. Otherwise, the situation would have been much worse. Millions of doctor-patient interactions happen in our country every single day. Out of them, even at this very moment, some may go wrong either because of the doctor or patient’s illness. Some of them are definitely because of the doctors, but one should observe the fact that they are very few, not even 0.01 per cent. The public should note the fact that there are more good people than bad men in our profession.
We agree that we are all not good men. We reflect the current society because we are drawn from it. When the society goes bad, the doctors also go bad. But don’t forget one thing – doctors in comparison to other professions are the last people to go immoral because of the ethics inherent in their profession and if it is happening, it shows the society’s direction. But one thing is sure — we, doctors, still draw inspiration from an occasional patient living against all odds because of our efforts and an occasional patient saying, “Thank you very much, Doctor”. Sometimes, these simple words remind us of our noble profession and arrest our moral slide.
Most of us lost our youth studying those immense books and diseased patients. Most of us became indifferent after seeing death from close quarters but never lost our empathy and humanity. Most of us lost our family lives and pampered our kids because of the limited time we have for them because of our profession. Most of us feel happier when a patient recovers from a complication than when our own children are cured from illnesses. Most of us stretched our limits when patients put complete faith in us. Most of us even when we are sick attend to the patients with a single thought — “what would happen to the patients if I am not there”. We don’t embody higher spiritual goals and sacrifice lest we be sages and live in Himalayas but most of the time what drives us is the noble cause because after some time, money won’t drive us.
Let’s go back and examine the case and learn from the mistakes instead of committing them because the sequence of events even though 15 years old can happen to anyone if they are not careful enough.
1) The accused doctor was the most reputed and leading doctor according to the complainant, which I think could not have been achieved with pure luck. Sometimes this works like a double edged sword — the more reputation and patients one gets, the less reliable the treatment becomes over a period of time because the time spent on each individual patient drastically reduces and he/she does not get adequate time to update him/herself. It is better to restrict the practice than spending whole time in the clinic/hospital. Even a senior and intelligent doctor like him could not diagnose the condition (the dermatologist could diagnose the condition later but by that time the condition was full blown). This shows that every new case teaches new things and one should be willing to learn throughout one’s life. This also shows that future doctors should see sufficient number of patients during their training, should have a reasonable intellect and should update them constantly throughout their lifetime. But nowadays people are buying medical seats with money and not being trained sufficiently during their stay at the colleges — the number of disputes will definitely increase in the future.
2) Why the doctor prescribed high doses of steroids, the particular preparation and the dose — whether he by mistake gave that particular dosage or whether he had already treated a similar condition with the given dosage of Depo Medrol 80 mg twice a day is only known to him. In medicine presumptive treatments are used sometimes when the diagnosis is not obvious. The mistake the physician had done was not seeking a dermatologist’s opinion in the early stages of the disease and using long acting preparation instead of short acting ones. Whether the patient would have survived or not with or without steroids is a different question altogether. This episode indirectly shows the dependence of practitioners on medical representatives for their education (because Depo Medrol comes in 3 different dosage forms – 20,40,80 mg, the doctor must have gone for the higher dosage). This also reveals the limitation of knowledge even a senior physician can have beyond his field. Medicine is getting branched into specialties and subspecialties nowadays and when in doubt or not able to precisely identify the problem, it is better to include other specialists in the treatment process to avoid litigation.
3) When the patient was sick in the hospital, the treatment was not recorded properly — there was no notes, no vital signs recording for days. The supportive care was not given properly or not recorded properly. No IV line was started because of the fear of introducing infection when the patient was already in sepsis. There is a peculiar term in medicine called VIP syndrome — the more you treat a patient as VIP, the more mistakes you do. I think that’s what exactly happened to the patient — the more they treated her as VIP, the more she deteriorated. There is also a famous adage — “Everyone’s patient is nobody’s patient”. When the main treating physician left for US, there was nobody leading the treatment because there was not a proper note by any treating doctor. The importance of recording all the parameters (Vitals, Drugs etc) and doing the necessary investigations cannot be overemphasized with this episode.
When we examine the case closely, we would definitely find many lapses in the treatment. But before examining the case with 2013 X-rays, let’s go back to 1998 and take time to compare the medical infrastructure situation in 1998 and 2013. Most of the hospitals were just looking to upgrade their infrastructure in 1998. There were few specialists and most of them treated patients with their hunches and experience rather than EBM (Evidence Based Medicine), which was just being talked about in institutes. Writing notes was not considered important those days. Last 15 years had seen major changes in the medical field in India. The importance of infrastructure, EBM and daily notes are all recognized now. For a patient who returned from US in 1998, every thing must have looked horrific that time. But there was a definite time gap between the adoption of medical advances between US and India, which is only getting narrowed nowadays.
I am not trying to protect the doctors but only trying to emphasize the fact that the fine imposed was outrageous because the court increased the fine by almost 1100 per cent (the last highest amount was 1 crore rupees) because it would have widespread social ramifications. Society would not notice gradual changes but sudden changes are definitely noticed. The sudden drastic increase in fine will make doctors more defensive and the patients’ attendants greedier. Every action of doctor would be scrutinized under microscope, which would not augur well for the doctor-patient relation.
The sad thing is we lost half of our credibility when money entered the system blatantly — money for degree scheme (which was started by politicians) which corrupted the production of doctors (Even in Medicine, 50 per cent used to belong to the bottom half of the class and as money entered the system blatantly, the number will rise to 90 per cent in a short time) and the other half because of the kickbacks we receive from the diagnostics and pharmaceutical industries which corrupted the conduct of the established doctors.
It’s sad that the Supreme Court is also trying to corrupt the system first by scrapping the NEET Exam and later by increasing the fines exorbitantly. I hope the government and court would look into the matter and make correct decisions. The Indian Medical Association (IMA) and the Medical Council of India (MCI) should take a lead in representing the interests of doctors to the executive and judiciary.
Dr Kalyan R Kone