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CONSUMER PROTECTION ACT FOR MEDICAL PROFESSION IN INDIA

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Title: CONSUMER PROTECTION ACT FOR MEDICAL PROFESSION IN INDIA


1
CONSUMER PROTECTION ACT FOR MEDICAL
PROFESSION IN INDIA
  • Dr. Bipin Pandit
  • MD.DGO.DFP
  • Hon. Gynaecologist at Dr. Balabhai Nanavatii
    Hospital, V Parle
  • Hon. Gynaecologist at Dr. L.H. Hiranandani
    Hospital, Powai
  • Hon. Gynaecologist at Municipal Maternity
    Hospital, Marol
  • Hon. Gynaecologist at L T Welfare Center
    Andheri.
  • Chairman Medico-legal committee MOGS
  • Past President of Association Of Medical
    Consultants Mumbai
  • Committee Member of Indian Education Society.
  • Past President Andheri Medical Association (E
    W)

2
Time line Guidelines for good medical practice
across the ages
  • The Code of Hammurabi ( 2000 B.C. )
  • Parks textbook of PSM,16th edition

3
Time 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)

Parks textbook of PSM,16th edition
4
Time line..
  • CHARAKS OATH (200 A.D.)
  • Thou shalt be free from envy, not cause
    anothers 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 patients
    house, be accompanied by a person known to the
    patient. The peculiar customs of the patients
    household shall not be made public. "
  • Parks textbook of PSM,16th edition

5
Time line ..
  • ARABIC CODE OF MEDICAL ETHICS (800-1300 AD)
  • Adab al Tabib
  • Parks textbook of PSM,16th edition

6
Time line ..
  • The Declaration of Geneva 1948
  • The Indian Medical Council Act 1956
  • The Consumer Protection Act 1986
  • The inclusion of medical services in CPA 1995

7
Medical 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

8
WHERE TO GO ?
Consumer Dispute Forum
Civil Court
Criminal Court
Medical Council
9
WHY CPA?
  • MCI
  • Biased
  • Cant award
  • damages
  • THE COURTS
  • Delay
  • Expensive
  • The answer Alternate dispute resolution system
  • Easy, quick, accessible,
    cheap and effective

Sec 3A, 12, CPA 1986
10
Consumer Protection Act, 1986
  • Empowers the consumer with the Right to
  • Safety
  • Information
  • Choose
  • Heard
  • Redressal
  • Consumer education

Sec 4 to 8 of The CPA ( Amendment ), 2002
11
LODGING A COMPLAINT
  • FORMAT Written
  • PERSON Complainant / Representative
  • PLACE Consumer Dispute Redressal Fora
  • FEE Nominal
  • TIME LIMIT 2 yrs
  • FATE Accepted
  • Dismissed



Sec 12 CPA 1986
12
Consumer Disputes Redressal AgenciesDISTRICT
FORUM
  • Jurisdiction Upto Rs. 20 lakhs
  • Composition President 2 Members
  • Powers Examines complaints
  • Issues notices
  • Orders analysis / tests
  • Conducts hearings
  • Award damages

Sec 9 to 15 of THE CPA ( Amendment ), 2002
13
Consumer Disputes Redressal AgenciesSTATE
COMMISSION
  • Jurisdiction From 20 lakhs Up to 1Crore
  • Composition President 2 Members
  • Power Similar to district forum
  • Hearing of appeals

Sec 16 to 19 of The CPA ( Amendment ), 2002
14
Consumer Disputes Redressal AgenciesNATIONAL
COMMISSION
  • Jurisdiction gt Rs. 1 Crore
  • Composition President 4 members
  • Powers Similar to State forum
  • Hearing of
    appeals

Sec 20 to 25 of The CPA ( Amendment ), 2002
15
Professional Negligence
  • Definition
  • Absence of reasonable care or skill or
    willful negligence
  • on the part of the medical practitioner in
    the treatment
  • of the patient whereby the health or life of
    the patient is
  • endangered.

Parikhs Textbook of Medical Jurisprudence,
Forensic medicine.
16
Types of Professional Negligence
  • Civil Negligence Malpractice, Deficiency in
    Service
  • Criminal Negligence gross lack of competency,
  • gross
    inattention
  • reckless
    behavior

17
In general a doctor's innocence is presumed
The complainant has to prove negligence.
18
Proof of Negligence
  • 4 Ds
  • The essentials of negligence are four "D"s
  • There was a Duty towards patients
  • There was Deficiency in duty
  • This Directly resulted in (causa causans )
  • Damage which may be physical, mental or
  • financial loss to patient or relatives.

Tiwari S.K, Baldwa M. - Medical Negligence.
Indian Pediatrics 2001 38 488-495  
19
Res 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.

20
Vicarious Liability
  • Liability for anothers 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.

21
A patients journey through the realm of medical
malpractice
Quality of care
Commitment of medical error
A Doctors Defense
Outcome judgment and awards
22
Quality of Care
  • Patient - Doctor Relationship
  • ( Implied contract )

23
The Sacred Patient-Doctor Relationship A thing
of the past
  • Caring and healing.

24
Patient - 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 emergency
  • Pre-employment medical
    examination
  • Examining a patient under
    court order

Parikhs Textbook of Medical Jurisprudence
Forensic medicine
25
Requirements of Doctor Patient Relationship
  • Reasonable skill
  • An average
    degree of skill
  • possessed by
    his professional
  • brethren of
    the same standing
  • Reasonable care
  • Such care and
    attention for the
  • safety of the
    patient as their
  • mental and
    physical condition
  • may require
  • Communication

26
Common Patient Complaints
  • Too little time for patients
  • Does not listen
  • Does not explain well
  • Shows no sympathy
  • Neither understands the patient nor his family

Hey, DOC!
Harris Poll, 2000 Roper Center Polls, 2000
27
Informed Consent
  • How well do you understand it?

28
Informed 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 Loves Short Practice of Surgery,
24th Edition
29
Types of consent
  • Implied inferred from actions
  • Express actively stated
  • Proxy consent on behalf of others

30
Why is Consent Necessary
  • Willing patient,
  • better outcome
  • defense against a charge of assault / battery

31
When is Consent Necessary
  • Everything in the Doctor - Patient Relationship
    is CONSENSUAL

32
Express Consent is expected..
  • Surgical/Invasive Procedures
  • Chemotherapy / Radiotherapy
  • Radiological / Investigational Procedures
  • Medical Research
  • Teaching - intimate examination

33
Competence/Capacity in Informed Consent
  • Competent Adult ( gt 18 yrs )
  • In case of Minors ( lt 12 yrs ) Parent or legal
    guardian( Loco Parents ).
  • Emergency ( the law implies consent )
    (Sec.92.I.P.C.)

34
Rules 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.
35
Why do patients sue?
  • Original injury is not enough.
  • Prime concern perceived lack of caring
  • 3 reasons for litigation
  • Altruism protect others
  • Expose the truth
  • Financial restitution.
  • Lack of communication.
  • Over 1/3 would have opted out of litigation with
    explanation, apology

Vincent, Young, Philips, Why do people sue
doctors? Lancet, 1994
36
How does fear of lawsuits alter patient care?
37
Defensive Medicine the use of costly diagnostic
efforts of medical treatments for the sole
purpose of avoiding potential litigation
definition
  • Litigation has decreased quality of care
  • More tests than medically needed
  • More specialist referrals than needed
  • More invasive procedures than needed
  • More medicines than needed

Fear of Litigation study, Harris Interactive, Apr
2002
38
Fear of the patient !!Altered patient-doctor
relationship
  • Potentially adversarial relationship
  • Each patient a potential plaintiff
  • Each 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
39
IOM - To Err Is HumanThe American health care
system is not as safe as you might think
  • 1 deaths by medical error
  • 2 motor vehicle collisions
  • 3 breast cancer
  • 4 AIDS
  • 44,000 - 98,000 deaths by PREVENTABLE medical
    errors in hospitals each year

Institute of Medicine, To Err is Human Building
a Safer Health System, Nov 1999 Harvard School
of Public Health, from Testimony of Harvey
Rosenfield, FTCR, Feb 2003 Jrnl of Health Care
Info Management, A System Approach the Error
Reporting, Vol. 16, No. 1
40
To err is human Building a safer health
system, IOM, 2000
41
ALLEGATIONS
  • THE SURGEON
  • Articles left in patients body.
  • Consent not taken prior to
  • operation.
  • Operation on wrong side.
  • Failure in diagnosis or
  • operation.
  • Not operating in time.

42
ANAESTHESIOLOGIST
Allegations
  • Excessive anesthesia
  • Injury to eyes/skin
  • Injury from mask/mouth gag

43
Allegations
  • RADIOLOGIST
  • Electrical shock burns
  • Injuries to vision
  • Pigmentation
  • Loss of hairs

44
GYNAECOLOGIST
  • Consent not taken before abortion
  • Failed tubal ligation
  • Injury to uterus
  • Operation causing sterility

45
MEASURES
  • PREVENTION AT
  • PERSONAL LEVEL
  • Qualification
  • Communication
  • INTERPERSONAL LEVEL
  • Courteous and polite if
  • any mishap
  • ACADEMIC AND TECHNICAL
  • UP GRADATION
  • Attend CME,Workshops and
  • Conferences


46
PREVENTION AT PRACTICE
  • MEDICAL
  • Reasonable skill and care
  • SOCIAL
  • Exhibit skill to patient body language
  • LEGAL
  • Document in legible handwriting
  • Record of failure

47
OTHER MEASURES
  • PEOPLE SUPPORT GROUPS
  • Forum to discuss acts and cases fought
  • Never talk loose of your colleague
  • MEDICAL ETHICS
  • Thorough knowledge is a must
  • PROFESSIONAL INDEMNITY
  • Insurance

48
DOS AND DONTS FOR DOCTORS HISTORY TAKINGDOS
  • Listen attentively
  • Maintain privacy
  • Face patient
  • Start afresh if distraction
  • Ask questions intelligently
  • Give time to the patient

49
HISTORY TAKINGDONTS
  • Dont discriminate.
  • Dont assume all what patient says as correct
  • Dont smoke
  • Dont look overconfident

50
EXAMINATION OF PATIENTDOS
  • Thoroughly examine the pt.
  • Oblige again if patient considers examination
    incomplete
  • Review next day if patient is examined hurriedly

51
EXAMINATION OF PATIENTDONTS
  • Don't examine if you are
  • sick
  • exhausted
  • intoxicated
  • NEVER examine a female patient in the absence of
    a female nurse or an attendant especially during
    genital or breast examination

52
PRESCRIPTIONDOS
  • MENTION
  • Qualification/training/experience/designation
    (Indian Medical Degree Act1916)
  • Date and timing of the consultation
  • Age and sex of patient
  • Precise history of illness/physical finding
  • Diagnosis under review if unsettled

53
PRESCRIPTIONDOS(cont..)
  • MENTION
  • Refusal for investigation/administration in local
    language with proper witness
  • H/O drug allergy
  • Names/dosage/route of administration of drugs
    clearly with precautions like ac/pc.

54
PRESCRIPTIONDOS(cont..)
  • MENTION
  • If patient is pregnant/lactating
  • Side effect/interaction of drug
  • Emergency treatment in chronic illness
  • Not to stop drug suddenly if tapering required
  • If a particular drug/equipment unavailable

55
PRESCRIPTIONDOS(cont..)
  • MENTION
  • Reasons for deviation from standard
  • care
  • Prognosis explained
  • Where patient should contact if you
  • are unavailable
  • Review SOS.

56
PRESCRIPTIONDON TS
  • Dont prescribe without examination/ banned
    drugs/ for experimental reasons.
  • Dont write multiple drugs/instructions on
    separate slip.
  • Don't allow substitutions.

57
INVESTIGATIONSDOS
  • Analyse cost benefit ratio
  • Read reports carefully and interpret results of
    tests/X-rays properly
  • Rule out pregnancy before subjecting uterus to
    X-ray
  • Consent-invasive invest.

58
INVESTIGATIONSDONTS
  • Never order an investigation unless result is
    likely to help direct treatment
  • Dont allow modern diagnostic test to substitute
    your clinical judgment
  • Dont inform patient has HIV till confirmatory
    test is done

59
MANAGEMENTDOS
  • Update with latest management by attending CME
    and conferences
  • Employ qualified assistants
  • Update facilities and equipment
  • Obtain legally valid consent before any procedure

60
MANAGEMENTDOS(contd..)
  • In case of MTP/sterilization, follow
  • guide lines issued by Govt of India
  • Ensure proper post - operative care
  • Relieve pain specially in cancer patients

61
MANAGEMENTDONTS
  • Dont perform procedures in agitated patients
    eg. broken needle can be a cause for law suit
  • Dont forget to count swab and instruments when
    ending operation
  • Dont hesitate to take seniors or colleague help
    if in trouble
  • Dont deny medical care to HIV positive
  • NEVER AVOID EMERGENCY CALLS

62
OTHERDOS
  • Extend your sympathy to bereaved family
  • Label a condition as functional only when other
    causes are ruled out
  • Issue certificates only when full verification
    is done

63
OTHERDONTS
  • Dont refuse leave against medical advise
  • Dont withhold information however harsh and
    difficult(sensitive communication)
  • Dont refuse patients right to examine and
    receive an explanation about your bills

64
Outcome judgment and awards
65
Award designated
Verdict for plaintiff
19
Court verdict
7
81
Case to trial
8-13
93
Litigation lottery and frivolous law
suits?
Claim filed
1.5
92-87
Patient injured
98.5
Hyatt, et al, A study of medical injury and med
mal an overview, NEJM, 1989
66
Doctors IndemnityWhy do doctors need insurance
anyway?
Peace of mind
67
Insurance does not cover
  • Any Criminal act
  • Services rendered while intoxicated
  • Any procedure under GA outside hospital
  • Use of miracle drugs
  • Cosmetic surgery

68
Other Problems With Insurance
  • High premiums
  • Do not pay whole of the damages
  • Lot of running around
  • Defense lawyer in the insurance co.panel lacks
  • adequate medico-legal knowledge
  • Patients are encouraged to go in for
    litigation

69
The Best Insurance Policy
  • THE 3 Cs
  • CARE
  • CONCERN
  • CONSIDERATION

Faith is the only currency between a doctor and a
patient ( Dr. K. C. Mahajan FRCS)
70
THANK YOU
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