Sunday, 24 September 2017

Medical Errors: “I am sorry”

Medical Errors: “I am sorry” Adverse events and medical errors are a part of clinical practice. A report from the Institute of Medicine “To Err is Human: Building a Safer Health System” published in the year 1999 has defined medical error as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim”. Some examples of errors as mentioned in the IOM report include transfusions, surgical injuries and wrong-site surgery, restraint-related injuries or death, falls, burns, pressure ulcers and mistaken patient identities. The IOM report also noted that errors occur more commonly due to faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them. According to the Journal of the American Medical Association (JAMA), medical negligence is the third leading cause of death in the US, behind heart disease and cancer. In 2012, over $3 billion was spent in medical malpractice pay-outs, averaging one pay-out every 43 minutes. Every year, 200,000 patients in the US die due to medical errors. Should a doctor apologize for his/her mistake? A very common, perhaps natural, apprehension is that acknowledging a mistake before the patient may leave one vulnerable to litigation. Admitting to a mistake may also undermine the doctor-patient relationship. Doctors are often counselled not to apologize to patients. A common view is that if you say you’re sorry for something, you are implicitly taking some degree of responsibility for whatever has happened; in other words, saying sorry is an admission of guilt. But, apologizing after a medical error is the humane thing to do. Often, patients sue simply because it’s the only way to find out what went wrong. Physicians should inform patients, no matter what caused the events, of the facts and the nature and circumstances of the problem while expressing regret and showing sympathy for the situation (Can Fam Physician. 2007 Feb; 53(2): 201). Doctors should always communicate with their patients. A two-way communication is the key to a strong doctor-patient relationship. Remaining silent and not communicating to the patient may sometimes result in distrust and an angry patient, who is only too willing to sue the doctor. Apologizing at this point of time may not work to defuse the situation. Many states in the US have passed ‘Apology laws’ that do not permit apologies to be used against doctors in malpractice court Apology the spiritual answer • The word ‘sorry’ is synonymous with apology. • To err is human and to admit one’s error is superhuman. • Sorry should be heartfelt and not ego felt. You should not only say sorry, but you should also mean it. An insincere apology may only complicate matters further. • It requires tremendous courage to face the victim of our wrong doing and apologize. • It is generally seen that those who are in harmony with their life and consequently with themselves, find it easier to say ‘I’m sorry’. They are the positive, conscientious ones who are at peace only after making amends for their misdeeds. • The word ‘sorry’ in itself is imbued with so much potential and power. Within a fraction of a second, grave mistakes are diluted, tepid and estranged relations are brought alive, animosity and rancour are dissolved, misunderstandings resolved and tense situations ease out resulting in harmony and rapprochement. • To forgive and forget is a common spiritual saying. • Remember we all do mistakes and seek forgiveness from God every day. No doctor practices medicine with an intention to harm the patient. Beneficence and non-maleficence are the guiding ethics of clinical practice. But, despite all care, sometimes errors may happen inadvertently. To err is human and every doctor is likely to make mistakes. Difference of opinion, error of judgment, medical errors and medical accidents are not medical negligence. Experiencing a bad outcome does not always mean medical negligence. This has also been the position of the Supreme Court of India in its various judgements. For medical negligence, there is always an element of wilful omission and commission, which causes injury or damages to a patient. Such an act is liable for medical negligence or malpractice claim. Disclaimer: The views expressed in this write up are entirely my own.

IMA organizes Centenary Celebrations of Medical Conferences

IMA organizes Centenary Celebrations of Medical Conferences • Awards announced on Doctors Day presented on the occasion • The event also entailed discussions on key issues, recommendations on the same, and a promise to keep fighting for the cause of the medical fraternity New Delhi, 23 September 2017: As a follow-up to the awards under various categories announced on Doctor’s Day in July this year, an award ceremony was held in The Grand, Vasant Kunj on the 23rd of September 2017. The ceremony was organized as part of the Centenary Celebrations of Medical Conferences in India by the IMA. The doctors were honored for their contribution in the field of medicine and for their work towards the betterment of the medical fraternity at large. The event saw the coming together of the medical fraternity to discuss and debate on, among other things, the various issues plaguing the medical profession today. Discussions also focused on the revised fluid intake recommendations, among pediatricians, surgeons and physicians. Speaking about the awards, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, "The medical fraternity is at a crossroads today. While on the one hand, this award ceremony is being held to honor those who are consistently striving to uphold the integrity of the medical profession, on the other, the fact that many issues still remain unaddressed cannot be ignored. These awards are an encouragement for all concerned to continue working towards restoring the nobility of this profession. They will also inspire others work harder to reach this level. I congratulate all the winners and urge them to carry on the good work being done by them.” Apart from the awards, consensus meetings were also held which discussed various guidelines, one of them being the revised fluid intake recommendations. The revised recommendations indicate that hydrating a patient should entail a mix of energy and electrolytes. Apart from this, different levels of physical activity need different levels of hydration. As a general rule, the fluid intake should be low-sodium, low-sugar, non-caffeinated, and non-alcoholic. However, fitness activities of one hour or more may require additional hydration. Adding further, Dr Aggarwal, said, “Fluid balance is essential for life. The daily liquid requirement can be calculated as 30 ml /kg body weight. Fluid is not only in the liquid form but also solid. For example, all vegetables and fruits are weighed equal. When a person is normally hydrated, they will have no thirst, their armpits will be wet, and they will pass urine every 3 to 6 hours. Hydration requirements increase in summer, after exercise, and in fever. About 5% of fluid loss is symptomatic. To find out whether a person is adequately hydrated, a comparison of their body weight during morning and evening can be done.” The following days of this event will entail a meeting of the Central Working Committee, wherein pertinent issues will be discussed along with the way forward. The recipients of the IMA awards are as follows. Women Empowerment Award • Dr Jayshree B. Mehta and Dr Soumya Swaminathan (2016) • Dr Rishma Pai (2017) Doctor of the Decade Award • Dr A Marthanda Pillai and Dr Shashank Joshi (2016) • Dr Randeep Guleria (2017) Centenary Awards • Dr Ketan Desai • Dr Ajay Kumar • Dr Vinay Aggarwal • Dr KK Aggarwal Life Time Achievement Award • Dr Ved Prakash Mishra (2017) Doctor of the Year Award • Dr R N Tandon, Dr Girish Tyagi, Dr R V Asokan, Dr Hrishikesh D Pai, and Dr K K Kalra (2016) • Dr Shiv Kumar Mishra, Dr Bhupender Ahuja, Dr Saumitra Rawat, Dr H P Saraf, and Dr Mona Desai (2017) Medical Eminent Teacher Award • Dr Georgi Abraham, Dr C G Bahuleyan, Dr M C Mishra, and Dr J A Jayalal (2016) , Dr Swati Bhave IMA Eminent Nurse Award • Ms Anita Deodhar and Ms Evelyn P Kannan

Saturday, 23 September 2017

A must-watch IMA event

A must-watch IMA event The Central Working Committee (CWC) of IMA is meeting today at Hotel The Grand, Vasant Kunj in New Delhi. It is a residential event for members of CWC with a continuous live webcast on IMA website for non CWC members at http://ima-india.org/imalive/ 2-5 PM Saturday and 10-2 PM Sunday. Celebrations of centenary year of medical conferences in India will be observed simultaneously with the 218th CWC Meeting. One of the issues that will be discussed among other such issues of concern to the medical fraternity is “Is the time ripe to shift from non-violence way of protest?” Drafting of Restoration guidelines is another issue on the agenda. For every 1000 members there is one CWC member elected by the IMA state branch. They form the lower house of IMA and recommends all the policies. The CWC forms the IMA upper house. Local branches select one CC member for every 100 members. This is the supreme body of IMA. Though policy suggestions can be sent by individual members, it is always better to bring resolutions through the states via state CWC members. All suggestions of states and branches should be routed through CWC.

Endometriosis may cause complications during pregnancy

Endometriosis may cause complications during pregnancy The disease has symptoms which can be confused with other conditions New Delhi, 22 September 2017: Endometriosis in pregnant women can cause many complications during pregnancy and delivery, including preterm birth and cesarean section. The findings come from a recently conducted study, which also indicates that such women should be closely monitored during the course of their pregnancy for any complications. Endometriosis can cause problems such as inflammation of the endometrium and inhibit the action of progesterone during implantation and throughout the pregnancy, as per the IMA. Endometriosis is a painful condition in which the tissue lining the inside of the uterus, grows outside it. It is estimated to affect about 10% to 15% of the women in the reproductive age. The condition mostly involves the ovaries, fallopian tubes, and the tissue lining the pelvis; but can spread beyond the pelvic organs as well. Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, “Although there has been much progress on various issues related to women’s health, endometriosis is a condition marred by lack of awareness in the country. In this condition, displaced endometrial tissue has no way to exit the body and becomes trapped. When endometriosis involves the ovaries, it can cause formation of cysts. This can lead to an irritation in the surrounding tissue and eventually scar tissue and adhesions. Endometriosis can be mistaken for other conditions that can cause pelvic pain. Some of these include pelvic inflammatory disease (PID) or ovarian cysts and irritable bowel syndrome (IBS). However, in some cases endometriosis may be accompanied by IBS, which can complicate the diagnosis.” While the primary symptom of this condition is increased pelvic pain associated with menstruation, the other symptoms include pain during intercourse and bowel movement, excessive bleeding, fatigue, diarrhea, constipation, and bloating or nausea, especially during menstrual period. Adding further, Dr Aggarwal, said, “Healthy diet and physical activity improve immunity which in turn can help reduce inflammation to some extent. It is imperative to look for heart disease in women with endometriosis. Women with endometriosis are known to have systemic, chronic inflammation, an atherogenic lipid profile, heightened oxidative stress and several overlapping risk factors for cardiovascular disease.” The upcoming Perfect Health Mela being organized by HCFI, to be held from 4th to 8th October 2017 at the Talkatora Stadium in New Delhi will provide a platform to discuss many of these health issues. IMA is the knowledge partner for the event. It is a must visit for those interested in learning more about preventive health and well-being. The Mela will also have free health camps for checking various health parameters. Here are some tips to prevent the risk of endometriosis in women. • Hormonal birth control methods such as pills, patches or rings with lower doses of estrogen can help in preventing this condition. • It is good to indulge in regular exercise regularly. This will help in reducing body fat and decrease the amount of estrogen circulating through the body. • Avoid over consumption of alcohol as it can cause an increase in estrogen levels. Women should limit alcohol intake to one drink per day. • Avoid large amount of drinks with caffeine as more than one caffeinated drink a day, especially sodas and green tea, can raise estrogen levels.

Friday, 22 September 2017

Scientific System of Medicine

Scientific System of Medicine The practice of medicine is an art based on science. Today, evidence-based medicine has become the norm in clinical practice. Application of evidence-based medicine in day to day practice means relating individual clinical signs, individual clinical experience with the best scientific evidences obtained by the clinical research. Scientific system of medicine evaluates any health practice, product, based on the scientific evidence available. Scientific system of medicine takes into consideration all of the scientific evidence in their entirety. It also takes into consideration prior scientific plausibility or prior likelihood, whether that treatment is a valid treatment and is effective, when evaluating health or scientific claims or assertions, which evidence-based medicine does not. Any pathy can have treatment at any level of evidence. • Level I: Evidence from a systematic review or meta-analysis of all relevant RCTs (randomized controlled trial) or evidence-based clinical practice guidelines based on systematic reviews of RCTs or three or more RCTs of good quality that have similar results. • Level II: Evidence obtained from at least one well-designed RCT (e.g. large multi-site RCT). • Level III: Evidence obtained from well-designed controlled trials without randomization (i.e. quasi-experimental). • Level IV: Evidence from well-designed case-control or cohort studies. • Level V: Evidence from systematic reviews of descriptive and qualitative studies (meta-synthesis). • Level VI: Evidence from a single descriptive or qualitative study. • Level VII: Evidence from the opinion of authorities and/or reports of expert committees. Randomized controlled trials (RCTs) are regarded as Level 1 evidence and have been ranked highest. Observational studies, generally regarded as Level II or level III evidence, have been shown to be comparable to RCTs. Therefore, observational studies are also important as evidence for a said practice or treatment or product. The word ‘observation’ is defined in the English dictionary as “an act of noting and recording any event”. In terms of science, this can be likened to recording any data generated out of an experiment. Any observation therefore is potential evidence (JAMA. 2000;284(10):1290-1296). There should be only one system of medicine, the scientific system of medicine. And, all pathies must validate their effectiveness through scientific evidence. Disclaimer: The views expressed in this write up are entirely my own.

Elderly with Type-2 diabetes at high risk of fractures

Elderly with Type-2 diabetes at high risk of fractures
• Poor lifestyle habits can exacerbate this disease • A healthy diet is key in managing the symptoms in those with Type-2 diabetes New Delhi, 21st September 2017: A study conducted recently has indicated that older adults with Type-2 diabetes have deficits in their cortical bone, which can increase their susceptibility to fractures. Cortical bone is the dense outer surface of bone that forms a protective layer around the internal cavity. Type-2 diabetes can alter the micro-architecture of this bone in the elderly and increase the risk of fracture. The IMA added that Type-2 diabetes is a serious public health problem. With the population of the elderly on an upward trend, this is only likely to increase further. Diabetes is a life-long disease that affects the way the body handles glucose in the blood. Most people with diabetes have Type-2 diabetes. People with Type-2 diabetes make insulin, but the cells are unable to use it as well as they should. This is known as insulin resistance. Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, “Type 2 diabetes is typically brought on by poor eating habits, too much body weight and too little exercise. As the body cannot effectively use insulin to bring glucose into cells, it relies on alternative energy sources in the tissues, muscles, and organs. This is a chain reaction that follows up with many symptoms. Type-2 diabetes tends to develop slowly over time and the symptoms are very mild in the beginning. Apart from lifestyle issues, there are other factors that can contribute to the development of this disorder. In some people, the liver produces too much glucose. Some people may also have a genetic predisposition to Type-2 diabetes. Obesity is a major factorin increasing the risk of insulin resistance.” While the early symptoms of Type-2 diabetes include constant hunger, a lack of energy, fatigue, weight loss, excessive thirst, frequent urination, dry mouth, itchy skin, and blurry vision; an increase in the sugar levels eventually can lead to yeast infections, slow-healing cuts, dark patches on the skin, foot pain, and feeling of numbness in the extremities. Adding further, Dr Aggarwal, said, “A healthy diet containing leafy vegetables, fresh fruit, whole grains, lean meat, fish, and nuts can help reduce a person’s risk of Type 2 diabetes and avoid complications. However, a healthy diet is more expensive than an unhealthy one. The wide availability of cheap, energy-dense, low-nutrient food is contributing to the global epidemic of Type-2 diabetes. Foods that reduce the risk of this disease such as vegetables, fresh fruit, whole grains, and unsaturated fats need to be made more affordable and more widely available.” Diabetes will be one of the many key topics of discussion at the upcoming Perfect Health Mela being organized by HCFI, to be held from 4th to 8th October 2017 at the Talkatora Stadium in New Delhi. IMA is the knowledge partner for the event. It is a must visit for those interested in learning more about preventive health and well-being. It will also have free health camps for checking blood sugar levels and other health parameters. The following tips can help in managing Type-2 diabetes. • Include foods rich in fibre and healthy carbohydrates in your diet. Eating fruits, vegetables, and whole grains will help keep the blood glucose levels steady. • Eat at regular intervals and eat only until you are full. • Control your weight and keep your heart healthy. This means keeping refined carbohydrates, sweets, and animal fats to a minimum. • Get about half an hour of aerobic activity daily to help keep your heart healthy. Exercise helps in controlling blood glucose as well.

Thursday, 21 September 2017

Draft Recommendations to decide professional incompetence: Report of the Study Group

Draft Recommendations to decide professional incompetence: Report of the Study Group For Comments The present Study Group came to be constituted by the President Medical Council of India in response to a communication from National President Indian Medical Association Dr. K. K. Aggarwal addressed to her bringing to notice that Rule 8.6 in the Code of Medical Ethics Regulation 2002, which brings out that Medical Council of India has to prescribe guidelines with respect to judgment by a peer group pertaining to ‘professional incompetence’ of a professional. Accordingly the Study Group critically debated and discussed the said issue and is pleased to observe as under: Rule 8.6 of the Code of Medical Ethics Regulations 2002 reads as under: “Professional incompetence shall be judged by peer group as per guidelines prescribed by Medical Council of India” As such, it is evident that professional incompetence of a professional duly registered with the State Medical Council upon fulfilling the precondition of the eligibility of having acquired recognized medical qualifications from a University and duly incorporated in the concerned schedule appended to the Indian Medical Council Act, 1956, is required to be judged by a peer group in accordance with the guidelines prescribed by the Medical Council of India. It is noted that as of now no such guidelines have been prescribed by the Medical Council of India as contemplated under Section 8.6 of the Code of Medical Ethics Regulation 2002 whereby the modality of the assessment of professional incompetence of a professional required to be dealt by the registering council through a peer group constituted for the said purpose is not in vogue for want of prescribed guidelines by the Medical Council of India. In this context the Study Group noted that ‘professional incompetence, professional misconduct and professional incapacitation’ by and large are used interchangeably in a colloquial as well as operational sense on practically more occasions than not primarily because all the three within their fold include failure on part of the professional to take reasonable steps to safeguard the life and health of the person under his care. It is for this reason it is imperative that the distinction between the three needs to be taken note of. Preamble: These guidelines shall be titled as ‘Guidelines governing assessment of professional incompetence by a peer group under Rule 8.6 of Code of Medical Ethics Regulation 2000 as amended from time to time. 1. These shall come into the force from date of its Notification by the Medical Council of India. 2. Extent and coverage: These shall be applicable for any medical trial jurisdiction at the institutional or at any council level. They shall not cover criminal aspect of professional negligence. 3. Definitions: Unless the context requires otherwise a) ‘Adverse event’ means an unintended injury to patient that results from healthcare management (rather than the underlying condition of the patient), which results in measurable disability, prolonged hospitalization or both b) ‘Bolam Test’ means the test evolved out of the judgment in the case of Bolam v Friern Hospital Management Committee [1957] 1 WLR 582 used to assess standard of care when deciding medical negligence. c) ‘Clinical Establishment’ means an establishment as defined in the Clinical Establishment Act, notified by the Government of India. d) ‘Guidelines’ means recommendations or standards notified by the Medical Council of India in terms of Section 8.6 of Code of Medical Ethics Regulation 2002. e) ‘Institution’ means a medical college permitted / approved / recognized by the Medical Council of India/Non teaching Hospitals f) ‘Medical accident’ means an unforeseen or unexpected medical event causing loss or physical damage or injury, brought about unintentionally, as a result of treatment or failure to treat appropriately due to ignorance or lack of knowledge. g) ‘Medical Council of India’ means the council constituted in terms of section 3 of the Indian Medical Council Act, 1956. h) ‘Medical error’ means the failure of a planned action to be completed as intended or use of a wrong, inappropriate, or incorrect plan to achieve an aim. i) ‘Medical malpractice’ means negligent or improper or unreasonable lack of skill in the treatment of a patient, on the part of a health care professional or health care facility that causes harm, injury, or death to a patient or any act or omission by a physician during treatment of a patient that deviates from accepted norms of practice in the medical community and causes an injury to the patient. Or improper, unskilled, or negligent treatment of a patient by a Health Care professional. Or medical malpractice is the failure of a medical professional to follow the accepted standards of practice of his or her profession, resulting in harm to the patient. j) ‘Medical mishap’ means an unfortunate accident k) ‘Peer’ means a person who is equal in ability, standing, or rank with another l) ‘Professional incapacity’ means inability to carry out professional activities and responsibilities/obligations due to a physical or mental condition/illness that may limit the capacity of a professional person to fulfill his/her professional responsibilities/obligations temporarily or permanently m) ‘Professional incompetence’ means failure to exercise due care and diligence in professional responsibilities due to lack of knowledge, skill. n) ‘Professional misconduct’ means unacceptable/dishonorable and unethical behavior by a professional person or noncompliance with the applicable laws and regulations o) ‘Professional negligence’ means an act or omission (failure to act when there is a duty to act) which a reasonable man in the circumstances would do or an act of commission (wrong doing) by a medical professional, which a reasonable man in the circumstances would not do. p) ‘State Medical Council’ means a council constituted and notified under the governing legislative enactment adopted by the concerned State legislature. q) ‘Untoward event’ means an unfavorable or adverse event 4. Mandate: To judge professional / medical incompetence of a registered medical practitioner by a duly constituted peer group 5. Composition of the peer group: a) Peer Group shall be constituted at Institutional / Clinical Establishment / State Medical Council / Medical Council of India level to judge the professional incompetency of a registered medical practitioner in a time-bound manner. b) The peer group shall be a three-member committee with a chairman, one IMA nominee and one professional subject expert. c) The peer group on receipt of any complaint shall examine the allegation in a time-bound manner, preferably within two weeks and forward its reasoned-out speaking order following the principle of natural justice and based on “Bolam’s Test” to the Institutional Head, Clinical Establishment Head / Chairman of the Ethics Committee of the State Medical Council / Chairman of the Ethics Committee of the Medical Council of India as the case may be. Report submitted to the President, Medical Council of India, New Delhi, for needful. Dr Vedprakash Mishra Chairman, Academic Committee, MCI & Convener Study Group Dr KK Aggarwal Dr RN Tandon National President, IMA Secretary General, IMA Member Member Dr Vinay Aggarwal Past National President, IMA Member Place: New Delhi Date: 23rd Sept. 2017