Medical negligence and compensation, time to have more practical approach

From: thehindubusinessline.com

Body blow to the medical profession

Compensation for medical malpractice should be capped. Else, there will be no doctors left to perform surgeries
The recent Supreme Court ruling on medical compensation of ₹11 crore in Kolkata has raised several issues related to the medical profession and its practice. The Supreme Court has rightly upheld the law of the land.

In 2030 BC, during the Old Babylonian period, the Code of Hammurabi read: “If the doctor has treated a gentleman with a lancet of bronze and has caused the gentleman to die or has opened an abscess of the eye for a gentleman with a bronze lancet and has caused the loss of the gentleman’s eye, one shall cut off his hands”.

Chopping off doctor’s hand for making a mistake is definitely effective but after some time there will be few doctors left with the hands to operate. The current Indian law governing the medical negligence is not vastly different than that of Hammurabi’s Code.

Gynaecologists will retreat
And, what is the state of healthcare delivery in India? As many as 84 per cent of the hospitals in India are less than 30 beds in size, where more than 60 per cent of the children of this country are born. Among doctors, gynaecologists are most vulnerable to litigation.

A majority of these nursing homes do not even have a medical records department to protect them in the case of litigation. Any sincere effort to save the life of a patient, not backed by a well documented medical record, can never stand in the court of law.

A gynaecologist builds a typical 30-bed nursing home in a small town after slogging for decades and building a reputation for himself and the nursing home.

However, if an unfortunate incident occurs and someone sues the gynecologist for ₹2 crore — which is not a lot of money compared to ₹11 crore compensation offered in Kolkata — there will be a problem.

Even if the small town gynaecologist sells his nursing home, his house and farmland, if he has any, he will not be able to come up with ₹2 crore.

Doctors, in general, are in a very insecure profession, since they are dealing with human life. We are now adding an angle of financial insecurity, which can potentially bankrupt the doctor and his family.

One or two stray incidents across the country claiming a compensation of ₹1 or 2 crore against these gynaecologists in small towns is good enough to send shock waves among the medical community.

The media spotlight is bound to amplify the impact. In a very short time most gynaecologists taking care of pregnant ladies in small towns will move to big hospitals in cities where they are protected.

If the issue is not addressed soon, we can expect maternal mortality to double.

Get real
Our policymakers boast of India having 6 lakh doctors. What they have not realised is that nearly two lakh doctors, instead of seeking invaluable learning by the patient’s bedside, are busy mugging MCQs (multiple choice questions) for two to five years in Kerala or Kota in pursuit of one of those elusive PG seats.

As a result, junior doctors doing night duty in small towns simply do not exist. Specialists in small towns are handicapped with very little support from junior doctors, trained nurses and technicians.

In the early 1990s the medical profession in the US was reeling under the impact of astronomical compensation for malpractice.

As expected, malpractice insurance premium went up to three months of doctors’ salary. The doctors decided to stop conducting deliveries. As a result, the government had to airlift pregnant ladies during childbirth from small towns to bigger city centres. Obviously, it was unsustainable and risky.

So, several states in the US capped malpractice compensation at $ 250,000 (₹1.5 crore). This capping reduced malpractice suits significantly. Today, the US has one lawyer for every 300 people! No wonder, one in every seven doctors is sued there every year. India is not too far behind; Delhi has one advocate for every 300 citizens!

Change the law
Capping compensation is not new to Indian law. Government officers cannot be fined for more than 33 per cent of their basic salary. In the US and several European countries, capping the malpractice compensation is a norm.

Human life is precious. Leave alone ₹11 crore, even if the family is paid ₹1,000 crore it cannot compensate for the loss of life. The only question is: What can we afford?

Of course, medical malpractice deserves punishment. Doctors who have neglected the patient are punished through the Medical Council, which can remove their right to practice temporarily or permanently, and this is one of the worst punishments for a doctor. Added to that some financial compensation is definitely required.

However, if the compensation is going to ruin the doctor, his family and his future, we are not far away from the rule of Hammurabi.

As a country, we need to protect everyone’s life. But if we try to implement first-world regulatory structure with third-world infrastructure, we will be in trouble. We are a country short of one million doctors, two million nurses and three million beds.

With this scarcity, we should concentrate more on improving the infrastructure, creating the right regulatory framework to protect the life of the patients as well as an ideal working environment for the doctors. On this issue, governments’ mandate should be to cap the malpractice compensation.

Compensating the family by ₹2 crore instead of ₹20 lakh will not revive a lost life. But it can wreck the doctor’s family and close down small nursing homes in backward areas, putting the lives of thousands of people at risk.

Professional bodies such as the Indian Medical Association and Association of Healthcare Providers of India (AHPI) should write to the Minister of Health to request the Ministry of Law to cap the malpractice compensation.

The writer is founder and chairman, Narayana Health.

social obstetrics

Social obstetrics may be defined as the study of the interplay of social and environmental factors and human reproduction going back to the preconceptional or even premarital period. 

The social and environmental factors which influence human reproduction are many. 

Some examples include:

• age at marriage 
• child bearing
• child spacing
• family size 
• fertility patterns
• level of education
• economic status
• customs and beliefs
• role of women in society 

Social obstetrics has another dimension: the influence of these factors on the organization, delivery and utilization of obstetric services by the community. 

In other words, social obstetrics is concerned with the delivery of comprehensive maternity and child health care services including family planning so that they can be brought within the reach of the whole community.

Dietary Guidelines

Right nutritional behavior and dietary choices are needed to achieve dietary goals.
The following 15 dietary guidelines provide a broad framework for appropriate action.

1. Eat variety of foods to ensure a balanced diet.
2. Ensure provision of extra food and healthcare to pregnant and lactatingwomen.
3. Promote exclusive breastfeeding for six months and encourage breastfeeding till two years or as long as one can.
4. Feed home based semi solid foods to the infant after sixmonths.
5. Ensure adequate and appropriate diets for children and
adolescents both in health and sickness.
6.Eat plenty of vegetables and fruits.
7. Ensure moderate use of edible oils and animal foods and very less use of / butter/ vanaspati .
8.  Avoid overeating to prevent overweight and obesity.
9.Exercise regularly and be physically active to maintain ideal body weight
10. Restrict salt intake to minimum.
11. Ensure the use of safe and clean foods.
12. Adopt right pre-cooking processes and appropriate cooking methods.
13. Drink plenty of water and take beverages in moderation.
14. Minimize the use of processed foods rich in salt, sugar and fats.
15. Include micronutrient-rich foods in the diets of elderly people to enable them to be fit and active.

Dietary Goals

• Maintenance of a state of positive health and optimal performance in populations at large by maintaining ideal body-weight.

• Ensurement of adequate nutritional status for pregnant women and lactating mothers.

• Improvement of birth weights and promotion of growth of infants, children and adolescents to achieve their full genetic potential.

• Achievement of adequacy in all nutrients and prevention of deficiency diseases.

• Prevention of chronic diet-related disorders.

• Maintenance of the health of the elderly and increasing the life expectancy.

Current Diet and Nutrition Scenario

from: Dietary Guidelines for Indians (NIN)

Nurses day

Adolescent Stress Linked to Severe Adult Mental Illness, Mouse Study Suggests

Working with mice, Johns Hopkins researchers have established a link between elevated levels of a stress hormone in adolescence -- a critical time for brain development -- and genetic changes that, in young adulthood, cause severe mental illness in those predisposed to it.

"Genetic risk factors in these experiments were necessary, but not sufficient, to cause behaviors associated with mental illness in mice," Sawa says. "Only the addition of the external stressor -- in this case, excess cortisol related to social isolation -- was enough to bring about dramatic behavior changes."Sawa, director of the Johns Hopkins Schizophrenia Center, and his team set out to simulate social isolation associated with the difficult years of adolescents in human teens. They found that isolating healthy mice from other mice for three weeks during the equivalent of rodent adolescence had no effect on their behavior. But, when mice known to have a genetic predisposition to characteristics of mental illness were similarly isolated, they exhibited behaviors associated with mental illness, such as hyperactivity. They also failed to swim when put in a pool, an indirect correlate of human depression. When the isolated mice with genetic risk factors for mental illness were returned to group housing with other mice, they continued to exhibit these abnormal behaviors, a finding that suggests the effects of isolation lasted into the equivalent of adulthood.

The investigators not only found that the "mentally ill" mice had elevated levels of cortisol, known as the stress hormone because it's secreted in higher levels during the body's fight-or-flight response. They also found that these mice had significantly lower levels of the neurotransmitter dopamine in a specific region of the brain involved in higher brain function, such as emotional control and cognition. Changes in dopamine in the brains of patients with schizophrenia, depression and mood disorders have been suggested in clinical studies, but the mechanism for the clinical impact remains elusive.

To determine whether cortisol levels were influencing dopamine levels in the brain and adult behavioral patterns in the abnormal mice, the investigators gave them a compound called RU486, known to block cells from receiving cortisol. (The drug is commonly known as the "abortion pill.") All symptoms subsided. RU486 has also been studied in a clinical trial of people with difficult-to-treat psychotic depression, showing some benefits. "The mice swam longer, they were less hyper and their dopamine levels normalized," Sawa says.

To shed light on how and why the mice got better, Sawa and his team studied the gene tyrosine hydroxylase (Th) and found an epigenetic change, essentially the addition of a methyl group to one of the gene's DNA letters, limiting the gene's ability to do its job, which is to create an enzyme that regulates dopamine levels. Without a fully functioning Th, dopamine levels are abnormally low.

Scientists have long studied gene mutations, permanent DNA changes that can tweak the normal function of a particular gene. But epigenetic alterations do not change the actual letters of the DNA sequence. Instead, they add a chemical group like methyl that can affect the function of the DNA. These changes can be transient, whereas genetic mutations are permanent.

Sawa says the new study points to the need to think about better preventive care in teenagers who have mental illness in their families, including efforts to protect them from social stressors, such as neglect. Meanwhile, by understanding the cascade of events that occurs when cortisol levels are elevated, researchers may be able to develop new compounds to target tough-to-treat psychiatric disorders with fewer side effects than RU486 has.