Lamhe ne khata ki thi, sadiyon ne saza paayi

An activist judge on the State Consumer Forum of Rajasthan, has single handed 'revolutionized' and 'up graded' the patient treatment in private hospitals of Jaipur by his pronouncements in recent cases.

He has forced the care providers to practice law while practicing medicine, at a huge cost to the patients.

The learned judge ruled that every act of medical intervention must be supported by 'legally' acceptable evidence. Statement under oath by a physician, alone will not do. It must be supported by documentary evidence. In an ICU or in case of seriously ill patient, on average, about 250 interventions are done every day. Every one of them, the learned judge rules, must be explicitly documented. 'What is not documented is not done.' The doctors who prescribe, the nurses and technicians and others who execute these orders, must, individually, document them. It must be duly dated, timed and signed.

The record must be preserved and stored for at least five years or in certain cases for over 18 years. In a 150 bed hospital where about 20 thousand patients are admitted every year, 1 lakh files, each containing on average 100 pages (100 lakh) have to be preserved and stored. Besides, to take care of disappearance of any vital paper, each page must be scanned and stored on cloud. Detailed summary of a case is not acceptable. The human and monetary resources required for it had to be mobilized.

The judge also ruled that nothing that is purported to be done on a patient, if not supported by legally executed 'informed consent', will constitute negligence. The learned judge says 'There should be proof that patient was counseled in the language he or she understands. The patient is illiterate or lay and is not expected to understand any medical terms used in the consent taking process.'

The judge rejected all the consents taken in the patient's language in a case on the ground that they had medical terminology used in the consent. He even ruled that all the consents taken were to protect the doctor and that they constituted virtually a license to do harm. As a result, the doctors do not touch an emergency case (where risk of serious complications is high) unless a detailed high risk consent is signed by the attendants and witnessed by others and the whole process of counseling is video graphed and preserved for production before the court. The resources required to do the same as a routine had to be provided.

The learned judge had ruled that not referring a patient to an organ specialist, for any complaint pertaining to a specific organ, is negligence. As a result, in a multidisciplinary hospital, on average a dozen specialists are required to treat a patient. No one likes to take a risk. It's legally required. Physicians must practice law.

The learned judge had also ruled that not doing an investigation or a test, indicated in a medical text book, or now freely available medical literature, is deficiency of service and negligence. No investigation is unnecessary anymore. The clinician has to have a proof that a particular condition was ruled out, that is negative evidence.

Evidence based medicine!. Test reports are the only evidence acceptable in the court. However senior, or experienced a specialist may be, his subjective opinion based on experience is no more legally acceptable. There must be supportive evidence. Vendors, the Labs, and capital-intensive- investigating-facilities, are glad to provide the world class facilities. The patient is provided the benefit of all the sophisticated investigations of highest grade available in the market. A paying patient, it is enjoined, is legally entitled to avail them. A poor patient has to submit to the same as it has become a legal norm.

The learned judge has also ruled that in ICU, patient's attendants should be provided free access to the patient to enable them to assess the patient's condition personally. It is further asserted, that as what is done to the patient behind the closed doors, is not known to the attendants, to be transparent, the attendants should be informed about every treatment intervention.

The fact that every major intervention in ICU is done after a written consent and that every drug prescription is provided and procured by the attendants waiting outside, is not considered transparent enough. The briefing by the visiting consultant has to be recorded by videography and preserved for perusal of the court. The entry in the patient record that attendants were apprised of the patient's condition and prognosis, is not acceptable in the absence of a proof.

In a private corporate set up the reimbursement model for payment is fee-for-service model. It is activity based payment model. Patient has to pay for every activity performed (service provided) on him. All service-products are priced. The legal rights of a patient, to have everything as per the legal requirement , suits the vendors. They are glad to cater to a demanding client.

The activist Judge has single handed forced the hospitals to provide 'highest grade' of legally acceptable evidence based medicare. The marketing managers of the hospital, 'as risk management', have to strategize availability of resources to underwrite lakhs and crores being awarded against them. Hospital revenue is from the patients. Hospital managers have to raise the revenue to survive.

The whole exercise may be of benefit to 1 percent of the patients that go to the court. For the rest it is a costly venture without any medical benefit. The whole working of the hospitals have been thrown into disarray. For the medical professionals, working in hospitals has become a tremendous stress. CPA is a hidden 'landmine' under patient bed. They have to spend more time practicing legal requirements to escape CPA than in treating a case. For patients too,the whole environment of distrust in doctors working in a private hospital has made the patients' hospital stay and treatment a torture.

Lamhe ne khata ki thi, sdiyon ne saza paayi

Written By: Dr. ShriGopal Kabra
MBBS, LLB, MSc, MS(Anatomy), MS(Surgery)
15, Vijaya Nagar, D-block, Mlaviya Nagar, Jaipur-302017
Ph no: 8003516198