Wednesday, January 21, 2009

Responding to Medical Mistakes in India

For anyone interested in (a) India and (b) medical ethics, (c) the Indian Journal of Medical Ethics (IJME), which is available online, is the key resource.

During my recent stay in Mumbai (I'm in Bhopal now) I met with Sandhya Srinivasan, the executive editor. I learned that IJME was born out of activism. In 1992 a group of reform-minded physicians contested the Maharashtra state medical council election on a platform of "ethical medical practice." The slate lost badly. But the reformers created a newsletter for discussion of ethical issues and promotion of ethical practice. Over time the newsletter became the IJME.

I am especially interested in how the interplay of modernization and tradition in Indian medicine affects ethical norms. By U.S. standards Indian physicians are on a pedestal. I was told that many of the poor see the doctor as "a God on earth." But at the same time western values embodied in concepts like informed consent, physician-patient collaboration, and open acknowledgment of medical mistakes are increasingly part of public discourse.

What happens when "physician as God on earth" meets "physician as collaborator"? The most recent issue of IJME provides a window onto this question.

Dr. Ashok Sinha, a private practitioner in Agartala, the capital of Tripura (a small northeastern state bordering on Bangladesh) discusses - in thoughtful and personal terms - how to respond to poor practice on the part of colleagues. Here are the first two paragraphs of his engaging commentary:
"One of the major ethical issues that I face very often in my practice is whether to criticise my colleagues or not. Complaints, criticism and condemnation lead to terrible consequences and never help anyone, they say. I am told that my colleagues are to be treated like my siblings and I should never criticise them in front of patients.

That seems logical enough. We may or may not agree with a particular diagnosis offered by fellow physicians, and it is not necessary that either of us would be right every time. But to criticise him or her in front of the patient would degrade the whole medical community. Even the patient would be in doubt about whom to trust. Moreover, very often this criticism is fuelled by competitive one-upmanship. Rather than bettering our performance to get ahead, we used the tactic of putting the other fellow down..."
Dr. Sinha reports that "sometimes I spoke out and made myself unpopular, and sometimes I did not, and hated myself for it." But his dominant ethical perspective is that "while we must have loyalty to the profession and the medical community, what about loyalty to patients?"

Dr. Sinha's discussion is followed by two commentaries. Ann Sommerville, head of ethics at the British Medical Association, argues that "in case individual integrity is not enough, doctors also have a duty to take action if they witness evidence of colleagues failing...lessons should be learned, future errors avoided and natural justice dispensed to patients who have been inadvertently harmed." Prabha Chandra, Professor of Psychiatry at the National Institute of Mental Health and Neuro Sciences in Bangalore, concurs. His emphasis, however, is on the need for a practical learning curve regarding how to talk with physicians and patients about mistakes.

The trio of articles strike me as precisely on target. The broad values of honesty with patients and professional responsibility for assessment of practice and self-regulation, do not appear to be culture-bound or limited in their relevance to the west. But values require practical implementation. There is currently very little teaching of medical ethics at medical schools in India, and professional societies do not have strong traditions of self-regulation. I expect the medical community to endorse Dr. Sinha's framework of values, but as Dr. Chandra points out, there is substantial research and skill-development to be done to put that framework into action.


Anonymous said...

I thought you might me interested in this magazine feature:;-The-outsourcing-of-clinical-trials_nw3213.html

Jim Sabin said...

Dear Anonymous -

Thank you for this link. When I was in Mumbai in January I had the privilige of meeting with Sandhya Srinivasan, the author. I may do a post of my own based on the story.



Unknown said...

Everyday, we hear stories about patients being given the wrong drug, siblings getting a drug meant for someone else, children getting the wrong dose, spouses getting drugs that they are allergic to, friends taking two drugs that interact with each other and acquaintances taking the drug in the wrong way. All of these people involved in it go through tremendous amount of personal pain and expense because of preventable and needless medication mistakes. This is a sad reality, but a reality nonetheless. Preventing medication errors and improving efficiency should be the main focus of the healthcare reform plan. Not only will reducing medication errors improve the quality of patient care it will also provide a significant cost savings to our nation. For more information visit Clinical Negligence .

Jim Sabin said...

Hello John

I agree that preventing medical errors and increasing medical efficiency should be the central focus of health reform. And medication errors are a significant problem in health care.

I see that you are associated with what appears to be a malpractice litigation enterprise in the UK. The situation in the UK and India may be different, but in the US the last thing we need is more litigation. People who are injured by medical errors should obviously be compensated for their losses. And negligent clinicians and hospitals should be disciplined. But in my own litigation-happy country we know that the vast majority of genuine examples of malpractice never come to litigation and the vast majority of litigation lacks merit.

Drug errors are especially amendable to correction through improved systems, especially electronic prescribing, bar codes for products in hospitals, and the like. I know from my own experience how vulnerable we all are to potentially preventable human error.

Thank you for your comment, and for giving an opportunity to think about the role of litigation in different societies. If we in the US could reduce our own over-litigated system by exporting litigation capacity to societies in which injured parties are under-protected, there would be overall global improvement!