By Jay Desai
Doctors, once held in high esteem, are now often approached with scepticism or even disdain by Indian patients. The doctor-patient relationship in India is rapidly changing. One of the most important aspects of this evolution is an exponential increase in the number of medical negligence cases in recent years. This is likely to have a significant impact on the way medicine is practised in India.
This evolution is beneficial to an extent and will lead to improved accountability of doctors and hospitals and better documentation of the care provided. It will substantially decrease the instances of unethical and reckless provision of care. However, it is likely to lead to an increase in the practice of defensive medicine.
What is defensive medicine? The first definition came as early as in 1994, provided by the Office of Technology Assessment in the US. Defensive medicine can be in the form of excessive tests, procedures, or visits by doctors to primarily to reduce their exposure to legal liabilities. Or it can be in the form of avoidance of high-risk patients or procedures. A majority of the literature about defensive medicine comes from the US, where it is believed to be more prevalent than any other country in the world. This correlates with its very high rates of allegations of medical negligence. Several other countries have tried to study this phenomenon as well, including Spain, Israel, Japan, New Zealand, Mexico, Italy, the United Kingdom and the Netherlands.
The most commonly scrutinised aspect of defensive medicine is the rate of caesarean section in a practice, a hospital or a community. Some other examples include: the use of technology such as magnetic resonance imaging (MRI) and drug prescription patterns. There is little available data about the prevalence of the practice of defensive medicine in India. It is not uncommon in the urban areas based on anecdotal reports. However, the scenario is likely to worsen dramatically in coming years.
What is the impact of defensive medicine? The economic cost to the society is huge. The results of a recent national survey of orthopaedic surgeons in the US were published in a peer-reviewed medical journal last year. This article noted that the estimated cost of defensive medicine in the US for the speciality of orthopaedic surgery alone is 2 billion dollars annually. One can easily understand the cost to the individual patient from interventions such as excessive use of computed tomography (CT) scans with resultant exposure to harmful radiations.
So what would be the rationale to practice defensive medicine? Medicine is an imperfect science. The practice guidelines, which are usually, based on statistical evidence are often not definitive and change quickly. In the modern day and age, patients expect early diagnosis and perfect outcomes. Over-investigating or over-treating is perhaps a form of reassurance for doctors against a possible future court case. It is a safeguard against the element of uncertainty in medical practice. The motives for avoidance of high-risk patients and procedures do not need explanation.
It is time for those in decision-making positions in India to act. A plausible intervention is to mandate that all cases of unintended adverse outcomes be handled by arbitration and not allow any court cases. Arbitration instead of court intervention is likely to decrease the shame and fear on the part of the involved doctors and their subsequent defensive approach. Independent authorities would need to be formed additionally to monitor the proper delivery of healthcare and assure patient rights. The concept of ‘standard of care’ is often utilised when cases of medical negligence are being assessed. The standard of care translates to any intervention that is medically appropriate under the prevailing circumstances. Over time, the standard of care changes with the availability of newer technologies, medications and practice guidelines. It is also decided by the community where the patient is treated, whether urban or rural. The judiciary is ill-suited to decide complex cases with its limited understanding of the art and science of the practice of medicine. Independent monitoring authorities, with experts on board, would be more appropriate for deciding whether a doctor fell below the standard of care in a given case.
The aforementioned suggestions are quick fixes. There are issues that are more fundamental in nature and need to be addressed. The commoditisation of medicine over the years has reduced it to a low-level service industry. With a substantial hike in fees for medical education and a staggering increase in the number of private medical colleges, young doctors are forced to learn concepts such as return on investment instead of focusing on precepts of medical ethics or principle of altruism. The recent wave of privatisation of healthcare does not help either. Unfortunately, it is supported by the government unabashedly. In the mercenary attitude of the healthcare machinery lies the root of degeneration of this once noble profession. The trust in the doctor-patient relationship can be brought back if the business aspect of medicine is minimized. This can only be achieved if medical education and healthcare are provided free of charge, by the government and with the use of public funding.
(Jay Desai is a faculty member at University of Southern California Keck School of Medicine)