Medical Errors: How to Negotiate the Minefield?

Modern medicine today promises much. Advances in medical technology are enabling medical miracles and spawning specialization and subspecialization with a separate doctor for each condition. In an earlier era, the family physician took care of all from the young to the old and was a family friend in addition to being a doctor. There was one doctor for many patients. Today, there are many doctors for one patient. The consequence of these advances is increasing complexity and challenges in meeting the expectations, occasionally unrealistic, of patients. The efforts to cope with the exponential growth in medical information and to frequently upgrade skills can be stressful. Today, the physician has to continue running to keep standing in the same place. The doctor caring for a patient in the present environment works in a team. He depends on the accuracy and reliability of a battery of laboratory reports and the results of many sophisticated investigations where many players and devices enter the scene. Malfunction in any of the paraphernalia or a human error can occur due to lack of diligence, inadvertently or by chance (normal values are derived from probabilities). The drugs a doctor prescribes may turn out to be not of standard quality (NSQ) or spurious. There can be drug interactions with medicines prescribed by other specialists or practitioners of alternative systems of medicine. The corporate model of medical care has magnified the complexity manifold. In corporate hospitals, often administrators overtly or covertly influence treatment decisions, encroaching on the autonomy of doctors. Worse, the hospital administrator may dominate and dictate medical practices in some hospitals. There is a conflict between quality care, the doctor's domain, and financial interests, the administrator's benchmark for success.1 Willy-nilly, in case of any mishap, the blame falls on the treating doctor. While medicine remains an art, currently it has become the art of managing extreme complexity—and a challenge to what levels such complexity can be humanly mastered.2 To negotiate this minefield, Gawande recommends a measure that because of its simplicity will tend to be not taken seriously. It is a checklist. His book, "The Checklist Manifesto,"2 should be essential reading for all hospital administrators, and the National Accreditation Board for Hospitals and Healthcare Providers (NABH) should ensure that all their inspectors are familiar with this classic on patient safety. Despite our best efforts, errors occur. According to a review, around 10% of inpatients in hospitals experience an adverse event, mostly surgical cases, of which 7.4% can be lethal.3 A more recent review estimated that the adverse events among indoor patients ranged from 5.7 to 14.2%, of which 31 to 81% could have been prevented.4 These figures translate to a large global burden by way of health costs and quality of life. A study estimated that there are 421 million hospital admissions annually at the global level and around 42.7 million adverse events.5 The disability-adjusted life years (DALYs) lost every year due to medical errors are 23 million.5 While most doctors may intuitively think that disclosing medical errors to their patients will undermine their trust in them and also give them ground for litigation, research shows that patients expect and appreciate honesty from their doctors.6 Only 12% of medical errors lead to litigation.7 The Indian Legal Perspective on medical errors is fairly balanced. It strikes a careful balance between the autonomy of a doctor to make judgments and the rights of the patient to be dealt with due care and diligence.8 The consequences of medical errors under Indian law fall into either of the three categories" criminal liability, financial liability, or disciplinary action.8 Criminal liability is general in nature and not specifically for "medical errors." Section 304 A of the Indian Penal Code (IPC) deals with the death of a person by any rash or negligent act and can earn imprisonment up to 2 years. This section applies to death by rash driving and to death due to medical negligence. Short of death, two other provisions of IPC, Section 337 (for hurt) and Section 338 (causing grievous hurt), can also be applied to medical errors. Civil liability deals with monetary compensation awarded by the appropriate civil court or consumer court. Lok Adalats can also be approached for injuries resulting from medical errors during services provided by "public utility hospital and health services." Permanent Lok Adalats enjoy powers equivalent to those of civil courts for claims up to rupees one crore.8 Disciplinary actions against erring doctors fall in the purview of the Indian Medical Council (IMC) Professional Conduct, Etiquette and Ethics Regulations, 2002, made under the IMC Act, 1956. The State Medical Councils are also empowered under this Act to take disciplinary action. The punishment may entail the permanent removal or suspension of the practitioner. Too many litigations are not in the best interest of doctors, or, even patients. It leads to defensive medicine that not only raises the costs of treatments due to a battery of unnecessary investigations, some of which are likely to turn up false positives, leading to a "wild goose chase," but may also lead to hesitancy on the part of doctors to take "calculated risks" in an emergency. This may endanger an odd patient's life who would have otherwise benefited from a desperate intervention in a desperate situation. I started my career as an anesthesiologist, and for a few years in my service career, I worked as an ad hoc anesthesiologist before switching over to epidemiology and public health. Years after I had stopped working as an anesthesiologist, there were situations in remote service hospitals where some emergency surgeries had to be performed to save the life of a patient and the anesthesiologist was not available. I did volunteer on a couple of such occasions to step in, and fortunately, the outcomes were favorable. Looking back, now, with increasing distrust of doctors and litigations, I am sure that most in my position today would not take such "calculated risks" and I would not blame them. Rapport, trust, and transparency and involving the patient in decision-making in treatment options can prevent many litigations. The decision to take legal action against a doctor by a patient may not depend on the harm perse but is motivated by insensitive handling and poor doctor-patient communication.9 Patients sue doctors not medical errors. This point is driven home by Gladwell when he narrates a case of a patient with breast cancer that was not detected before it spread.10 The patient wanted to sue her internist for the delayed diagnosis. When informed that it was the radiologist who erred she remained adamant saying that she found the behavior of the internist rude and abrupt, ignoring her other symptoms, and did not behave with her humanely. The radiologist was more empathetic and treated her nicely. The take-home message is that to avoid litigations doctors should have competence, skills, diligence, and then some, that is, good communication skills, honesty, and transparency, earning the trust of the patient. Data availability statement Not Applicable. Author contribution AB was responsible for the concept, writing and final approval of the manuscript.