Indian Journal of Medical Ethics

Not long ago the family physician held a special place both as a trusted friend and as a healer, specially endowed with almost God-like powers. Today, however, doctors in India feel that they are under siege. The attacks on them are oral, written and physical. The charges are criminal and civil. Allopathic doctors have become veritable punching bags, if we consider the frequent allegations hurled at them.

Doctors must contend with patients' great expectations, government red tape and the threat from other 'medicine men'. They must handle all this while conforming to their own personal values-a situation that produces much stress.

Most practitioners wish to serve society and alleviate suffering. They conduct themselves with dignity and are accorded respect as belonging to a special section of society. Unfortunately, the entire medical community is viewed with suspicion for the wrong-doings of a small minority.

Times have changed. Doctor shopping is on the rise. Before one doctor has had enough time to diagnose a condition, another is consulted. Patients demand instant, guaranteed results. The prevailing demand for 'the best' has led to more aggressive and expensive prescribing. Patients come to doctors' offices demanding specific treatments based on information from the internet. At the same time, we are expected to inform them of every possible side-effect of a drug down to the last detail.

Traditionally, the physician gave his own views on what should be done and the patient was expected to agree. The modern 'informed' view demands that a treatment's pros and cons are presented and the choice left to the patient. Indian patients probably want a combination of these, but what does that actually mean? And, in any case, how can one explain that the human body is not just a sum of its parts? And that the parts are not identical and don't react in a set pattern? It is also difficult to explain to patients that detailed answers to their problems cannot be given over the telephone.

Why are only doctors singled out and held responsible for inadvertent failures in spite of well-meaning efforts? An engineer, lawyer or other professional is rarely hauled up for a defect. Even in medicine in the event of adverse results, alternative practice goes largely untouched. Good communication, prior information and proper bedside manners do not necessarily prevent reproaches. In the event of a mishap, the doctor is treated like a common criminal. No one ever heard of doctors being sent to the lock-up in earlier days. Today it has reached a state that, if a patient dies, practitioners even consider asking for an anticipatory bail.

A doctor cannot really relax on holiday even if his patients are being looked after by another competent doctor. It does not absolve him of vicarious liability for what happens in the hospital. The Consumer Protection Act is a major cause of worry for physicians. Here again, it is usually the allopath who bears the brunt of these commandments. Patients complain even if nothing goes wrong. A man sued a doctor because he felt that a caesarean section was not indicated for his wife. It is a no-win situation. If things had gone wrong, the doctor would have been sued for not having performed one.

Society is quick to decide that a particular situation is caused by negligence. No one wants to understand or acknowledge the complexities of medical treatment, especially in a difficult case. Of course, no one condones a blatant act of commission or omission while discharging one's duty. However, this is rarely the case. Soon every undesirable result in a case will be presumed to be due to negligence, unless proved otherwise.

If the public believes that we are protected by the professional indemnity insurance policy, please remember that it is expensive and makes various unreasonable demands. Patients will not benefit from this atmosphere of fear among the medical profession. For example, an unaccompanied woman who approaches a doctor for a medical termination of pregnancy could be refused care as the doctor will fear possible legal complications if something goes wrong. Isn't the patient actually being denied her right?

Doctors are being physically attacked or kidnapped, hospitals are being damaged. Such actions could be sparked off by incidents such as the non-issuance of a death certificate. Doctors have been manhandled for not 'obliging' and have been forced to become fugitives till tempers cool. The physician has to bear such assaults more than other sections of society. Mob fury has crept into educational institutions and other establishments as well, but the person affected is usually the one in command. When doctors are attacked, the community does not even empathise. It is difficult for doctors to work whole-heartedly if they have this sword of Damocles dangling over their heads.

It is becoming less and less possible to fully abide by the Hippocratic oath as it exists today. Indian physicians are expected to follow certain principles and work in a set-up where their charges may not permit modernisation such as computerisation or an increase in facilities. Whereas a referral fee is acceptable in England and advertising one's services permitted in the USA, both are illegal for Indian allopaths.

Meeting the requirements of regulatory bodies and newer guidelines-biomedical waste, PNDT Act, etc-can be cumbersome. Surprise checks can cause great inconvenience besides violating confidentiality. Doctors must worry about potential health hazards such as HIV and hepatitis B infection in a set-up where they cannot always follow precautions as in the West.

Patients complain of long delays in doctors' waiting rooms. Doctors can be held up in an emergency or delayed in travel. Patient overload must be handled as well. Appointments may be over-booked with the expectation-justified-that some patients will not turn up. If appointments are spaced out, patients might have to wait months to see a doctor. In family practice a certain period of waiting is inevitable.

Investigations are necessary for diagnosis and also to prepare for surgery or a procedure. The gamut of tests has certainly increased, and some are asked for because doctors would like to play safe and avoid litigation. Some patients suspect that the tests are unnecessary. But if a test has not been asked for and treatment suffers, the patient will say that had a test been asked for it would have been done.

An increased awareness among patients also contributes to over-testing. How should the doctor respond to a clinically healthy, risk factor-free 40-year-old woman who asks, 'Doctor so you don't think I need a mammogram?' Doctors are also criticised for suggesting that a test should be carried out in a particular centre. Some routine tests could probably be undertaken at a laboratory or X-ray unit of the patient's choice. But often the interpretation of the test reports is crucial and this depends on the technician who reads them. While some tests are standardised, there could be a variation in others, depending on the centre where they are performed. It is for this reason that some hospitals make it mandatory to get tests done at a specified place.

Record-keeping requirements imposed by insurance companies and legal prerequisites can be extremely time-consuming and increase costs. While it is necessary to record what has been done, this information should not become more important than the treatment itself. When accountability becomes 'answerability' it can bog down a well-meaning practitioner.

Gifts from pharmaceutical companies do not translate into prescriptions for that particular product. It could be simple camaraderie, respite for the busy doctor and, in case of an occasional dinner programme, the opportunity to meet colleagues-a kind of perquisite to this daily-wage earner.

Are all allegations levelled at doctors baseless? Indeed, NO. There are problems which deserve to be addressed. If one is late in keeping appointments, a gentle apology can ease the tension. Busy doctors can employ assistants who explain the case or the procedure, in the vernacular if necessary. Giving patients the names and contacts of colleagues is a good way to ensure that they are well taken care of. The fee structure, particularly consulting fees, should be mentioned or displayed. Regarding other fees there may be variations, but patients deserve to be informed about the expected expenses to the extent possible.

To close, I will recount the following incident which illustrates the problem as seen by doctors. A crowd of visitors were sitting in the waiting room of a busy maternity home. The delivery took place and the gynaecologist heard a lot of noise in the corridor. The nurse came into the room and explained. 'Madam,' she said, 'All this while there were many relatives who kept asking me about the patient. As soon as I told them that a baby girl was born the crowd dispersed. I had to shout and call some of them back to give instructions and ask them to be around to be with the new mother.'

Jyoti Taskar,Gynaecologist, immediate past president, Indian Medical Association, Mumbai Branch. Pophale Nursing Home, Indian Mercantile Building, Madam Cama Road, Mumbai 400039, India