i solemnly pledge myself to consecrate my life to the service of humanity; i will give to my...
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I solemnly pledge myself to consecrate my life to the service of humanity;
I will give to my teachers the respect and gratitude which is their due;
I will practice my profession with conscience and dignity;
I will respect the secrets, which are confided in me, even after the patient has died;
I will maintain by all the means in my power, the honour of the noble traditions of the medical profession;
My colleagues will be my brothers;
I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patients;
I will maintain the utmost respect for human life from its beginning even under threat, and I will not use my medical knowledge contrary to the laws of humanity;
I will make these promises solemnly, freely and upon honour.
Functions of the Medical Council
……….
Exercise and maintain discipline in the practice of medicine with the assistance of its Medical Disciplinary Tribunal
Establish a code of practice for the medical profession on standards of professional conduct and medical ethics and monitor compliance with such a code
13.1-PRELIMINARY INVESTGATION BY COUNCIL “Subject to section18, the Council may investigate any complaint of -
-professional misconduct,
-Malpractice,
-Dishonesty or
-Negligence or
-A breach of the code of practiceagainst a registered person including a public officer in respect of whom it holds a delegated power.
COMPLAINT RECEIVED AT COUNCILCOMPLAINT RECEIVED AT COUNCIL
Possible fault on the part of M.P •Medical practitioner not concerned
•No obvious fault of doctor
Council informed
Set aside
Complainant informed
Preliminary Investigation (I.C)(Section 13)
Notify Doctor of the nature of the complaint
Summon and hear doctor +/-complainant
Summon and hear witness
Call for documents
Judge in chambers(if refusal by a person to give evidence or communicate document on ground of confidentiality
Evidence of fault of doctor No prima facie evidence of fault of doctor
Set aside
Inform doctor & complainant
Section 14(1)
•Breach of code of practice
•Act of fraud, dishonesty, negligence
•Act of professional misconduct or malpractice
•Any other act likely to bring the medical profession into disrepute
Section 14(2)
•Prima facie evidence of negligence, incompetence or grave misconduct
•Public interest requires that the registered person should instantly cease to practice medicine
Charges drafted
MDT
Report to Council not >14 days after completion of proceedings
Cont/d
Suspend for not > 6
mths
Private Public officer (+delegation of power)
Report to PSC for decision on suspension
Disciplinary Proceedings
•Show cause
•Warning/severe warning
Inform doctor & complainantD Proceedings cont/d
17(3)
•Charges proven
•Aggravating/alleviating circumstance
Charges not proven
17(4)a
Public Officer (+delegated power)
17(4) b
Every Other Case
•Warning/severe warning
•Reprimand/severe reprimand
•Suspension from medical practice for not>12 months
•Removal of name from register
Report to PSC
Set Aside
Inform doctor & complainant
17(5)
Punishment (Dismissal or Retirement) by PSC
•Decision under 17(4) or (5): inform doctor within 14 days
Removal of name from the Register
COUNCIL
Section 18
CONVICTION OF REGISTERED PERSON
Show Cause
Section 19
Summary Proceedings (Minor Fault)
Show Cause
Warning/Severe Warning
Punishment as per 17(4) (b)
Preliminary Investigation – Evidence based -Accepted practice
- Literature
- Expert opinion
- Written explanations/interview of defendant doctor
- Interview of complainant party
- Documents: patient file, Investigations
Deliberations at Council - Views of full board
- Composition of Council
-Nominated members (non-medical)
-1 Rep. each from PMO,MOH,SLO
-vote ± casting vote of Chairman
Sanction- Show cause
Judicial review – aggrieved parties.
-Doctors :public/private
:General practitioner/specialist
•Presided by Judge + 2 senior medical practitioners
•Evidence based
•Hearing of parties + witnesses
•Defence lawyers
Show cause
Doctor at fault
Sanction
MDT
COUNCIL
Deliberations + determination
Charge provenCharge not proven
MOH/PSC (Public officer)
Show cause
Sanction
Set aside
Parties informed
No fault of doctor
Set aside
Doctor+complainant informed
Parties Informed
• Malpractice
Medical Council Act: “includes a failure to exercise due professional skill or care, which results in injury to or loss of life of a person”.
•Medical Negligence
Medical Council Act: “includes failure on the part of a registered person to exercise the proper and timely care expected from a registered person”.
Act of Omission
Act of Commission
To succeed in a claim for negligence, a plaintiff patient must prove, on a balance of probabilities,
The following:
The defendant doctor owed him a duty of care
The defendant doctor breached that duty by failing to exercise the necessary level of care
Harm and injury was caused by that breach and
He suffered damages which was not too remote ( i.e. it was foreseeable by the doctor)
“But for” test for proving causation.
“ A doctor is not negligent if he has conformed with responsible professional practices”.
A G.P must meet the standards of a competent G.P
A Consultant Gynaecologist must meet the standard of a competent consultant in that speciality
A common practice might be declared not to be rightly accepted: (common professional practices might be wrong)
The judiciary find it acceptable to challenge medical opinion, but only when the latter has no rational basis.
There may be circumstances where the provision of information will be “ so obviously necessary to an informed choice that no prudent medical men would fail to make it”.
“the facts speak for themselves”
can help a patient in situations where he cannot specify what exactly caused the injury.
the doctor has to establish his innocence, rather than the patient having to prove the doctor’s guilt.
“take your victim as you find him”
the doctor is liable for all damages even if the damages are more serious because of the patient’s pre-existing illness or condition.
Failure in regard to the contractual obligations by a doctor when he agreed to treat a person.
Burden of proving negligence and damage on a balance of probabilities lies with the patient plaintiff.
A medical accident can be compensated but not the natural development of an illness.
Claims for compensation may be based on:
- the tort of negligence
- tresspass to the person and battery; or
- breach of contract
Arises in case of death or serious injury to a patient.
The degree of negligence must be so grave as to go beyond a matter of compensation.
The doctor may be prosecuted by police or charged in a criminal court for culpable homicide.
Concurrent negligence by the patient and the doctor, resulting in delayed recovery or harm to the patient.
Defence for the doctor in civil cases.
Burden of proof on doctor.
Liability of the master (employer) inspite of absence of blame worthy conduct on his part.
Negligence
Employer responsible for negligent acts of his servants.
Within the scope of his employment/range of services.
Tort of occupier’s liability (e.g. visitor injured on hospital grounds).
The assailant is responsible for all the consequences of his assault – the immediate and remote – which link the injury to death.
! Breach in continuity of events by entirely new and unexpected happening (not reasonably foreseeable).
Doctor
Non- medical staff Institution (Employer)
Patient
: :Time factor, workload (no. of patients)
Fatigue – lack of concentration
Experience / competence
Referral to specialists (specialized centres)
Medical certificate
Easy money – illegal abortions
Doctor
Financial
Monitoring &Follow up
Other Doctors
Reports-Histopath,X-ray
PatientWithholding information
Not following doctors’instruction
CONTRIBUTORY NEGLIGENCE
Institution (Employer) Vicarious Responsibility
Understaffing NursingX-Monitoring
Others X-Execution of doctor’s orders
Equipment Unavailability/Faulty
Essential/Emergency drugs
Non Medical Staff Laboratory technician-lab. Errors, delays
Professional relationship between colleagues
Making disparaging comments about colleagues( in front of other colleagues, staff, patient party).
Taking over a patient under care of another colleague without prior information to the latter.
Proper referral of patients to other colleagues.
Sharing of medical knowledge/new technologies + assistance to colleagues.
“Overcharging” of patients.
During surgery/anesthesia, e.g. monitoring
Esp. after surgery/intervention
Instructions/orders not executed properly
Availability of treating doctor Postoperative complications
Anaphylactic shock
Handing over to other colleagues in case of unavailability
Deficiencies in nursing care-monitoring of head injured patient
-delay in executing instructions
Patient smelling alcohol: May mask certain signs in head-injured patient
Wrongly tagging as alcoholic without excluding other diagnosis
Follow up, monitoring + management of critically ill-patient especially in ICU
Too many patients in casualty
Rationale for request
Not seeing results of URGENT INVESTIGATIONS
Unnecessary delay in requesting special investigations, e.g. CT scan
Use of decorative letter head
Over description of doctor’s
qualities /competence (publicity)
Handwriting – wrong dispensing
Explaining to patient
Perception of indiscriminate prescription /
over prescription of certain drugs (e.g.
steroids) in chikungunya
Gastric perforation (in patient of chikungunya)
Death certificate issue
Without examining corpse
Cause of death (true?)
Use of abbreviations
Time of death
Requirements of Medical Council Act
Date of examination
Full name and address of the patient
Registered name and address of the RMP
Signature of the RMP
Cases: Backdating and postdating
diagnosis (?confidentiality)
Not confirming identity of patient (patient in police custody)
e.g.. Blood transfusion form –Identity of patient
- Degree of urgency/when needed
- X-match/type & screening
- type of products and quantity
Doctor-Doctor
Patient Non Medical Staff
Scanty/ no clinical notes
Name of doctor
Date and time of examination, diagnosis/D.D
Pre operative status
Treatment/Operation notes
Progress
Investigations/Monitoring
Handwriting-wrong dispensing
Use of Abbreviations (CST,ISQ, ADS)
1. Believe your monitors!
2. Record keeping
3. Surgical team agreeing as to what occured
(Avoid rushing to condemn)
4. Communicate with patient before and after
Four most frequent themes in case of a bad outcome:
“If it isn’t written, it wasn’t done”
Flow Chest ( common surgical accidents leading to Medical malpractice Suits
Blood Transfusion Mistakes
Wrong Patient Paralysis from Splints
Medical
PractitionerSurgery on wrong Digits
Tight Plaster Casts
Retained Objects
Removal of Wrong Organ
Surgical Errors (e.g. ligation of ducts)
Anaesthetic Mishaps
Failure to X-ray Fractures
Wrong Side of the Body
Good-Proper-Adequate……?
Questioning-Listening-Responding-ExplainingPrecautions to comply with:
Disclose information only to the proper person or authority
Preserve confidences as far as possible (avoid idle conversation about patients, use “aliases”)
Do not disclose beyond what is required by the law and the situation
Document in patient’s record the reasons for and circumstances of the disclosure.
Situations where it is ethically and legally required to reveal information:
When the patient consents
To medical colleagues
As a statutory duty (Re: Infectious diseases)
As information to relatives
In the interest of research projects
In disclosure to court
In the discovery of documents in court proceedings
In the public’s interest
INFORMED CONSENT1 (BRAND)
Benefits of treatment
Risks of treatment
Alternatives (other treatment options)
No treatment (risks of)
Documentation + signature(patient, doctor, independent witness)
Material Risk The “Prudent Patient” Test Therapeutic PriviledgeBattery/Tresspass
INFORMED CONSENT2 based on information about:
The name of the operation
The nature of the proposed treatment
What the operation involves
The potential complications
The special precautions required postoperatively
The limitations of treatment
The success rate of the operation
How the patient will feel after treatment
What happens on admission
Respect for patient’s autonomy (self determination)
Non-maleficence (the duty to do no harm)
Beneficence (contribute to patient’s welfare).
Justice (equitable distribution of benefits and burden).
Fidelity (truthfulness and medical confidentiality).
Veracity (honesty).
Concerned with the conventional laws and customs of courtesy which are generally followed between members of the same profession.
A doctor should behave with his colleagues as he would like to have them behave with him.
Concerned with moral principles for members of the medical profession in their dealings with each other, their patients, and the state.
AIM: to honour and maintain the noble traditions of the medical profession
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