MEDICOLEGAL ASPECTS IN OPHTHALMOLOGY

1. Ethics Unethics MEDICOLEGAL ASPECTS IN OPHTHALMOLOGY Dr. S. C. Batalia Batalia Eye Hospital Dr. Batalia Road, Jabalpur.

2. INTRODUCTION • Gone are the days when doctors were considered next to GOD. There was a general belief that he is LIFE Savior. • BUT NOW A DAYS With changed circumstances the doctors are given suspicious look. Inspite of the thorough knowledge • Specialization in the subject and with the best efforts invariably has to undergo many allegations. • Doctors should always accept cases only in which he has mastered. • A medical council registered doctor is not allowed to undertake any other business or profession.

3. IMPORTANCE OF INFORMED CONSENT • CARRYING OUT A SURGERY without informed consent would result in criminal liability as well as civil liability for paying compensation. • Obtain written consent for any procedure that carries risks, hazards, complications, or that has an alternative surgical procedure; determine what reasonable prudent patient would want to know about proposed procedure; if procedure refused, document informed refusal with supporting evidence, and KEEP a copy as evidence and data that support decision to perform procedure; documentation that you “discussed with patient per usual customary practice”, what you discussed.

4. COMMUNICATING WITH PATIENTS Use lay language, not medical terms (particularly for informed consent); do not criticize previous physician’s actions; maintain user-friendly telephone system; make sure patients have emergency access to physician; ensure access for those with language or physical barriers; return all calls

5. MEDICAL RECORD Acts as “number one” witness in litigation; contains documentation of examination, information used to make diagnosis and treatment plan, and results of continuing treatment; records should be as thorough as possible; note and date any changes to chart and reason for change

6. Endophthalmitis occurs in best of hands in best of set ups. Only people who do not get endophthalmitis are those who do not operate.

7. INTRA-OCULAR INFECTION Intra-ocular infection has always brought disrepute to the ophthalmologist and this problem is not only rampant at eye-camps but also in hospitals, which include the five star ones. Only surgeon who does not have endophthalmitis is the one who does not operate. The problem is general and it is not the surgeon who is to be blamed although he is responsible for surgery. Despite the best possible care, mishaps cannot always be avoided because the error in one link of the entire chain may sometimes result in a disaster.

8. IF YOU HAVE A MISFORTUNE OF INFECTION THEN HOW TO SAVE YOURSELF ? • Record all findings including vision-including projection of rays, intraocular pressure, status of cornea, anterior chamber reaction, pupillary reaction, details of iris, IOL (if present) and fundus. Get B-Scan ultrasound done. • Record them daily and keep a copy with you. • Do not do telephonic treatment. eg. if patient calls up in the night and complains of pain, redness, watering and if you tell him to continue or add steroid drops, then this is asking for a disaster. That means that instead of giving telephonic treatment tell the patient to go to nearby ophthalmologist available and show to him.

9. IF YOU HAVE A MISFORTUNE OF INFECTION THEN HOW TO SAVE YOURSELF ? • Patient who is on treatment for endophthalmitis, see him daily and always write on the prescription to report SOS. If patient is from far flung area write on his card or prescription slip that in case of any pain or redness or decreased vision or unusual symptoms report to nearest ophthalmologist and mention “do not ignore.” • Even at the cost of … please document, document & document. • When in doubt seek peer review, refer to retinal surgeon or hospital. • Involve multiple people or hospitals to safeguard you. • Greatest malpractice risk associated with endophthalmitis- Analysis of claims show that liability arises from a delay in diagnosis or treatment, including a delay in referring the patient to a vitreo-retinal specialist.

10. A Doctor is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art. It is also held that in the realm of diagnosis and treatment there is ample scope for genuine difference of opinion and a doctor is not negligent merely because his conclusion differs from that of other professional men. It was also made clear that the true test for establishing negligence in diagnosis or treatment on the part of a doctor is whether he has been proved to be guilty of such failure as no doctor of ordinary skill would be guilty of if acting with ordinary care. Chief Justice of India Bench

11. After laying down the law, the learned Chief Justice Shri Lahoti opined that in cases of criminal negligence where a private complaint of negligence against a doctor is filed and before the investigating officer proceeds against the doctor accused of rash and negligent act, the investigating officer must obtain an independent and competent medical opinion preferably from a doctor in Government service, qualified in that branch of medical practice. Such a doctor is expected to give an impartial and unbiased opinion applying the primary test to the facts collected in the course of investigation. Hon'ble Chief Justice suggested that some statutory rules and statutory instructions incorporating certain guidelines should be issued by the Government of India or the State Government in consultation with the Medical Council of India in this regard.

13. DEFINITION OF ETHICS Medical ethics is an area that has particular interest for the general public and as well as the medical practioner, and issues concerning medical ethics seem to be constantly in head lines. English lexicons trace it to the Sanskrit word “Swadha” which briefly connotes a sense of self respect that as a mere custom denies you the right to do anything wrong.

19. Ethics Unethics it is of utmost importance to remain within the accepted norms. With the growth of population, the size of cities number of doctors and the specialty in our subject has increased. Besides the expenditure as capitation fee for admission in Medical college and enormous cost of ophthalmic instruments to equip a new eye clinic one would definitely like to recover the cost at the earliest by all means.

20. WHERE TO BALANCE : The Technology and machine dependency is another factor influencing our ethics. In the company of our gadgets we become machine like and behave machine like. The tension of very high investment and competition and high bank installments compel us to change our attitude to the patients sitting across the paper. We become market driven forces and accept so many unethical practices as normal.

21. Where to Balance : How the Ethics play role in technologies let me take the specific causes in points (No individuals, Organizations or Institutions are Implied please excuse) The mostly widely quoted technology to hit the market is the use of Phaco in cataract surgery. Wide publicity has given the patients a feeling that this is the ultimate laser cataract surgery. False premature claims have been made not only in the press and media but putting big hoardings Waveform Phaco, Cold Phaco, ICE Phaco better than Cold, Micro coaxial phaco. Cataract removal in 30 seconds. Similar gimmicks keep appearing to project oneself as great surgeon and researcher.

22. Where to Balance : How the Ethics play role in technologies let me take the specific causes in points (No individuals, Organizations or Institutions are Implied please excuse) Pain Less Suture Less NO INCISION Cataract Surgery

23. Where to Balance How the Ethics play role in technologies let me take the specific causes in points (No individuals, Organizations or Institutions are Implied please excuse) • With the introduction of Lasik surgery there has been an outburst of advertising in the lay press by projecting the names of the surgeon in place of hospital. Patient awareness of the different procedures and their benefits and limitations are often flawed. One doctor says that he doing Zyoptix and the other doctor is doing LASIK. It is well known to all of us that lasik is name of the operation may be by wavefront, fematosecond or by any costly laser machine.

24. NEW CLINIC OR HOSPITAL It is admitted that the people have the right to know not only the opening of new clinic or hospital but the development of latest equipments and new operations & researches. For this purpose press conference can be organized.

25. Dr. P. N. Nagpal says :- • The media is already ridiculing the medical men for greed & neglect. The phenomena of fall of prestige of this so called “Noble Profession” needs to be explored and investigated. Are we loosing the ethics of this profession? Are we getting more commercial & business like? Are we playing with the Hippocrates oath? • He further quotes Ethics the science of morals are a very must for every profession and infact for the smooth running. Unfortunately, ethics as a subject has no definition and no discipline. Ethics also tend to differ with time, place & culture.

26. COMMUNICATION TO THE PUBLIC Communication with the public must be accurate. They must not convey false, untrue, deceptive or misleading information through statements, testimonials, photographs or by means particularly through the news media & PAID NEWS. Communication must not misrepresent ophthalmologist’s credentials, training, experience or ability, and must not claim of superiority

27. Some people work on the hypothesis that there is nothing ethical or unethical, only thinking makes it so. Also, it will be wrong to presume that whatever is not illegal is ethical, since there is a wide gap between ethical and lawful activities. Every unethical practice by any member of profession / society will harm the already fading reputation of the medical profession.

28. At one time known as “Healing Physicians” we are slowly converting into commercial corporate with specialties, doctor, opticians & pharma as partners. • We have guided missiles but misguided men • Ethical practice is decided by one thing and only one thing “Good of the patient and community”

29. GOLDEN RULES • To reduce medico-legal problems for ourselves, it is important to practise the Golden Rule in our professional life: • Do not do to your colleagues what you do not wish them to do to you • Avoid cheeky remarks and criticisms. • Recognise that complications do occur even in the best of hands. "The only surgeons who does not have complications is the surgeon who does not do any surgery. • Do not say to the patient that the best person to do this kind of surgery is Dr so-and-so.

30. GOLDEN RULES • Be demonstrably true in all respects. • Not be misleading vulgar or sensational • Maintain the decorum and dignity of the profession • Not contain any testimonial or endorsement of clinical skills. • Not claim that one doctor is superior to others nor contain endorsements for any particular doctor. • Avoid aggressive forms of competitive persuasion, such as those that prevail in commerce and industry.

31. Thank you