Dr. Satish Tiwari lists the ABCs of medicolegal awareness for practising doctors along with dos and don'ts for doctors that will help prevent medical negligence cases. 

The practice of medicine has evolved from art (in ancient days) to medical science and then subsequently with technical advances to commercialisation in the present era. Urbanisation and globalisation have resulted in newer and newer gadgets, instruments, facilities etc. The entry of insurance companies and their cashless schemes have increased the cost of medical treatments.

Government schemes like Ayushman Bharat and others have added fuel to the fire of deteriorating doctor-patient relationships. Every relationship is a dynamic process and the doctor-patient relationship is no different. The soaring expectation of patients/relatives has increased over time and this has led to increased accountability, responsibility/liability on doctors and hospitals.

Dos and don'ts for medical practitioners

Patients' perceptions are changing and the doctors' status has come down. The continued erosion of faith, belief, trust and the relationship between stakeholders has resulted in increasing medicolegal disputes and court cases. In order to prevent or minimise litigations, doctors should follow some dos and don’ts in their practice.

1. Accept the evolving changes in the practice of medicine. Attend the cases properly, listen carefully to history (ask and record the history of any allergy) and examine the patient carefully. If examined hurriedly, ask to come again for review. Do have a differential diagnosis.
2. Behaviour with the patient and relatives should be compassionate, sensitive and humane. Don’t be overconfident. Don’t over-react. Be sensible and professional. Be a patient-friendly doctor. Be empathetic towards the patient. Avoid confrontation and don’t meet anger with anger. Remember there can be difficult patients. Show genuine concern and establish a good rapport. Don’t behave in a rough, rude or inhuman manner.
3. Consent (informed and valid) should be taken after explaining the various facts and circumstances. Don’t exceed the consent. If the patient is not willing for any treatment; record negative consent. Communication skills shall be used while dealing with patients or relatives. Be a patient listener.
4. Document the communications, information given, investigations, complications and the treatment protocols followed. Documents are the property of the hospital. Maintain confidentiality of the patient’s information and details. The discharge card should be patient-friendly. Give proper instructions and follow-up advice. Remember documents can be ‘friends or foes’.
5. Expertise, efficiency, the standard of treatments must be followed diligently/meticulously. Explain and give proper instructions. Remember there can be a difference or cleavage of opinion (Bolam’s principle) among medical practitioners.
6. Finances, bills must be explained at the beginning of treatment and subsequently during the continued indoor/outdoor treatment. Don’t avoid communicating with relatives.
7. Give guarded prognosis especially in critical cases. Guarantee for ‘care and not cure’. Please remember there can be unexpected outcomes. Don’t claim that you are the best; since it increases your responsibility/liability.
8. Have properly and adequately trained hospital staff. If staff is untrained it results in vicarious liability. Hence, delegate the duties or powers to equally competent and qualified juniors. Individually we perform, collectively we excel.
9. Insurance of the hospital (error and omission policy), instruments must be taken. In the present era, we should have adequate professional indemnity from a reliable company.
10. Juniors and other staff must also communicate/behave properly with the patients, relatives and amongst themselves.
11. Knowledge should be updated regularly by reading the latest books/journals or attending the CMEs, workshops, conferences etc. Be a CME (Continued Medical Education) doctor and not a CMRE (Company Medical Representative Educated) doctor.
12. Latest instruments must be available in your setup as per the scope and spectrum of your practice. The facilities or treatments claimed or displayed must be available in the hospital.
13. Medico-legal associations/groups should be joined so as to have updated awareness about various laws and legislations related to practice.
14. No Manipulations should be done in documentation, case records/papers etc. Write correct notes, dates and times in the documents. Don’t issue false or bogus certificates including immunisation certificates.
15. Opinion (second) must be taken especially in rare and complicated/serious cases. Take the opinion/help of the experts in the field. Avoid undue/unjust criticism of colleagues. Avoid medical jousting.
16. Professionalism and ethics should be followed in practice. Human touch is still important and relevant even in the modern era. Our aim should be: Never do harm to anyone. Display or write only the degrees recognised by the medical councils. Don’t bring disrepute to the profession. Do group practice. Have a multi-disciplinary approach.
17. Qualifications, skills must not be exceeded as per the directions in various case laws. Avoid irrational drugs or drug combinations. Avoid shotgun therapy.
18. Records must be maintained for the periods as per the National Medical Commission (or MCI) guidelines. Record if the instructions or advice are not followed by the patients or relatives. Record the deficiency, negligence on part of the patient/relatives. Don’t fabricate the records or documents.
19. Selection of patients, drugs, investigations and treatment are the rights of the doctors. Avoid cut-practice or referral fees.
20. To err is human. An error of judgment may not be negligence. But, try to avoid errors in diagnosis/treatment. Medication errors are frequent and common. Foresee the complications and refer at proper time. Convince the relatives regarding the reasons for referral.
21. Unnecessary investigations must be avoided. Do necessary investigations as per the suspected differential diagnosis. Profession and commerce needs to be separated.
22. Various rights of the patients must be recognised and respected but, beware of ‘Google doctors’.
23. Working hours should be clearly displayed or declared. If you don’t want to give your services during night hours, avoid displaying 24 hours emergency services available. Visit during night hours can be avoided for various reasons.
24. X: Don’t do cross-pathy or cross-speciality practice. It prevents avoidable misdiagnoses, mistreatments and misunderstanding.
25. Your conscience should be clear so that you have a sound sleep. Follow the morality rules and recommendations. Have a positive attitude, self-introspection and self-regulation. Doctors have to do a lot of soul searching. Cleaning and mopping should begin at home. The only court, which identifies and proves all of your sins & mistakes, without even any proof, is your own conscience.
26. Zeal and enthusiasm shall be maintained irrespective of the difficult situations in practice. Remember that 'Haani- Labh, Jeevan-Maran, Jas-Apjas Bidhi-Haath' i.e ‘Loss-Gain, Life- Death, Fame- defame is in the hands of destiny’. It is said that a doctor’s treatment works in patients who are destined to live.

Other dos and don’ts

1. Consider every patient as a potential litigant but, don’t be frightened.
2. Install CCTV coverage in the hospital entrances and waiting areas.
3. Have a Crisis Management Committee for tackling any unwanted crisis situation.
4. Inform the police if you suspect some foul play, violence by aggressive relatives, unexplained deaths or difficult situations.
5. Don’t disrespect the court or legal procedures.
6. Follow the rules and laws of the land/country.
7. If there is a case in the court, take the help of legal as well as med-legal consultants.
8. Continue to follow-up & treatment of patients.
9. Don’t give unnecessary details.

Note: This write-up is an attempt to create medicolegal awareness amongst doctors. The aim is to discuss various medicolegal concepts and issues. The article is not an exhaustive piece of document. The readers can refer to the standard textbooks or journals for further and detailed information, rules, recommendations or guidelines.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The author is the Founder President of the Indian Med-legal & Ethics Association.