Comment

India is experiencing fundamental changes on social, cultural and economic fronts.

The doctor-patient relationship is no exception and is rapidly evolving. In the coming years, one aspect of this evolution, namely the recent increase in alleged medical negligence cases, is likely to have a huge impact on the way medicine is practiced in India.

Ironically, this trend is likely to have many positive effects including improved accountability on the part of the doctors and hospitals, better documentation of the care provided and proper compensation in case of occurrence of a preventable adverse outcome.

On the other hand, this trend is very likely to have some negative effects as well. The practice of defensive medicine is particularly common in countries where medical negligence cases are a frequent occurrence. This usually takes place in the form of performance of diagnostic and therapeutic interventions to avoid medical liability rather than to benefit the patient. This is usually for the assurance of the treating doctor. It may also occur in the form of doctors avoiding high risk procedures or circumstances.

The practice of defensive medicine can in other words be described as any deviation from ‘standard of care’ in order to avoid litigation. The concept of standard of care is a complex one, but in short, means any intervention that is medically appropriate under the circumstances. The standard of care is usually decided by the community where a patient is treated. Hence, it is likely to be very different in rural setting when compared to urban areas where specialised care is more readily available. Once the fear of litigation increases amongst doctors in a community, the standard of care evolves to include interventions that cover the doctors’ legal obligations rather than merely those that are medically necessary. Obvious examples of the practice of defensive medicine include performance of excessive imaging studies, institution of polytherapy and an unreasonably low threshold to performing cesarean section rather than wait for natural birth. All of these translate to poor care for the patients. Additionally, they drive up the healthcare costs of the society significantly.

The fear of rising liability on the part of doctors is also likely to make them hesitant in performing the role of the Good Samaritan in emergency situations; or giving curbside opinions which is currently commonplace in India and often very helpful. Finally, a major concern would be an increase in frivolous allegations of medical negligence which do not result in any benefit to the patients or the doctors, but result in increased procedural costs and medical liability premiums.

It will be interesting to see how this scenario unfolds in India in the coming years. A sincere hope is that India does not follow the model of the west, especially the United States of America where high rate of alleged medical negligence cases, including many frivolous ones, has had the most telling effect on the manner in which medicine is practiced. However, this is very likely to happen in India and there is an urgent need to intervene preemptively. A possible approach is to form independent authorities to monitor the proper delivery of healthcare and have arbitrators intervene in case a breach leading to an adverse outcome does occur.Additionally, a measure to discourage frivolous cases would be to institute financial penalties for doing so. Even if India is unable to find a good balance, one certainly wishes that the cases of alleged medical negligence will get settled in the court of law or by arbitration, and not on the streets as has happened quite commonly in recent years.

Jay Desai is an assistant professor of clinical neurology, Keck School of Medicine, University of Southern California and a child neurologist at Children's Hospital Los Angeles. The opinions expressed are those of the author and not of the institutions.