MEDICOLEGAL ASPECTS IN

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

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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.

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COMMUNICATING WITH PATIENTS
Use lay language, not medical terms (particularly
for informed consent) do not criticize previous
physicians 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
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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
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Endophthalmitis occurs in best of hands in best
of set ups.
Only people who do not get endophthalmitis are
those who do not operate.
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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.
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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.

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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.

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• 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
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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.
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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.
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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.
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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.
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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.
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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
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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.

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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.
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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.

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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
ophthalmologists credentials, training,
experience or ability, and must not claim of
superiority
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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.
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• 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

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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.

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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.

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Thank you