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Medical malpractice


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AN elderly relative was having severe chest pains. We took him to a well-known private hospital nearby. The doctors thought he had had a heart attack and wanted to admit him immediately and schedule a bypass.

The relative, feeling stable enough, decided to get a second opinion from a specialised public-sector cardiac institute. The doctors at the institute advised him not to go for a bypass as they thought his heart was too weak for it. With medication, they said, he could have a reasonably comfortable and active life. He chose the latter.

Was the advice of the doctors at the private hospital their best professional advice? Or, since they stood to gain financially from the bypass, were they loading the dice in favour of it and willing to perform a major surgery where the burden of the risk fell on the patient completely?

We will never know. But my relative was happy he consulted the second team and always felt he had made the right decision.

Medical malpractice is quite common in Pakistan. From over-testing, over-medication and doing excessive surgical procedures for making extra money to negligence (such as leaving a sponge in the stomach during an operation), not following standard procedures and indulging in outright criminal behaviour, our newspapers report cases of all sorts. But seldom do we hear of these cases being fairly, promptly and adequately investigated and dealt with by the administrative or judicial system of the country.

Medical malpractice or negligence is a problem across the globe. The core issue is information asymmetry, and that is inherent in exchanges in the medical setting. When you go to the doctor for diagnosis, she has knowledge you do not. How do you know she is using her knowledge to the best of her ability in your interest? What if her interests are not aligned with yours or she is just careless? You could always go for a second opinion, but if you have two different opinions, how do you decide which one to follow? Even if they are the same, how can you be sure they are right? Should you go by the most common opinion?

There are a number of ways various countries have tried to reduce the risk of malpractice. It cannot be eliminated, as the risk of mistakes and errors of judgment will always be there even if factors like self-interest are removed completely. But most large hospitals have strict standard operating procedures that are checked and evaluated by third parties: professional bodies of doctors and other medical staff, state authorities, and insurance companies.

The motivation for having strict procedures might be the fear of legal or administrative sanctions, which are available quite readily to aggrieved parties, but it works to a significant degree. Professional bodies have strict codes of conduct too and do take action in cases where medical professionals breach them. The reputation of each of the institutions involved is also a stay against opportunistic behaviour on their part.

All of the above raise the administrative burden and cost of medical practice significantly. They also sometimes encourage excessive testing and risk-averse treatment, but they do make the patient a lot safer and allow them to feel more protected. The more risky and less established procedures and medical options are sometimes still available outside the mainstream. But these are usually advertised as such and are not covered by mainstream insurance companies. So if patients still choose to go for these, they are likely to be well aware of the option they are taking and the risk they might be running. Even in these cases legal remedies against malpractice are still operative and available.

Even after all of the above and other protocols and protections, some estimates have shown that the health service in UK still faces a 10 per cent medical negligence rate. And other developed countries have comparable statistics. Though we do not keep any statistics, nationally or even regionally on the issue, given the lack of protection it is very likely that the rates are much higher in Pakistan and the nature of negligence or criminal activity is more severe, with more serious consequences for patients.

To lose a loved one is hard enough. To have the feeling that the loved one was lost due to a mistake that a professional made or the greed of a professional is a tragedy that should never happen. But it happens far too often in Pakistan.

To err is human and we cannot remove the possibility of errors completely. But we can build protocols that reduce the possibility of errors to a minimum while keeping costs and other variables in mind. And we can build protocols that eliminate conflicts of interest: profits for doctors or hospitals should not be guiding decisions regarding our health and well-being. But for this we have to take a number of steps.

The law on malpractice and negligence has to be tightened, implemented better and made more effective; maybe we should have separate benches that look at this issue. But the law, however efficient, will not be enough. It should be more of an encouragement for hospitals and for associations of doctors and other medical professionals to develop internal systems, standard operating procedures and protocols that reduce the incidence and possibility of negligence and punish it when it happens.

However, this step is unlikely to be taken by these organisations without the law and the regulatory set-up of the state coming down hard on them. The real problem is that despite the return to democracy and the recent changes in the judiciary, our institutions have not done a credible job of legislating on and implementing effective regulation or providing effective judicial recourse in any area.

The writer is senior adviser, Pakistan, at Open Society Foundations, associate professor of economics, LUMS, and a visiting fellow at IDEAS, Lahore.

The views expressed by this writer and commenters below do not necessarily reflect the views and policies of the Dawn Media Group.

Comments (25) Closed

Fasih Aug 17, 2012 11:10am
I'm sure you mean to say "cysts"
azra Aug 17, 2012 10:06am
Humanist Aug 17, 2012 04:35pm
A medical doctor myself, a graduate from a medical college in Pakistan and having postgrad studies and some years hopital working experience in Uk & Ireland, I was in Swizerland unde the force of circumstances. Diabetic on Insulin injections, I once had a slight faint of an hypoglycemic attack during exercise in a Swiss Gym. Ambulance was celled as the attendant boy thought I had a heart attack, I was shifted to the main hospital of the city ; although I never had a hear problem in my life. Doctors heard of an heart attack from the abmulance man and without asking any question or making any diagnosis started treating me with hear drugs, although ECG and blood tests were normal. When I woke up from the shock of so many drugs, a cardiac surgein appeared and told me that he wanted to do a cardiac byepass as he found some evidence on sone ultrasound test, he had decided but only wanted a cerempnial yes fromm e as the Insurance company had to pay the expenses. I refused; they wanted to force the operaation, I raised hue and cry, so they had to stop. I suffered lots of psychiatric and cardiac drugs without any diagnosis, and an ever-present danger of some surgical operation or Pacemaker surgery which might have made me handicapp for life and would have given thousands of dollars to the hospital and the surgeons, as well as satisfied his superior-race ego by making another colored person a handicap, as some known to me had earlier experienced. One evening while they were planning some surgical procedure on minimum evidence and without any diagnosis at all, i ran away from the hospital. They sent some paramilitary staff to bring me back, I ran away from the backdoor of my apartment and stayed in a hotel for few days. It is one year, I still never had any heart problem, and I am licky to be alive and still un-handicapped. <humanist AT>
illawarrior Aug 17, 2012 04:36pm
Doctors are human.... mostly they are skilled and make their diagnoses accordingly. Yes ... errors of judgement can and do happen... and yes ,,, as with all other professions .... there are con-men / women. If you wish to reject doctors ... such is your choice .. go for it!
imran Aug 17, 2012 03:34pm
This is difference of opinion not malpractice there is a huge difference between the two, how can the writer write about malpractice when he doesnt even know what it is
aaa Aug 17, 2012 10:27am
1)Some diseases mimick each other its not about malpractice but it happens because of the fact that its impossible to know what is what. I personally have seen cases where everything the patient tells shows acidity but it actually is a heart attack. 2)Different doctors have different opinions it is completely normal that one doctor may advise bypass and another may not. Same is true for a number of other diseases it has nothing to do with malpractice. 3)Many such issues are not present in educated countries as they understand such fine problems and it is even possible to talk to them about the fact that many different options are present which is quite difficult with many patients in pakistan due to lack of education. Last but not the least there should be more check on private hospitals. Or better there should be better and more in number govt. hospitals.
M Sal Aug 17, 2012 02:36pm
And if with the conservative treatment,the patient had died later on,the doctor would be blamed for not being aggressive enough.Pakistan population generally is significantly uneducated in health issues and has a poor understanding of medical protocols and systems.
maryam Aug 17, 2012 02:04pm
its a fault of government who does not give us the basic facilities to treat patients. i m a medical student and have always observed the miserable state of government hospitals due to this miserable state people go to private hospitals and such incidents happen. now what can we doctors do we can not give money from our pocket to establish better health system like in US n UK its the responsibility of government.
maryam Aug 17, 2012 02:06pm
and people blame doctors for this n for faults of government and other people
Gerry D'Cunha Aug 17, 2012 01:56pm
I talked about NHS treatment in UK not USA which you are unaware of - get your facts right.
Noor Aug 17, 2012 12:38pm
Malpractice can occur in any profession including medical. However, the case narrated by the writer is more of difference of opinion rather that malpractice. It is natural to choose easy way out when one is ill. What if the opinion of the first doctor was better for the patient and it was better for him to undergo surgery. Sometimes, surgery may be needed to improve quality of life of a cardiac patient even if it is not going to prolong his life. Problem is that we have very few doctors looking after a population growing at alarming rate. Majority of patients are not able to discuss their prognosis with their physician because either the patient is ignorant or the doctor is busy. Having said that, I feel there is dire need of reappraisal of medical ethics among the medical community and formation of such government bodies which would ensures that the interest of patient remains primary focus in any physician patient interaction.
aaa Aug 17, 2012 10:45am
I do also believe that one should also at times try to write an article on as to what is better in pakistan as compared to other countries in health department. Every country has its positive sides. 1) Due to huge population number of patients every doctor treat is far more than other well developed countries. More ill patients are present in pakistan due to problem in health department. This all leads to doctor being extremely competent on limited resources with far more experience and ability to deal with all sorts of patients. 2)Alot of charity work is done by doctors which is never mentioned anywhere. People dont like to listen to this and believe in it but many places doctors half practice goes in charity practice. Noone other than a doctor knows best the situation of the people coming to him or her leading to alot of charity work.
Gerry D'Cunha Aug 17, 2012 08:13am
In Pakistan there is no check and balance on private doctors and hospitals - all are there to make money. I thank God, I and my family are in London under the NHS treatment when ever there is health problem.
TNA Aug 17, 2012 12:29pm
Agree there's no malpractice in the case, but still if the patient is Old and pssoibly in bad shape, as in this case, i dont think its adviceable to make the patient go through bypass. Better with a conservative approach, give tablets, stabilize. Not that any of us know the exacts in this case, but it does seem like that the patient got the correct treatment eventually. What exactly does pointing fingers at "foreign hands" have to do with his case? 1. All patients, end up with one or another condition mainly due to lifestyle. 2. Good to point out how other countries tackle their problems, what can pak.ppl learn of others? ( doctors under consumer act in india is probably a good way to handle the issue of malpractice if it works). 3. Pak miseries are all politics, just like india: corruption, black money and extortion of the weak.
Asad Malik Aug 17, 2012 01:14pm
Well guess what? Malpractice exists in the US and UK as well. In the US where I live, doctors routinely schedule more appointments, order CT and MRI scans for the smallest things just to squeeze the most out of your health insurance and it's your bad luck if you're not covered. An MRI which costs a couple of thousand rupees costs a couple of thousand dollars. Before making such a tall claim about there being no check and balance, get your facts straight.
Bakhtawer Bilal Aug 17, 2012 04:22am
Thank you for writing on a problem due to which numerous people are effected on a routine basis. Very true that no one is going to act on their own. Laws have to be formulated and enforced to tackle the menace of medical malpractice. Doctors need to adhere to the Hippocratic oath, rather than favoring their colleagues when ever, if ever, a case goes to court. We certainly need new legislation. Unfortunately, in a country where lawmakers have not done any legislation to control the terrorism, where culprits apprehended with a suicide vest can secure release on bail, in such country it is too much to ask the lawmakers to formulate laws to curb medical malpractice.
azra Aug 17, 2012 04:42am
My mother went to AlMaroof Hospital, F-10, islamabad,with a bad cough. The doctor diagnosed her with 4th stage of Cancer and would have started treatment and all but luckily she flew off to Sydney in the next available flight. There she had every thing re-examined and "Nothing" was wrong with her alhamdolillah, just some harmless sists. How many people have this option?
azra Aug 17, 2012 04:45am
And in the same hospital a neighbor went with some pains and the doctor gave him some syrup for acidity. The poor man came home, passed away and later it was found out that he was having a heart attack.
SAROJ Aug 17, 2012 05:54am
Hassan Aug 17, 2012 07:02am
I agree that malpractice is there and serious efforts are required to remove this factor completely even if self advantage is removed completely... But I am amazed to see that an article always comes up highlighting malpractices by doctors... I am not saying malpractice doesn't happen but I would like to see someone and i mean literally anyone of you mentioning the problems faced by doctors and the poor facilities that are provided to doctors and patients in government setups... Just cheap and ineffective rather free and ineffective drugs are not going to cure patients... Above that most of the time those ineffective drugs are not available as well... Just proclaims by government isn't everything... Someone should look into what government is saying and what actually it is doing... Pointing finger always at the doctors isn't the option that is going to rectify everything...
Shapi Aug 17, 2012 08:46am
@azra ...u mean Cysts ...i assume
gangadin Aug 17, 2012 09:03am
The doctors at the first hospital suggested a 'bypass'. Where's the malpractice? Your relative could have taken some preventive measures to avoid all this. Where is the personal responsibility of Pakistanis? Why are you as a nation, always blaming others for your miseries.?
Dr.M.M.Khan Aug 17, 2012 08:17pm
I humbly disagree with the writer about the case he mentions. This is all about the difference in opinion and patient consent. This occurs all over the world! I work in Scandnavia and we have minimized this by having standard protocols reg. most procedures. The patients are well educated and know their rights. Medical negligence is entirely a different category of fish. It can be adressed by rigorous control. It should not be confused with incompetency. The problem in Pakistan is lack of accountability. Every mishap is personalized. The doctors are either glorified or beaten up. The patients carry their files and those who have resources go to several doctors--indeed i receive copies of their reports which i find very confusing. As a senior Cardiologist i underwent a serious procedure om my neck. The risks were explained to me i accepted them and was treated like any other patient though doctors tend to get more complications than other ---by nature we seek advice late. we should try to build a level of trust between the medical profession and the public. Death is ia part of any serious operation but unfortunately it is not accepted in Pakistan--it is the fault of the DOCTOR.
Dr Shahab Aug 17, 2012 08:41pm
A well written article. The author has pointed out flaws in our medical setup but at the same time has gone beyond than blame game. I am a practising doctor and i admit that things in our medical setup are far from ideal but dear countrymen in addition to readily pointing out flaws and short comings of doctors, please for a moment ponder upon the reasons for these flaws and shortcomings and you would get many answers. Doctors are not angels, not superhumans, they have desires and shortcomings but tell me that if humanly a doctor can justify a certain number of patients how can be the same standards be expected with many times more patients ? The debate is long. I sincerely hope that our policy makers do something about it ....
MSethi Aug 18, 2012 02:52am
I am a physician working in USA. Yes we do tend to over do on the testing on the smallest things as you mentioned. But the driving force for the physicians to go on this path is the fear of being sued by patients and the lawyer lobby in case a diagnosis is missed. As any other science or field there are multiple reasons for a problem and we go from the most common cause to the least common one. But we tend to cover as much ground as possible to avoid being sued. So please think before you blame the doctors.