VOLUME 16 NUMBER 6 November/December 2003

Letter from Mumbai

A matter of little importance
A hospital in Mumbai holds periodic meetings between its administrators and senior staff members. At one such meeting, suggestions for improving the care of patients were invited. One person from the audience referred to a common malpractice. ‘From time to time, patients develop acute, troublesome symptoms. When the ward sister pages the relevant resident doctor, drugs—including injections—are prescribed over the telephone without the doctor coming over and examining the patient.’

He gave an example. An ageing patient had impaired mental faculties. He was due for surgery. Around 1 a.m., his wife contacted the nurse on duty. The patient was pacing up and down, wandering out of his room and even trying to descend the stairs. Unable to restrain him physically, she requested help in quietening him and persuading him to go to sleep. She could not understand his restlessness. The nurse paged the resident doctor. He did not come over. Over the telephone, he asked the nurse to give the patient a strong hypnotic tablet. Despite this drug, the patient continued to try to leave his room and go out of the hospital. His wife begged for help. When paged, the doctor sounded upset as it was around 2.30 a.m. ‘Give him another tablet.’ By 3.30 a.m., the wife was in tears. Not only did the patient continue to attempt moving around but now, groggy from the effects of the drug, he was very unsteady on his feet and actually fell to the ground, almost hurting his head. He had passed urine in his bed and all over his room as he could not make his way to the bathroom in his befuddled state.

In another instance, the consultant on his daily rounds came across a patient who complained of the effects of the intravenous injection given the previous night. Since he had not requested any such injection, the puzzled consultant studied the patient’s case notes. Indeed, no injection whatsoever had been prescribed. The nursing sister looked up her notes. The nurse on duty at night had recorded the injection in her report with the statement: ‘Given on telephonic instructions from Dr ABC.’ It turned out that the doctor, when paged, ordered the injection over the telephone without coming to see the patient. He made no note on paper of this prescription ordered by him!

Concluding his plea, the doctor asked the administration to outlaw this practice on the grounds that it was unscientific, bad medicine and dangerous for the patient. He did not refer to the medicolegal consequences for the hospital and the consultant. Failure to examine a patient with acute symptoms might lead to loss of valuable time in the treatment of a potentially hazardous medical complication. The drug itself may play havoc with the patient’s systems.

More interesting than this doctor’s observations and plea were the responses they elicited from the other consultants in the audience and the administrators. The chief administrator felt that if the resident doctor had seen the patient a few hours earlier, the prescription of a drug over the telephone might be in order. Other consultants suggested that to ensure that no mistake was made, the resident doctor should repeat the name and dose of the drug to two separate nurses on the floor, spelling out the name of the drug and dose. There was some discussion over which tablets and injections could be ordered thus. A few agreed that having ordered the prescription, the resident doctor should, at a later stage, note this on the patient’s case sheet. The administrator brought the discussion on this topic to a halt saying that the majority felt that there was nothing wrong with such a practice.

Hospital medical records
At another meeting, the department of surgery attempted a retrospective audit of patient care on the basis of a study of hospital case records. A consultant spent some months reviewing all the case papers obtained from the medical records department of the hospital.

A few interesting but unexpected facts emerged from his study.

  • The study could not be extended beyond 5 years as all records prior to this date had been destroyed by the hospital. The administrators base this decision to destroy records on lack of space for storage of such records. When asked whether microfilming and microfiche, available for decades or electronic storage devices freely available more recently, had been pressed into use, there was silence. Since this hospital—like all others of its size in Mumbai— also serves as a research organization, such destruction of records evoked considerable surprise and scepticism.
  • Notes on hospital records were sketchy, incomplete and often illegible. Operation notes provided few details. Some consisted of just one sentence such as ‘Mastectomy done under general anaesthesia’. The consultant undertaking the analysis made the following observation: ‘I often learnt more about the patient’s clinical state, progress and medication from the notes maintained by our nurses than from the notes made by doctors.’
  • Deterioration in the patient’s clinical condition was recorded using stereotyped statements. ‘G.C. poor. Blood pressure unrecordable. Attempts at resuscitation failed. Patient declared dead at 3.40 a.m.’ It was impossible to trace the progress of the disease, the mechanisms that had resulted in acute catastrophic failure of the patient’s systems and precise cause of death from most case notes. There could be no answers to questions such as ‘Did the patient die from a postoperative complication or the natural progression of the disease?’ ‘Was there evidence of widespread infection?’ ‘Was there bleeding within the body cavity and if so, which blood vessel(s) gave way?’

Paucity of autopsies in private hospitals in Mumbai
Discussion on this topic at the above meeting yielded interesting facts. Few, if any, of the large and prestigious private hospitals in the city carry out a large number of autopsy studies. Consultants defend their refusal to request an autopsy on the following grounds:

  • Autopsies are not possible in the hospital. The consultant pathologist refuted this, saying that he was willing to come at any hour to perform the autopsy. He also noted that his hospital had a fully equipped autopsy room that was seldom used.
  • Relatives would never agree to an autopsy. A senior consultant neurologist showed that he had just obtained permission for an autopsy on one of his patients where he remained puzzled by the illness despite all the tests performed. He had explained his dismay to the relatives of the dead patient and requested permission for examination of the brain. They had immediately acceded on the grounds that this may benefit some future patient.

In an informal discussion outside the auditorium, the consultants voiced their real fear. In this litigious era, relatives may sue the doctor if some complication from a procedure or surgery is detected at autopsy. Stern looks were directed at the timid soul who suggested that such complications would otherwise never be detected and other patients might suffer as a consequence. The pathologist rightly shot down the suggestion that there be two autopsy reports, the first edited for ‘public consumption’ to be placed in the medical records and the second, complete report, for ‘private circulation’ to the clinicians concerned.

Remembering Justice Lentin
When the possibility of doctors being sued by patients or their relations was brought up, a respected consultant physician was reminded of his discussions with the late Justice Lentin. (For a review of Justice Lentin’s report on the deaths in Bombay following the use of contaminated glycerol see Natl Med J India 1988;1:144–8.)

Justice Lentin told this physician of the cardinal principle employed by him when he was judging an accusation of malpractice by a doctor. In his dealings with the patient and relations, did the doctor show ‘the four Cs’? Seeing the puzzled look on his listener’s face, he elaborated: competence, care, compassion and communication. If there was evidence of these, the doctor had nothing to fear. He pointed out that judges were aware that doctors were experts in their fields and knew more about medicine than did lawyers and judges. Judges also recognize that there can be differences of opinion among doctors as to how a specific illness should be treated and that disparate methods can be employed. As long as generally accepted principles and practices were followed, judges would permit considerable latitude.

Woe betide the arrogant and supercilious doctor! Judges do not take kindly to an attitude of ‘I know best’ or ‘No one can question me’. A doctor tried to defend the fact that he did not see his seriously ill patient at night on the grounds that such a visit would cost the patient more than the fee during office hours and that the patient’s relations had not asked him to see the patient in the dead of the night. Justice Lentin pointed out that the onus of deciding whether or not to see the patient rested with the doctor, who, in turn, must base his decision only on the clinical state of his patient and gravity of illness.

Justice Lentin was also critical of the quality of notes on medical case papers scrutinized by him in the course of his inquiry into the glycerol tragedy. The use of acronyms understood only by a select few, lack of meaningful and relevant detail and the insensitivity of those writing the notes dismayed him.

Our consultant physician narrating these lessons learnt from the eminent jurist told of a distressed friend who showed him a discharge summary from a hospital that described his wife as ‘a fat old woman’. While the description has the merit of brevity and accuracy, it caused acute embarrassment whenever and wherever this summary had to be displayed.

The discharge summary and insurance companies
The aforementioned physician also highlighted another problem resulting from thoughtlessly written discharge summaries. Insurance companies scrutinize these summaries with great care, looking for grounds on which the applicant’s claim can be rejected.

He quoted the example of a patient in her eighties who had been admitted for the treatment of an ischaemic stroke in the vertebrobasilar artery territory. As the resident doctor was taking down her history, he enquired about earlier episodes of a similar nature. She denied any such episode. He persisted. ‘Did you never, ever, suffer from giddiness?’ After some thought, she told him about an event in childhood, when she had felt giddy for a few days after a fall and injury to her ear. Triumphantly, the resident doctor noted on the case paper—and later on the discharge summary—‘History of giddiness from childhood’. The insurance company seized this statement and tried to deny the claim. It took much effort on the part of the physician to convince the company that the giddiness in childhood had followed injury to the labyrinthine apparatus in the ear and was in no way related to the stroke suffered 7 decades later.

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