September 23   2015, Wednesday
eMedinewS
Court drops all charges against ex-MCI chief
Dr KK Aggarwal TNN | Sep 22, 2015, 01.20 AM IST

LUCKNOW/AHMEDABAD: In what is the end of criminal proceedings against former Medical Council of India's (MCI) ex-president, Dr Ketan Desai, a special CBI court in Lucknow on Monday dropped charges of cheating and criminal conspiracy against him.

Desai was already exonerated on corruption charges by Lucknow high court earlier in this case. The charges of having disproportionate assets did also not stand against him in the past. He was then facing the only charges of conspiracy and cheating, which the special CBI judge dropped on the ground that prosecution agency had not obtained the mandatory sanction from the government to prosecute Desai, said his counsel Purnendu Chakravarti.

The case was registered against Dr Desai, MCI inspector Suresh Shah and others under prevention of corruption act and conspiracy for granting permission to Ram Murthy Medical College in Bareilly though the college was not fulfilling the required conditions. The CBI built the case on basis of a confession extracted from Dr Shah during investigation. Shah later retracted his statement against Dr Desai.

Both the accused unsuccessfully sought discharge from the CBI court in this case in 2012 after CBI filed a chargesheet against them. When the high court was moved, it quashed the corruption charges against Dr Desai and directed that the CBI court shall decide on the sanction for prosecution under section 197 of CrPC, which was missing, before proceeding further.

Dr Desai had filed a discharge plea again with the CBI court and advocate Chakravarti argued that the action on part of the accused was part of the discharge of their duties as office bearers of MCI. Hence Dr Desai could not be prosecuted without sanction from competent authority, and CBI did not obtain any prior approval in this regard.

After hearing the case, the special CBI judge dropped charges of conspiracy and cheating against Dr Desai for want of sanction.

Dr Desai was booked in five cases by CBI and later the probe agency gave clean chit to him in connection with charge of possessing disproportionate property. Interestingly, after Desai's arrest, the Centre dissolved MCI without waiting for investigation reports. The council was substituted by six retired government officials and private practitioners.

Interestingly, CBI had booked Dr Desai on the allegation of accepting bribe of Rs 2 crore. However, during the search operation by CBI at all his premises in Delhi and Ahmedabad, only Rs 53,000 cash was found. "We also argued in the court that this was a conspiracy to defame Desai because practically there was no evidence to implicate him in this case," said Chakravarti.
IMA,IJCP,HCFI
eMedipics
IMA,IJCP,HCFI
Congratulations to Dr Anil Goyal

Dr Anil Goyal has been elected President-elect 2015 of North Zone Urological Society of India.
News
Obstetrics and Gynecology/Diabetes

The optimal timing of induction of labor in women with gestational diabetes appears to be 39 to 40 weeks' gestation, suggested a new study published online in the Journal of Perinatology.

Gastroenterology

Use of celecoxib is associated with an increased risk of acute pancreatitis, suggests new research published online in The American Journal of Gastroenterology. The results stress that acute pancreatitis should be considered in the differential diagnosis for patients who are currently taking celecoxib and having acute abdominal pain.

Psychiatry

The assessment and management of cognitive impairment in patients with schizophrenia should be as high a priority as they are for functional disability, suggests a new consensus report published online in Schizophrenia Bulletin.

Oncology/Imunology

New research suggests that the enzyme receptor-interacting serine-threonine kinase-3 (RIPK3) has a role in fighting against both cancer and autoimmune diseases by sending messages between the cells' mitochondria "powerhouses" and the immune system. The findings are published in the journal Nature Communications.

Infectious Diseases

Results from the first phase 3 HIV study to enroll only women demonstrated improved safety and efficacy of the drug combination of cobicistat, elvitegravir, emtricitabine and tenofovir over multi-pill antiretroviral drug regimens. The research was presented at 55th Interscience Conference of Antimicrobial Agents and Chemotherapy (ICAAC/ICC).
IMA,IJCP,HCFI
Cardiology eMedinewS
  • Middle-aged and older adults who are able to achieve ideal control of various cardiovascular risk factors, as well as be active, are significantly less likely to develop cardiovascular disease later in life and are likely to have better heart structure and function as measured by echocardiography, suggests a new study published online in Circulation.
  • People with end-stage kidney disease who receive chronic dialysis have high rates of cardiovascular disease and death from cardiovascular disease. However, a new study suggests that in-hospital nocturnal dialysis may be good for patients' hearts as well as their kidneys. The findings are published in the Canadian Journal of Cardiology.
Pediatrics eMedinewS
  • A new study, published in PLoS ONE, suggested that higher/stress dose hydrocortisone does not appear to be associated with brain injury or neurodevelopmental impairments in extremely low birth weight infants.
  • Girls with higher impulsivity and poor planning were more likely to gain weight, and even engage in binge eating as teenagers, suggested a longitudinal analysis published in Pediatrics.
Pulmonary Embolism
The differential diagnosis of pulmonary embolism includes many other entities that present similarly with dyspnea, pleuritic chest pain, pleural effusion, hypoxemia, and shock.
Dr KK Spiritual Blog
Think positive and think different

The Mantra to acquire spiritual health is to think positive and differently. Positive thinking produces positive hormones and takes you from sympathetic mode to parasympathetic mode. When you think different, it gives you several opportunities and from multiple options available, you can ask your heart to choose one of them.

Thinking positive was a message given by Lord Buddha and thinking different by Adi Shankaracharya.

The candle light march, which was held to fight for justice in the Jessica Lal murder case, has been picked up by most of the protest campaigns because it was positive and different.

I have seen three examples in my life where I used this and prolonged the life of those persons.

My grandfather–in–law at the age of 85 thought it was time to go but when we made him work positively and differently, he died at the age of 100 years. He was asked to teach youngsters law, write daily to the Prime Minister on certain issues and find matrimonial matches for the youngest persons in the family.

In other two cases, one was suffering from terminal prostate cancer and the other had terminal brain cancer. The first one lived for 10 years and the other is still alive. Both were told that they had a very early cancer and that was cured by a surgery.

When you think different, it creates creativity and when it is with positive attitude, it is accepted by all.
Inspirational Story
The miracle of love, true story!

Like any good mother, when Karen found out that another baby was on the way, she did what she could to help her 3-year-old son, Michael, prepare for a new sibling. The new baby was going be a girl, and day after day, night after night, Michael sang to his sister in Mommy’s tummy. He was building a bond of love with his little sister before he even met her.

The pregnancy progressed normally for Karen, an active member of the Creek United Methodist Church in Morristown, Tennessee, USA. In time, the labor pains came. Soon it was every five minutes, every three, every minute. But serious complications arose during delivery and Karen found herself in hours of labor.

Finally, after a long struggle, Michael’s little sister was born. But she was in very serious condition. With a siren howling in the night, the ambulance rushed the infant to the neonatal intensive care unit at St. Mary’s Hospital, Knoxville, Tennessee.

The days inched by. The little girl got worse. The pediatrician had to tell the parents there was very little hope. Be prepared for the worst. Karen and her husband contacted a local cemetery about a burial plot. They had fixed up a special room in their house for their new baby they found themselves having to plan for a funeral.

Michael, however, kept begging his parents to let him see his sister. “I want to sing to her,” he kept saying. Week two in intensive care looked as if a funeral would come before the week was over. Michael kept nagging about singing to his sister, but kids are never allowed in Intensive Care.

Karen decided to take Michael whether they liked it or not. If he didn’t see his sister right then, he may never see her alive. She dressed him in an oversized scrub suit and marched him into ICU. He looked like a walking laundry basket. The head nurse recognized him as a child and bellowed, “Get that kid out of here now. No children are allowed.”

The mother rose up strong in Karen and the usually mild-mannered lady glared steel-eyed right into the head nurse’s eyes, her lips a firm line, “He is not leaving until he sings to his sister.” Then Karen towed Michael to his sister’s bedside. He gazed at the tiny infant losing the battle to live. After a moment, he began tossing. In the pure-hearted voice of a 3-year-old, Michael sang:
“You are my sunshine, my only sunshine; you make me happy when skies are gray.”

Instantly the baby girl seemed to respond. The pulse rate began to calm down and became steady. “Keep on singing, Michael,” encouraged Karen with tears in her eyes. “You never know, dear, how much I love you, please don’t take my sunshine away.”

As Michael sang to his sister, the baby’s ragged, strained breathing became as smooth as a kitten’s purr. “Keep on singing, sweetheart.” “The other night, dear, as I lay sleeping, I dreamed I held you in my arms”. Michael’s little sister began to relax as rest, healing rest, seemed to sweep over her. “Keep singing, Michael.” Tears had now conquered the face of the bossy head nurse. Karen glowed. “You are my sunshine, my only sunshine. Please don’t take my sunshine away…” The next day…the very next day…the little girl was well enough to go home.

Never give up on the people you love. Love is so incredibly powerful.

This is a true story happened in 1992 in Tennessee, USA. The baby girl’s name is Marlee. As of 2012, Marlee is 20 years old and she thinks she is normal like any other girl.
Wellness Blog
Treatment of Fatty Liver
  • A 10% weight loss can improve fatty liver and possibly inflammation.
  • Metformin and ursodeoxycholic acid (UDCA) are not recommended.
  • Statins are safe in patients with fatty liver but whether they can reduce fatty liver is not known.
  • Omega–3 fatty acids have been tried
  • Pioglitazone is useful in the treatment of biopsy–proven fatty liver with inflammation
  • Vitamin E at a dose of 800 IU/day improves liver inflammation
  • Use of bariatric surgery for treatment of fatty liver is premature and should be avoided in patients with cirrhosis.
Beneficiaries of Sameer Malik Heart Care Foundation Fund
IMA,IJCP,HCFI
Make Sure
Situation: An adult undergoing bronchoscopic biopsy developed infective endocarditis.

Reaction: Oh my God! Why was IE prophylaxis not given?

Lesson: Make sure, that all procedures of the respiratory tract that involve incision or biopsy of the respiratory mucosa include IE prophylaxis.
Dr Good Dr Bad
Situation: A patient with fever was found to have raised SGOT, SGPT levels with SGOT>SGPT.

Dr. Bad: It is classical viral hepatitis.

Dr. Good: This can be dengue fever.

Lesson: Mild elevations in SGOT/SGPT are common in both dengue fevers and DHF. However levels are significantly higher in patients with dengue hemorrhagic fever. Elevated SGOT levels are noted earlier in illness and normal SGOT levels is a strong negative predictor of dengue hemorrhagic fever in the first three days of illness (J Infect Dis 1997;176:313)
Media
IMA,IJCP,HCFI
eMedi Quiz
What is the number one cancer killer of women?

A. Colon cancer.
B. Breast cancer.
C. Lung cancer.
D. Cervical cancer.
E. Esophageal cancer.

Yesterday’s Mind Teaser: What is the main reason women have trouble becoming pregnant after age 30?

A. Their ovaries release fewer eggs.
B. Their eggs have begun to degenerate.
C. They have sex less frequently.
D. The uterine lining thins.
E. It is a high-stress period in their lives.

Answer for Yesterday’s Mind Teaser: B. Their eggs have begun to degenerate

Correct answers received from: Dr Jainendra Upadhyay, Dr Poonam Chablani, B R Bhatnagar, Dr K V Sarma, Dr Shangarpawar, Dr K Raju, Dr Avtar Krishan.

Answer for 20th September Mind Teaser: D. A and C.

Correct Answers received from: Dr K V Sarma, Dr K Raju.
Quote of the Day
Education is the best friend. An educated person is respected everywhere. Education beats the beauty and the youth. Chanakya
Reader Response
I do think that everybody has gone through such critical phase. Why does no one understand that everybody has kids irrespective of their position. We doctors suggest bed rest for the patient and to all high risk & precious pregnancies. This is applicable to us also. All women do not go on maternity leaves at the same time. This is to be kept in mind. Honoring women does not satisfy everything. I totally disagree with the views of president. Dr Om
eMedinewS Humor
Blind man in a store

A blind man walks into a store with his seeing eye dog. All of a sudden, he picks up the leash and begins swinging the dog over his head. The manager runs up to the man and asks, "What are you doing?!!" The blind man replies, "Just looking around."
HCFI Videos
Rabies News (Dr A K Gupta)
Do antibodies from rabies vaccination cross an intact blood–brain barrier?

No. Antibodies from vaccination do not cross an intact blood–brain barrier.
IMA,IJCP,HCFI
IJCP Book of Medical Records
IJCP’s ejournals
CPR 10
Successfully trained 113241 people since 1st November 2012 in Hands-only CPR 10
Video of the Day
Sameer Malik Heart Care Foundation Fund
The Sameer Malik Heart Care Foundation Fund is a one of its kind initiative by the Heart Care Foundation of India instituted in memory of Sameer Malik to ensure that no person dies of a heart disease because they cannot afford treatment. Any person can apply for the financial and technical assistance provided by the fund by calling on its helpline number or by filling the online form.

Madan Singh, SM Heart Care Foundation Fund, Post CAG

Kishan, SM Heart Care Foundation Fund, Post CHD Repair

Deepak, SM Heart Care Foundation Fund, CHD TOF
Press Release
Never administer aspirin or Ibuprofen to patients suffering from dengue fever

The cases of dengue are at an all-time high this year, especially in New Delhi. While most people are seen scouting through journals and articles looking for dengue symptoms and its treatment, they often miss one of the most crucial pieces of information. One must never administer aspirin or ibuprofen to a patient suffering from or suspected to suffer from dengue since it can cause internal bleeding.

Dengue presents as fever with bodyache in the beginning; hence, most people mistake it as a case of viral fever caused due to a change in season. They in-turn self-medicate themselves with either aspirin or Ibuprofen to get relief from the symptoms. This is extremely dangerous because if the patient actually has dengue, their chances of severe bleeding and complications go up drastically.

Speaking about the issue, Padma Shri Awardee Dr A Marthanda Pillai National President IMA and Padma Shri Awardee, Dr K K Aggarwal Honorary Secretary General IMA and President Heart Care Foundation of India in a joint statement said, “Delhi is presently going through a dengue outbreak and not an epidemic, and the cases will continue to come in for the next one month. The reason for this is that for the first time, strain four dengue has spread in the Capital on such a large scale. At present, it must be assumed that any person suffering from fever in this season along with headache, body ache, fatigue, nausea, and vomiting has dengue fever unless proved otherwise. Because of the adverse effects ibuprofen and aspirin can have on dengue patients, their administration to all patients must be avoided. Instead, paracetamol should be used to treat common symptoms such as fever and body aches."

Dengue fever is transmitted by female Aedes Aegypti mosquitoes, which acquire the virus while feeding on the blood of an infected person. Dengue occurs in two forms: Dengue fever and dengue hemorrhagic fever or severe dengue. A person is said to be suffering from severe dengue when there is capillary leakage. Patients who have dengue fever do not have capillary leakage.

Dengue fever is marked by the onset of sudden high fever, severe headache and pain behind the eyes, muscles, and joints. There is no specific treatment for dengue fever apart from early recognition and adequate hydration. Use of aspirin during dengue fever is not recommended owing to increased bleeding tendency.

The infecting organism in dengue affects the platelets, which are responsible for clotting (stopping bleeding) increasing the tendency of the person to bleed. Aspirin and Ibuprofen also have similar action. Both of them together could cause the person to bleed excessively pushing the patient into what is called the ‘Dengue Shock Syndrome.' And once in this stage, medical treatment is needed in an emergency basis, and hospitalization becomes necessary because of its life-threatening nature.

One must, however, remember that platelet transfusion is not the solution in the majority of the dengue cases unless the counts are less than 10,000, and there is active bleeding. Unnecessary transfusions can cause more harm than good. Instead, one must keep a tab on the hematocrit levels as their count decides the adequate requirement of fluids required by the body.

Here is a simple formula of 20 that can be followed to identify high risk patients
  • Rise in pulse by 20
  • Fall in upper blood pressure by more than 20
  • Rise in hematocrit by more than 20 percent
  • Rapid fall in platelets to less than 20,000
  • More than 20 hemorrhagic spots on the arm in one inch after tourniquet test
  • Difference between upper and lower blood pressure is less than 20
Start fluid replacement at 20 ml/kg/hour immediately in such patients, and shift to nearest medical center for observation.
eIMA News
IMA National Protest Day November 16
Dear Leaders

The 214th Central working committee held at Thiruvananthapuram on 19th and 20th of September has unanimously decided to observe protest day on November 16th, 2015 to press our demands on
  1. Amendment of Clinical Establishment Act
  2. Capping of compensation in the consumer forums and commissions
  3. Central hospital protection act
  4. Prevent mixopathy and AYUSH empowerment
  5. Abolish BSc (Community Health)
  6. Increase budgetary allocation for health
  7. Strengthen primary health care/rural health services
  8. Drugs at affordable cost
Indian Medical Association, the largest medical association in the world with a membership of more than 2.5 lakhs of doctors who are the cream of the society, who are so influential and who are institutions by themselves, should not fail to decide what is best for the people and the profession. IMA also should reach the pre-eminent position enjoyed by the other national medical associations as far as policies affecting the medical profession are concerned. Presently IMA is not part of the decision making body at the government. This situation has to change. Only if we are united and strong, can we dictate terms to the government. IMA has been doing lot of political lobbying, meeting administrators and resorting even to legal measures. Still we are not being able to achieve all our objectives, particularly those mentioned above. In a democracy, only a strong protest, unity and number counts.

Our D day to demonstrate our determination to achieve what we think is good for the medical profession is 16th of November, 2015. That is our protest day. The working committee unanimously exhorts every member of IMA to stage a protest march followed by presentation of our demand to administrative officer at your local level be it a Taluk officer, municipal commissioner, district collector or even chief secretary. This should be followed by a press release. At least one lakh of our doctors should be on the street protesting on that day. The medical students in the medical colleges in the locality should also be motivated to participate.

If IMA could mobilise a lakh of our doctors on that day, then any further protest will not be needed. The government will be forced to heed to our demands. So make it happen. The responsibility rests with every member of IMA.

As a build up to this,
  1. A fact sheet on the above issues, which will be prepared by IMA, will be shared with each local branch.
  2. General bodies of every local branch should be convened to educate and motivate every member to participate in the protest march.
  3. Every peoples’ representative including MPs, MLAs, councillors, panchayat members should be given the representation and the fact sheet prepared on these issues and they should be educated about it.
  4. Uniform write-ups on these issues, which will be given to the local branches should come in local papers.
  5. Open house discussions calling every segment of the public on these issues should be conducted to educate them and to ensure their support.
  6. Every national state and local branch past and present leaders should visit local branches and carry out awareness programs on these issues and motivate the members for participation.
  7. Every medical college should be visited by IMA leaders to make the medical students aware of the issues, which have a direct implication on their future.
  8. Already decided local branch president/secretary meet in New Delhi in October (10th,11th) will be utilised as a review meeting for the preparedness for the protest day
We may not get another opportunity
Awake, Arise, React and Achieve

Dedicated to the health of the nation

Prof. Dr A Marthanda Pillai                Dr KK Aggarwal
National President                   Honorary Secretary General
IMA Rise & Shine
Dengue admission needed: DM, HT, CAD, morbid obesity, renal failure, chronic liver disease.

Dr Pillai Dr KK
Dengue menace: Indian Medical Association clears out dengue myths
Monday, 21 September 2015 - 9:20pm IST | Agency: DNA webdesk/ DNA Web Team

While people are told not to panic, IMA still cautions everyone as it is possible for a former dengue patient to be infected again.

Given the large-scale panic that the increasing incidence of dengue has created, it is essential that awareness is raised about the myths and facts of the disease.

Clearing common misconceptions Padma Shri Awardee Dr K K Aggarwal, President HCFI & Honorary Secretary General Indian Medical Association (IMA) said, “Dengue incidence will continue to exist in the coming one month and instead of creating unnecessary chaos and panic, it is essential that awareness is created about prevention and timely steps are taken towards disease management. One must remember that only 1% of the dengue cases are life-threatening. Most dengue cases can be handled on an outpatient basis and do not require hospitalisation".

Some of the myths cleared out by IMA are:

Myth: We are facing a dengue epidemic.
Fact: Delhi is at present going through a dengue outbreak, and it has not yet become an epidemic, said IMA.

Myth: That all dengue cases are the same and must be dealt with in the same manner.
Fact: Dengue can be classified as dengue fever and severe dengue. A person is said to be suffering from severe dengue when there is capillary leakage. But patients who have dengue fever do not have capillary leakage. Four types of dengue have been identified to exist in the country out of which type II and type IV dengue are more likely to cause capillary leakage and so have to be treated differently.

Myth: Everyone suffering from dengue must be hospitalised.
Fact: Dengue fever can be managed on an outpatient basis and patients who do not have severe abdominal pain or tenderness, persistent vomiting, abnormal mental status or extreme weakness, do not need hospitalisation. Only patients suffering from severe dengue need hospitalisation. While they can also be hospitalised on discretion of their consulting doctor. One must always remember that 70% of the dengue fever cases can be cured just through the proper administration of oral fluids. Patients must be given 100-150 ml of safe water every hour, and it must be ensured that they must pass urine every 4-6 hours.

Myth: Dengue can never re-occur if you have had it once in the past.
Fact: There are four types of dengue infections, which exist in our country. While dengue from the same type cannot re-occur, that from a different type can. A second occurrence dengue (secondary) is more serious than first infection (primary). In the primary infection, IgM or NS1 will be positive and in secondary infection IgG will also be positive.

Myth: This is the worst outbreak of dengue that Delhi has ever witnessed.
Fact: The present outbreak of dengue in the national capital is that of dengue IV. The reason for a large number of cases is that dengue four has spread in the capital for the first time. The outbreak of dengue II in 2013 was more dangerous than the present dengue four outbreak.

Myth: Platelet transfusion is the primary treatment option for people suffering from dengue fever.
Fact: Platelet transfusion is only needed in cases where the patient's counts are less than 10,000, and there is active bleeding. Unnecessary platelet transfusion can cause more harm than good. The best treatment for dengue is to administer large amounts of oral fluids to patients. For patients who are unable to take oral fluids, intravenous administration may be necessary.

Myth: Machine platelet count is accurate.
Fact: Machine platelet count reading may be less than the actual platelet count, and a difference of about 30,000 can occur.

Myth: Testing platelet levels alone accounts for complete and effective management of dengue.
Fact: A complete blood count (especially hematocrit) is needed to monitor prognosis and increased capillary permeability, which is the starting point of all complications. Falling platelet counts with rising hematocrit levels are most important
Raise Fund Allotment for Health Sector: IMA
By Express News Service
Published: 21st September 2015 04:36 AM
Last Updated: 21st September 2015 05:34 A

Thiruvananthapuram: The Indian Medical Association (IMA) has stressed the need for scientific and humane approach in healthcare delivery and urged the government to increase the allotment for the sector to at least four per cent of the GDP.

Stating that the government should immediately address the issues faced by the medical fraternity, IMA national president A Marthanda Pillai and general secretary Dr K K Agarwal said the government funding should be exclusively reserved for proven scientific methods. They called for prioritising care for the poor and the marginalised sections of society and rural community, and assured that the association would provide all assistance in this regard. The IMA made the demands in its working committee meeting held here, which was attended by national leaders, presidents, secretaries and leaders from state branches. The two-day meeting concluded here on Sunday.

Price Control

Pointing out that drug prices should be effectively controlled, the IMA called for cost-based price control instead of market-based control. It also demanded manufacturing of drugs, vaccines and medical equipment in the public sector on priority basis. Pillai and Agarwal also called for reopening of vaccine and sera manufacturing public sector units that were closed down years ago.

With the small and medium hospitals, which are considered the backbone of the healthcare system, facing serious threats, they said that such hospitals should be saved from closure by providing aid and tax benefits.

Calling for scraping of the Clinical Establishment Bill, they said that it would lead to the closure of small scale hospitals.

In the light of rising number of attacks on hospitals and doctors, they demanded the implementation of Hospital Protection Act.

Stating that Consumer Protection Act is detrimental for medical care as it was a service sector and not a business venture, the IMA leaders noted that the unscrupulous compensations pronounced in some of the judgments have pushed up the treatment costs further.

The working Committee also decided to implement ‘Save the Girl Child’ project in all its branches as part of strengthening patient care and community service. And to strengthen the rural service through the ‘Aao Gaon Chalen’ project.
eBOOKs (Click on the Image)
IMA Digital TV
eBOOKs
IMA,IJCP,HCFI IMA Digital TV IMA Digital TV
IMA Digital TV
IMA Digital TV
Bioethical issues in medical practice
A patient’s right to information

Dr Smita N Deshpande
Head, Dept. of Psychiatry, De-addiction Services
PGIMER-Dr. Ram Manohar Lohia Hospital
New Delhi

A doctor’s healthy father suddenly started complaining of weakness, dyspnea and loss of appetite. A chronic smoker for many years, he was diagnosed with pulmonary cancer with few weeks to live.Keeping in mind his father’s happy go lucky nature, total ignorance of health issues and his own sadness for his father, the doctor did not disclose the diagnosis to his father. He asked the treating doctor not to tell his father either. One day the father came for consultation alone and asked the treating doctor point blank- what is wrong with me? What should the treating doctor do?

a. Tell the entire truth and betray his friend’s trust?
b. Tell a white lie to his patient?
c. Any other choice?

Which is the way you would prefer and why? Can you suggest some other solution and why?

Do write in with views and your suggestions!
  • I am surprised by the method by which some of the respondents have arrived at their answer, rather than by their answers themselves. The query posed is not directed towards eliciting personal opinion on ideal physician behaviour, but rather to delineate the ethical conduct prescribed under the extant rules and regulations, including Code of Ethics Regulations, 2002 http://www.mciindia.org/
    RulesandRegulations/Codeof
    MedicalEthicsRegulations2002.aspx prescribed by the MCI on the duties of the Physician. Hence, it may be appropriate to start by identifying the rules/regulations applicable to the fact-situation, and then infer the answer. I find that the following clauses of the above regulations are applicable:

    1.3.2. If any request is made for medical records either by the patients / authorised attendant or legal authorities involved, the same may be duly acknowledged and documents shall be issued within the period of 72 hours.

    2.3 Prognosis: The physician should neither exaggerate nor minimize the gravity of a patient’s condition. He should ensure himself that the patient, his relatives or his responsible friends have such knowledge of the patient’s condition as will serve the best interests of the patient and the family.

    7.14 The registered medical practitioner shall not disclose the secrets of a patient that have been learnt in the exercise of his / her profession except –

    1. in a court of law under orders of the Presiding Judge;

    2. in circumstances where there is a serious and identified risk to a specific person and / or community; and

    3. notifiable diseases

    Therefore, I would say that the doctor has to disclose the true condition of his health to the patient. If he is applying 2.3, he has to personally ensure that such disclosure would not harm the patient. The opinion or recommendation of the patient's son in this matter is irrelevant, just as if the son had not been a doctor himself. Swapna Sundar
  • I instinctively seem to agree with Swapna, any agreement to treat is between the patient and the doctor-most compassionate and empathetic way to tell him must surely be found, but he needs to be told. Pooja
  • As he has a right to know, I would give him part truth with hope (e.g a tumor that could be treatable) and tell him not to disclose it to his son as it could upset the son. This will ensure that the son does not feel betrayed by me. While he may have a right to know all, the full knowledge is not going to save his life or even improve his quality of life in any way. On the contrary it can cause major damage and make the rest of his life miserable. He has a right to happiness in the terminal stages of his life. I would not lie as that can jeopardize the doctor-patient relationship. Prof. Dr U Gauthamadas, Professor & Head, Dept. of Psychiatry, MAP Institute of Medical Sciences & Research, Chennai
  • Howsoever it may appear unethical and unlawful but in this case I would suggest "If a person has lived with dignity let him die with dignity a few weeks later" Don't tell him anything. Dr BB Singh, IPR Attorney & Scientific Advisor and Advocate, High Court, Mumbai
  • The doctor first should give an answer to the patient that they are working to get to the bottom of things and it is a serious problem but every problem will have some solution. Important is QOL. And that he would talk in detail once he and his son would get the diagnosis. Must reassure him. The doctor then must talk to his friend about his father's wishes and that every patient in sound mind must know his condition. It gives him time and chance to do important things. Dr Pratibha Pereira
  • As you know disclosing bad news is an art too. Let us do it properly. I would opt the third choice in your MCQ. Dr Ajithkumar K
  • C. The patient undergoing the problem knows the treating doctor is a friend of son and may be keeping the report confidential. His coming to the doctor alone and wanting to know the result is a matter of his right. The doctor should tell his friend’s father about the result to enable him take decisions about his health and related issues. For health matter his doctor son’s friend was there but other matters the patient had to make decisions. In case this doctor is busy he can take help of a counsellor to help the patient in disclosing the report confidentially who would opportunity to overcome patient's anxiety at the stage of disclosing and help in decision making. Nita Mawar
  • I see two issues. 1. To tell father or not? 2. Regarding treatment. I am sure the father, an intelligent person, will know that things are hidden hence he came alone to find out. There must be full disclosure. No less. Regarding treatment, it is the adult patient's right to decide what he wants, not his children. He should decide it. There is no ambiguity about it. I know of people in the same predicament and I have seen the difference in opinion between the children and the sick parent. It is often that the children do not want to see their parent in a difficult state and not want to handle it. If there are financial issues it is a different context altogether. Saradha Suresh
  • This is a glaring example of ethical dilemma! There are two issues here to be weighed 1. Right to information and 2. QOL. If the doctor finds the father to be sound and strong to understand the situation as he is willing to know, so breaking the bad news can be the next step ...of course it requires expertise! This can help in his further decision making process. QOL issues (according to his son) also need to be taken care of. Final goal of looking into ethical dilemma is to analyze risk and benefit, which is to be assessed on case to case basis. So a doctor's judgment on analyzing that situation is the main step, keeping his friend also into confidence. Finally the answer goes for (C) in the MCQ. Thanks for bringing up such issues. Looking forward for more such. Dr Barna Ganguly, Prof & Head, Dept. of Pharmacology & Head, UNESCO Bioethics Unit, Gujarat International Network of UNESCO Bioethics Chair.
  • Option C: We have to tell the truth to the patient. It need not be a sudden disclosure as it may have negative impact and add to the suffering of the patient. It can happen in multiple sessions after preparing him for coping up with the bad news and counsel him. It may be time consuming but the patient has all rights to know about the illness he is suffering from. If the doctor finds it difficult to disclose the result, he may seek the help of a professional counselor and the same may be discussed his colleague who is the son of his patient. Dr AS Valan, India EIS officer, NCDC, New Delhi.
  • It has two components: content and the method. Both are equally important, whether we see it through ethical perspective or legal perspective or human rights perspective or humanitarian perspective, (or some other) the person should get a decent deal. First thing is how much and how he would like to know, why he wants to know, what are his concerns, what other help he would like to get, what is the relationship with the son, how much the patient wants to involve him in the process, how much help he wishes to have in planning his own future and treatment, and lot more. I would prefer the doctor (if necessary a team) will be able to develop a therapeutic relationship to disclose and counsel him comprehensively through his sickness/ illness and death if it happens. Let us give importance to the patient not the son. Dr Ajith
  • It has been already reiterated by most that the father has a right to know about his illness. I agree totally with that. The treating doctor can call his friend, the patient's son, explain the dilemma, and if possible disclose the diagnosis in the son's presence. But if the son is still not in favor of disclosure, the doctor has to over-rule him and tell the patient, even if it is at the cost of a friendship. The doctor, since he is a friend may also garner the support of someone else in the patient's family-his wife or other offspring. In fact, what about the wife? Shouldn't she know? Dr. Ratinder Jhaj, Associate Professor, Dept. of Pharmacology, AIIMS, Bhopal, MP.
  • The patient has the right to know about his illness. In any case he has come to inquire about his illness shows that he has some doubt and hiding may affect him psychologically also. He might have to prepare himself for the inevitable, may be writing a will, saying goodbye to his close friends and relatives. These are very important issues and he may not get time when he finally gets to know. The friend should be told about all these issues and may plan some other happy moments for his father to go peacefully. Triptish Bhatia, PhD, Principal Investigator, GRIP-NIH, USA Project, Dept. of Psychiatry, Dr Ram Manohar Lohia Hospital, New Delhi
  • This scenario is not uncommon in our Indian context, where family members request the doctor to refrain from sharing the diagnosis with the patient. The intention is usually to protect the patient from the emotional impact of the unfavorable diagnosis or prognosis. However, this 'collusion' is not always in the best interest of the patient. The primary responsibility of the doctor is to the patient and honesty with the patient is critical to preserve trust in the relationship. The doctor should use his judgment to decide whether the patient has the capacity to deal with the bad news. Breaking bad news can be postponed in cardiac cases or certain phases of psychiatric illness, where the emotional response may worsen the condition. Breaking bad news is a communication skill that can be learned. The concerns of the family members must of course, be taken into account and evaluated. Family may even need to be counseled on the benefits of truth telling and respect for the patient’s right to information about his body and health. It will enable the patient to participate in decisions about treatment and end of life. Patients usually have a well developed sense about their state of health and some may wish to prepare for death; denying them information can only lead to distress and confusion. In the example above, the doctor's request to withhold information appears emotional due to the distressing circumstances, and the treating doctor would have to take the lead in advising appropriate disclosure to the patient. More so, since the patient is clearly asking for the truth. Olinda Timms
  • My answer is 'c'. The patient is already aware that there is something wrong and his family is hiding that from him, so keeping him ill informed still may not be the right thing even if it is for a few weeks (again it may be months and is difficult to predict with a lung cancer)? This scenario (and the previous one) hints at a traditional dyadic informational relationship between son and patient, doctor and son, patient and doctor slowly breaking down to make way for a newer pluralistic informational infrastructure? (More here: http://www.ncbi.nlm.nih.gov/pubmed/26123908). In my own practice I believe in a metaphorical approach to communicating with patients who have terminal illnesses (more here: http://annals.org/article.aspx?articleid=715632) and I often ask patients (such as the one under discussion) to look out of my office window and notice the upcoming concrete buildings where previously green forests and river streams reigned (my office actually overlooks a slowly dying Kaliasot forest and river). After that I inform them that this is exactly what is happening inside their body and it is possible that in time all the greenery will be eventually wiped out. No one can really predict how soon: weeks, months or years. All of us have this process going on within us and all of us will have to one day come to terms with dealing with the same dilemma and will need to face our imminent departure and provide for our loved ones before that. (More disease metaphors here: offline full text: http://searchworks.stanford.edu/view/7929525). Dr Rakesh Biswas, Professor, Medicine, LN Medical College, Bhopal
  • The nature of illness has to be told to the patient. The disclosure has to be done in such a way that the patient receives the information that is his right and at the same time discussing the concerns and feelings of his son. Although I believe the son should have taken his dad into confidence and told him and also the treating doctor should have impressed upon the son that his father is entitled to know the truth. Dr Tribhuvan Pal Yadav, Prof of Pediatrics. PGIMER, Dr RML hospital, New Delhi.
  • The autonomy of the patient has taken precedence over beneficence and nonmalfeasance nowadays. Paternalism is no more advocated. It is believed that withholding pertinent information violates a patient's autonomy rights and violates the fundamental duties of a physician. First of all the physician should have offered the advice to reveal the truth to the doctor friend. Considering his father’s happy go lucky nature he might have taken it as an inevitable & might have accepted it with courage. Even if physician doesn’t revealed the truth, in this modern era patient will try every bit to find it from another source. And he may come to know the fact sooner or later, that may have a deep scarring effect on him to the extent that father-son, patient-doctor relations may get strained. Explaining the truth about diagnosis, prognosis, and treatment options to the patients is needed for a good professional relationship and for exercising informed choices by patient. Now the only plausible thing to do is communicating the ugly facts and here the experience, attitude, skill of physician & timing of communication will be of utmost importance. So I think the best possible resolution for this dilemma is to ask the patient to come other day with his doctor son and then revealing the truth. Dr Manik S. Ghadlinge, Assistant Professor, Dept of Pharmacology, PGIMER & Dr RML Hospital, New Delhi
  • The trust of the patient is more important than the trust of the doc's friend. So I consider option A is more relevant for the doctor. Sreenivas Vishnubhatla, Professor of Biostatistics, All India Institute of Medical Sciences, New Delhi
  • It depends upon the condition of his illness and accordingly doctor will disclose. Because doctors have to speak truth to their patients. NN Mishra, Asstt Prof & Head/Bioethics Consultant. Dept. of Psychology, LS College, Muzaffarpur, BRA Bihar University, Muzaffarpur, Bihar.
IMA IPMO Initiative
Kindly go to http://module.ima-india.org/ipmo/
and pledge your organs. Unless we do it, the public will not listen to us.

Team IMA
IMA in Social Media
https://www.facebook.com/ima.national 28768 likes
https://www.facebook.com/imsaindia 46913 likes
https://www.facebook.com/imayoungdoctorswing 1795 likes
Twitter @IndianMedAssn 1139 followers
http://imahq.blogspot.com/
www.ima-ams.org
http://www.imacgpindia.com/
http://www.imacgponline.com/
http://www.ima-india.org/ima/
www.indianmedicalassociation.info
Over 50 doctors attended the IMA Rise & Shine CME on Vitamin D deficiency in Rudrapur
IMA,IJCP,HCFI
IMA Videos
News on Maps