HCFIe-Medinews A Service of IJCP Publications Pvt. Ltd.WFR
  Address:  39 Daryacha, Hauz Khas Villege, New Delhi, India. e-Mail: drkk@ijcp.com , Website: http://www.ijcpgroup.com

Dr K K Aggarwal

Dr KK Aggarwal
Dr BC Roy Awardee
Sr Physician and Cardiologist,
Moolchand Medcity
President, Heart Care
Foundation of India
Gp Editor-in-Chief,
IJCP Group
Delhi Medical Council
Director, IMA AKN Sinha Institute (08-09)




29th November Sunday

Dear Colleague,

 Professional Negligence vs Professional Deficiency vs Professional Misconduct (emedinews revisited)

These are the three definitions which must be understood by all of us as well as the specialists called as experts. When an inquiry is held, in the report of the experts it is very important not to intermix these definitions as they may have serious medico legal implications.  

1. Professional Deficiency is an act of omission or commission leading to  a loss to the patient or to his or her family. Here, the case is decided on the Bolam's principles where it is judged whether or not the doctor has acted by providing an average degree of skill, care or service. Any deficiency in the service is not a medical negligence and also is not professional misconduct. Professional deficiency is liable for compensation under Consumer Protection Act and the same is paid by the insurance company under the Indemnity Insurance. (Bolam Test See Below)

2. Professional misconduct is well defined in Medical Council of India Rules and is punishable by the Council in the form of warning or suspension of practice for a specific period.

As per MCI the following acts of commission or omission on the part of a physician shall constitute professional misconduct rendering him/her liable for disciplinary action

7.2 If he/she does not maintain the medical records of his/her indoor patients for a period of three years as per regulation 1.3 and refuses to provide the same within 72 hours when the patient or his/her authorised representative makes a request for it.

 7.3 If he/she does not display the registration number accorded to him/her by the State Medical Council or the Medical Council of India in his clinic, prescriptions and certificates etc. issued by him or violates the provisions of regulation 1.4.2.

7.4 Adultery or Improper Conduct: Abuse of professional position by committing adultery or improper conduct with a patient or by maintaining an improper association with a patient will render a Physician liable for disciplinary action as provided under the Indian Medical Council Act, 1956 or the concerned State Medical Council Act.

7.5 Conviction by Court of Law: Conviction by a Court of Law for offences involving moral turpitude / Criminal acts.

7.6 Sex Determination Tests: On no account sex determination test shall be undertaken with the intent to terminate the life of a female foetus developing in her mother's womb, unless there are other absolute indications for termination of pregnancy as specified in the Medical Termination of Pregnancy Act, 1971. Any act of termination of pregnancy of normal female foetus amounting to female foeticide shall be regarded as professional misconduct on the part of the physician leading to penal erasure besides rendering him liable to criminal proceedings as per the provisions of this Act.

7.7 Signing Professional Certificates, Reports and other Documents: Registered medical practitioners are in certain cases bound by law to give, or may from time to time be called upon or requested to give certificates, notification, reports and other documents of similar character signed by them in their professional capacity for subsequent use in the courts or for administrative purposes etc. Any registered practitioner who is shown to have signed or given under his name and authority any such certificate, notification, report or document of a similar character which is untrue, misleading or improper, is liable to have his name deleted from the Register.

7.8 A registered medical practitioner shall not contravene the provisions of the Drugs and Cosmetics Act and regulations made there under. Accordingly,
a. Prescribing steroids/ psychotropic drugs when there is no absolute medical indication;
b. selling Schedule H & L drugs and poisons to the public except to his patient;
in contravention of the above provisions shall constitute gross professional misconduct on the part of the physician.
7.9 Performing or enabling unqualified person to perform an abortion or any illegal operation for which there is no medical, surgical or psychological indication.

7.10 A registered medical practitioner shall not issue certificates of efficiency in modern medicine to unqualified or non medical person.
(Note: The foregoing does not restrict the proper training and instruction of bonafide students, midwives, dispensers, surgical attendants, or skilled mechanical and technical assistants and therapy assistants under the personal supervision of physicians.)

7.11 A physician should not contribute to the lay press articles and give interviews regarding diseases and treatments which may have the effect of advertising himself or soliciting practices; but is open to write to the lay press under his own name on matters of public health, hygienic living or to deliver public lectures, give talks on the radio/TV/internet chat for the same purpose and send announcement of the same to lay press.

7.12 An institution run by a physician for a particular purpose such as a maternity home, nursing home, private hospital, rehabilitation centre or any type of training institution etc. may be advertised in the lay press, but such advertisements should not contain anything more than the name of the institution, type of patients admitted, type of training and other facilities offered and the fees.

7.13 It is improper for a physician to use an unusually large sign board and write on it anything other than his name, qualifications obtained from a University or a statutory body, titles and name of his speciality, registration number including the name of the State Medical Council under which registered. The same should be the contents of his prescription papers. It is improper to affix a sign board on a chemist's shop or in places where he does not reside or work.

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
i. in a court of law under orders of the Presiding Judge;
ii. in circumstances where there is a serious and identified risk to a specific person and / or community; and
iii. notifiable diseases.
In case of communicable / notifiable diseases, concerned public health authorities should be informed immediately.

7.15 The registered medical practitioner shall not refuse on religious grounds alone to give assistance in or conduct of sterility, birth control, circumcision and medical termination of Pregnancy when there is medical indication, unless the medical practitioner feels himself/herself incompetent to do so.

7.16 Before performing an operation the physician should obtain in writing the consent from the husband or wife, parent or guardian in the case of minor, or the patient himself as the case may be. In an operation which may result in sterility the consent of both husband and wife is needed.

7.17 A registered medical practitioner shall not publish photographs or case reports of his / her patients without their permission, in any medical or other journal in a manner by which their identity could be made out. If the identity is not to be disclosed, the consent is not needed.

7.18 In the case of running of a nursing home by a physician and employing assistants to help him / her, the ultimate responsibility rests on the physician.

7.19 A Physician shall not use touts or agents for procuring patients.

7.20 A Physician shall not claim to be specialist unless he has a special qualification in that branch.

7.21 No act of in vitro fertilization or artificial insemination shall be undertaken without the informed consent of the female patient and her spouse as well as the donor. Such consent shall be obtained in writing only after the patient is provided, at her own level of comprehension, with sufficient information about the purpose, methods, risks, inconveniences, disappointments of the procedure and possible risks and hazards.

7.22 Research: Clinical drug trials or other research involving patients or volunteers as per the guidelines of ICMR can be undertaken, provided ethical considerations are borne in mind. Violation of existing ICMR guidelines in this regard shall constitute misconduct. Consent taken from the patient for trial of drug or therapy which is not as per the guidelines shall also be construed as misconduct.

7.23 If a physician posted in rural area is found absent on more than two occasions during inspection by the Head of the District Health Authority or the Chairman, Zila Parishad, the same shall be construed as a misconduct if it is recommended to the Medical Council of India/State Medical Council by the State Government for action under these Regulations.

7.24 If a physician posted in a medical college/institution both as teaching faculty or otherwise shall remain in hospital/college during the assigned duty hours. If they are found absent on more than two occasions during this period, the same shall be construed as misconduct if it is certified by the Principal/Medical Superintendent and forwarded through the State Government to Medical Council of India/State Medical Council for action under these Regulations.

3. Medical negligence is an act of negligence which can be filed in the Criminal Court for prosecution as well as in the Civil Court for compensation. The examples are operating under the influence of alcohol with resultant harm, operating a wrong limb or the wrong person etc. Medical negligence as well as professional misconduct may not be covered by the insurance company.

Bolum test?
In England, standard applicable is popularly known as the Bolam Test, first laid down in Bolam v. Friern Hospital Management Committee [1957] 2 All.E.R. 118. McNair J., in a trial relating to negligence of a medical practitioner, while instructing the Jury, stated thus:

1. A doctor is not negligent, if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art. Putting it the other way round, a doctor is not negligent, if he is acting in accordance with such a practice, merely because there is a body of opinion that takes a contrary view. At the same time, that does not mean that a medical man can obstinately and pig headedly carry on with some old technique if it has been proved to be contrary to what is really substantially the whole of informed medical opinion.

2.  When a doctor dealing with a sick man strongly believed that the only hope of cure was submission to a particular therapy, he could not be criticized if, believing the danger involved in the treatment to be minimal, did not stress them to the patient.

3.  In order to recover damages for failure to give warning the plaintiff must show not only that the failure was negligent but also that if he had been warned he would not have consented to the treatment. 

Dr K K Aggarwal


 News to use

1. Eat less to remember more, is the new prescription for the elderly. Calorie restriction boosts memory and cognition by reducing insulin resistance and inflammation, which may be linked to age related cognitive decline. Improvements in memory could be especially important, because memory losses are an early indication of Alzheimer's disease and its precursor, mild cognitive impairment.

2.  Eat less, weigh less: Cutting calories leads to long term weight loss. The body's energy requirements progressively decline with age, energy intake must mirror that decrease or weight gain occurs. Women who practice eating restraint avoid the significant weight gain commonly observed in middle age. Tips for better eating: Record what you eat and how much. Put less food on your plate. Eat more fruits and vegetables. The U.S. food pyramid recommends at least five servings each day.

3. Nitrates rich diet is good for the heart: Do not heat leafy vegetables twice. Nitrates in foods such as spinach, beet root and lettuce spur production in the body of nitric oxide, a molecule that relaxes blood vessels. Ingested nitrate is reduced by oral, commensal  bacteria to nitrite, which can further be reduced to nitric oxide Foods in which nitrite are present are bacon, fermented sausage, hot dogs, bologna, salami, corned beef, ham, and other products such as smoked or cured meat, fish, and poultry. The conversion of dietary nitrate to nitrite has antimicrobial benefits in the mouth and stomach. Some epidemiological studies show a reduced rate of gastric and intestinal cancer in groups with a high vegetable-based nitrate intake.

4. By spending thirty minutes each day for four days to write out innermost thoughts and feelings, one can significantly boost mental and physical health. So called expressive writing requires only pen and a paper. In expressive writing therapy, patients are encouraged to express whatever is on their mind, letting their hopes and fears flow out in a natural, unrestrained way. It is like keeping a journal, but more focused on the things that might be bothering one or triggering stress.

5. Snoring at night or sleepy during the day may be a symptom of obstructive sleep apnea, a potentially life threatening problem affecting one out of three diabetics. It occurs when the airway becomes blocked during sleep and is usually caused by the collapse of soft tissue in the back of the throat during sleep. Between snores, breathing stops for a period of 10 seconds or longer, and this pattern repeats itself multiples times over the course of a night.

6.  Smoking while pregnant can damage thyroid function of both the mother and the foetus. Good thyroid function is the key to maintaining a pregnancy. This, in turn, affects metabolism and the risk of miscarriage, premature birth, low birth weight and impaired brain development.

7.  People who develop chronic cough and phlegm (sputum production) are at four fold risk of developing Chronic Obstructive Artery Disease.

8.   Anemia is common in congestive heart failure and if associated carries increased mortality and morbidity. All patients of heart failure should be evaluated for Anemia. {Acta haematology CIA:2-3,109-19 (2009)}

9.  A Data from a literature review has suggested that liver toxicity may be an uncommon adverse effect of AC Inhibitors. These findings are based on an abstract presented at the American College of Gastroenterology meeting.

10.  Even at a low dose, naproxen has been shown to increase the risk of peptic ulcer.   As per a study presented at the American College of Gastroenterology meeting, 500 mg dose per day increases the risk 2.5 times and 750 mg per dose 3 times. 

11.   H pylori regimen is now four drug regimen.  H pylori regimen LOAD has significantly higher eradication rates than current standard 3 drugs LAC regimen.  The new 4 drugs treatment LOAD comprised of Levofloxacin, omiprazole, nitazoxanide and doxicycline. The three drug regimen has been lansoprazole, amoxicillin and clarithromycin. The findings were presented at the American College of Gastroenterology meeting by Dr H P Basu of Columbia University.

12.  A data of retrospective case control study has shown that one in every 5 patients with non alcoholic fatty liver diseases has Hypothyroidism. Presenting a study at American College of Gastroenterology meeting, Dr. Mangesh Pagadala said that all patients with hypothyroidism should be considered a risk group for NAFLD. The study concluded that people of NAFLD are twice as likely to have hypothyroidism as people who do not have liver condition.

13.   C. difficile  spreads from hospital to community: Clostridium difficile infection, a bacterial infection of GI now has become more and more common in the community. Though it is less common than the hospital acquired form of infection, patients with community acquired infection are younger, more females and usually with mild infections.

14.   Dual anti platelet therapy, used to prevent clots associated with coronary stents does not markedly increase the risk of GI bleeding as per a study presented in the American College of Gastroenterology meeting.

15.  As per Dr. W. Chen of Brigham Woman's Hospital in Boston, chronic acid suppression therapy may pre dispose otherwise healthy persons to clinically significant small intestinal bacterial overgrowth (SIBO).

16.  As per a university of North Columbia studies by Dr. Sethcrocaett, use of acne drug Isotretionn is associated with increased risk of inflammatory bowel diseases.


Letters to the editor

1. Dear sir, I am Dr. Dweep J. Vaidya, MBBS AFIH. I am very interested in your daily newsletter emedinews. Its a great innovation for Indian medical world. Thank you. Dweep Vaidya 

2. From Dr Vivek Chhabra
a. Dear AFMCites, in case you are not aware of this interesting initiative by Dr KK, one can subscribe by mailing request to him as well.
b.  Another very important consideration before giving morphine is availability of Naloxone (Narcan) in the stockpile, which one must cross-check for before going ahead of giving the opiates.
c.  Hello Sir, In case of ongoing H1N1 pandemic, I request to have a subsection in the daily news on the same topic to keep us aware of the unfolding scenario. I am happy to contribute if OK on your side.

3. Dear Sir, I came to know about emedinews from one of my senior colleague, Dr. Surendra Daga of Kolkata. I am a Gastroenterologist attached to a premier teaching Institute in Kolkata and have keen interest in recent advances in Gastroenterology & Hepatology. If you kindly send me the regular emedinews updates, it would be of tremendous benefit to me. Dr. Sanjay Bandyopadhyay: SDLD, IPGMER, Kolkata

4.  Dear Doctor, I am an emergency physician. My experience is subcutaneous route is the best for injecting adrenalin in anaphylaxis, with very good results, instead of trying intravenous or intraosseous route as some doctor has mentioned, as when pt is in shock, veins might be collapsed ,instead of wasting valuable time, one should go by S/C route. Dr Veena Mattu

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Make Sure
Mistake: A 50 year old woman with peptic ulcer disease was crying with low backache

Reaction: Oh My God! Why was not topical NSAID considered

Make Sure that no patient is denied the benefits of topical NSAID if the oral ones can not be given.

Clinical tip
Supplements containing B complex and vitamins C and E are efficacious in reducing adverse pregnancy outcomes, including fetal loss, low birth weight and prematurity among HIV infected women. Nutr. Rev. 2004 July;62(7 Pt. 1):269 275.

Dr Good Dr Bad

Situation:  A diabetic woman came with atypical chest pain.
Dr Bad:  This is most likely a silent heart attack
Dr Good: don’t worry
Lesson:  Diabetic women are less likely to have silent infarction; a finding noted in a report from the HERS trial.

Funny clinical notes (Dr. Minakshi)

Patient has chest pain if she lies on her left side for over a year.

 Ambulance colour specifications

FRONT: The word AMBULANCE, minimum 10 cm in height, shall be mirror image of [reverse reading] for mirror identification by drivers ahead, with a blue 'star of life' minimum 8 cm height, to left and right of the word AMBULANCE. if vehicle design permits, their shall be a blue star  'star of life' of no less than 30 cm in height on the front section of the patient compartment.

SIDE: Each side of the patient compartment shall have the blue star 'star of life' not less than 30 cm in height. The word AMBULANCE not less than 15 cm in height, shall be under or bedside each star. the name of the licensee as stated on their provider's license shall be of lettering not less than 8 cm in height.

 REAR: The word AMBULANCE not'less than 15 cm in height, and two blue  'star of life' emblems of not less than 30 cm in height.

 TOP[roof]: Here shall be a blue star 'star of life' of not less than 60 cm in height as well as the individual provider's ambulance number of not less than 30 cm in height. (Dr G M Singh)

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emedinews: revisiting 209

IJCP Group is organizing emedinews: Revisiting 2009, a day long conference on 10th Jan  2010 at Maulana Azad Auditorium. It will be attended by over 1500 doctors. Topics will be happenings in the year 2009. There is no registration fee however advanced registration is required.  Top experts will deliver lectures. CME will be followed by lively cultural evening, doctors of the year award, dance and dinner. For regiatration mail  emedinews@gmail.com. We have crossed 800 registrations.

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