Author: akshay

Last week, an interesting question was raised in our primary care fellowship ECHO session. “Can you give consultation to a minor without the guardian’s consent?” A simple scenario could be when a 15 year old girl comes to your clinic alone, anxious, and asks for a consult. Would you proceed normally? Would you ask her to call her parents and come back? What would you do?

During the session I quickly searched and found an article in Indian Pediatrics, which said that “A child between 12-18 years can give consent only for medical examination but not for any procedure”. But then, I went back to see on what legal basis this was said. They seem to have referred Legal Aspects of Medical Care, a book by RK Sharma. I unfortunately do not have this book to figure out which source in law RK Sharma has used.

So I started searching more. In National Medical Journal of India, Karunakaran Mathiharan goes through various clauses of multiple statutes and state that there is a need for clarity, specifically that “The Indian Penal Code is silent about the legal validity of consent given by persons between 12 and 18 years of age”

In a “special article” in Indian Journal of Anaesthesia co-authored by a couple of anaesthetists and a lawyer, they say “A child >12 years can give a valid consent for physical/medical examination (Indian Penal Code, section 89).” (sic). And then they give reference to “Rao NG. Ethics of medical practice. In: Textbook of Forensic Medicine and Toxicology. 2 nd ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd.; 2010. p. 23-44. ” Sure enough, Rao NG’s book does mention this on page 35.

But, unfortunately, Section 89 of IPC doesn’t really say so. Section 89 talks about “Act done in good faith for benefit of child or insane person, by or by consent of guardian.” (emphasis supplied). In my reading of section 89, it only applies to acts by guardian or by the consent of guardian. A doctor doesn’t become the guardian or “other person having lawful charge of that person” at no time in their usual work. So this is just propagation of errors.

There is a “Scientific Letter” in Indian Journal of Pediatrics, which reads only sections 87 to 90 of IPC and boldly claim that a child above 12 years age can give consent for routine elective surgery. The authors have affiliation to departments of forensic medicine or pathology. I agree with their interpretation of the sections, but I have to warn others that this does not ensure that a judge will agree with this interpretation. I could not find from sources I have whether this interpretation has been tested in any court.

The other side of the story is that according to Indian Contract Act, only someone who has attained age of majority is competent to contract. Age of majority is 18 in India. The doctor patient relationship is a contract – implied or explicit. Therefore, a minor cannot really enter into a doctor patient relationship. But in my opinion, this should only matter when there is a question about the legality or the validity of the doctor patient relationship. To just talk to a minor, there needn’t be a doctor-patient relationship.

Here is a link to the Indian Penal Code. Read sections 87 to 90 and form an opinion on your own.

If you ask me what I would do when a 13 year old comes to me for a consult, I would say “I would go ahead and talk to them to see what they are here for, but I would not do any procedures or anything that could (even theoretically) cause harm”.

Dr Payal Tadvi committed suicide exactly a week ago. She was a postgraduate student in Obstetrics & Gynecology. Investigation is going on about the death. There are quotes from family members that she was being harassed on the basis of caste by seniors. Those seniors have written their side blaming workload. (Please go through the links if you do not know the details)

Let us leave them aside and ask ourselves a few questions now.

Is their discrimination in medical colleges?
There is. All kinds of it. Economic capacity. Skin tone. Age. Seniority. Language. Region. Residence in the state where the medical college is in. Category of seat. Every damn kind of discrimination. There is discrimination in medical colleges.

Is their caste-based discrimination in medical colleges?
I think the answer is yes. I haven’t seen much first hand. But, there is definitely discrimination based on reservation. And since reservation is based on caste, it can indirectly be told that this is caste-based discrimination (I guess).

Reservation is seen as giving unfair advantage to people. People who get their seats through reservation are seen as people who do not deserve the seats. When they get low marks this is brought up again as the reason (and not that most people end up with low marks in medical colleges, no matter which kind of seat they got while entering).

Is their excess workload in medical colleges?
Undoubtedly, yes. This is a complete failure of the public health system of our country. Have you seen the medical OPD of a government tertiary care hospital at 10am? The doctor there has no time to even breathe. Patients with any kind of condition – simple/complicated are referred/self-referred to tertiary care centers necessarily/unnecessarily. This kills the efficiency of government tertiary care centers. And on the other hand, primary and secondary level centers go underutilized. Not many hospitals have the system to reject patients. I have heard NIMHANS does this. They screen, they accept/reject patients. They refer back to lower hospitals as soon as possible. This perhaps prevents NIMHANS from going crazy (pun intended). But what about other big government hospitals?

Is this workload issue exacerbated by seniority based hierarchy?
Yes again. Medical colleges work on the principle of infinite delegation. The Head of Unit delegates to Professor. Professor to Assistant Professor. AP to Senior Resident. Senior resident to final year PG. Final year PG to second year PG. Second year PG to First year PG. First year PG to Intern. Intern to the patient, sometimes, even.

When the delegation culture is accepted, there is no way adding more staff helps, either. If you are a new staff and you don’t delegate, you are an idiot.

Is ragging accepted?
Yes. The entire system is a form of ragging. The hierarchy I just described, that is the foundation of it. That a junior is the slave to the senior is the concept that underlies the hierarchy. The sort of visible ragging that is prohibited through law is just tip of the iceberg. This visible ragging is the initiation step into the hierarchy. The catch-them-young process of making people subservient. The training phase for silent acceptance.

If it is so bad, why does nobody speak about it?
Can’t you see the irony of the situation? The system is designed to prevent people from asking questions. From the first day of medical college people are taught to stop thinking for themselves, to mend in like sheep, to stay low and not attract attention. (This happened to me. I was overjoyed on the first day of medical college about the fact that I am finally in a medical college and I was wearing a small smile on my face in the histology lab when attendance was being taken. One of the faculties was offended by my smile. A “helpful” old faculty suggested to me that I change my ways. Literally on day one.)

Who do you think, trained “well” in such a system, will come out and criticize the system? Only those who could keep their spirit alive throughout, or those who could rekindle their spirit afterwards. How many of us are capable?

Plug: Is this herd mentality also the reason why people are stuck in the race for specialization?
You answer.

When I hear “Artificial Intelligence” and “Healthcare” together in a sentence, it is usually never a pleasant thing I’m listening to. There almost always is some kind of reinvention of wheel where Google’s hardware cycles are spent in trying to solve something meaningless.

For example, it is futile to differentiate between tuberculosis and cancer from an image of the chest where the answer may never lie in the image, but rather in the symptoms of the patient. Even if AI tells the physician that the ECG it is reading is normal (which the physician probably noticed on their own), the physician still has many reasons to refer the patient to a higher center.

These are isolated examples. But it is the isolation that makes these good examples. AI’s role is not in isolation. AI’s role is in integration. AI (or computers) should come in and fill in where humans struggle – processing large amounts of data. (Processing data, not for the sake of figuring out patterns that humans have easily learned, but for the sake of figuring out patterns, perhaps within an individual, that a human cannot easily learn by going through information)

AI can be a very good physician assistant. I have previously written about an intelligent EMR. The only barrier to using digital EMRs is the user interface. There are ways to optimize that interface. An intelligent combination of predictive suggestions, tapping rather than typing, reading data from text, etc will help.

Once physicians can start using EMRs the possibilities are endless. Here is a list of things that come to the top of my mind:

1. Intelligent to-and-fro symptom/sign/examination suggestion (that physicians can use to not miss important symptoms)
2. Standard treatment guidelines based suggestions on medications and investigations
3. Drug interaction checker
4. Locally relevant and contextual antibiotic resistance patterns
5. Patient’s past reports based insights, trends, analytics, etc
6. Medical records exporting, highlighting important information, etc.

If you are interested in building something like this with me, let me know.

My
favorite book is “The Emperor of All Maladies – a Biography of Cancer”.
If you ask me, it is a textbook of medicine (especially public health)
that every medical student should read. But I can make a fairly
reasonable bet that the college library wouldn’t have that book, even
today. But, I also know for a fact that it has multiple copies of all
the editions of a book titled “Companion for 1st MBBS” (and also 2nd
MBBS, 3rd MBBS, and 4th MBBS). This is a question bank which contains
past questions asked in the university exam. It is perhaps the most
widely read book by the undergraduate student in Rajiv Gandhi
University. And that speaks volumes about what our education system
prioritizes. Libraries are only victims to the same.

The other day I saw an impassioned plea from a doctor asking associations to “regulate the profession”. The reason they cited was that healthcare is turning commercial and often this goes against the best interest of the patient.

One of the many things I learned in National Law School listening to Prof Nandimath and others is that “regulations” come with their own set of problems.

Let us look at it more closely.

First, what is the problem we are trying to solve? The healthcare system in our country (many other countries too, perhaps) have huge flaws in it that lead to suffering and poor quality of care for the end user (the patient). Medical training is focused on the wrong parameters (recent change of UG curriculum to a competency based curriculum is proof of this). Distribution of healthcare providers is disproportionately concentrated in urban areas. Healthcare is episodic. Government policies are weakening public health system. (Public health system, even otherwise, has a huge set of problems of its own). Private healthcare is becoming increasingly commercialized with doctors themselves becoming silent or vocal salespersons of treatment that costs more and earns more profit rather than treatment that the patient actually needs and prefers.

Where is the problem? If you can find out a single problem as the “root cause” you perhaps are being too optimistic. There are problems everywhere, many cross cutting factors are responsible. Many factors are outside anyone’s control. Many factors require complex solutions that span economics, politics, education, and other dimensions of the nation.

Sure, we need to start somewhere. Can we look at regulation of the profession as one possible starting point out of many? Let’s take a deeper dive into that.

When someone says “we need more regulations”, what do they actually mean?

Regulation is always a top down thing. There needs to be a regulatory body or a regulator. And then this regulator has to control or rule over the regulated. Who constitutes a regulatory body? People with various backings, various moral stances, and various external forces acting on them. Who appoints these people? What is the process of selection? Who keeps them accountable? Who are they answerable to? What lobbying power do large establishments have on them? What lobbying power do patients have on them?

Let’s say we found a perfect, ethical, practical, reasonable, diverse, sensitive, enthusiastic, energetic regulatory body. Such a regulatory body often “regulates” through policies or guidelines. Now when it comes to policy, there are two more fundamental issues.

First is formulation of policy. For the sake of simplicity of understanding, let us call it “law”. What are the considerations one has to have when a law is framed? It has to protect the vulnerable from the extremely powerful. It should not prevent progress. It should not be in contradiction with the Constitution. It should be sensitive to the needs and demands of the society, while at the same time being considerate of the needs and demands of the professionals. Imagine creating a one-size-fits-all law in a large country like India. What is practical in urban India may not be practical in rural India. What is practical among literate people may not be practical among illiterate. Sometimes things that make a lot of sense to the policy maker in their office room may make no sense in real world practice.

Despite all that even if a policy gets formulated, there is the question of implementation. In a country ruined by corruption and with single states that have population larger than most other countries, how should policies get implemented? Who will enforce implementation? Technology is usually thrown around as a solution. But technology has deep limitations, especially in solving problems that are fundamentally because of what is inside the devious human mind.

“Regulations” don’t come easy.

But, when ill-devised regulations come in, they can become really harmful to the entire ecosystem. There are countless examples and discussing the demerits of each is out of scope of this article.

What then is a better solution? The answer is that there is no simple or single solution to most of world problems. It takes patient and broad thinking, years (or generations) of effort, and commitment from all the stakeholders to work towards solving the problems to arrive at solutions. Sure, regulations may also be part of that solution. But even those regulations need to be the product of deep engagement from everyone. Pushing things onto others’ plate is not going to help. What is helpful is if those who complain are also making an attempt at the solution.

Many doctors have very little time to spend with the patient. So little time that sometimes they start writing prescription before even arriving at a provisional diagnosis. Imagine how then, would they explain to their patient why they have written a particular tablet for them?

Is there a product/service idea in this vacuum of counseling that should have been provided by the doctor? Are there people who are not able to ask the right questions to the internet to find the answers?

Perhaps there should be an app that is front-end for a prescription description service. The user uploads their prescription and also attaches a short voice note with their symptoms. This goes to a doctor/nurse/pharmacologist/pharmacist at the back-end who responds by reading out the prescription and counseling the patient about what the medication is, what it does, what side effects can be expected, etc.

The counseling of each medicine can be recorded and reused for the next patient who is prescribed the same medicine. That way, the time required by the specialist is minimized. If a patient can afford and requires a longer, customized consultation, they can request that for a higher cost. Then it can work economically as well.