October 8   2015, Thursday
Dr KK AggarwalDr KK Aggarwal
IMA White Paper Draft on Capping of compensation allowable on alleged medical negligence cases

In its judgment in “Dr. Balram Prasad versus Dr. Kunal Saha & Others”, the Hon’ble Supreme Court of India awarded an amount of Eleven Crore Rupees as compensation for medical negligence (Rs.6,08,00,550/- plus 6% interest). This judgment created a sense of panic among the medical professionals in the country. Subsequently in three more cases, the compensation awarded has been more than a crore. This has already led to a huge increase in the number of cases filed (several of which are on frivolous grounds) as well as a significant increase in the premiums paid to insurance companies.

The Hon’ble Apex Court in the case titled as “Dr. Balram Prasad versus Dr. Kunal Saha & Other, Civil Appeal No. 2867 of 2012” has held that: “Therefore, estimating the life expectancy of a healthy person in the present age as 70 years, we are inclined to award compensation accordingly by multiplying the total loss of income by 30. Therefore, under the head of ‘loss of income of the deceased’ the claimant is entitled to an amount of Rs.5,72,00,550/- which is calculated as ($40,000+(30/100x40,000$)-(1/3 x 52,000$) x 30 x Rs.55/-) = Rs.5,72,00,550/-.”

Thus, the Hon’ble Supreme Court has evolved a new formula for the calculation of loss of income of the deceased to be paid as compensation by the doctors. The formula is: 70 - age at death x annual income + 30% inflation - 1/3rd as personal expenses)

After the passing of the aforementioned judgment, now the doctors around the country will be forced to look into the income of their patients as now the doctors fear that in case of some medical complication or in case if the patient dies, then the doctors will have to pay a huge compensation taking into consideration the income of the patient and the formula as enumerated by the Hon’ble Supreme Court.

The said practice of looking into the income of the patient is against the code of medical ethics as enunciated in Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations 2002 as per which the physician, engaged in the practice of medicine shall give priority to the interests of patients.

(i) The said practice is against the declaration which is being given by the doctors at the time of registration with the Medical Council of India. The declaration which is being given by the doctors is enunciated in Clause d of the Appendix 1 of the Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002 which is reproduced hereunder:

“d: I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient”

(ii) Also, the said practice is against Clause 1.8 of the Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002 which is reproduced hereunder:

“1.8 Payment of Professional Services: The physician, engaged in the practice of medicine shall give priority to the interests of patients. The personal financial interests of a physician should not conflict with the medical interests of patients. A physician should announce his fees before rendering service and not after the operation or treatment is under way. Remuneration received for such services should be in the form and amount specifically announced to the patient at the time the service is rendered. It is unethical to enter into a contract of "no cure no payment". Physician rendering service on behalf of the state shall refrain from anticipating or accepting any consideration.”

As of today, the medical expenses / charges for the poor or the rich are the same for a given medical service and the doctors do not discriminate between the patients on the basis of their economic status. But the judgment is making the profession to rethink the charges as per the income of the patient and the same will be a violation of Clause 1.8 Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002.

The said formula of compensation will cause great economic inequality in the country as the doctors will give preference to rich people more than the poor people. For e.g. if in a situation a doctor has two patients and there is only an ICU room available in the hospital than the doctor will allot the said ICU room to a patient whose income is more than the other patient.

Thus, the aforementioned formula as enumerated by the Hon’ble Supreme Court for calculating the loss of income of the deceased violates the fundamental rights of the people as enshrined in the Article 14 of the Constitution of India, 1950 i.e. equality before Law. According to Article 14 of the Constitution of India, 1950, the State should not deny equality before law or equal protection of law within the territory of India. The equal protection of laws means the people have right to equal treatment in similar circumstances. However, because of the aforementioned judgment, the doctors will not be able to give equal treatment to all patients in similar circumstances.

Further, the said formula of loss of income of the deceased also violates the fundamental right of ‘right to life’ i.e. Protection of life and personal liberty as enshrined in Article 21 of the Constitution of India, 1950. This right to life also includes right to health and fair and timely medical treatment. If the doctors have to pay such a huge compensation in case of medical negligence or in any other case, then they will not be able to provide fair and timely medical treatment to patients whose income is less than the other patient whose income is high.

Also, the said judgment violates the Directive Principles of State Policy i.e. Article 38 and Article 39 of the Constitution of India, 1950 as per which the State is responsible to promote the welfare of the people and to minimise the inequalities in income.

Indian Medical Association considers this as a very serious matter and we fear that this may even result in increase in the expenses on medical care.

A review of literature by IMA shows that the process of capping of compensation of medical practice law suits has been well established in developed countries. It is revealed from the information available on records that in the US about 26 states have passed effective legislations for imposing capping on medical negligence compensation varying from state to state in the range of USD 250,000 up to USD 500,000. India needs to adapt the policies being practiced in developed countries to its own requirements and can benefit greatly from their experience.

In India also, there is a capping on the compensation being given to victims of natural calamity, which is approx. Rs. 4 Lakh, being given by the Union Government. Also, in case of failure of sterilisation there is a capping of compensation by the health ministry:

a) Death following sterilization (inclusive of death during process of sterilization operation) in hospital or within 7 days from the date of discharge from the hospital: Rs. 2 lakh.

b) Death following sterilization within 8 - 30 days from the date of discharge from the hospital: Rs. 50,000/-.

c) Failure of Sterilization: Rs 30,000/-.

d) Cost of treatment in hospital and up to 60 days arising out of complication following sterilization operation (inclusive of complication during process of sterilization operation) from the date of discharge: Actual not exceeding Rs 25,000/-.

e) Indemnity per Doctor/Health Facilities but not more than 4 in a year: Up to Rs. 2 Lakh per claim.

Further, according to Article 21 of the Montreal Convention, in case of death of passengers, the airline is liable to pay up to 1,13,100 Special Drawing Rights for each passenger. This works out to approximately $1,74,000 at current rates. (In Indian rupees, this works out to approximately Rs 1.04 crore). If there is a demand for compensation higher than this limit, the airline can contest it.
Also in the Clinical Establishment Act 2010 (23 of 2010), Central rules 2012, rule 9 ii ; “the clinical establishments shall charge the rates for each type of procedure and services within the range of rates determined and issued by the central government from time to time in consultation with the state government.”

When the government has decided to cap the charges, they also need to cap the compensation.

Thus, it is the need of the hour that there should be a capping on the compensation being given in cases of medical negligence by the doctors in India also.

Further, in the absence of any maximum limit/ceiling/capping on the compensation amount, the doctors too are in a dilemma and not able to decide the quantum of insurance cover for their practice. At the same time, the insurance cover is also becoming costlier and less available to the doctors in these circumstances.

In this regard, to safeguard the interest and fundamental rights of the people at large and to avoid un-necessary litigations and to save the precious time of courts as well as medical practitioners, IMA suggests the following:
  1. Amendments in the present act to cap the maximum allowable compensation in any case of medical negligence
  2. Mandatory screening of cases of medical negligence, before the case is admitted in the consumer court
  3. Mandatory provision of seeking expert medical opinion by the court before giving verdict on the technical issues
  4. Defining/ triaging the complaints into frivolous/ injurious/ grievous etc before submitting to the court of law
  5. Provision of penalty (to the Doctor/hospital) to be proportionate to the amount of compensation claimed
  6. The compensation is awarded on the basis of the income of the complainant. But irrespective of the income of the patient, the hospital always same amount for services. Hence the compensation should only be decided on the cost of the treatment.
  7. Health care Arbitrator: Just like insurance disputes are sent to arbitrators an alternative dispute resolution mechanism can be looked into. The provision will be for providers and patients to submit disputes over alleged malpractice to a third party other than a court. This will help compensate victims faster, more equitably, and with lower transaction costs (As of now the administrative cost of such law suits is approximately 53% of the total compensation claimed).
  8. Administrative Compensation Systems: It proposes to replace the current tort system with an administrative compensation system. The “health courts” model substitutes a specially trained judge as the finder of fact and arbitrator of law for the current system’s generalist judges and juries.
  9. Judicial audits of the lower courts to assess fairness and judicious application of mind by the lower court.
  10. A comparative analysis of the outcome of judicial verdicts given in past should also be carried out for better understanding of the effectiveness of the compensations awarded till date.
  11. The legal profession is kept out of the ambit of consumer court. Hence, medical services should also be excluded from the consumer court.
  12. As per Article 38 of the Constitution of India, 1950, it is the responsibility of the State to eliminate the inequalities in status, facilities and opportunities among individuals, groups of people residing in different areas or engaged in different avocations. Thus, the government is requested to set aside the aforementioned formula of calculating the loss of income of the deceased as it will only result in greater inequalities in status, medical facilities, treatment and opportunities among the people.
Breaking news
US approves ‘breakthrough’ drug to fight lung cancer

US authorities have approved a “breakthrough” drug to treat advanced non-small cell lung cancer, signalling a paradigm shift in the way the deadliest of all cancers is treated. In the largest study published to date using immunotherapy to treat lung cancer, the drug Keytruda (pembrolizumab) was tested on approximately 500 patients with non-small cell lung cancer. Because so many of the patients in the study showed significant long-lasting responses, in October 2014 the US Food and Drug Administration (FDA) granted the drug “breakthrough therapy” status for use in lung cancer, allowing it to be fast-tracked for approval. (Source: Financial Express)
Dr Good Dr Bad
Situation: A patient wanted to know if he could take levothyroxine with coffee.
Dr. Bad: Yes.
Dr. Good: No.
Lesson: Coffee, in comparison to water, reduces the absorption of tablet levothyroxine by 27 to 36%.

(Copyright IJCP)
Specialty Updates
  • Menopausal women who experience frequent hot flashes could be at increased risk for subclinical cardiovascular disease, suggested a new study presented at the North American Menopause Society 2015 Annual Meeting.
  • Older adults who have little face-to-face contact with family and friends are at almost twice the risk of developing depression, suggests a new study published in the Journal of the American Geriatrics Society.
  • Improvement in Model for End-Stage Liver Disease (MELD) score in critically ill trauma patients with chronic liver disease is associated with lower mortality, suggests new research published online in JAMA Surgery.
  • Healthy individuals with a first-degree family history of type 2 diabetes have an impaired response to exercise, suggests Swedish research published in the Journal of Applied Physiology.
  • Two new analyses of the Multi-Ethnic Study of Atherosclerosis (MESA) provide evidence that the use of coronary artery calcium screening can reclassify patients at risk from cardiovascular disease and better identify those who would most benefit from statin therapy compared with current guidelines. The studies are published in the Journal of the American College of Cardiology.
  • There is no statistically significant association between the presence of antibodies to Epstein-Barr virus antigens and rheumatoid arthritis, reported a new systematic review and meta-analysis published in Arthritis Research & Therapy.
  • Two major randomized clinical trials that compared laparoscopic surgery with traditional open resection for rectal cancer failed to establish the noninferiority of laparoscopic rectal cancer surgery. The studies were published in the October 6 issue of JAMA.
  • The US Food and Drug Administration (FDA) has approved an injectable, long-acting version of atypical antipsychotic aripiprazole to treat adults with schizophrenia.
  • Being under and overweight at birth is linked with poorer hearing, vision and cognition in middle age, suggests new research published in the journal PLos One.
  • A new study suggests that introducing sit-stand desks in the office spaces would help employees stand for 1 hour more a day at work, compared with co-workers who have sit-only desks. The study results, published in the American Journal of Preventive Medicine, reported that sit-stand desk users walked an additional 6 minutes a day at work and burned an extra 87 calories on average.
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 protest campaigns because it was positive and different.

I have seen three examples in my life where I used this philosophy and could prolong 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 to the Prime Minister daily 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 promotes creativity and when it is with positive attitude, it is accepted by all.
Legal Quote
NCDRC Judgment: Mrs. Rashal Kanwar & Ors V/s. Sir Ganga Ram Hospital & Ors, (Case No.950/2015, decided on 15/09/2015

“No cure is not a negligence of treating doctor.”
TB Fact
Mycobacterium tuberculosis is the second most common infectious cause of death in adults worldwide, the most common is HIV.
A Doctor’s Economic Lifecycle
The economic lifecycle of a doctor is different from that of other professionals like lawyers, bankers, etc. Physician’s earnings rise, but at a decreasing rate, for the first 20 years after medical training; they peak between the ages of 55 and 59; and they decline slightly toward the end of the career.

(Source: IJCP)
Industry News
  • CDSCO and MHRA sign MoU: The Central Drugs Standard Control Organization (CDSCO), part of the Ministry of Health and Family Welfare of India and UK’s Medicines and Healthcare products Regulatory Agency (MHRA) have signed a MoU to promote each other’s regulatory frameworks, requirements and processes. Dr Gyanendra Nath Singh, Drugs Controller General (India) said, “The MoU is going to create a new platform where patients will be given utmost importance. Quality medicine, affordability and transparency will be the tools for making medicines available to the people of the two nations.” (Source: Financial Express – PTI)
  • Rajasthan to invest Rs 500 crore in 500 startups by 2020: New Delhi: Rajasthan may announce its first ever Startup Policy in the coming weeks under which it plans to support about 500 startups in the state by the year 2020. This will make Rajasthan to be the first amongst India's northern states to come out with a policy dedicated to tech startups. (The Times of India- Harsimran Julka)
  • Cost Transformation in Healthcare: PwC’s Health Research Institute has predicted that healthcare costs will rise up to 6.8% in 2015 from the 6.5% estimate for 2014. With the advances in mobile technologies, social media, smartphone apps, wirelessly connected devices, and sensors will trigger a new level of patient expectations. Online appointment booking, finding the right doctor, and other features may soon be available on mobile devices. (ETHealthworld.in)
  • Most popular social sites in India: Facebook remains the most popular social networking site in India with 51% of users logging on daily, while WhatsApp tops the list of instant messaging (IM) apps with 56% users, according to report by global research consultancy firm TNS. (Firstpost)
Cardiology - Yesterday, Today & Tomorrow - A CME was organized by IMA HQs on World Heart Day at IMA House, New Delhi
Inspirational Story
We miss God's blessings because they are not packaged as we expected

A young man was getting ready to graduate college. For many months he had admired a beautiful sports car in a dealer's showroom, and knowing his father could well afford it, he told him that was all he wanted.

As Graduation Day approached, the young man awaited signs that his father had purchased the car. Finally, on the morning of his graduation his father called him into his private study. His father told him how proud he was to have such a fine son, and told him how much he loved him. He handed his son a beautiful wrapped gift box.

Curious, but somewhat disappointed the young man opened the box and found a lovely, leather-bound Bible. Angrily, he raised his voice at his father and said, "With all your money you give me a Bible?" and stormed out of the house, leaving the holy book.

Many years passed and the young man was very successful in business. He had a beautiful home and wonderful family, but realized his father was very old, and thought perhaps he should go to him. He had not seen him since that graduation day. Before he could make arrangements, he received a telegram telling him his father had passed away, and willed all of his possessions to his son. He needed to come home immediately and take care of things. When he arrived at his father's house, sudden sadness and regret filled his heart. He began to search his father's important papers and saw the still new Bible, just as he had left it years ago. With tears, he opened the Bible and began to turn the pages. As he read those words, a car key dropped from an envelope taped behind the Bible. It had a tag with the dealer's name, the same dealer who had the sports car he had desired. On the tag was the date of his graduation, and the words...PAID IN FULL.

How many times do we miss God's blessings because they are not packaged as we expected?
First aid for poisonous bites and stings

People often panic if they have been bitten or stung. You should tell the patient that many snakes, spiders, insects and sea creatures are harmless and that even the bites and stings of dangerous animals often do not cause poisoning.

Keep the patient calm and still. Moving the bitten or stung limb speeds up the spread of venom to the rest of the body. Fear and excitement also make the patient worse. The patient should be told not to use the limb and to keep it still and below the level of the heart. The limb may swell after a while, so take off the patient’s rings, watch, bracelets, anklets and shoes as soon as possible. A splint and a sling may help to keep the limb still. Avoid doing the following:
  • Do not cut into the wound or cut it out.
  • Do not suck venom out of the wound.
  • Do not use a tourniquet or tight bandage.
  • Do not put chemicals or medicines in the wound or inject them into the wound (for e.g., potassium permanganate crystals).
  • Do not put ice packs on the wound.
  • Do not use proprietary snake bite kits.
  • The patient should lie on one side in the recovery position so that the airway is clear, in case or vomiting or fainting.
  • Do not give the patient anything by mouth – no food, alcohol, medicines or drinks. However, if it is likely to be a long time before the patient gets medical care, give the patient water to drink to stop dehydration.
  • Try to identify the animal, but do not try to catch it or keep it if this will put you, the patient or others at risk. If the animal is dead take it to hospital with the patient, but handle it very carefully, because even dead animals can sometimes inject venom.
  • As soon as possible, take the patient to a hospital, medical dispensary, or clinic where medical care can be given. The patient should not walk but should keep as still as possible. If there is no ambulance or car, carry the patient on a stretcher or trestle, or on the crossbar of a bicycle.
  • Antivenom should only be given in a hospital or medical Centre where resuscitation can be given, because the patient may have an allergic reaction. If available, antivenom should be used if there is evidence of severe poisoning. It should not be used when there are no signs of poisoning.
Successful Marriage

A couple had been married for 45 years and had raised a brood of 11 children and were blessed with 22 grandchildren. When asked the secret for staying together all that time, the wife replies, "Many years ago we made a promise to each other: the first one to pack up and leave has to take all the kids."
Achieving Privacy and confidentiality in day to day practice- an ethical dilemma

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

Doctors in busy settings face an ethical dilemma. Maintenance of confidentiality and privacy becomes problematic due to the use of shared rooms. At times, the patient hesitates to share medical information due to this fact. More funds and better infrastructure may not always be possible. What is your preferred solution in such circumstances?

a) Ignore the issue as sharing information is culturally acceptable in India

b) Acknowledge overcrowding, try to make the patient comfortable within the shared setting

c) Extend work hours, push back appointments to ensure one patient per room at a time

d) Whisper/ talk in low voices

Do write in with your views and solutions.

Here are the responses received
  • I will go for a) Ignore the issue, as sharing information is culturally acceptable in India unless someone specifically asks for not sharing a small part of information. Saranya Devanathan, Psychiatrist
  • I think we cannot see 2 or 3 patients in one room. The patient’s right of privacy cannot be compromised for any reason. Each patient should be interviewed in a single room, and the patient and the family members should also be seen separately at least once and as and when needed. Infrastructural issues cannot be the excuse for inefficient treatment. Prof. Anil Agarwal, Psychiatrist
  • Lack of infrastructure is not an excuse for not observing privacy and confidentiality Patients should be seen alone as well as with family members. Prof. Satish Malik
  • Explain that the other person too is a doctor like me and assure that she would maintain confidentiality. Sudhakar Bhat, Psychiatrist
  • It is very difficult to provide a separate place and extending work hours may not be possible for doctors. They can talk in low voices and make the patient as comfortable as possible. If the issue really demands confidentiality like HIV or any other which patient is not at all confident to discuss in overcrowded situations, then extra time can be given after the crowding hours. Respecting the privacy of the patient is very important. Triptish Bhatia, Principal Investigator, GRIP-NIH, USA Project, Dept. of Psychiatry, Dr Ram Manohar Lohia Hospital, New Delhi
  • Firstly, we can have cabins or space with glass partitions, which prevent the sound from reaching other places. Secondly, if we are to be economical then probably the patients, of course depending upon their problem and certainly alongside giving him assurance and confidence about confidentiality, can be asked to record their voices in their phones and then ear phones can be used as a medium to listen to the voice recorded by the patient. These ear phones shall be inserted/worn by both - the patient as well as the client so that they are on the same track of conversation. But, this can be done only at the time of case history taking. If the client is educated, he can write and the doctor can ask and clarify. Enquiry questionnaires could be used. Structuring the room accordingly can help. I don't know how much do we support online counselling and case history taking. However, people (doctors and patients) who are ready for the online case history-taking, shall be taken separately by doctors at say a particular day and they must be given facility and services of the same with helpers available around in a particular room Or can be done in a booth placed to be able to communicate with the doctors in any given area within the compound. Parul
  • Lack of rooms is a fact in mental health care. But mental health service cannot and should not be stopped due to this fact only. Privacy is definitely an important issue but when infrastructure is not adequate then also treatment means a lot. When any country does not have adequate infrastructure then decision should be taken according to what is available in nearby surrounding. So treatment comes first as per hierarchy of decision criteria. So the clinician should explore the possibility of privacy if possible. S/he may evaluate himself/herself, the nature of information forthcoming during the interview and take decision accordingly whether to ensure privacy or not. However privacy of any nature should be given due respect. But this suggestion is for setting where rooms are not available in adequate number. So the clinician may also ask the patient and family about their comfort level. However it has been observed that people do not care that much in a hospital outpatient department as they have their mind made up for such crowded places. And again people feel a kind of security being stranger in the crowd. If there are not too many patients then privacy must be secured for the patient. But during a rush this issue should be dealt by considering the nature of the problem and the sensitivity of the patient and the family. Ranjita Thakur
  • Having interned at Sion Hospital in Dept of psychiatry department, this dilemma was an everyday problem. However, practitioner skills made huge difference. Doctors who were able to successfully get history and provide details at the same time respecting confidentiality showed the following:
    • Apologize to the patient for the overcrowding but saying at the same time that all these people require a doctor so we have to work with this.
    • Telling that other professionals in this room are competent and caring doctors and will not make fun of (most men who were hesitant came with premature ejaculation issues); instead can actually assist in solving the problem.
    • Allowing them to speak softly if it is a sensitive detail.

      Therefore if we really want to keep patient’s interest at the fore, a way can always be found to do so. Sadaf Vidha
  • Acknowledge overcrowding, try to make the patient comfortable within the shared setting and talk in an audible voice/tone. At the same time, if the number of patients is very high, capital expenditure in infrastructure is required. Dr S Rastogi, Director
  • It is quite natural that the patient will not like to express his symptoms before anybody and the doctors may not find a place to listen to him exclusively. In this situation, if the patient is hesitating to tell his problem, the doctors should ask him to write it on a paper and the doctor should read it and give it back to him after reading. Dr BR Bhatnagar
Breaking news
The Assisted Reproductive Technology (Regulation) Bill, 2014

(4) A child or children born to an ever married woman artificially inseminated with the stored sperm of her dead husband shall be considered as the legitimate child or children of the couple.

(7) If Overseas Citizen of India, People of Indian Origin and a foreigner married to an Indian citizen seeks sperm or egg donation, or surrogacy in India, and a child or children are born as a consequence, the child or children, even though born in India, shall not be an Indian citizen but shall be entitled to Overseas Citizenship of India under Section 7A of the Citizenship Act, 1955.

64. (1) Any medical geneticist, gynaecologist, registered medical practitioner or any person who owns or operates any assisted reproductive technology clinic or assisted reproductive technology bank is employed in such a assisted reproductive technology clinic or assisted reproductive technology bank and renders his professional or technical services to or at such assisted reproductive technology clinic or assisted reproductive technology bank, whether on an honorary basis or otherwise, and who contravenes any of the provisions of this Act or rules made there under shall be punishable with imprisonment for a term which may extend to five years or with fine which may extend to rupees ten lakhs or with both and on any subsequent contravention, with imprisonment for a term which may extend to seven years or with fine which may extend to rupees fifteen lakhs or with both.
Situation: A patient with diabetes shows deteriorating kidney function.
Reaction: Oh my God! His HbA1c is very high!
Lesson: Make sure that strict glycemic control is maintained in patients with type 2 diabetes in order to delay vascular complications.
IMA Digital TV
IMA Stress Detox & Leadership Meet

IMA is organizing a 2-day Detox Meeting of state/local branch presidents and secretaries at Om Shanti Retreat Centre, Pataudi Road, Near Manesar, Gurgaon on 10th and 11th October, 2015. This meet is being organized by IMA in association with Heart Care Foundation of India and Brahma Kumaris. The final program is as below.

Saturday 10th October 2015
12.00 noon to 2.00 PM
Allotment of Rooms to the delegates
4.00 PM to 4.30 PM
Address by National President & Hony. Secretary General
4.30 PM to 5.00 PM
Acquiring Leadership Qualities (BK)
5.00 PM to 5.30 PM
Detox Tea
5.30 PM to 6.30 PM
6.30 PM to 7.00 PM
Communication Skills (BK)
7.00 PM to 7.30 PM
IMA Satyagraha
7.30 PM to 8.30 PM
Detox Dinner
8.30 PM to 9.00 PM
Clinical Establishment Act (IMA)
9.00 PM to 11.00 PM
Spiritual Outing and Relaxation in Detox atmosphere (BK)

Sunday 11th October 2015
7.00 AM to 8.00 AM
Pranayam & Rajyog Meditation
8.00 AM to 9.00 AM
Detox Breakfast
9.00 AM to 9.30 AM
Acquiring Leadership Qualities (BK)
9.30 AM to 10.00 AM
Happy Group (BK)
10.00 AM to 10.30 AM
Violence against doctors
10.30 AM to 11.00 AM
Communication Skills (BK)
11.00 AM to 11.30 AM
11.30 AM to 12.00 Noon
Doctor-Patient Relationship (BK)
12.00 Noon to 12.30 PM
Clinical Establishment Act (IMA)
12.30 PM to 1.00 PM
Detox of doctors (Dr KK)
1.00 PM to 2.00 PM
Detox Lunch
2.00 PM to 2.30 PM
Parasympathetic lifestyle
2.30 PM to 3.00 PM
Parasympathetic lifestyle
3.00 PM to 3.30 PM
Open House Discussion
3.30 PM to 4.00 PM
Open House Discussion & Resolutions
4.00 PM onwards
Prasadam & Valedictory Function
WMA Supports New Call to Action on Climate Change
(06.10.2015) The World Medical Association, with its 111 national medical association members and constituent bodies, has joined the World Health Organisation’s new call for urgent action to protect health from climate change. The WMA has strongly supported today’s WHO call to action, which aims to mobilize the health community to call for a strong and effective climate agreement that will protect health and save lives.

Dr. Xavier Deau, President of the WMA, said: ‘It is vital that in the run up to the United Nations climate change conference in Paris this December the voice of physicians is heard loud and clear about the risks posed to health by our changing climate. As the WHO says today, the worldwide health community represents an unprecedented and influential collective voice. ‘The WMA has a potential reach out to 10 million physicians and we believe their voice can raise public awareness and explain the ways in which climate and health are closely linked. There is now irrefutable evidence that we need to take action on climate change to protect human health.

‘That is why health must be given a greater priority in the climate change talks in Paris. Climate change is the greatest global health challenge of the 21st century. But we must act now if we are to prevent the infectious diseases, increased malnutrition and premature deaths, facing particularly the most vulnerable populations, which will result from more heat waves and other extreme weather events.’
GP Tip: The Formula of 5-2, 5-2

For relapse, default or failure cases of TB remember the formula of 5-2, 5-2, which is 5 drugs for 2 months and 5 months with 2 drugs.
Breastfeeding support improves in many US hospitals

Hospital support for breastfeeding has improved since 2007, according to the latest CDC Vital Signs report released today. The percentage of U.S. hospitals using a majority of the Ten Steps to Successful Breastfeeding, the global standard for hospital care to support breastfeeding, increased from approximately 29 percent in 2007 to 54 percent in 2013, a nearly two-fold increase over six years. Improved hospital care could increase rates of breastfeeding nationwide and contribute to healthier children. “Breastfeeding has immense health benefits for babies and their mothers,” said CDC Director Tom Frieden, M.D., M.P.H. “More hospitals are better supporting new moms to breastfeed -- every newborn should have the best possible start in life.” (Source: CDC)
WHO/UNAIDS launch new standards to improve adolescent care

6 October 2015, Geneva: New Global Standards for quality health-care services for adolescents developed by WHO and UNAIDS aim to help countries improve the quality of adolescent health care. Existing health services often fail the world’s adolescents (10-19-year-olds). Many adolescents who suffer from mental health disorders, substance use, poor nutrition, intentional injuries and chronic illness do not have access to critical prevention and care services. Meanwhile, many behaviours that have a lifelong impact on health begin in adolescence. “These standards provide simple yet powerful steps that countries – both rich and poor – can immediately take to improve the health and wellbeing of their adolescents, reflecting the stronger focus on adolescents in the new Global Strategy for Women’s, Children’s and Adolescents’ Health that was launched in New York in September,” says Dr Anthony Costello, Director of Maternal, Children’s and Adolescents’ Health at WHO. (Source: WHO)
Readers column
  • Dear Sir, The bill is envisaged to register paramedics and physiotherapists. Such a council is required. On a preliminary scrutiny of the bill, my opinion is that, it is generally acceptable. Doctors are also included as members. We should demand a representation for IMA also. Dr Jayakrishnan AV, State Secretary IMA Kerala, National Coordinator, Committee for Medicine and Law
  • This looks like the NCHRC bill with a different name. Grossly it looks very ominous. Need to have a detailed study and deliberations urgently to formulate our opposition to certain provisions and include them in our charter of demands in the proposed Satyagraha of 16th November. Here are a few observations & objections: Will MCI/DCI etc. be dissolved? The Council is headed by the Secretary Health, so no democratic representation. The Central govt can supersede, this means no autonomy. The provision for imprisonment is draconian. What will be the fate of the state councils? Dr Ravi Wankhedkar
  • Dear Dr KK, thank you for the information regarding the new Allied and health care bill. An in-depth scrutiny of the bill is needed. Kindly provide full text of the bill. Dr Babu Ravindran
  • Respected IMA leaders, we need to oppose this act tooth and nail. How can a bureaucratic set up decide professional misconduct? We need to give the Govt, the conditions of health care facilities of developed countries and also their regulatory mechanisms. I request you all to form a core committee to study these aspects in details. I also feel that WHO or other similar International agency's guidelines should be considered about all these aspects and take this issue at International level as our standards of health care and medical education should be at par with international standards. Dr Sanjay Deshpande
  • This is an old wine in new bottle NCHRC. The Govt is trying to replicate what it did in regard to CEA, introduced the same bill with different name. Govt. is trying to do away with the role of MCI in the guise of amalgamating all healthcare professional education and training to be regulated by Central body of all Govt. appointed Babus and few handpicked Govt. favored Advisers. We need to study it in detail and create awareness among MPs and Parliamentarians and Public. Dr Krishna Parate, Chairman NPPS, Nagpur
  • Dear colleagues, whether you get paid for your service in stabilizing the patients or not, even in a primary set up, the most important point should be “treatment should be excluded from consumer disputes”. If there is a dispute, the State should defend the doctor and his/her establishment. Will it be possible? We have to face two swords... Not being paid and Consumer action with mob fury. God save the savior. Dr LVK Moorthy
All of the following features can be observed after the injury to axillary nerve except:

1. Loss of rounded contour of shoulder.
2. Loss of sensation along lateral side of upper arm.
3. Loss of overhead abduction.
4. Atrophy of deltoid muscle.

Yesterday’s Mind Teaser: Referred pain from ureteric colic is felt in the groin due to involvement of the following nerve:

1. Subcostal.
2. Iliohypogastric.
3. Ilioinguinal.
4. Genitofemoral

Answer for Yesterday’s Mind Teaser: 4. Genitofemoral

Answers received from: Dr Kusum Gandhi, Dr B R Bhatnagar, Dr Pravar Passi, Priyanka Kesarwani, Dr Jainendra Upadhyay, Dr Bitaan Sen & Dr Jayashree Sen, Dr Poonam Chablani, Daivadheenam Jella, Dr K V Sarma, Dr K Raju, Dr Avtar Krishan.

Answer for 6th October Mind Teaser: 1. Buccinator.

Correct Answers received from: Kusum Gandhi, Dr Pravar Passi, Dr Poonam Chablani, Dr B R Bhatnagar, Dr K V Sarma, Dr K Raju, Dr Avtar Krishan, Daivadheenam Jella, Dr Avtar Krishan.
Press Release
IMA, HCFI & Indian Oil Corporation release guidelines on dengue management

Put up over 50 hoardings in Delhi NCR with the aim of creating awareness and dispelling common myths

In an attempt to dispel myths and create awareness about the ongoing dengue outbreak in the city, IMA, HCFI and Indian Oil Corporation have released a set of guidelines for the management of the disease. These guidelines have been put up in the form hoardings across the National Capital Region in both English and Hindi.

Speaking about the issue, Padma Shri Awardee Dr. A Marthanda Pillai – National President IMA & Padma Shri Awardee Dr KK Aggarwal – Honorary Secretary General IMA in a joint statement said,” The incidence of dengue will continue to exist this month and instead of creating unnecessary chaos and panic, it is essential that awareness is created about its 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 hospitalization. We have put up over 50 hoardings in the city in association with the Indian Oil Corporation to be able to educate people about the basic preventive measures and necessary treatment options for effective dengue management."

Some of the locations where the hoardings have been put include all important Indian Oil fuel stations including the Centre Half Service Station, JB Tito Marg, Sadiq Nagar; Super Auto, Srinivas Puri; Dhingra Service Station, Chirag Delhi; Rajkumar Service Station, IIT Crossing; Gupta Service Station, Motibagh; Coco Service Station, Jungpura; Khyber Service Station, Ring Road and Ashoka Service Station, opposite Asiad village.

Guidelines for Dengue Management

Simple Dengue Fever:
  • Over ninety-five percent people suffer from simple dengue fever, which is not as threatening as severe dengue fever.
  • In simple dengue fever there is no capillary leakage, the person requires only oral fluids, 100 ml per hour, and is advised to visit a local doctor
  • Additionally, the patient is recommended to drink 500 ml water at the time of diagnosi Only those patients with dengue fever who have vomiting should consume intravenous fluids
Severe Dengue Fever:
  • Those suffering from severe dengue develop capillary leakage and intravascular dehydration. Also, they suffer from a rapid fall in the platelet count along with rapid rise in their hematocrit levels They will have rapid fall in platelets along with rapid rise in hematocrit levels
  • Persistent vomiting, nausea, extreme exhaustion and lethargy are some of the symptoms of dengue. Along with these symptoms, a victim might suffer unrelieved abdominal pain and mental irritability and confusion.
  • These people require close daily observation
  • Dengue patients are kept under close observation and are recommended to consume 1500 ml fluids (20 ml per kg) immediately
  • And in case, when they cannot consume liquids orally, then intravenous fluids are a must
Formula of 20 to identify high risk cases of Dengue fever:
  • If there is a rise in pulse by 20
  • Fall in upper blood pressure by 20
  • Rise in hematocrit by 20 percent
  • Rapid fall in platelets to less than 20,000
  • Platelets count of more than 20 in one inch after tourniquet test
  • If the difference between upper and lower blood pressure is less than 20, then such cases should be given 20 ml of fluid per kg immediately and then shifted to nearest medical center for medical assistance
What you need to do in case symptoms are prevalent?
  • The follow-up tests are required to witness the rise in hematocrit and significant fall in the level of platelets.
  • The tests are required to be screened simultaneously.
  • Platelets transfusions are not required unless there is active bleeding and platelet count is less than 10,000
  • Keep a tab on hematocrit levels are crucial as their count decides the adequate requirement of fluids required by the body
It is important to remember the following:
  • Capillary leakage only occurs when the fever is on the verge of subsidin
  • In the initial 48 hours, including 24 hours after fever is over, are crucial, and the patient requires plenty of fluids as a sub-treatment
  • Signs of itching or rash usually occur post the capillary leakage period is over
When is urgent admission required?
  • If the patient is unable to consume or tolerate the consumption of liquids
  • Pregnant women Underlying comorbid conditions
  • Infants or elderly people
  • Patients suffering from uncontrolled diabetes
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