|Year : 2015 | Volume
| Issue : 1 | Page : 1-3
Responsibility and accountability
Columbia Asia Referral Hospital, Yeswantpur, Bengaluru, Department of Anesthesiology, Karnataka, India
|Date of Web Publication||3-Feb-2015|
Prof. Rebecca Jacob
Columbia Asia Referral Hospital, Yeswantpur, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Jacob R. Responsibility and accountability. J Anaesthesiol Clin Pharmacol 2015;31:1-3
Excerpts from the second Past President Oration of the Research Society of Anaesthesia and Clinical Pharmacology
'Medicine is not merely a science but art: The character of a physician may act more powerfully upon the patient than the drugs employed.'
When we are young we are romantic, filled with dreams and aspirations of taking the world by storm, dreaming of finding answers to all the worlds woes and definitely standing by the Hippocratic oath.  Our duties are clearly demarcated into self-regulation, where we need to maintain an ethical code of conduct, avoiding negligence and malpractice and accepting external regulation by the law (The law does not cure all ills but does facilitate our "good behavior"). In the ambit of self-regulation it is also our duty to keep up with change and upgrade our knowledge. In addition, we have duties to our patients: Kindness, patience and confidentiality. However as time goes on, reality sets in and it gets more difficult to hold on to our ideals. 
| Commercialization of Health Care|| |
Over the years health care has become more commercialized as Benjamin Franklin put it "God heals and the doctor takes the fees." Sandeep Jauhar, an Indian origin American cardiologist, in his book "Doctored: The Disillusionment of the American Physician"  talks about the rush to "it over and done with", the short time we spend with patients, the referrals to umpteen specialists, the number of investigations that have no relevance to the treatment we plan to give and so on, all billed and accounted for. Are we forgetting the human element, the patient, in our busy, money generating, commercialized lives? Is it because we are in competition with surgeons who demand huge fees, or the corporates who demand we do more investigations to draw in a minimum income per patient, or pharmaceutical companies whose drugs we order so that they will fund our next trip abroad? Do we expect commissions from laboratories, radiologists, touts and others for providing basic good care to patients? How often do we forget that among the fundamental rights enunciated by our founding fathers is the (patients) right against exploitation.
We seem to be more involved in cutting edge technology, anesthesia workstations, and robotics and often forget the plight of the uneducated poor, forget humaneness and uncomfortable ethical issues. Take the case of the 13 women who died after tubectomies in Chhattisgarh. Ramesh Mahwar and his son Sunil provided the antibiotics to the government-aided tubectomy camp, drugs that were spurious and adulterated with insecticides. Their operation was suspect, but did anybody take action before these women died? Now there are 13 homes where the children have no mothers, 13 husbands with no wives. Who is to be held accountable, just the makers of bad drugs or the authorities who set unreasonable targets and fail to take action against charlatans or the surgeon who agreed to operate under abysmal conditions? 
| Research Ethics|| |
Requirements for clinical research are universal though they must be adapted to the health, economic, cultural and technological conditions in which the clinical research is conducted.  Often human frailty does prove to be the stumbling block of researchers who want to prove to the world that they are the best. In reality today's "evidence-based medicine" may be tomorrow's malpractice. The case of Joachim Boldt and his 'research' on intravenous starches comes to mind. Joachim Boldt, a German anesthesiologist, was considered a world leading researcher on intravenous colloids. Though the fraud was revealed, over ninety of his research publications withdrawn and his Professorship stripped the damage he has done to thousands of patients the world over is unimaginable.  Hopefully, his exposure as a fraud will have far reaching effects on clinical and research practices as well as on editorial policies.
Another example of research fraud is the case of the antiseptic solution ChloraPrep which was touted to be cheaper and more effective than povidone iodine. When the fraud was revealed the US Department of Justice levied a fine of $40 million on Care Fusion Corp. to resolve allegations that the company violated the False Claims Act by paying kickbacks to boost sales of ChloraPrep and promoting it for uses that aren't Food and Drug Administration-approved. Who received kickbacks? It is alleged that CareFusion paid $11.6 million in kickbacks to Dr. Charles Denham in an effort to influence the deliberations of the Safe Practices Committee at the National Quality Forum, which was co-chaired by Denham at that time. 
As a result of Don Poldermans published research on beta blockade the Surgical Improvement Project (SCIP) advocated the use of perioperative beta blockers as a life-saving measure. Is there a controlled study that demonstrates conclusively that the SCIP beta-blocker measure makes surgical patients healthier, or that they recover better from surgery? No, there isn't. What's worse is that aggressive beta-blocker use around the time of surgery may be hazardous. Beta-blockade reduced the incidence of heart attacks but increased the incidence of strokes and dangerously low blood pressure. This led Larry Husten of Forbes.com  to suggest that the use of beta blockers perioperatively may have caused 800,000 deaths in Europe over the last 5 years. He questions, 'Is this Medicine or Mass Murder?' (However the original article by Cole G and Frances D first published in the European Heart journal was retracted within 2 weeks) Chopra and Eagle in an editorial in the American Journal of Medicine suggest that anyone can fall victim to this kind of misconduct if they do not pay strict attention to protocols and procedures.  In the quest for money and fame, these so called leaders in the world of science have fallen far from grace. It is truly said 'tell a lie once, and all your truths become questionable'. In fact, your credibility becomes nonexistent.
| Medicolegal Issues|| |
The very first "official" anesthetic was performed successfully by William TG Morton in 1846 without electrocardiogram, pulse oximetry, capnography, intravenous infusion or blood pressure monitoring. We have all of the above, and much more, yet errors do happen, and we have to deal with morbidity and mortality.
Unintentional medical errors have been reported to be between 10% and 17% in the west. In a 2000 report in JAMA there are 2000 deaths per year from unnecessary surgery, 7000 deaths due to medical errors, 2000 from other errors in the hospital and 8000 from infections. , No such data is available in India.
Breach of duty:
not doing something that a reasonable man would do under ordinary circumstances or by doing some act that a reasonable prudent man would not do that is, give basic care. For example a consultant could be held negligent when he delegates his responsibility to his juniors with the knowledge that the junior was incapable of performing his duties properly (Spring Meadows Hospital vs. Harjol Ahuluwalia 1998)  and the consequential damage.
Malpractice is willful negligence on the part of Doctor during treatment leading to morbidity and mortality. Examples (from real life  ): A 75-year-old man is given a spinal for a transurethral resection of the prostate (TURP) in a small nursing home. The surgeon finishes the TURP and says he has to do an open cystectomy to remove a large bladder stone. The anesthetist now says that will take too much time, and he leaves to do a lower-segment cesarean section in another hospital. The first patient is in the care of a nurse with instructions to give fluid if the BP drops. 1 h and 3 L of fluid later the patient is semiconscious and in frank pulmonary edema. Who is to blame? Isn't this criminal negligence? Should we look for and assign blame to the anesthesiologist or should we support our colleague in his unethical practice just because he is a fellow anesthesiologist?
Another case in question
A 3-year-old child is given ketamine in the dental chair without any airway protection - no endotracheal tube, throat pack or monitoring of oxygen saturation. The anesthetist leaves to do another case elsewhere leaving the child in the care of the dentists. The child aspirates and dies. Is this death not indefensible? Simple lack of care or error of judgment constituting civil liability may be forgiven, but criminal liability with its high degree of negligence or reckless or gross negligence, or malpractice is difficult to condone.
Here it would be good to ponder on a few commonly faced problems. The policeman who takes the FIR is often not conversant with medical problems or aware of medico-legal issues, the media is just waiting to get their hands on "news", anything that will help make headlines be it factual or not. This I consider 'a Trial by Media'. The worst however is "the Trial by Peers". "Experts" who the media get hold of, who are waiting to air their views in public about how badly you have handled the case while in their opinion they could or would have managed it so much better. Though their behavior is condemnable is it not better to be extra careful and not get into any of these situations?
| Continuum of Ethical and Good Practice|| |
To help us maintain some semblance of ethical and good practice a number of checks and balances have been enunciated by external sources like the Indian Society of Anesthesia, The World Federation of Societies of Anesthesiologists, the Anesthetic Association of Great Britain and Ireland, the American Society of Anesthesiologists and so on.  There are standards set for preoperative and postoperative care, essential and advanced monitoring etc., by the Indian Society of Anesthesia - are we aware of them, do we ever visit their website and avail of what is available in our country? Do we on the other hand grumble because surgeons expect us to take care of patients postoperatively and in recovery even after hours? There are protocols and flowcharts available for almost every difficulty or complication one may face under anesthesia; be it the difficult airway, basic life support (BLS), advanced cardiac life support (ACLS), malignant hyperpyrexia, anaphylaxis, sedation for pediatrics and drug dosages. Have we taken the trouble to compile them, make them available in our OT's recovery areas and Intensive Care Unit's (ICU) or are we waiting for a calamity to occur or for "someone else" to do this - because "I am too busy," "that is not my job," that is "only for western standards" or worse still "I have practiced for so long with no problems that will never happen to me'!
There are a large number of ways we can improve our practice and help us practice safe anesthesia. Some of these are as follows. Institute a daily check on all equipment and crash carts, use only color coded labels for all syringes and infusion pumps, draw up all drugs yourself or supervise their drawing up, use the WHO Surgical Safety Checklist  regularly and as a matter of course for every case, make available all the protocols, flow charts and drug dosage charts in operation theatre complex and in ICU's, make crash carts, difficult airway carts and essential equipment in all patient care areas. It is important to hold refresher courses and encourage team building between anesthetists, surgeons and OT staff. Critical Incident reporting is a good learning experience. Morbidity and mortality meetings should be held on a regular basis. These should not be treated as a "witch hunt" or fault finding mission but should be held with a view to improving knowledge and care.
With great power comes great responsibility. Heads of departments and units should remember that a senior who is empathetic to the juniors goes a long way in relieving stress, preventing "burnout" and boosting confidence. The notion of a family in the OT is apt because in times of trouble or stress it is all about who is willing to hold your hand when you need it the most.
No man is an island, entirely of itself; every man is a piece of the continent, a part of the whole. Any man's death diminishes me, because I am involved in mankind, and therefore never send to know for whom the bell tolls; it tolls for thee.
-John Donne (1572-1631) 
| References|| |
Edelstein, Ludwig (1943). The Hippocratic Oath: Text, Translation and Interpretation. p. 56. ISBN 978-0-8018-0184-6.
Dossetor, John B. Beyond the Hippocratic Oath: A memoir on the Rise of Modern Medical Ethics. 1 st
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Wise J. Boldt: The great pretender. BMJ 2013;346:f1738.
Wachter B. Patient Safety′s First Scandal; the Sad Case of Chuck Denham Carefusion and NQF. Community. Available from: http://www.the_hospitalist.org
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Chopra V, Eagle KA. Perioperative mischief: The price of academic misconduct. Am J Med 2012;125:953-5.
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Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico F, et al.
Medication errors and adverse drug events in pediatric inpatients. JAMA 2001 25;285:2114-20.
Cases Taken from Reports in the Times of India, The Deccan Herald and The Hindu Newspapers.