Starting or stopping treatment must be based only on diagnostic results, and any such decision must be documented in medical records.
Simple as it sounds, a doctor did not adhere to this aspect of medical practice and therefore, was held negligent in this case.
Irrefutable Facts
The patient was accidently hit by a stone. His left knee got injured and hence, he consulted the doctor. The doctor diagnosed it as ‘Tuberculosis (TB) of bone’ and prescribed a 3-month course of Anti-Tubercular Treatment (ATT). However, the
Patient’s condition did not improve.
The doctor performed needle biopsy of the lesion, but the sample contained only muscle tissues. Consequently, the doctor recommended an open biopsy, which the patient did not undergo.
The doctor then referred the patient to an orthopedic surgeon and discontinued ATT. Unfortunately, the patient’s condition deteriorated further, leading to the resumption of ATT.
The orthopedic surgeon ultimately diagnosed the injury as a tumor and referred the patient to a higher centre. An open biopsy was performed at the other hospital; the patient was diagnosed with telangiectatic osteosarcoma – vari. Subsequently, patient’s left leg was amputated.
The patient filed a complaint with the Delhi Medical Council (DMC), which gave a decision against the doctor and suspended his registration for six weeks.
In the appeal filed by the doctor against this order, the Medical Council of India (MCI) concluded that the doctor was not competent to perform the biopsy.
The Central Government, Ministry of Health and Family Welfare, established a high-powered committee of six interdisciplinary super-specialists to review MCI’s recommendation. The committee determined that doctor’s negligence was not fully substantiated. Therefore, the six weeks suspension ordered by DMC was reduced to two weeks.
The patient sued the doctor alleging that he misdiagnosed and mistreated and claimed that early diagnosis of cancer could have prevented the amputation of leg.
Doctor’s Plea
The doctor stated in defence that the preliminary routine investigations, including an X-ray, were positive for TB of the bone. As a result, ATT was initiated for one week, but the possibility of a bone tumor was not ruled out.
He further stated that the biopsy sample collected by him contained only muscle tissues. Therefore, an open biopsy was advised, but the patient delayed undergoing the procedure.
Court’s Observations
The court agreed with the opinion of MCI, which had held that determining the type and area of biopsy is a technically demanding procedure that requires involvement of a surgical pathologist, surgeon or orthopedic surgeon.
As the doctor was a general physician, he was not competent to perform the biopsy. However, he performed the needle biopsy that yielded muscle tissues, resulting in an incorrect diagnosis and delay in the treatment of osteosarcoma.
The court further perused the medical records and concluded that: “The doctor’s duty was limited to primary treatment or proper referral, but he started ATT and same was stopped within few days and again restarted without any justification.”
The court also observed that the doctor expressed displeasure when the patient failed to follow his advice for an open biopsy, which the court deemed as an “unprofessional” approach of the doctor.
The court held the doctor liable for an “act of commission” for performing a needle biopsy that was beyond his expertise and for an “act of omission” for failing to refer the patient to an orthopedic surgeon.
The doctor was held negligent.
Prevention Is Better Than Cure
- Document the failure of a patient / attendant to adhere to medical advice in the medical records. However, doctors should not take such conduct personally.
- Thoughtful contemplation is required when advising a course of treatment and prescribing medicines. Even greater contemplation is necessary before discontinuing or restarting any treatment / medicine. This proposition holds more importance for certain medications, such as ATT. The reason for restarting / discontinuing should be medically justified and documented.
Source : Dr. T. K. Chakraborty v/s Mukesh Patra
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