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Indian Journal of Dermatology, Venereology and Leprology
Medknow Publications on behalf of The Indian Association of Dermatologists, Venereologists and Leprologists (IADVL)
ISSN: 0378-6323 EISSN: 0973-3922
Vol. 69, Num. 5, 2003, pp. 353-354
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Untitled Document
Indian Journal of Dermatology, Venerelogy & Leprology, Vol 69, No.
5 ,Sept-Oct, 2003, pp. 353-354
Medicolegal Window
Prescribing steroids and cytotoxic agents
Subodh P. Sirur
Medicolegal consultant & a practising dermatologist
Address for correspondence: Dr. Subodh P. Sirur, 8/16
Talmakiwadi, Tardeo Road, Mumbai - 400007, India.
E-mail: subodhsirur@yahoo.com
Code Number: dv03059
Every physician has a duty of care in the administration of treatment, a
breach of which may amount to medical negligence. Before administering or
prescribing any treatment, one should consider the attendant complications
and side effects. This duty to take care is particularly important when cytotoxic
or immunosuppressive drugs are prescribed.
We are all aware that various tests, including liver function
tests, complete blood count, and renal function tests, are mandatory before
starting methotrexate therapy. Sometimes a patient may not be able to afford
these investigations and a dermatologist may be tempted to start treatment
without them. Also, once treatment is started the dermatologist may not insist
on investigations for monitoring the onset of side effects. However, one should
not buckle under such pressure.
The following case that came up before the Calcutta State
Consumer Disputes Redressal Commission will illustrate the importance of ordering
all essential investigations.
A mechanic with a complicated mature cataract was operated
for removal of the cataract. During the surgery, it was noticed that the
patient had total retinal detachment with retinopathy. Post-operatively there
was
loss of vision. The ophthalmologist insisted that apart from the other routine
and essential tests, he had also advised a `B' scan (to determine the status
of the posterior segment), but the operation was performed without doing
it since the patient could not afford it.
The doctor was held negligent for not advising the `B' scan
(resulting in loss of vision post-operatively) before performing the operation
and a compensation of Rs. 1,00,000 was awarded to the patient. The Court refused
to believe the doctor's contention because there was no noting to that effect
in the case paper.
Thus, it follows that pre-treatment investigations must be
done if mandatory. Failure to do so can result in a claim for compensation
for loss or injury resulting from such negligence. In case the patient cannot
afford or refuses to get investigations done, it is therefore prudent to record
that fact in the OPD/indoor papers.
It is pertinent to note the observations of the Supreme Court
in the case of Poonam Verma vs. Dr. AP, where the patient was suspected to
be suffering from typhoid fever, but the doctor had not advised a Widal test.
The patient subsequently died of typhoid encephalopathy. The Court, hearing
an appeal of alleged medical negligence, said: "We cannot ignore the
usual practice of almost all the doctors that when they want pathological
tests to be done, they advise in writing on a prescription setting out the
tests which are required to be done. Admittedly, Respondent no.1 had not done
it in writing. He says that he had advised it orally. This cannot be believed,
as this statement is contrary to the usual code of conduct of medical practitioners."
Whenever investigations are asked for, proper documentation
in the medical records must be made. This will avoid future litigation alleging
that essential tests were not advised nor performed by the attending doctor.
The pharmaceutical market is flooded with innumerable drugs and some drugs are
phonetically similar to another drug. In addition, illegible writing can result
in the chemist dispensing one drug for another. It is always better to be conversant
with a few trade names to avoid confusion and medical mishaps.
According to the Indian Medical Council (Professional Conduct,
Etiquette and Ethics) Regulations, 2002, "Every physician should, as far
as possible, prescribe drugs with generic names and he/she shall ensure that
there is rational prescription and use of drugs."
Since the two major factors for the dissatisfaction of patients
or their relatives are morbidity and mortality, steroids, immunosuppressive
and cytotoxic drugs should be used sparingly and only when necessary, with
a constant watch for side effects. Appropriate precautions should be taken
before starting the therapy and during its course.
The Indian Medical Council Regulations, 2002, also
incorporates a provision with
respect to prescription of steroids: "A registered medical practitioner
shall not contravene the provisions of Drugs and Cosmetics Act and regulations
made there under. Accordingly, prescribing steroids/psychotropic drugs when
there is no absolute medical indication, and selling schedule H and L drugs
and poison to the public, except to his patients in contravention of the above
provision, shall constitute gross professional misconduct on the part of the
physician."
The contents in this article are for creating awareness about
litigation involving medical professionals and the contents are not in the
nature of legal advice. A reference should always be made to the latest judgments
and laws on the subject as laws are amended or repealed or new laws come into
existence from time to time. It is advisable to seek legal advice in specific
cases. The above article is an extract from the book `Dermatology and the law'
by the same author.
Copyright 2003 - Indian Journal of Dermatology, Venereology & Leprology.
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