Medical Negligence vs Medical Complications: The Need to Understand the Difference

Not a month goes by since I started working as an anaesthesiologist over a decade ago that an article about a case of medical negligence does not cross my timeline. The rise of social media over these years has resulted in a complimentary rise in the number of articles and events that now come before us, offering us a huge gamut of tragic deaths and complications across hospitals not just in India, but across the globe.

One thing that does stand out though is how in India the emotional aspect of the news article (and these days, social media post, I guess) often cloaks the factual aspects of the case. Yes, in almost every case, there is a death involved of a loved one but to assign the words “medical negligence” to every case is not just superfluous but as the years have gone by, extremely detrimental to future patients as well.

In this article, I will try to help you understand the difference in simple terms between medical negligence and medical/surgical complications and why not knowing the difference between the two can have a horrible impact for your loved ones.

What Constitutes Medical Negligence

When a patient comes to a hospital or doctor, they expect 

1. to receive medical treatment befitting the skill and knowledge of the concerned doctors and healthcare workers and secondly, 
2. that there will be no harm done to them due to carelessness, reckless decisions or negligent behaviour of the staff in the hospital. 

Failure of the hospital to provide this care constitutes medical negligence.

Some examples to help you understand include:

• The infamous incident of a doctor operating on the wrong side of the brain of Mrs Rajeshwari Ayyappan, the mother of the deceased Indian actress Sridevi back in 1995 was a clear-cut case of medical negligence, what we know as ‘res ipsa loquitor’ – the facts speak for themselves.

• An intoxicated doctor performing a surgery even if the operation goes well, 
• a surgeon leaving a foreign object inside the body during a surgery, 
• a doctor administering the wrong medication to the patient.
• Even a medical professional providing a healthcare service he is not trained for (for example, a quack doing a surgery) is a case of medical negligence.
  
  
   

Even though in all the examples above, nobody died, yet there was an obvious dereliction of duty involved. These are all cases of medical negligence.

What needs to be proved in medical negligence is that no doctor in his/her ordinary senses would have performed or omitted to perform the act resulting in the deterioration. 

What about when there are multiple therapeutic options available for the doctor but the one he/she chooses results in the deterioration of the patient? It is important you realize that this is NOT medical negligence. 

An error in judgment on the part of the doctor is NOT medical negligence.

Known Complications a.k.a. the Value of Consent

What actually happens when a patient goes in for a surgery and comes out with new complications or worse, dies after the surgery. The surgery definitely had a role in the deterioration of the condition so does this constitute medical negligence?

This is where the term “consent” – one of the most important terms in the modern-day doctor-patient relationship comes into play. A consent is often both verbal as well as written (for medico-legal purposes) and involves the doctor explaining what they intend to do as well as what are the possible complications because of this surgery.

• In an elective surgery, the patient has every right to object and say no after hearing the complications. 
• For me as an anaesthesiologist, a patient has every right to refuse spinal anaesthesia or an upper limb block if they have apprehensions for the same. In an emergency, things may not be so clear cut with surrogate consent (consent signed by a guardian) coming into the equation if the patient is not physically or mentally able to understand.
• When it is an abdominal surgery, the surgeon explains that there is a likelihood of there being pain, adhesions or infections in the post-operative period which could result in complications in the future. 
• An obstetrician will explain the possibility of there being excessive bleeding after delivery of a baby following a caesarean section if the uterus remains flabby. 
• For us anaesthesiologists, complications following general anaesthesia can range from a sore throat to actual cardiac arrest during surgeries.
• Working in the ICU, I am obligated to inform and take the consent of the guardian when I do an advanced procedure, from placing the patient on ventilatory support to inserting a central line. 

If adequate care was maintained during all the above procedures and appropriate clinical skills were used with the aim of saving/healing the patient and yet a complication - or even death - occurs, they are NOT cases of medical negligence. 

To quote from the Supreme Court judgment of Kusum Sharma vs Batra Hospital (a case where the patient’s condition deteriorated significantly post-surgery resulting eventually in death),    

“The medical professional is often called upon to adopt a procedure which involves higher element of risk, but which he honestly believes as providing greater chances of success for the patient rather than a procedure involving lesser risk but higher chances of failure. 

Just because a professional looking to the gravity of illness has taken higher element of risk to redeem the patient out of his/her suffering which did not yield the desired result may not amount to negligence.”

 

You see, the final outcome - a dead patient or a botched surgical job, though obviously visible to the naked eye - is not what determines the term 'Medical Negligence'. 

Impact of Calling Medical Complications as Cases of Medical Negligence

In India, especially in this country which wears its emotions on its sleeves, the heart-breaking wails of the bereaved and the vicious growls of the enraged are sounds that have echoed through the walls of every single hospital – from primary to tertiary care. 

Violence against healthcare workers, though not new, is now more frequent and visual, thanks to the ‘boon’ of social media. It ignores the distinct line between medical negligence and known complications, choosing indignation and retribution over a calm, understanding approach.  Prolonged legal cases and social ignominy invariably ensures that though the law is with the doctor both in terms of the case as well as the violence that followed, in the end, it is he who looks to settle. 

Doctors are not looking to harm patients. We get nothing out of it (if you don’t count the assaults). Complications definitely occur, though. In a country like ours with frugal healthcare resources be it doctors, hospitals, beds, ICUs or ventilators, there will always be losses that could have been avoidable in more healthcare-friendly nations. And yes, the loved ones suffer the worst loss but it is wrong to assume that the doctor does not carry the weight of the patients he could not heal. 

Yes, we smile remembering the difficult cases we successfully handled but in quieter tones as the day ends, our minds fall back to the ones we could not save. The ‘what ifs’ and ‘if onlys’ and ‘I should haves’ remain, festering wounds that never heal. Just as a single insult outweighs a hundred compliments, we relive a single death over the joy of aiding a dozen recovering patients.

The impact of claiming medical negligence for every complication and leaving it upon the doctor to fend for all the brickbats in the media, social media and society goes well beyond the individual doctor. 

I spoke about it years ago (in an article "Who Tends to the Healer's Scars" that for awhile was in the Huffington Post) and it remains relevant today.

In a nutshell, if I see that a doctor in Kanpur is beaten up by a mob following the occurrence of a known complication after a procedure and know he/she received no justice, then even though I – here in Kerala - am skilled in performing the same procedure and have done it a 100 times before, the next time I will hesitate. “Is it worth the risk of violence or legal cases” will float around ominously in my mind as I consider driving the patient away to a higher center away from me.

Who is the loser in the end here? Not you, right? 

Unfortunately, that is myopic thinking. Because irrespective of how fit you and your loved ones are today, a medical emergency can happen to anyone of us. And at that time, the actions of a violent mob in Kanpur could be the reason why a hospital near you today chooses not to admit you but refers you elsewhere. The loss – precious time, higher expenses, even life – is invariably yours. 

The doctor-patient relationship is a fractured bone in India. 

It has been for long. The path to uniting it – if that is what you desire – lies, as it always does, in education. Educate yourself and understand the difference between a known medical complication and medical negligence.  

If instead, you choose the emotional gratification of revenge and violence against a healthcare worker for not giving you a 100 percent perfect result or for the loss of a loved one - if the satisfaction of destroying the career of a doctor is all that matters - as we are seeing in India every day, understand that just as it emboldens others across India every day to be violent against doctors in their hometown, so too the converse – it discourages doctors every day too from taking risky patients. 

That scenario - the path India has confidently been walking along for over a tragic decade and more now - sadly will never end well.