How to limit medicolegal “scarring” in dermatology?

Madhulika Mhatre; Aseem Sharma

doi:10.4103/Pigmentinternational.Pigmentinternational_

How to limit medicolegal “scarring” in dermatology?

Madhulika Mhatre¹, Aseem Sharma²
¹ Wockhardt Hospitals, Mumbai, Maharashtra, India
² LTMMC & General Hospital, Sion, Mumbai, Maharashtra, India

Correspondence Address:
Dr. Madhulika Mhatre
C-803/804 Royal Court Society, Opp HDIL, Sahar Road, Andheri East, Mumbai 400069
India

The field of dermatology, and pigmentary disorders, specifically, has undergone a sea of positive changes since the turn of this millennium. The flip side to this change has been the influx of law into the realms of dermatology. Ego medicolegal issues are on the rise, caused by a variety of factors: the rise of interventional procedures, overpromising and underdelivering by physicians, quackery, and Internet awareness, to name but a few. Needless to say, a dermatology practitioner today will most likely be introduced to the medicolegal world, given the increased incidence of the aforementioned. And it is common knowledge that medical schools and residency colleges do not cater to these specific needs of medicolegal education even though serious efforts are being made to bridge this gap.

“Ethics is knowing the difference between what you have a right to do and what is right to do.”

—Potter Stewart

Conventional medical education has a single-point focus—to prepare experts who will preserve mankind; eliminate, control, and prevent disease; and spread health awareness. Unfortunately, medical schools, even postgraduate schools, do not prepare these experts to deal with the nitty-gritties of ethics, torts, and other legal implications of medicine.^[1] Despite the fact that medicine and law have gone hand-in-hand for a considerable amount of time, there exists a significant knowledge gap between this marriage. Albeit there are emerging concepts that attempt to bridge this gap, such as “medicolegal rounds,” dedicated legal case discussions, and intensive medicolegal workshops, there is a pressing need for concentrated medicolegal education.^[2],[3] Closer home, as dermatologists, this need is felt ever more. The field of dermatology has been sucked into a vortex of change—cosmetology is the new face; dermatosurgery, lasers, and aesthetic procedures are, continually, on the rise. These are therapeutic advances that, here insofar, could not possibly have been envisioned in the previous millennium. We are truly in a phase of “interventional dermatology.”.

And having said that, training for these advanced therapeutics is ubiquitous and available in all forms—online, crash programs, certificate courses, fellowship programs, and degree courses. And it is here that quality control has invariably suffered. Akin to the laws of momentum, what goes up (fast) must come down (faster). Add to this, the attitude of today’s patient–doctor shopping is a common practice, heavy discounts and tight packages are the norm of the day, and expectations have skyrocketed.^[4] And finally, the menace of quackery, owing to the significant financial prospects that aesthetic dermatology harbors, has made its way into our guild. Consequentially, this field, once considered “a safe bet,” is now inching toward becoming a “hostile specialty.” The wide gamut of risky procedures, the practice of overpromising and underdelivering, disgruntled patients, coupled with the traditional problems faced in clinical dermatology, including adverse effects of therapy, amount to a significant medicolegal burden. Add to this our allegiance with the legal practices of the West, and we are in a state where anyone can sue, or file a lawsuit, over anything, trivial or grave.

The greatest challenge with the legal environment in current dermatology, and in particular pigmentary disorders, is that patients are seldom happy with “minimal improvement.” Take, for example, Vitiligo. There were times when patients were satisfied with any measure of color matching, anything darker to offset their chalky white stigma. Come today, patients demand an even color shade and tone, with some patients even walking in with color shade catalogues! Even Melasma, which is the forerunner when it comes to disorders of hyperpigmentation, is known to be multifactorial in etiology and recalcitrant to treatment. It often requires multiple modalities, acting at different targets, with compliance to therapy being extremely important. Most patients, unless a part of a concentrated study or trial, often “give up” or modify the treatment protocol and eventually relapse or worse, resort to topical steroids. Thus, patients’ demands are on the higher side; with these heightened demands comes a high likelihood of error. Patients now want a one-stop treatment, preferably office-based, to limit their own efforts and are influenced heavily by hoarding and advertisements claiming magical, wondrous cures. Another impactful development has been online marketing—social media presence and Dr Google! The best search engine optimizer and the best website, literally win!

Not too long ago, we were considered nobility. The giver/preserver of life. And how hath we fallen from the pinnacle where we were once set! Such is the scheme of things that we now fall under the COnsumer PRotection Act, abbreviated and stylized to COPRA, which was updated in 2018. This stems from a simple deduction—corporate hospitals deem procedural items as consumables; and hence patients, on whom these are deployed, become consumers, and thereof. The problem arises when it comes to consumer satisfaction, which is required to be 100%; but this is next to impossible due to the plethora of factors governing the situation. Shah sums up these as the Ps of COPRA—Patient Protection, Physiological dysfunction posttreatment, Physical, Personal, or Psychological trauma postprocedure, and Paisa (money) excess being charged.^[5] Beauchamp and Childress delineated the four-point code of principles in healthcare ethics, namely, respect for autonomy, principle of nonmaleficence, principle of beneficence, and principle of justice.^[6] More often than not, it is the second principle that the physicians have to defend themselves against, especially while the threat of COPRA is looming.

In this era, a physician is likely to err on many echelons. To begin with, the art of deductive history-taking and sound clinical examination should never be undervalued. Failure at this juncture (and even failure to record the same) renders the likelihood of misdiagnosis, which might land the dermatologist in a medicolegal soup. Targeted investigations should also be meted out as per the diagnosis, keeping in mind their specificity and sensitivity. Distinct clarity must be offered to the patients in terms of “instructions of care,” including diet, restricted activities (if any), and so on. Educational leaflets and demonstration videos, which must be displayed in the reception or waiting area, go a long way in simplifying the aforementioned and would also hold in a court of law. The total cost of the drugs, procedure, consultation, and so on must be discussed in a transparent fashion with the patient, to avoid financial discrepancies later on. If claim through health or medical insurance is sought, appropriate guidelines for those must be addressed. For these occurrences, it would be fruitful to have a chartered accountant or a financial analyst on the panel. If a procedure is deemed necessary, proper consent forms (always informed, never implied), and preoperative, perioperative, and postoperative care must be explained or provided in a written format, and Standard Operating Protocols (SOPs) must be designed to convert this practice to muscle memory. Moreover, the paramedical and auxiliary staff must be trained, and retrained, to be on the same page in all these practices. And these should be followed to the tee even if it involves a minimalistic procedure like chemical cautery or a mole removal.

Even after these are maintained, a genuine error of judgment will not render a dermatologist liable. Similarly, in instances where a patient is non-cooperative with regard to his history, noncompliant with the medication or instructions, or fails to follow up as prescribed, the treating physician has a valid defense and hence these lapses should also be documented on the clinical sheet.

The authors, inspired from personal experiences and a review of pertinent literature, present some situations wherein medicolegal issues can be averted by a little soft skill polishing and streamlining the existing practice: rigorous documentation − historical, examination findings, dermoscopic, photographic, prescription, drug interactions, delivery, adverse effects foreseen, gestational effects (if), investigations ordered, procedures, infiltrative test dosage, anesthetic consents, so on and so forth. There are robust electronic medical record software and applications that can delineate and simplify this process. Specific guidelines should be in place for phototherapy, lasers, cryotherapy, sclerotherapy, injectables, and dermatosurgery. Even setting up of these units is clearly defined by the Indian Association of Dermatology, Venereology and Leprosy (IADVL) dermatosurgery and laser taskforces, and the Association of Cutaneous Surgeons of India (ACSI).

Consent forms should have apt disclaimers, translated into the patient’s vernacular language, and preferably signed in presence of a third-party witness. Medical malpractice lawsuits most commonly arise from improper documentation of or a casual extraction of informed consent. It is worthwhile to spend the most time on this, disclosing all pertinent information to the patient and coaxing him/her to ask questions and adding them to it. Video consents have also been recorded in a few centers overseas but the local laws on the same are at best sketchy. While administering therapy, the existing consensus guidelines of national bodies or international collaborative clinics or leagues should be used wherever feasible, or else, the level of evidence must be explained to the patient and mentioned clearly. In-house pharmacies are treated as small hospital pharmacies and have dedicated guidelines for them to be instituted.^[7] Medical tourism is another grey area, as is teledermatology, and is best left to experts in the field to decipher, decode, and discuss.

To err is human. And despite these stringent precautions, we can still be subjected to errors—human, technical, or indirect. Therefore, a professional indemnity or liability insurance is literally the need of the hour, and everyone, ranging from clinical dermatologists to dermatosurgeons, dermoscopists to hair transplant surgeons, and trichologists to injectors, must have a significant cover. The DVL Welfare Trust, an initiative of IADVL, aims to fulfill this requirement. In most cases, the annual premium for most of these policies sets a physician back by a fraction of his/her monthly earnings, but the benefits reaped, in terms of cover, is magnanimous. Lest we forget, one of the highest legal compensations ever paid was by a clinical dermatologist, in a clinical case of Steven Johnson Syndrome, with a commonly prescribed drug, for a well-documented adverse event. The gravity of this needs no further discussion. More so, in this age of difficult patients, unrealistic expectations and quackery, patient selection is of paramount importance, as is hand-holding and counseling.

A study by Bharti and Mahajan in a medicolegal compendium proposes a three-pronged approach—counseling, communication, and documentation—to avoid medicolegal hassles. Extensive, frank counseling, healthy, two-way communication between the patient and the dermatologist, and stringent, methodical documentation—be it consent forms, prescriptions, photography, or even electronic medical records—can prevent medicolegal cases.^[8]

To conclude, in the current epoch of dermatology, it is highly unlikely that a practitioner will steer clear of the medicolegal bandwagon. Unfortunately, the framework of a single article/chapter/write-up cannot encompass everything, or claim to be the one-stop reference for this ever-evolving subject, but awareness of the same is quintessential and may help prevent a medicolegal blemish.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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