Abstract
Purpose:
To assess the knowledge, attitude, and practice patterns (KAPP) of Indian ophthalmologists regarding medicolegal issues using an initial survey.
Methods:
An online form was circulated among Indian ophthalmologists of all ages over social media and email by the Young Ophthalmologists Society of India (YOSI) and its medicolegal working group. Anonymous responses were obtained and analyzed for each question. The questionnaire comprised questions about demographic details, KAPP of medicolegal issues including how to deal with medicolegal issues (if faced), medical indemnity insurance, deviation from the recommended minimum sum assured (Rs. 1 crore for Indian ophthalmologists), and legal service providers.
Results:
A total of 109 responses were obtained. The majority of the respondents were male (60, 55%). More than 50% of respondents (58, 53.2%) were younger than 35 years. More than one-fourth of the respondents were private practitioners (29, 27%), and the majority were of senior consultant designation (45, 41%). Around 80% of respondents (89, 81.6%) were aware of professional indemnity insurance; however, only 54% (n = 59) bought the insurance cover. A majority of the respondents (38, 64.4%) had an indemnity cover of a maximum of Rs. 50 lacs. Only 20% of respondents were aware of the expert body at the state/national level that deals with medicolegal cases. Thirty percent of respondents recommended the ideal cover amount to be more than Rs. 1 crore.
Conclusion:
The current survey highlights the dismally low rate of awareness of medicolegal issues among ophthalmologists. Specifically, a majority of Indian ophthalmologists surveyed did not have recommended minimum insured cover for professional indemnity insurance. Larger studies are needed to further explore KAPP of Indian ophthalmologists in various medicolegal issues.
Keywords: Indemnity insurance, legal service providers, medicolegal, ophthalmologists
Globally, trends in medicolegal issues are gradually catching attention. Awareness among ophthalmologists regarding legal issues has become imperative to carry out safe clinical practice. Litigations are filed in various scenarios including medical negligence, vague documentation, inappropriate consent, and failure to counsel the patient and relatives regarding the prognosis.[1] Increasing health-care cost has resulted in rising lawsuits being filed and increasing compensations being asked, as expectations and demands from the patients have gone up too.[2,3]
A patient or attendant can file complaints to the consumer courts, civil courts, criminal courts (in cases of criminal negligence), or the Medical Council of India (now the National Medical Council). If medical negligence is proven, the financial burden that follows, apart from psychological trauma makes the situation more troublesome for the treating doctor.[4,5] The current study aimed to assess the knowledge, attitude, and practice patterns (KAPP) on medicolegal aspects and awareness regarding professional indemnity insurance among Indian ophthalmologists via an online survey.
Methods
Survey development
A questionnaire was designed after reviewing previous survey questionnaires.[6] The survey was circulated among Indian ophthalmologists of all ages via the Young Ophthalmologists Society of India (YOSI) and its medicolegal working group over social media (WhatsApp; Meta Platforms, CA, USA) and email. The questionnaire comprised details on demographic profile and respondents' KAPP of various aspects related to medicolegal issues including indemnity insurance, consulting agencies, and how to respond to a medicolegal notice.
Survey population and design
Ophthalmologists working in India were the respondents. The survey was constructed on Google Forms (Google LLC, CA, USA) in English. Most of the questions had multiple options, and the respondents were required to submit the single best choice from the list. The link was active for 6 weeks, from April 5, 2022 to May 20, 2022.
Data management and analysis
The responses were collated on a spreadsheet using Microsoft Excel® (Microsoft Office Excel 2007; Microsoft Corporation, WA, USA) for further analysis. The result of each question was analyzed based on the number of responses obtained, individually. If “not applicable” was chosen as a response for any of the questions, it was eliminated from the analysis.
Statistical analysis
Categorical variables were summarized using descriptive statistics. Continuous variables were analyzed by mean and standard deviations. Subgroup analysis of the responses was done, wherein a comparison between variables like age, gender, practice setting, and designation at the workplace with awareness of professional indemnity and possessing indemnity insurance was done. Age groups were categorized into Group 1 (<30 years), Group 2 (30–35 years), Group 3 (35–40 years), and Group 4 (>40 years). The area of practice was categorized into zones, that is, North (Himachal Pradesh, Punjab, Uttarakhand, Uttar Pradesh, and Haryana), South (Andhra Pradesh, Karnataka, Kerala, and Tamil Nadu), East (Bihar, Orissa, Jharkhand, West Bengal, Assam, Sikkim, Nagaland, Meghalaya, Manipur, Mizoram, Tripura, and Arunachal Pradesh), West (Rajasthan, Gujarat, Goa, and Maharashtra), and Central (Madhya Pradesh and Chhattisgarh) zones, based on the geographic location in India. The z-test for proportion was used to know the association between variables. A P-value of less than 0.05 was considered statistically significant.
Results
Demographics
A total of 109 responses to the questionnaire were obtained in this initial survey. The mean age of the respondents was 38.4 ± 10.1 (range, 25–70) years. Male (60, 55%) predominance was noted among the respondents. More than 50% (58, 53.2%) of respondents were younger than 35 years [Fig. 1a].
Figure 1.
(a) Bar graph depicting respondents based on age groups. (b) Bar graph depicting a representation of various states/zone of the current practice of the respondents. (c) Bar graph illustrating designation of the respondents at their workplace. (d) Bar graph representing the practice setting of the respondents
Practice setting
Out of all the respondents, we obtained the maximum responses from the Central zone (33, 30%) followed by the South zone (28, 26%) [Fig. 1b]. When enquired about designation, majority of the respondents had responded that they were senior consultants (45, 41%) [Fig. 1c]. In terms of practice setting, more than one-fourth of the respondents were solo private practitioners (29, 27%) and around 32% (n = 35) respondents were practicing in a medical college setup (private + government) [Fig. 1d].
Indemnity insurance
When respondents were enquired about their awareness of professional indemnity insurance, 89 (81.6%) respondents knew the entity and the rest (20, 19.4%) were unaware. Out of the respondents being aware of the entity, slightly more than 50% (59, 54%) had taken indemnity insurance and the rest (50, 46%) were not covered under any policy. A majority of the respondents had a sum assured of less than or equal to Rs. 50 lacs (38, 64.4%). However, Rs. 1 crore or more as the sum insured was bought only by less than one-third of respondents (19, 32.2%). The correlation between various parameters like age, gender, designation at the workplace, and practice setting with awareness of professional indemnity insurance and possessing insurance was assessed. A statistical difference was noted between the respondents across all age groups as well as gender, where they knew about the insurance, but had not bought it for themselves due to various reasons [Fig. 2a–d]. A similar trend was noted in the analysis of designation at the workplace and practice setting [Fig. 3a–d].
Figure 2.
(a and b) Bar graph illustrating the difference between awareness of professional indemnity insurance and actually possessing indemnity insurance and its correlation with age. (c and d) Similar correlation with gender. Also mentioned are the P-values comparing the awareness versus practice in various groups (upper versus lower bars in the figure)
Figure 3.
(a and b) Bar graph illustrating the difference between awareness of professional indemnity insurance and actually possessing indemnity insurance and its correlation with designation at the workplace. (c and d) Similar correlation with practice setting. Also mentioned are the P-values comparing the awareness versus practice in various groups (upper versus lower bars in the figure)
Medicolegal cases
Two respondents (1.8%) had faced medicolegal cases in the past and as per the respondents, the process of hiring a lawyer and following court procedure was a challenging task for them. They had faced difficulty in hiring a lawyer, managing paperwork, and taking leave from professional responsibilities for work other than appearing for court hearings. When enquired if the respondents would be interested in medicolegal assistance or help, 103 (94.5%) respondents replied that they were interested to obtain one. Also, 105 (96.3%) respondents were interested in attending tutorials if a series of lectures were organized on various topics covering medicolegal aspects. Only 22 (20.2%) respondents knew about the expert bodies, at the state/national level, to help formulate the response plan in case of charges against the doctor.
Indemnity cover, insurance companies, and legal service providers
When enquired regarding the ideal cover amount of the indemnity insurance, 30% of respondents (n = 33) stated that the ideal amount should be more than Rs. 1 crore. Around 40% (n = 42) recommend it to be between Rs. 50 lacs and Rs. 1 crore. Respondents possessing indemnity insurance (59, 54.1%) had opted for various insurance-providing agencies. Out of them, the commonly opted agencies were ICICI Lombard (ICICI Lombard General Insurance Company Limited) and United India Insurance (United India Insurance Company) (14, 23.7%). Other companies were Oriental Insurance (Oriental Insurance Company Ltd.) (10, 17%), National Insurance (National Insurance Company Limited) (8, 14%), Indian Medical Association (IMA), and New India Insurance (New India Assurance Co. Ltd.) (4, 7%). Thirty respondents (30, 50.8%) had opted for indemnity insurance from various entities/brokers like IMA, Association of Medical Consultants (Association of Medical Consultants, Mumbai), Maharashtra Ophthalmological Society (MOS), Medeco (Medical Defence Consultancy India Pvt Ltd), Docshield (Experts Doctors Shield Services Ltd.), Allahabad Medical Association, Apex Consultant (Apex Insurance Consultant Ltd.), Docland (Docland Services Limited), Orange Capital (Orange Capital Insurance Broking), and Ophthalmological Society of West Bengal (OSWB).
Discussion
In today's era of clinical practice, the best knowledge regarding medical subjects alone may not suffice. A treating physician or surgeon must be aware of the legal aspects of the practice as well. Due to various factors, there has been a steep rise in the number of litigations being filed against doctors.[2,7] Currently, in the field of ophthalmology, due to various factors, the expectations of patients and attendants have also increased. These factors include an increase in the cost of health-care facilities, various advertisements suggesting ocular surgeries as minor procedures requiring lesser or minimal time, and free online access to details of various diseases and management options. Therefore, nowadays, if the expectations of patients or attendants are not met, a doctor gets sued by the patient, who files a case in the consumer court, or even doctors and health-care workers may suffer violence, which has been increasing, especially in India.[8,9] However, whenever a lawsuit is being faced by a doctor, not only it is mentally and physically challenging, but also it brings a financial challenge. To the best of the authors' knowledge, such a survey has not been done among Indian ophthalmologists in indexed peer-reviewed literature.[10,11,12] This survey highlights the importance of awareness regarding medicolegal aspects and professional indemnity insurance.
Medicolegal cases
Multiple medicolegal litigations have been filed in the past against doctors including ophthalmologists.[13] The process of filing a lawsuit via the consumer protection act is easy, and huge compensation may be claimed. Whenever medical negligence is found, the treating doctor or the hospital is directed to pay compensation to the patient in the form of money.[3,14,15,16,17,18,19] If there is a long judicial process, the interest is added to the compensation, which can be huge depending on the time and the interest rate. At times, the medical license of doctors has been at risk as well.[20,21] Litigations have been filed in almost all subspecialties of ophthalmology, including surgeries related to cataracts and cornea.[22,23] Retina subspecialty has recently seen a rise in terms of litigations, especially physicians dealing with retinopathy of prematurity have faced the heat from the court proceedings. In a few cases of negligence, heavy compensation has been awarded to the patient.[5,24] In literature review, the authors noted that practitioners from other specialties like neurosurgery, emergency medicine, forensic medicine, obstetrics and gynecology, etc., have also conducted awareness surveys related to medicolegal aspects among themselves. These articles have highlighted various issues, different from what is being analyzed in the current study. Key parameters of these studies have been summarized in Table 1.[6,11] Litigations can be against doctors practicing in any specialty or setup, be it a private or government sector, solo or institutional practice.
Table 1.
Comparison of the current study with similar studies in different specialties
| Author | Journal | Year | Country | Specialty | Parameters assessed | Key results |
|---|---|---|---|---|---|---|
| Garg et al.[11] | Neurosurgery Focus | 2020 | India | Neurosurgery | Perception of malpractice issues, adequacy of training of residency, informed consent | N=221, Around 10% respondents faced litigation. |
| Respondents believed that there has been a notable rise in the lawsuits being filed against the doctors, especially more in private sector than government. Residency programs do not include adequate training tools to deal with medico-legal cases. | ||||||
| Zaed et al.[6] | World Neurosurgery | 2021 | Italy | Neurosurgery | Awareness toward medicolegal aspects, defensive behavior, consent taking practice, general perception about medicolegal issues | N=64, more than three forth (87.5%) respondents in the survey were unaware of the contracts, terms and conditions of the hospital they are working in. Almost similar number of respondents (75.6%) were unaware of the central law bodies, which laid down guidelines of the defensive medicine. A majority (92.2%) felt the inadequacy in training to deal with medico-legal issues, if encountered. |
| Agrawal et al.(Current Study) | Indian Journal of Ophthalmology | 2023 | India | Ophthalmology | Awareness to avoid as well as deal with medicolegal cases, awareness on professional indemnity insurance | N=109, only 54% had professional indemnity insurance cover. Almost two thirds (64.4%) had an indemnity cover of a maximum of Rs. 50 lacs. Only 20% of respondents were aware of the expert body at the state/national level that deals with medicolegal cases |
Indemnity insurance and legal service providers
Despite maintaining all the records appropriately and following all the essential protocols, there is always a possibility of medical negligence and if found guilty, compensation may be awarded to the plaintiff. A post-cataract surgery patient (coolie by profession) did not follow the postoperative instructions and developed a corneal injury while working. The court held that “He should have been instructed about post-operative care and follow-up precautions. But the medical record was devoid of such instructions.” Compensation awarded by lower courts was upheld by the National Consumer Dispute Redressal Commission.[14] In a case in Delhi (2016), the treating pediatrician and ophthalmologist, both were penalized. This compensation was given due to improper documentation and treatment not being according to the guidelines; a compensation of Rs. 64 lacs was awarded. In another case from Chennai (2015), a government hospital's pediatrician was asked to pay a whooping amount of Rs. 1.8 crores for not guiding the parents of a newborn for retinopathy of prematurity screening.[5] The compensation is usually borne by the doctor and/or the hospital. Compensation can range from lacs to crores, and shelling out such a large capital, in one go, might be dreading for the defending doctor, especially in the early phase of practice. Therefore, it is advisable to possess professional indemnity insurance, wherein the insurance company bears the compensation amount for how much ever coverage one has opted for.[25] According to the current survey, almost 50% of respondents believed that it should be more than Rs. 50 lacs and 30% of them stated that it should be more than Rs 1 crore. The recommended minimum sum assured for an Indian ophthalmologist in the current scenario is Rs. 1 crore, and this might increase in the future.
Insurance companies provide cover only for the amount one has been penalized for. There is more to it, in terms of hiring a lawyer, managing paperwork, taking leave from professional responsibilities for work other than court proceedings, and dealing with the lawyer of the plaintiff and their family members. Therefore, to tackle these problems, a concept of legal service providers exists, which takes care of all the additional work that has been highlighted. They charge an annual premium and take care of the expenses of the lawyer and other court proceedings–related work, which are not covered by the insurance companies. In the survey, a few commonly hired service providers are highlighted, and one can assess the benefits of each company and make use of them as well.
Multiple national- and state-level bodies exist that help members in cases of medicolegal issues. These include the All India Ophthalmological Society (AIOS) and MOS. Various associations of ophthalmologists have legal cells (including AIOS legal cell), which can be contacted for legal and professional aid from peers. The opinion of the leaders in ophthalmology (including ophthalmologists in crucial positions at various national- or state-level organizations) may be submitted as a defense in the court when a member gets a legal notice. However, the organizations may need to be more proactive in supporting their members in various issues including medicolegal cases and defamation. Also, awareness of the members should be increased regarding medicolegal issues. YOSI (https://yosi.org.in/) has a medicolegal working group that conducts regular webinars (available at https://www.youtube.com/@YoTubeYOTube) to increase the awareness on medicolegal issues. The organizations may also support their members through their advocacy and various support systems including those in social media and mainstream news media. Also, various societies including IMA and MOS have arranged medical indemnity insurance from various brokers at a discounted premium. The leadership of large professional organizations including AIOS may think of creating a common platform of group professional indemnity insurance for all their members at reduced premiums, which would help the entire population of Indian ophthalmologists.
Some brokers may also provide lawyers or medicolegal professionals to help in responding to a legal notice or representing in a court of law. Many brokers may arrange for a cashless settlement of the lawyers and other expenses. The medical indemnity insurance must be continued without any gap, so that the original retroactive date (the time when the insurance was brought and came into action) can be maintained. In case of any legal notice, the medical indemnity insurer must be informed in writing as soon as possible with a written acknowledgment from the insurer. The details of the compulsory excess (the amount of money that the insured must pay in case of a claim; the insurer pays the rest) should be understood by the ophthalmologist. Also, the any one accident to any one year (AOA:AOY) ratio should be kept at 1, so that the full sum assured is available during one or multiple claims in a year.
Limitations of this study include the small size of the data and the absence of follow-up data on the gathered responses. Larger studies are needed to get more robust statistics on this subject.
Conclusion
In the current study, it has been highlighted that knowledge about medicolegal aspects and awareness regarding professional indemnity insurance are sparse. More awareness needs to be created, may be in the form of webinars, physical conferences, and addressing the issue more on open forums. Careful and detailed documentation, record keeping, sound medical and legal knowledge, and good professional indemnity insurance (recommended Rs. 1 crore or more) are some of the aspects which can help ophthalmologists deal with the scenario more competently.[26,27] However, the sample size was small and larger studies are needed to further explore KAPP of Indian ophthalmologists in medicolegal issues.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
We would like to acknowledge the sincere efforts of Dr. Digvijay Singh, Dr. Divakant Misra, Dr. Awaneesh Upadhyay, Dr. Mahesh Chattopadhyay, and Dr. Debanjan Sen.
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