Medicos Legal Action Group

04/08/2025

Are All complications the fault of the surgeon ?

Yesterday I was at Hyderabad for a Gynae conference predominantly on complications in Obstetrics & Gynaecology. The prestigious Oration was delivered by an illustrious personality who is Chairman and founder of a Hospital Chain which has trained thousands of laproscopy surgeons across India and the world. During his oration he opened his address with a statement that “All complications are fault of the surgeon” and reiterated this a few times during his oration. It raised my hackles , distressed me, upset me very much but the traditions of respect given to the “oration” prevented me from raising the issue there and then with him. Mostly however I was disappointed that a senior medical doctor, a teacher, an entrepreneur and a person who many of us would normally look up to and aspire to emulate held such a view.

All surgeons train long and hard to attain surgical skills and take it as a personal failure if they have a complication. They are known to undergo "second victim syndrome" whereby the event effects them psychologically and has a deleterious effect on their professional confidence and skills. A complication is just that “a complication”, it happens and mostly we do not know why. Ability to tackle the complication maybe directly related to surgeon experience, but the occurrence of a complication during surgery, intervention, procedure or even during medical treatment is definitely not always due the surgeon / doctor ‘s fault or related to a surgeon's experience.

As he mentioned in his oration it is important for surgeons to recognize tissues and how they feel. The only time I caused a perforation in my 65000 odd UGIE procedures was during a stricture dilatation being done second time by me after an interval of 12 years in the same patient and let me tell you the procedure and the feel of the stricture was soft, dilatation was done without any undue force or pressure and I could never imagine a perforation in that particular patient till it became evident 24 hours later. As it turned out she was on dialysis. So to answer the orator, I would not kiss every hand which felt like my wife’s hand with blind faith in my abilities to recognize the “touch and feel”.

If the surgeon is incompetent and causes a complication which another average surgeon would not have caused then the fault lies with those who have trained him and sold him a defective product while certifying that he was now as “Master of Surgery”. No I have not made any error. I meant it when I said that we are today selling medical education and if someone should be held accountable for the consequences of the substandard training it is the mushrooming medical education shops and the agencies which endorse them as being prim and proper for imparting medical education and training (NMC).

Even a vascular injury which may be trochar induced is an accident and though the accident may cause a patient her life it is not always actionable negligence. Multiple factors play a role, the lax abdominal wall, the previous surgical scar, the mesh placed for past umbilical hernia surgery, poor quality of instruments and even aneurysmal dilatation of artery. Instead of blaming and shaming the surgeon by calling all complications his fault we need to look deeper into how to prevent complications from happening. The live surgical demonstrations is one way but then the courts and the National Medical Commission have found another way to destroy medical education by placing restrictions on live workshops.

There are people in the medical field who are at the pinnacle of their careers having achieved name, fame and wealth beyond what can be dreamed of by others. In the absence of genuine leadership from our organizations such hugely successful personalities act as surrogate leaders in the profession. If they make such statements, then we cannot blame the judges, the society, and the press for blaming us whenever something goes wrong. I was disappointed when members of select committee entrusted with the matter by Supreme Court had endorsed the lack of need for a central Act for prevention of violence against Doctors. But I was positively devastated to hear this doyen in field of laproscopy say that “Complications are always a surgeon’s fault”.

Compare us with advocates where the Supreme Court says “Advocates should not be penalised for minor mistakes” and that “Profession of advocate is sui generis and hence should not be within purview of CPA” . If complications are our fault then every complication should be penalised, any treatment needed of the complication should be done free of cost, and every patient who comes to hospital should walk out to live happily ever after. We need to all follow a no compromise stance in matter of selective accountability of Doctors in our country. I will continue to defend any surgeon who faces a complication during surgery even if God himself says that "Complications are all due to fault of the surgeon".

Dr Neeraj Nagpal
Managing Trustee,Medicos Legal Action Group (MLAG)
Ex President IMA Chandigarh
Director Hope Gastrointestinal Diagnostic Clinic,
SCO 1066-67 Aerodale Market, New Sunny Enclave Sector 123 Mohali 140301
09316517176, 9814013735
HOPE CLINICS;9465109935, 9478082176
email; hopeclinics@yahoo.com, hopeclinics@gmail.com mlagindemnity@gmail.com
For Contributions; "Medicos Legal Action Group" Ac No 499601010036479 IFSC code UBIN0549967 Union Bank Sector 35 C Chandigarh;
Website;

Medicos Legal Action Group is a non-profit trust registered at Chandigarh by a group of allopathic doctors from all over the country who wish to legally engage the Govt of India regarding its various policies concerning medical profession, training, working conditions. MBBS doctors today are threate...

28/07/2025

A non profit trust registered at Chandigarh by a group of allopathic doctors from all over the country who wish to legally engage the Govt of India regarding its various policies concerning medical profession, training, working conditions.

28/07/2025

My understanding of the new NMC Guidelines on Live surgery

The overall objective has not been achieved and the individual organizers are left to best find a way out for themselves. These guidelines need to be amended for the following reasons;

1) Before any decision is made all parties should be consulted and given opportunity to give their views.

a. Those who conduct workshops routinely and are in favour of conducting live demonstrations; Acknowledged experts

b. Those who are experts but are not conducting and are opposed to conduct of live demonstrations ; Aspiring Experts

c. Those who benefit from the live demonstration of procedures ; Youngsters who have freshly entered the profession / speciality / super specialty

d. Patient party who has undergone such a procedure as part of live demonstration and benefitted because of the exceptional expertise (not available locally) of the performer.

e. Patient party who suffered a complication during such a live demonstration

This was not done hence the process appears to be biased and vitiated hence the conclusions debatable.

2) In this matter it is guidelines which have been issued which means the NMC Act, rules and Regulations have not been amended. As per law following guidelines of the regulatory body does not become mandatory. What is written in Act is absolute overriding any conflict in the rules which override any conflict with regulations. To follow Guidelines is voluntary as per law.

3) No insurer gives indemnity insurance of Foreign Medical Graduate Experts and even a patient harmed during a live procedure will find it difficult to seek redressal specially if criminal negligence is alleged. A supervisor will not have the vicarious liability in criminal law, even though this may be so under CPA and civil Law.

4) Definition of High risk procedure , incomplete investigations, unusual anatomy has not been given. Aberrant hepatic duct, pancreas divisum , choledochocoel, periampullary diverticulum are all unusual anatomies but some of them may not be diagnosed pre procedure.

5) Complications managed free of cost opens a Pandora’s box with similar demands rising in other cases as well. The cost of treating one patient free of cost due to the one complication will result in increase in procedure costs for all other patients to offset such an eventuality.

6) No insurer to my knowledge gives insurance coverage immediately before surgery / procedure for a pre existing disease. Let Government through its public sector insurers first design such a policy which would cover for treatment of any complications in a planned surgery. This would be beneficial for all patients and not only for those who get operated during live workshops. Patient could sign financial consent and be liable to pay a particular package and any costs over and above the package due to any complication would be reimbursed or paid by the insurer.

7) It is not clarified as to who is to take the consent and countersign it. Should it be the Foreign expert, the supervisor or the junior doctor in the organizers team.

8) The point of patients’ procedure being done free of cost is fraught with problems. The best experts are working in large corporate hospitals and the expert as well as the doctor is being asked to forego their charges. This disincentivises them from sharing their knowledge and skill. It carries ominous dangers for surgical procedural training of the next generation of doctors. Witnessing live procedure / surgery has enormous training value and should not be swept under the carpet and banned simply because some experts feel left out of mainstream since they are not invited to demonstrate their skills. In interests of many should override the interests of the few.

9) Conflicting message is given in passages for “selection of patient” and “ethical considerations” where one says only new procedures and techniques should be done whereas in the other it says only standard operative procedures should be done.

10) Even the undergraduate medical education today has been permitted for profit and commercial gains. Restricting demonstration of new technology by citing educational vs commercial debate seems ridiculous.

The only good thing I can see coming out of these guidelines is that organisers of superspeciality workshops (specially premier institutes) who were earlier contemptuous of State Medical Councils would now actively woo them for accreditation thus helping the delegates gain valuable CME credit hours.

Dr Neeraj Nagpal
Managing Trustee,Medicos Legal Action Group (MLAG)
Ex President IMA Chandigarh
Director Hope Gastrointestinal Diagnostic Clinic,
SCO 1066-67 Aerodale Market, New Sunny Enclave Sector 123 Mohali 140301
09316517176, 9814013735
HOPE CLINICS;9465109935, 9478082176
email; hopeclinics@yahoo.com, hopeclinics@gmail.com mlagindemnity@gmail.com
For Contributions; "Medicos Legal Action Group" Ac No 499601010036479 IFSC code UBIN0549967 Union Bank Sector 35 C Chandigarh;
Website; http://www.mlag.in
you can also follow us at https://www.facebook.com/medicoslegalactiongroup

A non profit trust registered at Chandigarh by a group of allopathic doctors from all over the country who wish to legally engage the Govt of India regarding its various policies concerning medical profession, training, working conditions.

08/07/2025

Homeopathic Consultants of Maharashtra;

https://timesofindia.indiatimes.com/india/homeopaths-with-pharmacology-cert-can-now-practice-allopathy/articleshow/122284081.cms

The idea that doctors should hold only MBBS degree is obsolete and a British legacy. The current political thinking of adding more numbers to the existing hordes of MBBS doctors by equating Homeopathic doctors with them is indeed laudable. It is not fair and in fact it is discriminatory that it is only MBBS doctors who remain unemployed and under employed, vulnerable to workplace violence, and deprived of any rights and privileges. Such opportunities of slave labour working for pittance should benefit every one and so we should open registration in Maharashtra Medical Council to all science graduates, pharmacists, physiotherapists, optometrists, nurses, yoga gurus, who complete a certificate course in modern pharmacology.

Already more than 45 surgical procedures are permitted to be done by doctors of Indian systems of medicine. Schedule X drugs can be stored and sold by them in some states. The problem only is something no one is visualising. We are so focussed on equating BAMS, BUMS, BHMS with MBBS that we have forgotten one minor fact which is that we have already emasculated MBBS and he cannot do anything (Not surgery, not obstetrics, not medicine, etc). So why would anyone want to be equated with MBBS. For many reasons an MBBS doctor today is neither trained nor willing to do any clinical work. They are employed for and know only how to take history of patient, make discharge summaries, act as transcriptionists and in some cases as phlebotomists. All this does not require a zero percentile cutoff , a huge bank balance and arduous 5 ½ years of skullduggery.

If there is a plague equivalent today it is the propaganda that MBBS doctors earn huge rewards. I foresee MBBS doctors being hired for salary less than that of a sweeper in next 5 years because of over supply, poor training, lack of jobs and superspecialist culture.

However if the reason for such a decision is to check the burgeoning population which definitely needs to be tackled then I will say it is a very politically astute move. We cannot go back to days of emergency and forced sterilization but we can definitely cull the population by giving them surgeons and physicians who will do the needful in national interest.

Dr Neeraj Nagpal
Managing Trustee,Medicos Legal Action Group (MLAG)
Ex President IMA Chandigarh
Director Hope Gastrointestinal Diagnostic Clinic,
SCO 1066-67 Aerodale Market, New Sunny Enclave Sector 123 Mohali 140301
09316517176, 9814013735
HOPE CLINICS;9465109935, 9478082176
email; hopeclinics@yahoo.com, hopeclinics@gmail.com mlagindemnity@gmail.com
For Contributions; "Medicos Legal Action Group" Ac No 499601010036479 IFSC code UBIN0549967 Union Bank Sector 35 C Chandigarh;
Website; http://www.mlag.in
you can also follow us at https://www.facebook.com/medicoslegalactiongroup

A non profit trust registered at Chandigarh by a group of allopathic doctors from all over the country who wish to legally engage the Govt of India regarding its various policies concerning medical profession, training, working conditions.

05/07/2025

What happens when we meekly surrender our professionalism;

I have been critical of National Medical Commission Act in the past too and the main reasons for my views are;

1) The preamble of the Act stated that those regulated electing those who regulate them is a conflict of interest. In a country which claims to be a democracy where its citizens elect those who govern them this is a bold statement indeed. MCI was a predominantly elected body whereas NMC is predominantly a nominated one.

2) The fact that 80 Member parliaments who had stakes in private medical colleges were part of the house which passed the bill regarding regulation of medical education. None of these 80 MPs with stake in private medical colleges abstained from voting on this bill which replaced elected representatives with central Government nominees, diluted the criterion to full fill for approvals to start and continue a course. If this was not conflict of interest then there can be no better example of the term

3) By definition a Profession should have “autonomy” as well as “self regulation”. NMC Act has made it clear that doctors do not have autonomy in their actions and they are to be governed by nominees of Government who may not be doctors.

Today I hear the news that a State Medical Council has struck the name of Dr Shantanu Sen from its rolls for 2 years for writing FRCP on his letterhead. Whether Honorary or earned a Fellowship of a professional body is awarded as recognition of their service in that field. It is given to select few members of that professional body after rigorous screening process. If medical councils are meant to only do the Governments Bidding then these are neither autonomous nor “self regulation”. The professional councils cannot act as mouthpiece of the Government in power. If they feel impotent against the might of the Government The members should resign. That this judgment by SMC is biased, motivated and will be challenged in High Court / Supreme Court is a given fact.

Law requires a person not to claim to be a specialist if he does not have a SMC recognized qualification in said branch. It does not stop me from writing my achievements (Fellowships included) on my letterhead as long as I do not claim to be a specialist based on the Fellowship which may be unrecognized by NMC. It is fashionable in India to penalize those who seek to follow the law irrespective of the fact that the number of those who break the same law with impunity.

In 2008 when the SC delivered judgment in case of Samira Kohli vs Dr Prabha Manchanda it stated clearly that a doctor can and should do the procedure which the patient has consented to. A doctor cannot decide to extend the procedure if patient is already under anesthesia even though he feels that it may be in patient’s best interest. This judgment effectively changed the doctor patient relationship from contract for personal service (where service provider provides solution to a problem as per his own experience) to contract of personal service (where a service provider does exactly what he is instructed to do). The change into a master servant relationship where a patient is the master removed autonomy of doctors in their medical practice.

Consumer Protection Act and Clinical Establishment Act both also encroached on the autonomy of the profession as well as the concept of self regulation. What is however interesting and noteworthy is that the same Dr Shantanu Sen was President of Indian Medical Association which did not vigorously object to the meek surrender of professional privileges either by going to streets or to court. Judgment of V P Shantha vs IMA of 1995, Samira Kohli vs Dr Prabha Manchanda both required intervention and appeal . NMC Act, CPA 2019, BNS 2023, CEA 2010 all have sections which are detrimental for medical professionals and some are even unconstitutional. However our professional organizations after initial whimpers consider it wiser to wait and watch and criticize those who do take these matters to court.

Dr Neeraj Nagpal
Managing Trustee,Medicos Legal Action Group (MLAG)
Ex President IMA Chandigarh
Director Hope Gastrointestinal Diagnostic Clinic,
SCO 1066-67 Aerodale Market, New Sunny Enclave Sector 123 Mohali 140301
09316517176, 9814013735
HOPE CLINICS;9465109935, 9478082176
email; hopeclinics@yahoo.com, hopeclinics@gmail.com mlagindemnity@gmail.com
For Contributions; "Medicos Legal Action Group" Ac No 499601010036479 IFSC code UBIN0549967 Union Bank Sector 35 C Chandigarh;
Website; http://www.mlag.in
you can also follow us at https://www.facebook.com/medicoslegalactiongroup

23/06/2025

The Hon’ble Chairman,
Committee on Health and Family Welfare,
Rajya Sabha

Subject: Representation on Affordability & Accessibility of Healthcare in Public and Private Sector

Dear Sir,

We came across your public notice in The Times of India regarding the Rajya Sabha Committee on Health and Family Welfare’s initiative to examine the affordability and accessibility of healthcare in both public and private sectors.

We write to you on behalf of Medicos Legal Action Group, a trust comprising approximately 1,250 allopathic doctors from across India. Our organization works to address issues adversely impacting medical practice, particularly those arising from policy, legal, and systemic challenges.

While we strongly support the objective of making healthcare affordable and accessible to all, we wish to express our deep concerns—based on past experiences—that the government may resort to capping doctors' fees and procedural charges in the private sector. This, we believe, is a flawed and potentially harmful approach. Our concerns are elaborated below:

1) Market Forces Should Govern Pricing
Market forces dictate which establishment can charge what for which procedure and if private hospitals and doctors over price themselves then they loose consumers.

2) Historical Precedent of Chaos

Past Experience where Government or its agencies have tried to interfere in the pricing exercise it has resulted in chaos with unviable charges notified resulting in hospitals and doctors resorting to fraudulent billing to recover costs under various Government schemes

3) Violation of Constitutional Rights
Right to practice profession as enshrined in the Constitution includes right to decide what to charge for one’s services and any restriction would be an infringement and violation of their fundamental right.

4) Root Causes of Rising Healthcare Costs
Understanding the basic reasons for increasing cost of healthcare is essential before embarking on trying to find a solution. Without tackling these it will be next to impossible to effectively make healthcare affordable. The reasons are

a. Defensive Medicine Defensive Medicine being practiced by doctors and hospitals faced with enormous increase in litigation for alleged negligence.

b. Liberal judiciary Over generous judiciary which has awarded compensation on compassionate grounds even when no negligence is proven.

c. Judicial simultaneous harassment Multiple simultaneous judicial and quasijudicial fora which simultaneously ask a doctor / hospital to defend him/it self before them on same facts against same complainant have not helped the matters.

d. Economic reality; A patient earlier used to pay a doctors’ fee and cost of consumables. Today he has to pay for the advocates, insurers, security persons, management consultants, quality inspectors, besides the doctors’ fee and consumables.

e. Technology and Import Dependency Increasing use of technology in healthcare. Since there is no research and development in our country we are dependent on western countries to provide us with the equipment.

f. Judicial Precedents One court decision awarding a crore to one patient results in hundreds of other patients paying for the one crore and more in cost of their own healthcare services. Any doctor who was seeing 50 patients per day with a fee of Rs 100, immediately after an allegation of negligence and going through the process start charging much more for the risk involved.

g. Over-regulation Increasing number of laws and compliances with their registrations and inspections and corruption associated with them. All these result in increased cost of running a healthcare establishment and consequentially increased cost of services.

h. Chronic underfunding Poor investment into healthcare in budget which results in substandard infrastructure, suboptimal human resources and poor quality services being provided by public sector hospitals and clinics.

i. Overcrowding The few public sector hospitals which provide quality care are overcrowded and leave a lot to be desired in terms of patient satisfaction.

j. Excessive Legal Interference; Interference of law in practice of medicine. The superspecialist culture and the judicial emasculation of MBBS results in all patients with chest pain being treated by cardiologist even if it is a case of simple heartburn. Courts today have become very proactive in declaring an MBBS negligent if he does any thing which falls in domain of a specialist and similarly declaring specialists negligent if they venture into the domain of a superspecialist. This is despite the fact that a LLB can rise to become Chief Justice of India and decide on cases of constitutional law, criminal law, service matters and others without any objection. What we need is good doctors who know more and more not more superspecialists who know less and less. If a surgeon in a teir 3 city can perform caesarean, thoracotomy, and Trans Urethral Resection of Prostrate then he should be encouraged for providing services at door step at low cost and not penalised as being negligent because he has done a procedure which should be done by a cardiothoracic surgeon or a urologist.

k. Superspecialist Overdependence If only a DM neuroanesthesia should give anesthesia in neurosurgical cases and only a DM cardiac anesthesia should give it in cardiac surgery cases and so on and so forth for DM onco anesthesia and DM Neuroanesthesia , every surgical centre would require at the very least 6 types of anesthetists in 8 hour shifts meaning thereby that 18 or more anesthetists are needed to cover for leaves and vacancies. With such laws and such requirements, cost of healthcare is bound to increase.

l. Costly Accreditations Accreditation by quality agencies like NABH, JCI and others. Whether accreditation actually improves patient outcome or increases patient satisfaction is debatable but the business of the agencies providing these accreditations is booming with their consultants and their processes adding significantly to the cost of running an establishment. The reason the business of these private agencies is booming is because Government and public sector agencies have made the accreditation a mandatory requirement before approving any clinical establishment to participate in various insurance and Government schemes.

m. Price Fixation Leads to Corruption When Government fixes rates for services in private establishments it increases corruption which indirectly further raises cost of healthcare.

n. Discriminatory Regulation When Government has no power to control the rates charged for services by other professionals it is discriminatory to control the rates charged by private Doctors and Hospitals.

o. Medical Education Costs Cost of Medical Education cannot be dissociated from cost of healthcare. If the Government finds a 3 crore Fee for a DM Gastroenterology course to be fair then it is only fair that those who have spent these amounts should recover Discriminatory Regulation their “investment” without undue restriction.

5) Accessibility: A Public Sector Challenge

Accessibility is not so much a problem in private healthcare establishments as it is in the Public sector. The reason is not difficult to seek. 80 percent of Government Healthcare establishments are dilapidated, understaffed, and cannot provide even most basic services required of them. This results in the population rushing for most minor complaints and diseases to the very few tertiary care Government Institutes which have maintained their standards causing overloading and compromise in services given even in these few institutes. To improve accessibility we need to strengthen the grassroot level primary healthcare system of the PHCs whose number has remained stagnant at 28000 for past 3 decades. No budget in recent years has provided money to upgrade these Primary Health Centers. Similar infusion of funds is needed to strengthen the Secondary level of care by improving the civil Hospitals and District Hospital and Sub Divisional Hospitals. Good primary and secondary care along with freedom given to doctors with required experience to provide their full range of services (If a gynaecologist is trained and experienced in giving anesthesia do not automatically label her services negligent simply because something has gone wrong) will filter 90 percent of patients who otherwise choke the corridors of our few premium tertiary care hospitals preventing them from doing the research and teaching so desperately needed.

SOLUTIONS;

1) Increase the health care budget substantially to provide for

a. Increasing the number of Primary Health Centres from 28,000 to 60,000

b. Repair, Maintenance, equipping, staffing the existent and new PHCs

c. Hire 50000 more MBBS doctors to work in PHCs and intermediate level public sector healthcare facilities

d. Hire 50000 more specialists to work in Intermediate and secondary level of public sector healthcare facilities

2) Amend healthcare policy whereby a MBBS doctor with training in a particular field and experience is encouraged to provide services in that field without fear of harassment and prosecution. If an MBBS doctor has worked in a CCU for a few years and now is confronted with an acute MI in a rural setting he should give thrombolysis without being afraid of prosecution. Defensive medicine where every serious patient is referred to higher center simply results in cost escalation as well as loss of precious life in golden hour. The Principle followed should be That though a Gynaecologist may do a better caesarean than a surgeon and a surgeon may do a better caesarean than an MBBS doctor but that an MBBS doctor has done a caesarean in itself not illegal.

3) Most superspecialists have been taught by those who were themselves only specialists by qualification. If tomorrow there are 1500 DM Hepatologists in the country it should not automatically make a DM Gastroenterologist or an MD Medicine treating a cirrhotic with decompensation ; negligent. No nation can afford to provide all types of superspecialists in all the healthcare facilities. But all kinds of diseases are encountered in all healthcare facilities. Judicious use of human resource will bring down cost of healthcare.

4) Insurance is the epicentre of corruption in healthcare and we should not copy paste failed western models of healthcare to our country.

5) For profit medical education should be scaled back to previous model where charitable trusts and non profit organizations only could start a medical college.

Conclusion:

India’s healthcare affordability crisis cannot be resolved by simplistic, populist solutions like price caps. We urge the Committee to address structural deficiencies, judicial overreach, systemic inefficiencies and economic realities before finalizing any recommendations. Ensuring affordability and accessibility requires deep systemic reform, not surface-level price controls. And penalizing private practitioners.

We remain available for oral presentations or further consultation on this matter.

Warm regards,
Dr. Neeraj Nagpal
Managing Trustee
Medicos Legal Action Group

093165 17176