Author: mygynaec

Lata rushed into my consulting room with tears rolling down her cheeks. She was angry and visibly
upset. Lata’s both kids were delivered by me. She was an experienced mother. She was very diligent
about the baby’s health and never missed on the vaccination schedule. She used to take her kids to
the same pediatrician for years together. On one fine day, her pediatrician informed her that the
child was given a vaccine which had expired one month back…and Lata was shattered. Like many of
my patients who consider me to be their “friend- philosopher- guide” besides being their
gynecologist, Lata came to me for help and guidance.
Lata was literally fuming. She said. “I trusted that doctor so much and how could she be so negligent
to me and my child?” It was a clear case of medical error. The pediatrician was extremely apologetic
and felt sorry about the whole incidence. We know that medication errors are the commonest errors
in healthcare. Actually. this mistake was caused because of a goof up in the pattern of writing expiry
date. We know that the Americans write the date in “mm/dd” format and In India we use “dd/mm”
format. Precisely this was the cause of this blunder.
Lata was extremely worried and tensed about the ill effects of the expired medication. “Doctor, I
even check a loaf of bread for the “consume best before” date. I don’t allow anyone to eat even a
slice after that date. We make fresh food every day. We don’t consume “Basi” (stale) food at home.
And look here. My little one has been injected with a vaccine which has expired a month back!!!”
Lata blew off.
She was not wrong at all. Most people believe that medication post expiry, like food, may rot or turn
into some poisonous substance and be very harmful if consumed. So is this true? What is the
meaning of expiry date? This article focuses on these issues.

(source: google)
A few years back US air force found a huge stock of medications worth thousands of dollars stored in
odd places like bathrooms at various locations in the country. They had just dumped those expired
medicines as they did not know what to do with them. Purely out of interest some intelligent
pharmacologist decided to conduct a study on these drugs. And Bingo! Almost 90% of the medicines
had retained their potency although they had expired few months to few years back. On the basis of
these finding US air force and Food and Drug Administration created a programme called “Shelf life
extension programme”. Under this programme. the expired medicines were rechecked for potency,
revalidated and re-used for medical treatment successfully. It saved millions of dollars for the
government. Few medicines … sprays, liquids had more chance of losing their potency as compared
to injections and vials containing medicine in powdered form. But one thing came out loud and clear
… none turned into poisonous substances or created harm!
The system of writing expiry date began in in the United States in 1978. The same system was
followed across the world. So what does the expiry date mean? Is it the date beyond which medicine
becomes completely ineffective? Is it the date after which the drug will rather cause harm? The
answer to both the questions is “No”. The expiry date is the date beyond which the company does
not assure of full potency of the medical ingredients. It is a conservative estimate by the company. In
a way, it helps the sales of the company as expired medicines will be discarded and new stock will be
ordered! In order to strike the right balance between cost and benefit, the American Medical
Association asked FDA to review the system of giving expiry date in 2006.

Few clear messages emerge out of research on this topic:

•   Medicines do not get stale or rot or turn poisonous post-expiry.
•  The above sentence may not hold true especially in case of syrups containing substances like
  glucose.
•  If the bottle/ vial is opened then bacteria can grow into it. But if the injections or vials
  containing dry powders are stored correctly in a sealed pack they cannot “rot” or get
  infected.
• The expired medications may not have the same potency. Hence one may need to revalidate
  the potency or simply take an additional dose.
•  In nutshell, if expired medications ( tablets/ injections) get used inadvertently, no guarantee
  can be given about its effectiveness but it will not cause harm or untoward effect too.

So what did Lata do? Lata met two pediatricians and discussed the matter. Both suggested that the
child should be given another dose of vaccine. Sadly, the child had to take additional injection but
Lata was sure that there is no harm caused to the child. Her pediatrician gave an additional dose of
vaccine to the baby. Lata continues to follow up with the same doctor. She and her doctor both have
become more vigilant about the medications as they both know that human errors are possible in
any one’s hand.

By Dr Nikhil D Datar. MD DNB FCPS FICOG DGO LLB

Obstetrician, Gynaecologist and Health Rights Activist, Mumbai

www.mygynaec.com

“Patient no 13/2017” calls out a nurse. A patient reduced to a number, as if she were in jail. Sounds demeaning, doesn’t it? May I say that this practice is legal and in fact, desired in India by the “Medical termination of pregnancy regulations 2003” (MTP regulations). Shocked? Confused? The Government of India framed these regulations in 1975 and amended them in 1993. The regulations state that the name of the woman undergoing termination of pregnancy (TOP) should not be entered anywhere except on the admission register and consent form. At all other places it is the serial number assigned from the admission register that is to be entered. This “special” provision has been made to safe guard the privacy of the woman. Well, that is fantastic! Privacy of every patient is of paramount importance.

However, let us see how this provision works in real life.

A woman comes to my clinic. An OPD case sheet is made in her name before I see her. Only after some conversation can it be determined that she wants to terminate her pregnancy. Thus it is obvious that one cannot not have the patient’s name on OPD sheet. If an MTP is to be done surgically I need to admit her in the hospital. Now I need to inform the clerk on admission counter to make an indoor paper/ case sheet with a serial number instead of her name. Since this provision is only meant for MTP cases, the clerk or non-medical staff automatically understands the purpose of this admission. Moreover there is a system of obtaining general administrative consent upon admission. When the woman signs it, her name is naturally revealed to those administrative personnel not connected to patient care.

In addition to that, since her name is not written on any other paper work, how should the nursing staff address her? By number? Our teachers in medical college used to be very upset if a medical student would call out any patient by their bed number or by the name of the medical condition patient suffered from. The practice of reducing a human being to a number is a bad bed side practice and extremely devaluing. However in this case it seems to be perfectly legal.

Even the anaesthetist should not (officially) know the woman by her name. The WHO patient safety checklist gives a lot of importance to the identification of the patient in order to reduce medical errors. However here we are expecting the anaesthetist to administer anaesthesia without even knowing the name of the patient!

These MTP regulations state that the consent form should be sealed into an envelope with the serial number and the word “secret” be written on it and sent to the administrator. In India most of the MTP services are provided by small healthcare facilities which are single doctor owned. This means that the doctor doubles up as an administrator or the owner. Thus, the regulation would require a doctor to send the envelope to himself with the word “secret”. Absurd, isn’t it? But the rule of law is followed to the T by government inspectors. They want to see these sealed envelopes presented by the doctor to himself!

According to the regulations, even the discharge card or follow up card should not have the name of the woman on it. So what happens if the patient asks the doctor to write a certificate stating that she has undergone termination of pregnancy? Should the doctor write her name?

The Ministry of Health and Family Welfare itself has contradicted it’s own provision of not writing the name on the follow up card. In 2010 the ministry released a publication titled “Comprehensive abortion care guidelines”. (http://www.nrhmhp.gov.in/sites/default/files/files/Guidelines_CAC%20Training%20%26%20Service%20Delivery%20.pdf ) On page 50 of this guideline the ministry has showcased a standard format of the follow up card. The first column of the format reads as patient’s name followed by the phone number!

Privacy is paramount, not only for the termination of pregnancy but for healthcare in general. The question is: Is the designed system achieving its goal? Or else we are just making complex systems that are more prone to clerical errors for which individuals can be held liable?

PS: In last 32 years no doctor’s association has raised any objection to these absurd, anomalous and impractical provisions or suggested any change.

By  Dr Nikhil D Datar

Gynaecologist and Health Rights Activist

“Doctor, you stood behind us like a rock when we felt all else had failed and showed us the way forward to get justice!” said a 42 years old man. He was accompanied by his wife and daughter of 11 with tears rolling down their eyes.

While most of the doctors do get their share of appreciation while doing their professional duty as healers, this was different. The little girl was brought to me few years back. She was just a  child of eight years and was referred to me for treatment of “precocious puberty”, as she had started menstruating way too early. The girl looked tensed, sad,always had her head low and never talked. Initially I thought that she was just reacting to the medical condition and the physical, emotional and psychological stress. However, soon I started noticing that she was not responding to the treatment. When I tried to dig a bit deeper into why this was happening I found that she kept herself very lonely lately and refused to go to school often which was very unlike herself according to the parents. It was soon found that she was a victim of sexual abuse by a school teacher. This came as a huge shock and the parents were shattered.

When I explained the need to inform the police, they were just not willing to do so.They had almost decided to leave their life in Mumbai and move to another city. The mother’s quivering voice still rings in my ears. She said “Doctor, please leave us alone. Don’t make us go through the trauma all over again. What are police going to do? They will come home to investigate. The whole locaility will know. Soon the media will come to know and our names will be all over the place. It will be just one more ‘story for them but our lives will be ruined. We have no one here in the city. It is only three of us. The police, courts, delays… they will make my daughter narrate all those things in the open court. She is a small child. It will be like making her undergo same thing again and again.”

I was stunned and shocked. I had no words to express. On one hand I was an advocate for legal remedies and on the other hand I did understand the child and her family’s pain and suffering. They were living under constant fear. Looking at the bigger picture, I knew that pusuing a legal course was important so that the offender is punished otherwise he would go scot-free and destroy the childhood of another little girls and boys.

I sat with the the parents and gave them my time to explain why going to the police was important. I explained to  them the  provisions of the POCSO Act… the law that is made for the protection of  children from sexual offences. This Act deals with child abuse with great sensitivity. Under this Act, only senior female police officers are supposed to investigate the matter. The police are normally not supposed to visit the house but in case they do so they have to be in plain clothes and not in uniforms. The child is not supposed to be called again and again to police station. The child can not be kept for long in the police station.  In case of a medical examination, it is conducted by a lady doctor and in the presence of the victim’s parents. The special courts under POSCO Act conduct in camera proceedings. The media is not allowed in the court. The child is not exposed to the  offender and no aggressive questioning (what we typically see in the movies) is allowed. The media is not allowed to reveal the identity if the child in any way. I helped them connect to a social worker to boost their morales for a legal recourse.

Two years after, the same family was in front of me. The mother said that the offender was immediately arrested and is now behind bars. “Every thing happened exactly how you had told us. We were on the verge of leaving our house. We stay in the same house today. The police came in plain clothes and no one in locality even knows about it. The news papers did give the news but no where did our name or location featured. No one knew that we were those victims.  The lady judge made my daughter sit next to her, played with her gave her a chocolate while questioning. The offender has hired a veteran lawyer but all in vain. He is still in jail,” she said.

The father said that they did end up changing the school though, and their daughter really enjoys it now. She is again her churpy, bubbly self. Their lives have returning to normal and they live with confidence again. While the trauma cannot be forgotten, the family has solace in justice atleast.

All three of them were crying in front of me. The mother said “Doctor, we still remember your words. You had said to us then “I am with you. Call me whenever you want. I will be with you for any help right from going to police station to whatever you need. I will walk with you shoulder to shoulder in this fight for justice” That sentence was enough for us to keep going.”

I felt proud of my self and the police force. I felt proud of my country in which there is a law that protects children and the law is not merely on paper but is in action.

When Mr. Das went to the hospital for his wife’s surgery he proudly flashed his insurance card for availing cashless services. He was under the impression that his financial responsibility will be over only by showing the card. At least that is what was told to him by his agent when he took the cashless mediclaim policy.  Most of us do not really pay attention to the fine print of the insurance policy.  Most of us come out of the hospital with a mixed feeling… On one hand we feel happy that our near and dear one is safe and in good health but on other hand we are not happy with the administrative experience related to the billing and insurance. If you want to avoid this, you must know how the system works! As a consumer on insurance company it is your right to demand the benefits and services for which you pay the premium.

How does the cashless mediclaim work?

An individual or group of individuals buy mediclaim policy or healthcare insurance from an insurance company. The company enters into a contract with the consumer. The insurance company in turn allocates your policy to a third party administrator (TPA). The TPA in turn have contracts with the hospitals. These network hospitals basically agree to treat the patient of TPA at pre-decided rate. Thus the hospital will be able to claim only that sum of money which is pre agreed with TPA and it has nothing to do with your sum assured.

What should you know about the policy?

The policy specifies certain terms. Almost all insurance companies have a fixed allowable room rent which is proportional to the sum assured. For example, an insurance company may specify that the room rent allowable shall be 1% of the sum assured. Thus, if you have a cover of 500000 (This is called as “sum assured”) then company will only take upon itself the financial liability when you stay in a room that has a rent of Rupees 5000/- or lower. It is important to understand that all other charges such as theatre charges are linked to the basic room tariff. So you must know this aspect of the insurance policy correctly.

How to find out the hospital which will provide cashless mediclaim to you?

The TPA will provide a list of its network hospitals to you. It is expected that TPA should update this list from time to time. You may be able to find the list of network hospitals from the call centre or website of the TPA.  You should then choose a hospital based on the vicinity, quality of services, speciality offered and of course the doctors working at the hospital.

What should you do when you go to the hospital?

Hospitals have a dedicated help desk or nominated person for insurance related work. You must carry the valid insurance card, your identity proof, and policy document along with to the hospital. If you are going to use the cashless mediclaim you must inform the hospital before hand.

What does the hospital do?

When the hospital treats a patient it should clearly know about who is going to pay for the services. Individuals pay for themselves. In cashless arrangement, since you are the customer of the TPA, it is the TPA  that pays to the hospital for the service provided. The TPA issues “Authorisation letter (AL)” to the hospital indicating that it will take the responsibility to pay the hospital as per terms of contract. Actually getting the AL is the responsibility of the consumer. But hospitals help to initiate the process by sending the requisition for the AL to TPA. As a consumer it is important to be vigilant and be actively involved in procuring the AL.  

When can hospital ask you to pay directly?

1.  When TPA has denied to pay. : In such a case you need to sort it out with your TPA.  It is common that health information given by you while taking insurance is found to be in mismatch with the medical information given by the doctor from the hospital. Hence you should disclose the truthful and factual details about your health when you take insurance.
2. Co- payment : Some companies have a co-payment system. It means that you have to pay your share and only then the company will pay or undertake to pay.
3. Exclusions: It is important to read the small print in the policy document. There are few exclusions in the policy. Your company may have put restrictions that it may not pay for specific treatments or for first few years.Besides that the insurance company or TPA may not pay for few items needed during the treatment. For example, diapers, baby soap , certain antiseptic solutions , disposable towels etc.

   It is obvious that the customer has to pay for the expenses incurred directly.

4. Additional expenses : The hospital incurs certain expenses such as registration, documentation, postage etc.  The TPA does not pay these charges to the hospital and the consumer has to pay directly to the hospital.

What happens when patient is discharged?

Before the discharge the TPA has to give final authorization to the hospital. Only upon receiving the same the hospital discharges the patient. The hospital has to do a lot of paper work before discharge. This may cause delays in discharge process.

Even after the discharge is done, the TPA may raise queries which need to be addressed jointly by the patient and the hospital.

In conclusion, consumer of cashless mediclaim must exercise his/her rights dutifully. Being vigilant and informed is the need of the hour.