🩺 MEDICAL MALPRACTICE - Complete Exam Notes

MBBS 2nd Year | KAHS, Jumla | Easy Language

📌 WHAT IS MEDICAL MALPRACTICE?

1. Medical Negligence
2. Professional Misconduct

PART 1: MEDICAL NEGLIGENCE

🔴 Definition (5 marks - learn word for word!)

"Failure to exercise reasonable care and skill of an ordinary prudent medical practitioner, resulting in bodily injury, harm, or death of the patient."

🔴 ACTS OF NEGLIGENCE (2 types)

🔴 CRITERIA FOR MEDICAL NEGLIGENCE - "4 Ds" (Black's Law Dictionary)

1. Duty of care - Doctor had a duty to treat the patient (doctor-patient relationship existed)
2. Dereliction of duty - Doctor failed/broke that duty
3. Damage - Patient suffered harm/injury/death
4. Direct causation - The doctor's failure directly caused the harm

Exam tip: If asked "what are the criteria/elements of medical negligence?" - write all 4 Ds with a one-line explanation each.

🔴 EXAMPLES OF MEDICAL NEGLIGENCE (by specialty)

• Inadequate medical records
• Failure to get informed consent
• Wrong diagnosis

• Not referring to specialist when needed
• Toxic effects of wrong drug

• Leaving instruments/swabs/towels inside operation site
• Operating on wrong patient or wrong side of body

• Unwanted pregnancy after failed tubal ligation
• Performing abortion without indication

• Over-tight or prolonged plaster cast causing nerve damage
• Missing intracranial hemorrhage

• Neurological damage from wrong spinal injection
• Incorrect/excessive anesthetic agents

🔴 TYPES OF MEDICAL NEGLIGENCE

PART 2: DEFENSES AGAINST NEGLIGENCE

1. No duty of care - No doctor-patient relationship existed
2. No breach of standard of care - Doctor followed standard medical practice
3. Informed consent - Patient was properly informed of all risks
4. Contributory negligence - Patient's own actions caused the harm
5. Error in judgment - Doctor made honest mistake while acting with reasonable skill
6. Mistake of fact - Doctor acted on wrong but honest understanding of facts
7. Res judicata - Case already decided before; cannot be tried again between same parties
8. Unavoidable complications - Harm was an inherent/unavoidable risk despite best efforts
9. Lack of causation - Injury would have happened even without the negligence
10. Statute of Limitations - Patient filed case after legal time limit (in Nepal: must file within 6 months - Civil Code 2074, Section 684)

PART 3: IMPORTANT DOCTRINES (5-mark favorites!)

🟠 1. Doctrine of RES IPSA LOQUITUR

• Patient does NOT need to prove negligence
• The mistake is SO obvious that the doctor must prove his innocence
• Applies to both civil AND criminal negligence

1. Injury would NOT occur without negligence
2. Doctor had control over the cause
3. Patient did NOT contribute to the injury

• Wrong site surgery
• Leaving instruments inside the patient
• Loss of hand use due to prolonged splinting
• Prescribing overdose of medication

🟠 2. Doctrine of CALCULATED RISK

• Applied when injury occurs even though reasonable care was taken
• Important defense for doctors
• Doctor must show statistics proving the risk was unavoidable

🟠 3. Doctrine of COMMON KNOWLEDGE

• When negligence involves common sense, not specialized medical knowledge
• Similar to Res Ipsa Loquitur
• Patient must prove the act (commission or omission), but does NOT need to prove standard of care

🟠 4. Doctrine of AVOIDABLE CONSEQUENCE RULE

• Doctor is NOT liable for additional harm the patient could have avoided
• Applies to patient's unreasonable conduct AFTER the injury

🟠 5. NOVUS ACTUS INTERVENIENS

• A new act interrupts the link between original cause and outcome
• Can transfer responsibility from original doctor to a new negligent act
• Rarely accepted by courts
• Negligence must be proven

PART 4: PREVENTION OF MEDICAL NEGLIGENCE

1. Legal and ethical awareness - Follow ethics, obtain informed consent
2. Effective communication - Clear doctor-patient communication, proper documentation
3. Continuous Medical Education - Regular training, stay updated
4. Maintain standard medical service - Limit workload, follow protocols
5. Proper counseling and informed consent - Mandatory before procedures
6. Proper investigation - Thorough examinations, seek second opinions
7. Adequate supervision and timely referral - Detect complications early, refer to specialists
8. Surgical interventions - Operate only where proper equipment and qualified staff exist
9. Meticulous record keeping - Records can prove innocence
10. Morbidity and mortality audits - Analyze errors to improve care
11. Medical insurance and risk management - Have malpractice insurance, risk management team
12. Patient safety measures - Use checklists, double-check patient identity before procedures

PART 5: PROFESSIONAL MISCONDUCT

🔴 Definition

"Any conduct which might be regarded as disgraceful or dishonorable as judged by a professional man of good repute and competence."

🔴 OCCURRENCES OF PROFESSIONAL MISCONDUCT

1. Practices unethical advertising or endorsement
2. Does NOT maintain indoor patient records for 3 years OR refuses to provide them within 72 hours of request
3. Does NOT display registration number in clinic, prescriptions, and certificates
4. Rural doctor absent on 2 or more occasions during inspection
5. Medical college faculty absent on 2 or more occasions (certified by Principal/Medical Superintendent)
6. Provides falsified or misleading information

🔴 THE "6 As" - Important Offences (MUST MEMORIZE!)

Association with unqualified persons Advertising Abortion (Criminal) Adultery Addiction Alcohol

🔴 UNPROFESSIONAL ACTIONS - What a Doctor Should NOT Do

• Must use 18 x 14 inch signboard
• Must write: name, NMC number, qualifications, specialty
• Letters: blue on white background
• Cannot use International Red Cross symbol
• Cannot affix signboard on a chemist's shop

• Use touts or agents to get patients
• Insult or misbehave with fellow doctors
• Commit adultery or misbehave with patients
• Be drunk and disorderly
• Be convicted by court of law
• Do sex determination test
• Issue false or misleading certificates
• Supply addiction-forming drugs
• Perform illegal abortion or operation
• Disclose professional secrets
• Publish case reports/photographs without patient consent

PART 6: POWERS OF PROFESSIONAL CONDUCT AND HEALTH COMMITTEE

1. Warn and Conclude the Case

• Doctor found innocent → case concluded

2. Put on Probation

• Doctor placed on probation for a specific period
• Professional referees appointed to watch conduct
• If satisfactory report → case concluded

3. Erasure from Register (Strike off)

• For serious misconduct or criminal conviction
• Doctor's registration is erased → cannot practice
• Erasure period: 2 years (as per NMC Act)

4. Application for Restoration of Registration

• Can apply after 2 years from date of erasure
• Committee may grant:
  • Unconditional restoration, OR
  • Conditional restoration, OR
  • Extend erasure by 1 more year
• If application fails, must wait 12 more months before applying again

⚡ QUICK REVISION TABLE - Most Exam-Likely Topics

📝 POSSIBLE 5-MARK QUESTIONS FROM THIS SLIDE

1. Define medical negligence. What are the criteria (4 Ds)?
2. What is Res Ipsa Loquitur? Give examples.
3. What are the defenses against medical negligence? (write any 5-6)
4. What is professional misconduct? Write the 6 As.
5. How can medical negligence be prevented? (write any 5-6 points)
6. What are the powers of the Professional Conduct Committee?
7. Differentiate between civil and criminal negligence.
8. What is the Doctrine of Avoidable Consequence? Give an example.

📢 COMMUNICATION SKILLS — Complete Exam Notes

MBBS 2nd Year | KAHS | Dr. Jeetendra Bhandari

📌 WHAT IS COMMUNICATION SKILL?

Abilities you use to convey and receive messages effectively through verbal, non-verbal, written, and visual means — ensuring mutual understanding between sender and receiver.

PART 1: BASIC ELEMENTS OF COMMUNICATION

PART 2: SEQUENCE OF COMMUNICATION

🔵 STEP 1: PREPARE

• Review previous consultation outcomes
• Identify key medical issues for the patient
• Check recent test results and correspondence
• Know about family members who may accompany the patient
• Note personal preferences (e.g., needle phobia)

🔵 STEP 2: OPEN

• Greet the patient and address them by their preferred name
• Make the patient feel comfortable — smile
• Appear unhurried and relaxed
• Focus firmly on the patient
• Use open-ended questions (e.g., "Tell me about your cough" — not yes/no questions)
• Make appropriate reassuring gestures

🔵 STEP 3: GATHER

• Tone (how it's said)
• Rhythm (speed of speech)
• Context (situation)
• Take notes without creating barriers (computer should not be intrusive)

• Allow pauses (don't rush)
• Make encouraging sounds like "mm hmm"
• Echoing — repeat patient's phrases (e.g., "So you feel tired and weak?")
• Ask "Is there anything else?" or "Any other problem?"
• Use open-to-closed cone (start with open questions, then get more specific)

• Summarize what the patient said to ensure you understood correctly
• Check with: "Is that right?" or "Is there anything else?"

🔵 STEP 4: NON-VERBAL COMMUNICATION

Key fact for exam: Non-verbal communication makes up the MAJORITY of a message's impact!

• Gestures
• Postures
• Distances (how close you sit)
• Head nodding
• Eye contact

• Enhances rapport and communication
• Helps understand patient concerns
• Awareness of body language helps doctor adjust their behavior

🔵 STEP 5: PATIENT'S PERSPECTIVE — ICE

🔵 STEP 6: COMMUNICATING DURING PHYSICAL EXAMINATION

• Always obtain consent before touching the patient (just like for surgery)
• Recognize that physical exams can be intimidating (due to past experiences, culture, gender issues, phobias)
• Explain the process and findings during the exam — helps patient feel valued
• Stay attentive to additional concerns raised during examination

🔵 STEP 7: PATIENT EDUCATION

1. Signposting — Explicitly state what has been done or is about to be done (helps patient relax and focus)
2. Chunk and Check — Give information in small chunks and check understanding each time (allows early correction of misunderstandings)
3. Avoiding Jargon — Minimize technical language; use simple words the patient understands
4. Visual and Physical Techniques — Use visual aids (diagrams, pictures) to enhance patient understanding

🔵 STEP 8: NEGOTIATE AND AGREE ON PLAN

• Plan collaboratively with the patient — don't just tell them what to do
• Mutual Respect — respect each other's concerns; reach a consensus on treatment
• Mindfulness — be aware of both doctor's and patient's values and feelings
• Empathic Bridge — anchor conversations in the patient's experience; gently steer back if needed
• Shared Experiences — build trust to foster collaborative decision making

🔵 STEP 9: CLOSE (Ending the Consultation)

• Inform in advance that consultation is about to end (so patient doesn't feel rushed)
• Check for additional concerns — "Is there anything else you wanted to ask?"
• Summarize key points of consultation and planned actions
• Prepare a safety net for unexpected outcomes
• Parting statement — Thank the patient, farewell; consider cultural preferences for gestures (e.g., handshake)

PART 3: SPEECH CENSORING

What is Speech Censoring?

When a patient decides NOT to tell you something important

• They are afraid or embarrassed
• Worried the doctor will judge them
• Don't think the doctor will be interested

Signs of Speech Censoring (How to Detect It):

1. Losing eye contact — patient looks away
2. Patient stops talking mid-topic
3. Hesitates mid-sentence or at the end
4. Vagueness — unclear, non-specific answers
5. Changes topic mid-sentence
6. Omits important details

PART 4: TECHNIQUES TO OVERCOME SPEECH CENSORING

🟠 1. MIRRORING

• Copy the limb positions and body angles of the person you're talking to
• Forms a mirror image of their position
• Creates a sense of connection and trust
• Avoid copying uncomfortable or unusual gestures (e.g., hands behind head)

🟠 2. PACING

• People have a natural rhythm in breathing, talking, and movements
• Copy the other person's pace to create a sense of oneness and rapport
• Once rapport is established, change their pace by altering yours — this is called "LEADING"

🟠 3. VOCAL COPYING

• Copy the patient's:
  • Intonation (rise/fall of voice)
  • Pitch (high/low)
  • Volume (loud/soft)
  • Pace (fast/slow)
  • Rhythm
  • Breathing
  • Length of sentences before pausing

PART 5: KEY FEATURES OF GOOD COMMUNICATION

1. Patient-centred approach — put patient at the center
2. Eliciting all of patient's concerns — don't miss anything
3. Exploring ICE — Ideas, Beliefs, and Expectations
4. Showing empathy and respect
5. Summarising — confirm understanding
6. Avoiding jargon — use simple language
7. Collaborative decision making — plan together
8. Good closure — end the consultation properly

⚡ QUICK MEMORY AIDS

📝 LIKELY 5-MARK EXAM QUESTIONS

1. Define communication. Write the basic elements of communication.
2. What is the sequence of communication in a doctor-patient consultation?
3. What is non-verbal communication? Write its importance and the 7-38-55 rule.
4. What is ICE in patient communication? Explain each component.
5. What is speech censoring? Write its signs and how to overcome it.
6. What is active listening? How does a doctor facilitate patient dialogue?
7. What is 'Chunk and Check'? What is Signposting?
8. Write the key features of good communication skills in medicine.
9. What is shared decision making / negotiation in consultation?
10. How should a doctor properly close/end a clinical consultation?

Exam tip: For any 5-mark question, write a short definition first, then give 4-5 numbered points with brief explanation. That always scores full marks! 💪