In the present days of increasing consumer awareness and distrust among the public towards the medical profession its time to introspect & rectify ....

1. Dr.Shirish Kumthekar.Consulting Surgeon Oncologist.
Kumthekar Multispecialty Hospital & Rsearch Center.
Main Road, Jule Solapur. Solapur.
www.kumthekarhospital.com.

2. Ethics Definition:
 The word ethics is derived from the Greek word
ethos, which means "character,“.
 The most important element in ethical
behavior is knowledge that actions are
accomplished for the betterment of the common
good of individual and society.
 To put it formally ethics is the branch of
philosophy that defines what is good for the
individual and for society and establishes the
nature of obligations, or duties, that people owe
themselves and one another.

3. Medical Ethics
 Medical ethics refers to the system of values
common to medical profession and
application of these values to practice of
medicine. It is the standard of behavior by
which physician evaluate their relationship
with their patients , colleagues and society.

4. Principles of Medical Ethics
Autonomy : Right to choose.
Beneficence :In the best interest
Confidentiality
Do no harm/ Non-maleficence
Equity or Justice

5. Ethical Codes
 Hippocratic Oath – 5th century BC
 Nuremberg Code -1948
 Declaration of Geneva - 1948
 Universal Declaration of Human Rights-1948
 Helsinki Declaration -1964
 International Code of Medical ethics
 Indian Medical Council (Professional Conduct,
Etiquettes and Ethics) Regulations, 2002

6. Hippocratic Oath
 One of the earliest document in medical ethics
– 5th century BC.
 Traditionally all doctors recite this oath at
swearing in. It is considered sacred for its
religious foundation and sanctity.

8. Nuremberg Code - 1948

9. Declaration of Geneva
 Adopted at World Medical Association General Assembly
in 1948.
 Amended in 1968, 1984, 1994, 2005 and 2006.
 Declaration of physicians’ dedication to the
humanitarian goals of medicine.

11. MCI Regulations - 2002
 The Medical Council of India notified the
“Indian Medical Council (Professional
Conduct, Etiquettes and Ethics) Regulations,
2002” on 11 March 2002.
 Last amended in 2010.

12.  Declaration-
Each applicant, at the time of making an application for
registration under the provisions of the Act, shall be
provided a copy of the declaration and shall submit a duly
signed Declaration.

13. Unethical Acts
 Advertising
 Patent and Copy rights:
 Running an open shop (Dispensing of Drugs and
Appliances by Physicians)
 Rebates and Commission
 Secret Remedies
 Human Rights
 Euthanasia
• Printing of self photograph, or
any such material of publicity in
the letter head or on sign board
of the consulting room or any
such clinical establishment shall
be regarded as acts of self
advertisement and unethical
conduct on the part of the
physician
• Not endorse any items
Formal announcement in press
(1) On starting practice.
(2) On change of type of practice.
(3) On changing address.
(4) On temporary absence from
duty.
(5) On resumption of another
practice.
(6) On succeeding to another
practice.
(7) Public declaration of charges
• May patent the items, methods &
procedures
• But it shall be unethical if
benefits are not made available
in interest of society
• A physician shall not give, or
receive, any gift, gratuity,
commission or bonus in
consideration of or return for the
referring, recommending or
procuring of any patient for
medical, surgical or other
treatment
Should not prescribe or dispense
secret remedial agents of which he
does not know (composition,
manufacture, use, etc.
Should not assist nor be a party to
either infliction of mental or
physical trauma or concealment
of torture by other person
• Practicing euthanasia shall
constitute unethical conduct.
• However on specific occasion,
the question of withdrawing
supporting devices to sustain
cardio-pulmonary function
even after brain death, shall be
decided only by a team of
doctors and not merely by the
treating physician alone

14. Misconduct
 Violation of regulations
 Adultery or improper conduct
 Conviction in court of law
 Sex determination test
 Signing false professional certificates, reports
& other documents
Any registered practitioner who is shown to have signed or given under his name
and authority any certificate, notification, report or document which is untrue,
misleading or improper, is liable to have his name deleted from the Register

15. Punishment & Disciplinary
Action
 The punishment given by the appropriate medical
council or MCI includes:
 Warning
 Reprimand – official action
 Cancellation of registration
 Temporary – for specific period of time.
 Permanent

16. Dr.Shirish Kumthekar. Surgeon Oncologist.
Kumthekar Multispecialty Hospital
Jule Solapur Solapur.

17. What is evidence-based
medicine?
“Evidence-based medicine is the integration of best
research evidence with clinical expertise and patient
values”
- David Sackett
 “Explicit, judicious, and conscientious use of current
best evidence from medical care research to make
decisions about the medical care of individuals”
7 July 2018 17Evidence Based Medicine

18. Definition
 Conscientious, explicit, judicious use of current best
evidence in making decisions about care of an
individual patient
 Involves integrating individual clinical experience with
best external evidence from systematic research

19. Types of EBM
 Evidence based guidelines- production of
guidelines, policy and regulations to be used at the
organizational or institutional level
 Evidence based individual decision making-
use of available evidence to provide best treatment
to an individual patient, by an individual physician

20. EBM - What is it?
Clinical
Expertise
Research
Evidence
Patient
Preferences
Evidence Based Medicine

21. I - Individual clinical expertise
 Skills
 Judgement
 which individual health care workers acquire
through
 clinical experience and clinical practice
Evidence Based Medicine 217 July 2018

22. II - Best available clinical evidence
 Clinically relevant research derived from:
 basic medical sciences and
 patient-centered clinical research into the safety and
efficacy of therapeutic interventions.
 Systematic Reviews
Evidence Based Medicine 227 July 2018

23. Why is EBM important?
 New types of evidence are being generated which
can create changes in the way patients are treated
 Although evidence is needed on a daily basis,
usually physicians don’t get it.
How much is actually being applied to
patient care?
lack of time
out-of-date textbooks
the disorganization of the up-to-date journals
7 July 2018 23Evidence Based Medicine

24. Importance of EBM for practicing
clinicians?
TIME AVAILABLE TO READ:
Less than
1 Hour per Week
TIME NEEDED TO KEEP CURRENT
ON GENERAL MEDICINE:
19 Articles per DAY
365 Days per Year
Source: Davidoff F, Haynes B, Sackett D, Smith R. BMJ. 1995;310:1085-1086.
24Evidence Based Medicine

25. Pre EBM: Passive diffusion (“publish it and
they will come”)
Early EBM: Pull diffusion (“teach them to read
it and they will come”)
Current EBM: Push diffusion (“read it for
them and send it to them”)
Future EBM: Prompt diffusion (“read it for
them, connect it to their individual patients”)
7 July 2018 25Evidence Based Medicine

26. For I once saved one group by
it, while I intentionally
neglected another group.
By doing that, I wished to
reach a conclusion .
Al-Rhazi
900 AD 1780 1840 1937/48 1967 1970’s
Alvan Feinstein
publishes his book
Clinical Judgement
James Lind
publishes review &
clinical trial in
Treatise on Scurvy
Pierre Louis
Develops his “numerical
method” and changes blood
letting practice in France
Bradford-Hill
publishes Principles of
Medical Statistics &
MRC trial of streptomycin
Some milestones in the history of EBM
7 July 2018 26Evidence Based Medicine

27. Why the sudden interest in EBM?
 Increasing realization among clinicians that years
of experience unaccompanied by updating of
knowledge can result in decline of clinical
performance
 The need for valid information about diagnosis,
therapy, prognosis, and prevention in this era of
consumer activism
7 July 2018 27Evidence Based Medicine

28.  The common man has access to the very same
medical literature as the clinicians through
numerous sources
 Limited time available to the clinician for
acquiring information is a major impediment for
updating the knowledge from traditional sources
7 July 2018 28Evidence Based Medicine

29. Assumptions of evidence-based practices
 Not all evidence is equivalent
 There is a hierarchy of study design
 External evidence can inform but can never replace
individual clinical expertise (Sackett et al., 1996)
 Starting from the best external evidence and work
from there.
 Values always influence decisions
7 July 2018 29Evidence Based Medicine

30. Where do we go
for help with
decisions when
we are not sure
how to proceed?
7 July 2018 Evidence Based Medicine

31. Decision making in clinical
practice using evidence
Decision-making is the cognitive process resulting
in the selection of a course of action among several
alternative possibilities
7 July 2018 Evidence Based Medicine

32. 7 July 2018 32Evidence Based Medicine

33. So in clinical practice
Disease
Treatment
options
7 July 2018 33Evidence Based Medicine

34. Ectopic
pregnancy
Medical
Laparoscopic
laparotomy
7 July 2018 34Evidence Based Medicine

35. Outcome – the only thing that
matters
7 July 2018 35Evidence Based Medicine

36. What EBM additionally provides is
Opportunity for change
Opportunity for better treatment
7 July 2018 36Evidence Based Medicine

37. How evidence affects clinicians
•Happy !!!
•I am the best !!!
•Will the patient recover or
not??
•Will they sue me??
•What about my reputation ??
7 July 2018 37Evidence Based Medicine

38. 7 July 2018 38Evidence Based Medicine

39. Think 100 times before refuting an
old time tested method of
treatment
 Classic example is vaginal hysterectomy for benign
diseases
 “Give me 2 retractors, 2 scissors , 2 clamps, one
tissue holding forceps and one needle holder, I will
do a vaginal hysterectomy in any setup”
Surgeon
7 July 2018 39Evidence Based Medicine

40. Changes in clinical practice
shouldn’t be like this
7 July 2018 40Evidence Based Medicine

41. Changes should be like this
7 July 2018 41Evidence Based Medicine

42. The Five-Step Approach to Practicing EBM
 Step 1- Framing a Proper, Pertinent, Focused and
Answerable Question
 Step 2 - Searching the Literature
 Step 3 - Critical Appraisal of the Literature
 Step 4 –Integrating the Evidence with Clinical
Expertise and Patient Values
 Step 5 – Evaluating the Process7 July 2018 42Evidence Based Medicine

43. What are the benefits of adopting EBM?
 Minimize the errors in patient care
 Reduces the cost of treatment to the patient
 Optimizes the quality of patient care
 Skills learnt in practicing EBM are the very same
ones needed for being a lifelong, self-directed
learner
 Habit of accessing literature on a daily basis is the
best guarantor of ensuring advancement of
knowledge and keeping abreast of scientific
progress
7 July 2018 43Evidence Based Medicine

44. Who benefits?
 Practitioners current knowledge to assist with
decision making
 Researchers reduced duplication
identify research gaps
 Community recipients of evidence-based interventions
 Funders identify research gaps/priorities
 Policy maker current knowledge to assist with policy
formulation
7 July 2018 44Evidence Based Medicine

45. Conclusion
 Medicine is not an exact science, but a science of
probability
 The challenge to physicians is to provide up to-
date medical care
 The ultimate goal for clinicians should be to help
patients live long, functional, satisfying, and pain
and symptom free life
 By adopting the principles of Evidence Based
Medicine, it will be possible to maximize the
benefits of scientific research for patient care
7 July 2018 Evidence Based Medicine 45

46.  Medical educators and medical colleges have the
singular responsibility of indoctrinating the
principles of EBM
as a concept,
a philosophy,
a religion necessary for being efficient,
compassionate, caring, and responsible clinician
among the future physicians during their
formative years of training
7 July 2018 Evidence Based Medicine 46

47. Society does not consider us as
“Gods” any more...........!
 Medical practice.....
 In Good old days = Ethical Profession.
 In the 20 the century = Profession.
 Now in the 21st Century = Professional Business.
 This profession was looked upon as the Noblest
Profession.
 If not God we were treated at least as Demigods.
 Now the society looks at us with Suspicion,Jealosey, &
we have almost become Villains.

48. Why this situation......
 Increasing Consumer awareness......
 Knowledgeable patients and relatives.
 Increasing presence of Insurance in Medical Practice.
 Increasing “shopping attitude” on the part of the
patients.
 Increasing social intolerance towards “Doctors” as a
Community.
 Availability of ample “Free Advice”.
 Unethical & un professional behaviour.

49. A wake up call for all of us.....
 The Government is trying actively to encroach on our
freedom & ease of doing the profession.
 We need to correct our professional & social attitude.
 We need to actively promote the Good side of our
Profession.
 We need to enforce on us “self imposed” regulations.
 We need to unite, stay united & fight united.
 We need to constantly remember that “we are an
important part of the society” constantly under the
microscope of the public eye.

50. Thank
You.........