What National Medical Commission’s new guidelines say on doctors’ refusal to treat patients, telemedicine and more

What do the guidelines say about the use of social media by doctors?

The document for the first time provides an 11-point guideline on doctors using social media. It says that doctors may provide information or make announcements online, but the information should be verifiable and not mislead people.

The doctors have been asked not to discuss the specifics of the treatment of their patients or post their scans online. “Once an image is posted in social media, it becomes data that is owned by the social media company or the general public,” said the progressive guidelines that are looking out for patient privacy.

Doctors have also been asked to refrain from sharing testimonials by patients or images and videos of cured patients. “Soliciting of patients directly or indirectly through social media is unethical,” the guidelines say.

The guideline also forbids doctors from “purchasing” likes, followers, or any fees to boost their profile on search algorithms and says that doctors should not participate in telemedicine platforms that provide ratings, reviews, and promotions of certain doctors by any means.

It adds that the educative material that doctors put out on social media must relate to their own field of expertise. Doctors have also been asked to follow decorum when interacting online or speaking about their colleagues.

Dr Girish Tyagi, secretary of Delhi Medical Council, said: “The previous guidelines are from a time when social media was not prevalent. Now, doctors are on social media platforms like Twitter, Facebook, and Instagram, discussing developments in their field, sharing knowledge, or putting out educational material. All of this is still allowed but the new guidelines ensure that a patient’s privacy is not violated, and their scans do not end up online. This was much needed.”

What do the guidelines say about doctors’ right to refuse treatment?

Doctors have been asked to write prescriptions in legible, capital letters. And, they have been asked to prescribe only generic medicines, except for cases where medicines have a narrow therapeutic index – drugs where a small difference in dosage may lead to adverse outcomes – and other exceptional cases.

The guidelines also urge judicious use of fixed-dose combinations, with doctors being asked to prescribe only the approved, rational combinations. They further ask doctors to educate people on generics being equivalent to branded medicines, urge pharmacies to stock them, and encourage people to purchase drugs from Jan Aushadhi Kendras and other generic drug outlets.

Dr Arun Gupta, president of the Delhi Medical Council, said: “There are several issues with prescribing generic medicines. First, medical stores generally do not stock them because the profit margins are narrow for generics. This would mean my patients will have to go from shop to shop looking for these medicines that might cost just Rs 50, not a big spend for people going to private clinics and hospitals. Second, if the generic version is not available then the responsibility of substitution is then shifted to pharmacists. This would promote only the brands – whether good or not – that have good profit margins. Third, the quality of all generic medicine is not the same.”

Dr Gupta added that the guidelines should clarify whether this point in the guidelines is a must or suggested. He said, rather than urging doctors to prescribe generics, the government should promote the manufacturing of generics alone.

In addition, the telemedicine guidelines also list the type of drugs by the type of consultation provided. For example, list O, with over-the-counter medicines such as cough suppressants, some pain medicines, and antacids among others, can be prescribed for any kind of online consultation whether through messages, telephone calls, or video calls. List A are drugs that can be prescribed only after video consultation, while List B are drugs that can be prescribed after any type of consultation but only for follow-up patients.

What are the scenarios under which a doctor may refuse treatment?

The guidelines give doctors the right to refuse treatment when patients or their family members are abusive, unruly, or violent. “The RMP (registered medical practitioner, meaning doctors) can document and report the behaviour and refuse to treat the patient. Such patients should be referred for further treatment elsewhere,” the guidelines say.

The doctors have also been given the right to refuse treatment if the patient cannot pay them. The guidelines say, “Consultation fees should be made known to the patient before examination or treatment of the patient. A reasonable estimation of the cost of surgery or treatment should be provided to the patient to enable an informed decision.”

The guidelines forbid doctors from refusing treatment, however, in cases of medical emergencies. They have been asked not to discriminate based on gender, race, religion, caste, social, economic or cultural grounds.

What is Continuous Professional Development (CPD) and what do the guidelines say?

For the first time, the regulator has made it mandatory for doctors to continue to learn throughout their active years. The guidelines say that with constantly evolving medical practices, new diseases emerging like Covid-19, new technologies coming in, along with a more aware patient base means that doctors must keep re-training.

The guidelines say that doctors should have studied 30 credit points in their relevant fields at the time of renewal of their license every five years. The doctors have been asked to undertake these sessions every year, ideally for six credits a year but at least three credits. And, not more than 50% of this training should be online. And, even professors at medical college hospitals have to undergo such training despite staying in touch with academics. There are guidelines for institutes that can provide these continuous training courses, which again have to be registered with NMC.

In fact, every degree, diploma, or recognised course undertaken by a doctor will keep getting added to their unique ID on the national medical register. The doctors have also been asked to only write these recognised degrees as suffixes on materials such as prescriptions and visiting cards. “At present CPD is not mandatory and not many doctors undergo such trainings but now they will have to for updating their registration every five years,” said Dr Tyagi.

What do the guidelines say about doctors participating in conferences?

While the guidelines make it mandatory for doctors to undergo CPD, they say that none of these educational sessions or conferences can be sponsored by the pharmaceutical industry.

“So if a doctor speaks at a symposium sponsored by the pharma companies, the doctor becomes liable. Unfortunately, if the government says that none of the conferences or CPD sessions can be sponsored by the pharma industry, the number of such sessions will go down to about 10% of what currently happens,” said Dr Ravi Wankhedkar, former head of the Indian Medical Association.

Doctors “should not be involved in any third-party educational activity like CPD, seminar, workshop, symposia, conference, etc which involves direct or indirect sponsorships from pharmaceutical companies” the guidelines say. Dr Wankhedkar added: “Why not make it mandatory for the pharma industry also to not provide such sponsorships? There is no mandatory restriction on pharma industry; the government does not even say that they should stop making branded medicines. Why should the onus only be on doctors?”

The guidelines say doctors or their families should not receive any gifts, travel facilities, hospitality, cash or monetary grants, consultancy fee or honorariums, or access to entertainment or recreation from pharmaceutical companies, their representatives, commercial healthcare establishments, medical device companies, or corporate hospitals under any pretext. This restriction does not apply to the salaries of doctors working for such companies.

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The guidelines also forbid doctors from accepting commissions from diagnostic centres, medical or surgical equipment etc for referral and from endorsing particular products.