Catch-22 for the radiologist

Here is a scenario not very uncommon for radiologists in day–to-day practice.

A pregnant woman, who has symptoms such as pain or bleeding per vaginam, comes to a stand-alone ultrasound clinic for an obstetric ultrasound examination in what is apparently an emergency. She does not have a prescription for ultrasound examination from her obstetrician, either because the obstetrician is not reachable for some reason or there is a technical difficulty in obtaining a prescription at that time. What should a radiologist do in such a case?

As per the format of form F under the Pre-conception and Pre-natal Diagnostic Techniques (PCPNDT) Act, a prescription is a must for obstetric ultrasonography. However, there are other questions which have not been clarified in the Act,. These are as follows.

1. Is it essential to have a prescription from a referring physician (third party) or can a radiologist self-refer an obstetric ultrasound study? The question of self-referral becomes pertinent because unlike a gynaecologist, a radiologist does not actually counsel a patient on antenatal care.
2. Can a request for obstetric ultrasound made by the referring physician verbally over the phone, via short messaging service (SMS) or e-mail be considered a valid prescription?

One finds that the answers to these questions depend on how the local authorities interpret the law, and are subjective and variable to the point of contradiction.

In such situations, common sense is supposed to guide the radiologist in taking the best decision. Logically, a radiologist, by virtue of being a doctor, should be able to self-refer a patient for obstetric ultrasound. Logically, in an emergency situation, a request from the referring physician, whether it takes the form of a prescription, an SMS or an e-mail, should suffice. However, the radiologist’s problem is that self-referring a patient or accepting informal requests would raise suspicion in the minds of the PCPNDT officials when they visit the clinic later to inspect the documents. Moreover, there is no way that a radiologist can be sure that a patient who has come for an apparently urgent obstetric scan without a prescription does not have malicious intent. With so many radiologists having suffered grave consequences for errors in documentation, it is not surprising if a radiologist is extremely reluctant to entertain such a request and refuses to perform an ultrasound scan. However, there is another angle to this situation that radiologists need to be careful about.

Emphasising the compulsion on doctors to provide emergency medical services, the Supreme Court of India, in the Parmanand Katara v. Union of India and Others case, stated that “Every doctor, whether at a government hospital or otherwise, has the professional obligation to extend his services with due expertise for protecting life. The obligation being total, absolute and paramount, laws of procedure, whether in statutes or otherwise, which would interfere with the discharge of this obligation cannot be sustained and must, therefore, give way” (1). Guided by this verdict, the District Consumer Forum and State Commission penalised a private doctor with a sum of Rs 3 lakh for having made no attempt to save an adult victim of a stab injury who was incidentally found lying bleeding on the road outside his clinic (2). The doctor apparently had no doctor–patient relationship/service contract with the victim. The argument that he was a private doctor and a paediatrician, and had no obligation to treat a patient lying on the road did not sustain. In short, what such cases tell us is that all doctors have a compulsion to serve society in case of medical emergencies, and that compulsion overrides the professional freedom of a doctor to refuse a patient.

If the pregnant woman whom the radiologist refuses to scan in an emergency situation suffers an adverse outcome, her case is likely to be viewed with sympathy by the legal system. The radiologist’s plea that he/she was following the PCPNDT protocol is not likely to suffice in such a case. So, whether a radiologist agrees or refuses to perform a scan, he/she is likely to breach one of the legal protocols – either PCPNDT Act or the absolute legal obligation to attend to a medical emergency. This is a radiologist’s Catch-22.

In the absence of clear guidelines from an appropriate authority on how to handle such situations, radiologists are well advised to consider all aspects of the case before refusing or accepting a request for emergency obstetric ultrasound without a valid prescription. A possible solution could be to make adequate written documentation of the circumstances, specifying in precise terms the nature of the emergency and the reason for the non-availability of a prescription, and asking the patient to sign this before performing the scan. One copy of this document could be sent to the appropriate authority at the earliest and another could be attached to form F. Such clear communication may help the radiologist to carry out his/her ethical responsibility while safeguarding him against legal complications. However, the best way of avoiding confusion and uncertainty among radiologists would be if such a protocol were officially incorporated in the PCPNDT Act.