Medicolegal knowledge and its practice among physiotherapists in Maharashtra

INTRODUCTION

The World Confederation for Physical Therapy defines physical therapy as ‘services for individuals and populations to develop, maintain and restore maximum movement and functional ability throughout the lifespan’.¹

Physiotherapy is a modern science and a growing profession in India. Despite the obvious need, there is no national government organization regulating the physiotherapy profession in India, owing to which state councils have been established in various states for the same.²

The status of physiotherapy as a profession changes between certain states resulting in varying rules and regulations pertaining to physiotherapy. This makes it necessary for all the physiotherapists to be aware of the existing laws and standards of practice to be followed within their respective states at the very least.

In Maharashtra, the physiotherapy profession is governed under the Maharashtra Act II of 2004.³ The Maharashtra State Council For Occupational Therapy And Physiotherapy (Council) has been established for the purpose of co-ordination and determination of standards of education in the field of occupational therapy and physiotherapy and for the maintenance of a register of occupational therapists and physiotherapists for the state of Maharashtra.³

As is the case with all healthcare professions, professional physiotherapy practice requires knowledge of medicolegal aspects. The healthcare sector has been labelled as an ‘industry’. The once noble medical profession has been tainted by disgraceful acts towards patients by professionals themselves or by those impersonating them.⁴ There is also the matter of false claims by patients, which needs to be considered.⁵ Since 1995, all healthcare services, have been brought under the purview of the Consumer Protection Act, 1986 (amended in 2019) (CPA) as a result of the case of Indian Medical Association versus V. P. Shantha and others.^6,7 In a medicolegal case, apart from CPA various other civil laws along with criminal laws may be applicable.⁸

As medical malpractice cases are increasing, it is essential for health professionals to safeguard themselves against such claims and prevent them by conducting an ethical practice. Appropriate documentation and proper consent taking will help in dealing with a malpractice claim.⁹ Professional Indemnity Insurance policies can give protection to healthcare professionals if any medicolegal issues arise.¹⁰ The Insurance Regulatory and Development Authority of India has recommended Professional Indemnity Insurance for medical malpractice claims.¹¹ It is advisable for all healthcare professionals including physiotherapists to have their own professional indemnity insurance.¹²

Accurate knowledge of the regulations set forth by the council and of different medicolegal aspects will establish a strong foundation for a legitimate and ethical practice. Against a background of rising cases of medical negligence, various studies pertaining to medicolegal knowledge have been conducted among healthcare professionals. The studies show that there is an urgent need to improve upon the knowledge of this subject and apply it in practice.^13-16 Presently, there is a dearth of literature focusing on medicolegal and ethical aspects of physiotherapy.¹⁷

Aim

This study aimed to assess the level of medicolegal knowledge and its practice amongst physiotherapists in Maharashtra with the objective of creating awareness amongst the surveyed physiotherapists and guiding future norms and policies, generating literature on the subject and encouraging further research.

METHODS

The study was an observational, cross-sectional study conducted from October 2022 to March 2023 to survey physiotherapists in the geographical region of Maharashtra, India. Sample size was 100. Sampling technique used was convenience sampling.

Inclusion criteria

Physiotherapists in Maharashtra with a completed B. P.Th degree were included.

Exclusion criteria

Academicians and M.P.Th students who did not practice outside college hours were excluded.

Procedure

A questionnaire containing 15 questions, aimed to assess the medicolegal knowledge and practice was designed after referring to similar studies and was face validated. Institutional ethical committee clearance was obtained and the questionnaire was circulated online. Consent was taken, after which demographic data was collected and the questionnaire was presented. 107 physiotherapists responded out of which 100, who met the inclusion and exclusion criteria, were included in the study.

Questions were asked pertaining to the Maharashtra Act II of 2004, use of the “Dr.” prefix, informed consent, documentation, medical negligence, laws and professional indemnity. The questions aimed to assess the knowledge and practice of these aspects. In the Google form, correct answers were scored one and incorrect answers were scored zero, with the maximum total score being fifteen.

Data analysis

The collected data was compiled in Microsoft Excel 2021 and analysed using descriptive statistics.

RESULTS

The study was conducted amongst a population of 100 physiotherapists in Maharashtra. The mean age of the population was 29.29±5.77 years.

Table 1 shows the demographic characteristics of the population. Majority of the participants had completed their M.P.Th (68%) and those having a diploma (D.P.T in sports science) post their B.P.Th were the least (1%). It was also seen that majority of respondents were females (73%). A large percentage (73%) of the population had an experience of 1-10 years and only 1% had experience of 31-40 years with the mean years of experience since completing B.P.Th being 7.96±5.96 years.

Maharashtra Act II of 2004

Table 2 shows the knowledge and practice related to Maharashtra Act II of 2004. The average correct practice was 74.33%, but the average knowledge was 38%.

Use of “Dr.” prefix and knowledge and practice of informed consent

Table 3 depicts the use of the “Dr.” prefix and the knowledge and practice of informed consent taking. It was found that 8% used the “Dr.” prefix without a (PT) suffix and 4% of them did not use the prefix at all. Nearly all participants knew of the term ‘informed consent’.

Knowledge and practice of documentation

Table 4 represents the knowledge and practice of documentation. It was seen that 89 out of 100 respondents said that they maintain documentation, but only 13 (14.61%) of them had the correct knowledge regarding its various possible uses.

Knowledge of medical negligence and laws

Table 5 represents the knowledge of medical negligence and laws. Out of the 86 physiotherapists who knew that physiotherapists can be sued for medical negligence, only 17 (19.77%) had knowledge about the laws that might be applicable.

Knowledge and practice of professional indemnity insurance

Table 6 shows the knowledge and practice of professional indemnity insurance. 64 physiotherapists knew about professional indemnity insurance out of which only 13 (20.31%) actually possessed the insurance policy.

Overall, only 20% of participants had scores below 50%. 80 out of the 100 participants scored above 50% with 11 of them having scored greater than 75%.

DISCUSSION

Physiotherapy is a young profession and there has only recently been a rise in awareness of physiotherapy among the general public as well among various healthcare professionals. Even though the scope of physiotherapy is increasing, there is a lack of adequate legislation and precise guidelines to be followed from a legal perspective in our country. The Maharashtra State Council For Occupational Therapy And Physiotherapy (Council) was established to address these issues in the state of Maharashtra. The two professions being governed under the Maharashtra Act II of 2004 indicates that physiotherapy has yet to achieve true independence as a profession and presently, efforts are being made for the same.

There is a scarcity of literature focusing on the medicolegal aspects of physiotherapy in Maharashtra as well as in India as a whole. This study is the first of its kind conducted amongst physiotherapists in Maharashtra that illustrates the knowledge and practice in accordance with the Council and with that of other medicolegal aspects.

Majority of the participating physiotherapists were registered with the Council, and they were correctly renewing their registration with the council after every 5 years. They also knew of the registration procedure to be followed after they complete their additional qualifications, such as M.P.Th, even if they have a valid B.P.Th registration at the time. A majority of them were prescribing electrodiagnostic tests (E.g., X-ray) to their clients when they deemed it necessary. Despite the fact that these findings indicated that physiotherapists were complying with the Council’s guidelines, it was found that most of them (73%) did not know about the Maharashtra Act II of 2004, which dictates the proceedings of the Council.

This indicates that there is a need to highlight the importance of the Council and increase awareness about its proceedings to ensure that physiotherapists in Maharashtra are practicing in accordance with the rules and regulations of the Council based on directives from the Council itself and not from information obtained from other sources. Since this is the first study that evaluates knowledge and practice based on the Maharashtra Act II of 2004, no comparisons can be made with other studies.

The number of participants who knew that physiotherapists are considered independent practitioners was very low (17%), with the majority considering themselves as allied healthcare professionals followed by paramedical professionals. This shows a lack of knowledge regarding legislation affecting their own and other related professions. In Maharashtra, the allied and paramedical professionals are governed under the National Commission for Allied and Healthcare Professions Act and the Maharashtra Paramedical Council Act respectively, while the Maharashtra OT and PT Council Act applies to physiotherapists, which indicates that they are considered independent of the other two professions.^3,18,19

When asked about their usage of the “Dr.” prefix, 88 out of 100 participants stated that they use the “Dr.” prefix with a (PT) suffix after their name. This illustrates the appropriate use of the prefix while avoiding confusion and conflict with other professions. In 2016, the then president of the Indian Association of Physiotherapists, professor (Dr.) Umasankar Mohanty (PT), explicitly stated that physiotherapists can use the “Dr.” prefix with a (PT) suffix in his defamation letter to Dr. S. S. Agarwal and Dr. K. K. Aggarwal.²⁰

In terms of knowledge regarding informed consent, nearly all the physiotherapists (98%) knew about the term. This is similar to the findings of the study conducted by Rai et al among interns and residents of a medical college in Vadodara, where nearly 90% of the respondents were aware of informed consent.²¹ There are other studies that also indicate that healthcare professionals have good knowledge of informed consent.^13,14

Majority of the respondents (88%) also take the consent from parents or legal guardians of minors before starting their treatment, which is a higher percentage than that found in the study conducted by Baheti et al wherein 76.31 % of participants believed that minors should not be treated without their parents’ consent.¹³

It was observed that 89% of the participating physiotherapists-maintained documentation regarding their clients’ treatment, which is in concordance with the results of the study carried out by Radhika et al published in 2017.²² The study aimed to assess awareness about medicolegal aspects and Consumer Protection Act amongst dentists where it was found that 91.1% of the senior practitioners knew about medical record maintenance.

In the present study, 89 out of 100 participants-maintained documentation, out of which only 14.61% knew of the possible uses of the records maintained. Such practice without knowing its purpose may lead to improper documentation or underutilisation of the records maintained. Thomas, in his 2009 study on medical records and issues in medical negligence, has stated the diverse aspects of medical record keeping, including various guidelines regarding the time period for preserving the records in India.⁹ The study also mentions judicial decisions on medical records in India. Currently, no rules and regulations exist on the subject of record keeping and documentation specific to physiotherapy professionals in India.

The knowledge about medical negligence was high among the respondents, with most of them (86%) knowing that a physiotherapist can be sued for medical negligence. The process for clients’ grievance redressal has been made easier and faster with the advent of the CPA. Physiotherapy services can be considered as ‘service’ as defined under CPA, making the consumer courts the quickest way for clients to seek compensation.

In spite of the large number of physiotherapists who knew about medical negligence, less than a quarter of the participants (18%) knew about the applicable laws. This is in contrast to the findings of the study conducted by Hisham et al in South India (3.2% of the total participants were physiotherapists), where 53% of the respondents correctly answered when asked about the laws applicable in a medical negligence case.⁸

Professional indemnity is an insurance policy that protects medical practitioners against financial losses due to legal damages in case of a legal proceeding resulting from clients’ complaints.¹⁰

The results of an online survey study conducted amongst resident doctors and consultants in Navi Mumbai, India, by Gadhe et al, published in 2023, showed that approximately 90%, 64%, and 22% of consultants with 10 years, 5-10 years, and 5 years of experience had acquired Professional Indemnity respectively.²³

Since physiotherapists may also be subject to legal proceedings, professional indemnity is an essential tool in physiotherapy practice as well.

In the present study, more than half (64%) of the participants knew that professional indemnity insurance can safeguard the physiotherapist against malpractice claims, but only a meagre 15% had an indemnity policy to their name at the time of answering.

The findings show that a higher percentage of physiotherapists know of and possess professional indemnity insurance as compared to the health professionals participating in the study conducted by Shivani et al (3.3% of the total respondents were physiotherapists), where only 15% of participants were aware of professional indemnity insurance and barely 6.7% had indemnity insurance to protect themselves.¹⁴

The results of this study pointed towards a pressing need to upgrade knowledge about the existing legislation and the various applicable laws. Also, there was inadequate knowledge on various aspects of documentation, which needs to be improved. Physiotherapists’ knowledge on professional indemnity insurance was not up to the mark and it is poorly utilised by them. These findings suggest a need to address these deficits to improve the quality of practice and raise the standards of professional physiotherapy practice.

This study has some limitations. Majority of the samples were collected from urban cities of Maharashtra with fewer samples from other regions. The convenience sampling technique was used for practical purposes. Using the stratified sampling technique would give appropriate representation to physiotherapists across all regions of Maharashtra.

Since the questionnaire was circulated online, some of the responses received may be deceptive.

CONCLUSION

Physiotherapists in Maharashtra have basic knowledge of the governing body and of the legal dimensions of their profession, but were found lacking when asked about the same in greater detail. With medical negligence cases on the rise, there is a strong need for them to update their knowledge and bring it up to the mark to conduct an ethical practice within the boundaries of the law. This will enable them to practice proficiently while preventing legal damages and ensuring financial security.

Recommendations

The benefits of knowing about medicolegal issues and practices to protect themselves against any malpractice cases should be broadcasted with a heavy emphasis on the possible downfalls of not doing so.

Subject matters like record keeping, professional indemnity, medical negligence and laws should be taught in greater depth than what is the present practice in undergraduate courses. Electronic record keeping should be encouraged for easy storage and retrieval.

The concerned authorities should propagate their agenda on a larger scale to impart correct knowledge and ensure legally correct practices based on legitimate sources of information. Conducting webinars, podcasts and conferences on such less-attended to, but undeniably important subjects can help in reducing the incidence of malpractice and negligence.

ACKNOWLEDGEMENTS

I express my gratitude to Dr. Pandurang Bokil (Principal, Sancheti College of Management) for his invaluable time and guidance. Sincere thanks to Dr. Parag Sancheti (Chairman, Sancheti Institute for Orthopedics and Rehabilitation), Dr. Ashok Shyam (Head of Academics, Sancheti Institute for Orthopedics and Rehabilitation) and all my teachers for their advice. I thank all participants for their effort and co-operation and all my family and friends for their constant support.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. World Physiotherapy. Glossary. Available at: https://world.physio/resources/glossary#p. Accessed on 5 October 2022.
2. 2. Maharashtra Council for Occupational Therapy and Physiotherapy. Acts and Rules-MH OT and PT Council Act (ACT II OF 2004). Available at: https://mahaotandptcouncil.in/Download/MH%20ACT%20II%20OF%202004.pdf. Accessed on 5 October 2022.
3. 3. Lok Sabha House of the People. Need to establish an independent National Physiotherapy Council. Available at: https://eparlib.nic.in/bitstream/123456789/782214/1/13397.pdf. Accessed 3 on October 2022.
4. 4. Maharashtra Council for Occupational Therapy and Physiotherapy. Press Note Devyani Padole Remdesivir Case Seetaburdi Police Station Nagpur. Available at: https://mahaotandptcouncil.in/Download/Notification/press%20note%20devyani%20padole.pdf. Accessed on 15 April 2023.
5. 5. Hindustan Times. IMA raises concern over authenticity of complaints received by PMC’s grievance redressal cell. Available at: https://www.hindustantimes.com/cities/pune-news/ima-and-hbi-raise-concerns-over-pmc-s-grievance-cell-fear-harassment-and-extortion-of-medical-staff-through-fake-complaints-101681582842322.html. Accessed on 17 April 2023.
6. 6. India Code Digital Repository of All Central and State Acts. The Consumer Protection Act, 2019. Available at: https://www.indiacode.nic.in/bitstream/123456789/15256/1/a2019-35.pdf. Accessed on 2 October 2022.
7. 7. Supreme Court of India. Available at: https://main.sci.gov.in/jonew/judis/10357.pdf. Accessed on 5 October 2022.
8. 8. Hisham S. Awareness of medico-legal aspects and documentation amongst health professionals in a tertiary care hospital. Medico-Legal Update. 2019;19(2):257-63.
9. 9. Thomas J. Medical records and issues in negligence. Indian journal of urology: IJU. 2009;25(3):384-8.
10. 10. Mathur MC. Professional medical indemnity insurance-protection for the experts, by the experts. Indian J Ophthalmol. 2020;68(1):3-5.
11. 11. Insurance Regulatory and Development Authority of India. Professional Indemnity Insurance Policy-Medical Malpractice. Available at: https://irdai.gov.in/document-detail?documentId=998886. Accessed 5 October 2022.
12. 12. Agarwal S, Agarwal SS. Professional indemnity insurance vis-a-vis medical professionals. J Indian Acad Forens Med. 2009;31(1):73-6.
13. 13. Baheti MJ. Medico legal awareness: Where are we? A survey among health professionals in Maharashtra and Haryana. Int J Public Health Res. 2015;5(1):525-30.
14. 14. Shivani S, Kumar A. COVID-19 and medical legal liability awareness: where are we? - a survey among health care professionals. Int J Res Rev. 2020;7(12):400-3.
15. 15. Makhani CS, Petkar MR, Chavan KD, Rao TV. Awareness of medical ethics and medico-legal issues amongst medical professionals. Indian J Forens Med Pathol. 2011;4(4):151-5.
16. 16. Rao GV, Hari N. Medico-legal knowledge assessment of interns and post graduate students in a medical institution. Int Arch Integr Med. 2016;3(10):105-10.
17. 17. Singh K, Gebrekidan HG. Medico-legal practice and physiotherapy: a study in Mekelle, Ethiopia. Res Rev J Med Sci Tech. 2014;3(1):1-7.
18. 18. India Code Digital Repository of All Central and State Acts. The National Commission for Allied and Healthcare Professions Act, 2021. Available at: https://www.indiacode.nic.in/handle/123456789/16824?sam_handle=123456789/1362. Accessed on 2 October 2022.
19. 19. Maharashtra Paramedical Council. Acts and Rules-Maharashtra Paramedical Council Act 2016. Available at: https://maharashtraparamedicalcouncil.org/Files/Maharashtra%20Paramedical%20Council%20Act%202016.pdf. Accessed on 2 October 2022.
20. 20. The Indian Association of Physiotherapists. Defamation Letter to Dr. S. S. Agarwal and Dr. K. K. Aggarwal. Available at: https://www.physiotherapyindia.org/news-events/notices/3579-open-letter-to-dr-s-s-agarwal-and-dr-k-k-aggarwal-regarding-defaming-physiotherapy-profession.html. Accessed on 3 October 2022.
21. 21. Rai JJ, Acharya RV, Dave D. Knowledge and Awareness among interns and residents about medical law and negligence in a medical college in Vadodara- a questionnaire study. J Dent Med Sci. 2013;3(4):32-8.
22. 22. Radhika T, Nadeem J, Arthi R, Nithya S. Awareness about medico legal aspects and consumer protection act among dentists. J Forens Odonto-Stomatol. 2017;35(1):1-8.
23. 23. Gadhe S, Kale S, Chalak A, Vatkar AJ, Doshi SS, Dey JK. Professional indemnity/medical malpractice insurance- awareness among medical students and consultants of India: an online survey study. MGM J Med Sci. 2023;10(1):38-42.