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Contents

THE OFFICIAL NEWSPAPER OF THE SRI LANKA MEDICAL ASSOCIATION

August 2012 Volume 05 Issue 08

President’s Note Dear SLMA Members, colleagues, friends, As we move on to the second half of the year we reach a time of the year that is packed with academic activities. This was not the case 15 years ago. At that time the second half of the year was a quiet time in terms of medical academic activities in Sri Lanka. To fill this void in 1997, the then President of the SLMA, Deshamanya Dr S. Ramachandran proposed the establishment of Foundation Sessions of the SLMA. The Foundation sessions that we hold in November this year would be the 15th in an unbroken series of conferences that we have been holding. We plan to have a unique programme this year the details, of which would be announced shortly. We request you to keep the dates – 9th to 11th November 2012 – free and join us for the Foundation Sessions. Thank you. On behalf of the Council of the SLMA,

Prof. Vajira H.W. Dissanayake President, Sri Lanka Medical Assosiation, No.06, Wijerama Mawatha, Colombo 07, Sri Lanka

Page No.  Notice Board 4 

Chronic Kidney Disease of unknown aetiology (CKDU)

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National Blood Transfusion Service wins the ISBT award for developing countries

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Looking to the future - Beyond the Millennium Development Goals

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SLMA cricket team wins OPA six a side cricket tournament

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SLMA Ethics Committee

Past Presidents of SLMA 16 - 17 Prof. Anoja Fernando Dr Kumar Weerasekera Prof. Nimal Senanayake Dr D. N. Athukorala Deshamanya Dr Surendra Ramachandran

Preserving the independence of the SLMC

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August, 2012

Notice Board UPCOMING EVENTS Joint Clinical Meeting with the Wathupitiwela Clinical Society 6 October 2012 at Wathupitiwela

Annual Scientific Sessions of the Anuradhapura Clinical Society in Collaboration with the SLMA 17 and 18 October 2012 at Anuradhapura

SLMA Foundation Sessions 9 to 11 November 2012 at the SLMA

Medical Dance 2012 8 December 2012 at Cinnamon Grand

FERCAP 2012 12th Asia Western Pacific IRB/IEC conference “Ethnicity, Culture, Religion and Ethical Research for Health” 18 – 22 November 2012 Colombo, Sri Lanka Organised by the Forum for Ethics Review Committees in Asia and the Western Pacific and the Sri Lanka Medical Association http://www.slma2012.com/FERCAP

Calling All Medical Inventors Are you an inventor? Have you invented a device that is useful in the medical field? Would you like to showcase your invention at the SLMA? If so, the SLMA would like to hear from you. Please email us on office@slma.lk giving details of your invention and your contact details 4


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August, 2012

Chronic Kidney Disease of unknown aetiology (CKDu)

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n February this year the Sri Lanka Medical Association organised a symposium to enable researchers to present their research findings. At that meeting a request was made to wait for the findings coming out of the work carried out by the WHO in collaboration with the Ministry of Health prior to coming to final conclusions. The research, which was presented, can be accessed at http://issuu.com/slmanews/ docs/ckdu_abstract_book A summary of some of the WHO work released by the Ministry of Health is now in the public domain and has been the topic of discussion in medical circles. It is reproduced below for the benefit of the readers of SLMAnews. If you have any comments about the report please send it to office@slma.lk. We will compile your comments and publish it in the next issue of SLMAnews.

World Health Organization (WHO) report on Chronic Kidney Disease of unknown Aetiology (CKDu) in Sri Lanka - A summary 01. Mission report, 6-8th June 2011, WHO, Geneva, Switzerland Chronic disease prevention and management, Senior advisor and coordinator, Dr Shanthi Mendis

 Results of the phase 01 of this research programme reveal that in the north central and Uva provinces a minimum of 15 per cent of people in the age group 15-70 years are affected by CKDu.  Men over the age of 40 years who are engaged in farming for more than 10 years are at higher risk of developing this disease. In addition exposure to agrochemicals also increases the risk of developing CKDu.  The majority of men and women suffering from

this disease excrete raised levels of arsenic and/or cadmium in the urine.  Exposure to a combination of factors that are toxic to the kidney seems to cause this kidney disease. Toxic factors identified up to now include arsenic, cadmium and nephrotoxic agrochemicals.  Recommend to develop a regulatory frame work to improve the quality control of imported fertilizer particularly with regard to nephrotoxic agents such as arsenic and cadmium.  It is imperative that the steps are taken as soon as possible. Delaying action will cause further accumulation of toxic agents in the environment and result in cumulative damage to the health of the people living in these areas. 02. Mission report, 5-7 October 2011

 Cumulative nature of heavy metal exposure and progressive natural history of CKDu, for which there is no known cure, demand urgent action to improve safe use and quality control of agrochemicals and quality control of fertilizer.  As advised by the Honorable minister of Health, a multisectoral strategic plan need to be developed jointly with relevant ministries with short, medium and long term measures by the end of 2011 and implemented as early as possible in 2012 to minimize the growing public health risks to the population.  It is essential that steps are taken as soon as possible. Delaying action will cause further accumulation of toxic agents in the environment and result in cumulative damage to the health of the people living in these areas and with time also affects younger age groups. In the long term there will also be severe social and economic consequences that will negatively impact the on-going development and poverty alleviation efforts of the region. 03. Progress report 13 Feb 2012

 In the urine analysis of 496 cases of CKDu 56 per cent had a urine cadmium excretion over 1 ug/g creratinine. Data from recent studies show that changes of early kidney damage occurs at cadmium excretion levels of even 0.6-1 ug/g creratinine. About 63 per cent of CKDu patients had urine arsenic levels above

21 ug/g Ceratinine. Urine arsenic levels above 21 ug/g creatinine have been shown to cause changes in kidney tissue that lead to chronic kidney disease.  Approximately 88 per cent of CKDu patients had urine arsenic >21 ug/g and/or urine cadmium >0.6 ug/g  Arsenic was also analyzed in hair and nails of people living in NCP including CKDu patients. In about 90 per cent arsenic levels in hair were higher than those observed in developed countries (0.02 ug/g).In about 94 per cent arsenic levels in nails were higher than those observed in developed countries (>0.03 ug/g)  Our analysis did not find high levels of cadmium exposure as reported in previous studies. The mean exposure for adults is at borderline of Recommended Total Weekly intake (TWI) of 2.5ug/kg body weight.  Water from 98 water sources used by patients with CKDu was analyzed for hardness. 99 per cent are hard to very hard. Hardness of water is known to affect heavy metal toxicity through antagonistic mechanisms and this may play a role in renal toxicity caused by heavy metals in the north central province.

Recommendations 1. Implement the recommendations in previous reports. 2. Strengthening the institutional arrangements for the implementation inter sectoral coordination, monitoring and evaluation of control of pesticides and fertilizer. 3. Increasing the public awareness of the adverse health effects of agrochemicals. The general public should be made aware of the actions taken to control agrochemicals and the importance of applying safety and control measures. Health education programmes should focus on high risk populations including farmers, vendors and also expanded to involve school children and the public at large. 4. Strengthen water purification schemes in north central region. Recommendations have been made for the maximum and minimum levels of calcium and magnesium in drinking water and total hardness. 5. As there are 66 ayurvedic prescriptions that contain aristolochia, increase awareness of ayurvedic practitioners and public of renal toxicity of aristolochia species.

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National Blood Transfusion Service Wins the ISBT Award for Developing Countries

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ational Blood Transfusion Service (NBTS) Sri Lanka has a distinguished history of more than fifty years for the timely supply of quality assured blood and blood components for the entire government sector hospitals and for the majority of the private sector hospitals. It’s a special campaign coming under the ministry of health having a network of more than ninety blood banks scattered around the country and National Blood Centre in Narahenpita being the operational headquarters. Organized according to the WHO recommended concepts and National requirements, the service has been able to provide quality assured blood and blood components required for the modern day medical treatments over the years.

NBTS has won the ISBT award for the transfusion services of developing countries The International Society of Blood Transfusion (ISBT) is the premier international professional society for the field encompassing transfusion and transplantation science and

National Blood Transfusion Service current director Dr. Vijith Gunasekara and National Blood Transfusion Service former director Dr. Ananda Gunasekara handing over the award plaque to the Minister of Health Maithripala Sirisena.

medicine. With a long and respected history of achievement, its current strategic vision is: ‘Facilitating knowledge about transfusion medicine to serve the interests of donors and patients’. Founded in 1935, The Society brings together more than 2000 professionals in the field, from over 97 countries. At the ISBT congress 2011 held at Taipei, Taiwan an open invitation

The National Blood Transfusion Service at Narahenpita

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was annoucing the selection of best transfusion service among developing countries. Applications were called on the official ISBT website and NBTS Sri Lanka also applied for the competition. Each competitor had to answer a structured essay type common questionnaire providing supportive evidence for all the answers given. In this competition performance during the years 2009, 2010 and 2011 were evaluated covering all aspects that account for the improvement of the relevant transfusion service. NBTS Sri Lanka was able to successfully prove its ability and win the ISBT award for developing countries for 2012. The news of this award is published on the Official website of ISBT http://www.isbtweb. org/news/article/winner-isbt-awardfor-developing-countries/ and the certificate was awarded at the 23rd International ISBT Congress held on 8 July 2012 at Cancun, Mexico to the Sri Lankan team headed by the former Director NBTS Dr Anada


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Gunasekara who is currently the Deputy Director General of Medical Services and Dr Vijith Gunesekara the Director NBTS. In addition to the international recognition this award brings to the entire Health Care System of the country, NBTS was invited to deliver a speech at the Central Body Meeting of the ISBT Congress. At the 3 day parallel educational sessions of the congress the NBTS team conducted an educational review on the Improvement of Education and Training programs of the NBTS Sri Lanka. The ISBT gave a grant of 10,000 Euros to the NTBS to conduct an international educational symposium in Sri Lanka for professionals engaged in the Transfusion Service in other countries. Winning the ISBT Award for Developing Countries is a consequence of a target oriented process of activities initiated at NBTS. It is another feather in the cap for the NBTS which would enable it to achieve its mission which is “To be a unique model for the world�.

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Looking to the Future - Beyond the Millennium Development Goals Birth Defects Surveillance, Prevention and Control

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ri Lanka Medical Association in collaboration with the Ministry of Health, Family Health Bureau and The Human Genetics Unit of Faculty of Medicine, University of Colombo organised a symposium to brainstorm and streamline the national initiative to prevent and control birth defects at the Sri Lanka Medical Association 125th Anniversary International Medical Congress. Additional Secretary to the Ministry of Health Dr Palitha Maheepala presented the Sri Lanka situation Beyond the MDGs - Significance of Birth Defects Prevention and Control. Consultant Community Physician and National Programme Manager for Maternal and Child Morbidity and Mortality Surveil-

lance Dr Kapila Jayaratne described Sri Lanka’s plans to introduce birth defects surveillance. The Roles of the Obstetricians and Paediatricians in Birth Defects Surveillance, Prevention and Control were presented by Consultant Obstetrician and Gynaecologist Dr Gayan de Silva, and Consultant Neonatologist Dr Medha Weerasekara respectively. Two world renowned experts - Prof. I. C. Verma

and Prof. Dhavendra Kumar spoke at the Workshop. The other foreign speakers were Dr S. Suresh from India and Dr Farha Zahir from Canada. The workshop concluded with a panel discussion with major stakeholders involved in birth defects prevention and control in attendance - Ministry of Health, National Focal Point for Birth Defects Prevention and Control Deputy Director General (Public

Health Services), Dr M. L. R. Siyambalagoda; Family Health Bureau, Director, Dr Deepthi Perera; Sri Lanka Medical Association, President, Prof. Vajira H. W. Dissanayake; World Health Organisation, National Professional Officer, Dr. Anoma Jayathilake; College of Community Physicians, President, Dr Vinya Ariyarathne ; Sri Lanka College of Paediatricians, representative, Dr Medha Weerasekara; College of Forensic Pathologists of Sri Lanka, President Elect, Dr S. M. H. M. K. Senanayake; College of Pathologists of Sri Lanka, Secretary, Dr H. A. A. Priyani,; and Perinatal Society of Sri Lanka, Sri Lanka College of Obstetricians and Gynaecologists and President, President Elect, Prof. Hemantha Senanayake.

SLMA SNAKEBITE HOTLINE Faced with a snakebite management dilemma? Now you can seek expert advice, day or night. Call one of the following: For adult snakebite victims Prof. S. A. M. Kularatne: 0812-388369 or 0773-420771 Dr M. K. Ragunathan: 0777-904500 or 0718-166599 Prof. Ariaranee Gnanathasan: 0112-508200, 0112-364088 or 0773-279659 Dr Suresh Mendis: 0773420491 For snakebites in the Jaffna District, especially saw-scaled viper bites Dr S. Sivansuthan: 0777916231 For paediatric snakebite victims Dr Udaya de Silva: 0718-607697 SLMA Expert Committee on Snakebite August, 2012 8


SLMANEWS NEWS SLMA

August, 2012 2012 August,

SLMA cricket team wins OPA six a side cricket tournament The SLMA cricket team won the six a side cricket tournament organised by the Organisation of Professional Associations (OPA), Sri Lanka held on 11 August 2012 at the Bloomfield Grounds, Colombo beating all other Professional Association, which participated in the tournament.

The winning team with the Team Manager, Dr Indika Karunathilake and the OPA President

The captain of the SLMA team, receiving the Champion’s trophy from the OPA President

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SLMA Ethics Committee This article is continued from the SLMANews July issue.

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he next session was chaired by Dr Malik Fernando. Dr Ajith Amarasinghe presented five cases that had been investigated by the Ethics Committee of a Private Hospital. Summaries of these cases are in the case boxes. The three discussants as well as the participants contributed to the lively discussion after each presentation. There was much interest in the cases and many issues were raised and discussed.

Case No 1 - Disclosure of personal information without consent: A Patient with HIV A male British patient admitted to the hospital was diagnosed to have HIV infection. He was reported as being “not completely sane”. His partner had been informed of his infection. His parents were arriving from the UK to take him back, to look after him. (“Not completely sane” is taken as “not competent to give consent”) Questions: Was it ethical to have informed his partner and his parents about his infection without obtaining his consent? Could the hospital be found fault with? The SLMC guidelines were not very clear about confidentiality issues. The GMC guidelines gave the following

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advice: “Disclosure of personal information without consent may be justified where failure to do so may expose the patient or others to risk of death or serious harm. Where third parties are exposed to a risk so serious that it outweighs the patient’s privacy interests, you should seek consent to disclosure where practicable. If it is not practicable you should disclose information promptly to an appropriate person or authority. You should generally inform the patient before disclosing the information.” The committee ruled that in this instance there was no breach of confidentiality. Contd. on page 18


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Past Presidents of SLMA 2001

Prof. Anoja Fernando MBBS (Cey), BA, FRCP(Lond)

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Emeritus Professor of Pharmacology, University of Ruhuna Founder Professor of Pharmacology, Faculty of Medicine, University of Ruhuna, 1981-2010 Dean, Faculty of Medicine, University of Ruhuna, 1991-1996 President, Physiological Society of Sri Lanka, 1994 and 1995 Chairperson, National Bioethics Committee, 2004-2008, and Chairperson, National Committee on Ethics in Science and Technology, National Science Foundation, from 2011 President, Asian Bioethics Association, from 2010

rofessor Fernando’s main areas of interest were medical education and medical ethics. She initiated the establishment of a new committee on Medical Education in 1995 and chaired it from 1995 to 2004. During this period, the committee, with contributions from many consultants, and WHO support, published “Recommendations on Internship Training”, with a log book. A shortened version of the log book was used by the Sri Lanka

Medical Council in the internship program. In 2002, the Medical Education Committee successfully conducted the first distance learning programme on Continuing Medical Education for general practitioners and grade medical officers in state hospitals in the Southern Province. Bimonthly CME Bulletins, containing an update on a common topic as well as MCQs, were posted to 450 doctors, and CME certificates awarded to those who completed the required

evaluation. Prof Fernando has chaired the Ethics Review Committee since 1999, and in 2003, initiated the formation of the Forum for Ethics Review Committees in Sri Lanka (FERCSL). Professor Fernando’s Presidential Address was titled “From Medical Ethics to Bioethics: Challenges for the 21st Century”. During her year, the first edition of the book “Guidelines for the use of Non-EPI Vaccines”, prepared by the Committee on Com-

1998

Dr D. N. Athukorala MBBS,FRCP(Lond), FCCP(SL),FAAD,Dip Derm(Lond) Consultant Dermatologist President Sri Lanka Association of Dermatologists 1998, 1999 President Ceylon College of Physicians 1988 Secretary of the SLMA 1986-88; Including the SLMA centenary in 1987

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he Presidential address titled “The profession and the Association” focused on encouraging research and audit and the need for continuing medical education. The first ever SLMA Ethical review committee on Biomedical Research, and a new committee on

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Mental Health was formed in this year. The “E.M. Wijerama endowment lecture” was inaugurated to recognize a person for continuing outstanding research in the field of medicine, and was delivered by Dr C.H. Uragoda. The foundation sessions, inaugurated by Dr S.

municable Diseases, was published, and the second floor of the extension to Wijerama House was completed. In addition to the regular CME programmes conducted by the SLMA and its committees, a series of lectures on non-medical topics were given by eminent people. Professor Fernando also initiated the formation of the new Committee on Women’s Health in 2001. Dr Anura Weerasinghe served as the honorary secretary in 2001.

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he late Weera took o SLMA at the century with to take the A into the new as a strong a taking the ce in advocacy. took over as he was the y person to tak President of an honour he the appointm Honorary Se the year 200 H. W. Dissan President of in 2012.

Ramachandran were carried forward creating a new tradition to the SLMA. The SLMA was recognized by the World Bank as a key player in health sector reform and health policy planning in Sri Lanka, Seven Regional meetings were held jointly with the regional clinical societies. The SLMA moved to its new office on the first floor of the new building, and sections of the building needing renovation was attended to. The new membership services committee added new incentives for SLMA members and an identity card for members was issued. Dr Prasad Kumarasinghe served as the Honorary Secretary in 1998.

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Rama renow Physi in the sion d


August, 2012

NEWS

2000

Dr Kumar Weerasekera MBBS, MD Consultant Oncologist, National Institute of Health, Maharagama

e Dr Kumar asekara over the e turn of the the vision Association w millennium association entre stage . When he s President, youngest ke over as the SLMAe held until ment of his ecretary in 00, Dr Vajira nayake, as the SLMA,

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His Presidential address was titled “Rupees and sense of Ageing”. The address set the tone for the Health Sector Development activities which he initiated and carried out during the year. The President proposed the use of a Health Card as referral system for the Health System in Sri Lanka. The Ministry of Health accepted this proposal on principle and he was working towards achieving this goal after he relinquished office as President, SLMA until his untimely death. The theme of the

he late Deshamanya Dr Surendra achandran was a wned Consultant ician and an icon e medical profesduring the past

year’s Annual Session was “New horizons in healthcare in the new Millennium”. This provided an opportunity for taking stock of Sri Lankan achievements in the field of health identifying where performance might have been better and what might have been the impediments and more importantly mapping out a strategy for the future. He was able to bring together the entire medical profession under one roof during the year, with all collages and associations participating in the sessions.

1997

Deshamanya Dr Surendra Ramachandran MD, FRCP, Hon. DSc Consultant Physician, National Hospital of Sri Lanka, Colombo President, Ceylon College of Physicians – 1990 half a Century; He was a man of rare distinction. During his lifetime he made a colossal contribution in several fields such as medical education, medical research, patient care and medical associations. He was the President of the SLMA in

1997. The theme of his Presidential address was ‘Meeting the challenges ahead’. During his tenure of office he rendered a very important service to the medical profession with the extension to the Wijerama House, the refurbishment of

1999

Prof. Nimal Senanayake MBBS, MD, PhD, DSc, FRCP, FRCPE, FAAN, CBiol, FIBiol Senior Professor of Medicine, Faculty of Medicine, University of Peradeniya

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or the first time in its long and cherished history of the SLMA the Annual Sessions were held outside Colombo in the hill capital the deliberation of the sessions were designed in general to converge on the theme “From the decade of the brain to a millennium of the mind”. His vision of the theme was as one approaches the end of the decade the profession and the rest of the society was to focus on the mind because “Mind is the forerunner of all states” (The Dhammapada) His presidential address was titled “Literary work and Medicine” held at the BMICH was very exhilarative and appreciated very much by the audience. Dr Shyam Fernando served as honorary secretary in 1999. the building and the Lionel Auditorium. The first ‘Foundation Sessions’ of the Sri Lanka Medical Association was his brain child and the first sessions were held in November 1997.The crowning glory of an unmatched career in research was the fact that Dr Suren Ramachandran was awarded no less than 14 Scientific Orations in Sri Lanka invited to deliver as many as 12 Guest Lectures abroad.

Dr Ramachandran was undoubtedly an artist. Single handed, he produced the decor for the prestigious Medical Dance of the Sri Lanka Medical Association on at least two occasions. His budget allocation was very small. Nevertheless he converted the Lanka Oberoi Grand Ballroom into a spectacular showpiece on these occasions. Dr Devaka Fernando served as the honorary secretary in 1997.

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Contd.from page 14

SLMA Ethics... Case No 2 - Relationships with colleagues and other health workers: Conflict between a surgeon and an anaesthetist. A relative of a patient awaiting surgery abused an anaesthetist ‘A’ over the phone stating that she had been told by the surgeon ‘S’ that her father’s surgery had been postponed due to the clinical incompetence of ‘A’. On the same day ‘S’ had also abused ‘A’ on the same issue over the phone. When ‘A’ complained to the ethics committee about these incidents, ‘S’ made a counter complaint claiming that ‘A’ was clinically incompetent. Question: Are there clinical ethics issues here or is it one of professional ethics? The committee perused the patient’s clinical records, interviewed both consultants, and also interviewed another senior anaesthetist to seek information about the circumstances when an anaesthetist may refuse to anesthetize. The clinical records revealed that the patient had IHD and COPD and had had two epi-

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sodes of spontaneous pneumothorax. He had also been refused surgery previously by several surgeons because of the anaesthetic risk. The patient had been admitted for surgery without prior consultation or agreement with an anaesthetist. A cardiologist had advised against surgery and the anaesthetist had refused to anesthetize the patient on that basis. The surgeon admitted at the inquiry that he had told the patient and the bystander that the operation was not done because the anaesthetist was obstructing the surgery. He also admitted that he abused the anaesthetist. The SLMC guidelines give the following advice regarding relationships with colleagues and other health workers (Adapted from the Commonwealth Medical Association – 1993, Guiding Principles in Medical Ethics and Human Rights):

1. Principle 12:- Medical practitioners have a responsibility to co-operate fully with their medical colleagues in the interests of providing the best possible health care for the community; 2. Principle 13:- Medical practitioners should recognize and respect the expertise of other health workers and collaborate with them in the interests of providing the best possible health care; and in section 5 of the Instructions on Serious Professional Misconduct 3. Deprecation by a doctor of the skill, knowledge, qualifications or services of another colleague constitutes serious professional misconduct. The committee ruled that the behaviour of surgeon ”S” constituted serious professional misconduct and recommended that he be advised to refrain from such behaviour in the future. At the same time, counselling to improve his relationship with colleagues was recommended. (Note: Surgeon ”S” continued to serve the hospital for another 3 years without any complaints against him.) Contd. on page 20


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SLMA Ethics... Case No 3 - Informed Consent and Medical Qualifications: Unethical practice by a consultant A complaint was made by 8 consultants to the effect that:  a consultant gynaecologist had been admitting patients for laparoscopic gynaecological procedures that were in fact performed by a gastroenterological surgeon, the patient being unaware of the involvement of another consultant in carrying out the procedure;  This gynaecologist was not qualified to be a consultant. This issue resulted in a major furore in the institution. An anonymous article appeared in a national newspaper followed by some letters to the editor. The SLMC requested a report from the hospital about the incident. Questions: Was there a factual basis for the complaint? Was the gynaecologist at fault in not informing/obtaining consent from the patient to obtain the help of another consultant in carrying out the intended procedure? Was the gynaecologist “unqualified” to hold the post of consultant? The ethics committee reviewed the degree certificates of the gynaecologist “G”, perused the clinical records of all patients who had undergone

laparoscopic procedures by “G” and interviewed all the consultants concerned including “G” and the gastroenterological surgeon. A comprehensive 7-page investigation report was compiled and submitted to the SLMC. Excerpts of this report appeared in a national weekend newspaper. The committee found that:  Of 78 laparoscopic procedures done by “G” the gastroenterological surgeon was involved in 19 and other consultants in 12 (total 31); and  Consent forms in relation to procedures by “G” mentioned only her name even where other consultants were involved, despite the consent forms having provision for the insertion of more than one name. In addition:  “G” stated that the surgical gastroenterologist was called in only to insert the laparoscope, as she was not competent to do so, and hence the patients were not informed about his involvement; and  She could not give an acceptable explanation how in that event she was able to do some of the procedures on her own. The committee found that “G” had adequate qualifications to function as a Consultant Obstetrician and Gynae-

cologist. The SLMC guidelines were not adequate to decide the issue of informed consent in this case. The GMC guidelines (Seeking patients’ consent) state thus: “You must not exceed the scope of authority given by a patient except in an emergency. Therefore if you are the doctor providing treatment or undertaking an investigation you must give the patient a clear explanation of the scope of consent being sought. This will apply particularly where different doctors provide particular elements of an investigation or treatment.” The committee ruled that the gynaecologist was adequately qualified to hold the post of consultant in the field of obstetrics and gynaecology. She had however, failed to obtain consent from the patients before obtaining the services of other consultants to perform procedures that she had offered. The SLMC decided to cancel the registration of “G”. Comment: There was much discussion relating to the issue of obtaining consent for procedures that centred on the circumstances when a surgeon can call for assistance from a colleague, whose involvement has not been intimated to the patient at the time of obtaining consent. In an unforeseen situation this would be ethical. It may depend on hospital rules and procedures e.g. in private hospitals patients may rightfully expect to be treated by persons of their choice; this may not always be true in Government hospitals. But generally speaking, consent should be sought, and given, for the procedure to be done by a named person. Hospital policy on this matter can go a long way towards clarifying the issue. Contd. on page 22

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Contd.from page 20

SLMA Ethics... Case No 4 - An issue of professional etiquette: Conflict between a Physician and an Administrator A consultant working in the hospital was admitted with a severe head ache and suspected dengue fever under a consultant physician “CP”. He was referred to a neurologist for an opinion by “CP”. A doctor involved in hospital administration visited the patient unknown to “CP”, informed the neurologist who had been called in consultation and prescribed medication. Neither “CP” nor the ward doctor had been informed by him of the treatment prescribed. “CP” complained about the incident alleging interference and breach of confidentiality.

Questions: Interference with patient care and Breach of confidentiality. The ethics committee sought a written explanation from the administrator; interviewed the patient; and perused the clinical records. The committee found that there had been an ongoing rift between “CP” and the medical administrator and hence the administrator had not attempted to inform the physician about the change of treatment. The administrator was not involved in any way with the clinical care of the patient. The GMC guidelines are

clear on the point that an administrator has the right to examine notes of a patient. If any notes of an administrative nature are made, this has to be entered on a sheet separate from the clinical notes. The committee ruled that there was no breach of confidentiality by the administrator perusing the patient’s clinical record. However, seeking to treat the patient without a request to do so by the patient’s physician was against medical etiquette. The administrator was informed about the findings of the ethics committee and requested to refrain from such behaviour in the future.

This article will be continued on the SLMANews September issue

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Preserving the independence of the SLMC The SLMA believes that freedom of speech is a fundamental right in a democratic society and that all members of the society should agree to disagree and tolerate one another’s views. We condemn the attempt to cause harm to Dr Ranasinghe and his family and call on the authorities to take measures to promptly identify the culprits and bring them before the courts of law.

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he Sri Lanka Medical Association condemns the recent grenade attack on the house of Dr Lalantha Ranasinghe, Consultant Surgeon and Member of the Sri Lanka Medical Council (SLMC). Dr Lalantha Ranasinghe is an honest and hardworking surgeon who has rendered yeoman’s service to the people of Sri Lanka. He is a person who is not afraid to express his views in any forum and we believe that his outspoken representation of the views of the medical profession that he represents at the SLMC would have led to this attack. The SLMA believes that freedom of speech is a fundamental right in a democratic society and that all members of the society should agree to disagree and tolerate one another’s views.

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We condemn the attempt to cause harm to Dr Ranasinghe and his family and call on the authorities to take measures to promptly identify the culprits and bring them before the courts of law. The SLMA also notes with sadness that none of the culprits behind such attacks on members and officials of the SLMC over the past few years have been apprehended so far. The SLMC is a government organization empowered with the task of protecting the patients by regulating medical education and postgraduate medical training thereby ensuring that only those appropriately qualified to practice medicine and surgery in Sri Lanka are allowed to do so. Therefore it is in the interest of the entire population of the country that the members and officials of

the SLMC are allowed to discharge their duties without fear, and ensure that patient safety is not compromised by commercial interests of a few. Any attack on the members and officials of the SLMC is an attack on the government and therefore the law enforcement authorities should spare no time in apprehending the culprits. Chronology of Acts of Violence against SLMC members and officials • Bomb Attack on the House of former President of the SLMC – Dr H.H.R. Samarasinghe – 2002 • An attempted shooting at the House of the former Registrar of the SLMC – the Late Prof. P.S. S. Panditharatne – 2002 • Assault on the current Registrar of the SLMC – Dr N.J. Nonis – 2011 • Grenade Attack on the House of Member of the SLMC Council – Dr Lalantha Ranasinghe – 2012 Vidyajyothis Prof. Lalitha Mendis, Immediate Past President of the SLMC says “Enough is enough”. Here is her full statement I have no doubt that the

whole medical fraternity of Sri Lanka will join me in condemning the grenade attack on Dr Lalantha Ranasinghe’s residence on the 16th of August 2012. He is a member of the Sri Lanka Medical Council (SLMC). This cowardly act is one of many that SLMC members have been subjected to. Dr Ranasinghe served on the medical council during the whole of my tenure of office as President SLMC. He is forthright, does not mince his words and speaks on matters of principle. He has done so on many issues facing the medical council at present. The foremost duty of the medical council is to promote and maintain the health and safety of the public by ensuring proper standards in the training of doctors and other health care workers (HCW); ensuring proper standards in the practice of medicine; Registering doctors, dentists and other HCW and regulating the practice of those registered. Contd. on page 28


SLMANEWS

August, 2012

Contd.from page 24

Preserving the independence... In the course of performing its duties, decisions have to be made and opinions expressed which may be unpalatable to some individuals and institutions. Here lies the problem, that in performing their duties by the public, some members of the medical council have had to face acts of intimidation. In 2002, the residence of a former President of the medical council was bombed, shots fired at the residence of the then Registrar, and an attempt made to set fire to the medical council office. In 2011, the Registrar of the medical council was assaulted

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at the gate of his residence. I myself as President of the medical council was verbally abused on various occasions including over the radio. Therefore, the grenade attack on Dr Ranasinghe’s residence is just another in a series of intimidatory acts by vested interests who resent having to conform to standards and who have reckless disregard for the safety of the public. Does the public of this country want its health and safety protected by the medical council? If so I hope they will with one voice rise and say “Enough is enough�

Vidyajyothis Prof. Lalitha Mendis

Vidyajayothi Prof. Lalitha Mendis is the only person in history to have been the Dean, Faculty of Medicine, University of Colombo; Director, Postgraduate Institute of Medicine, University of Colombo; President, Sri Lanka Medical Association; and President, Sri Lanka Medical Council.


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SLMAnews-2012-08