Discussion Forum: Anil Aggrawal's Internet Journal of Forensic Medicine, Vol.1, No. 2, July-December 2000
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Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology

Volume 1, Number 2, July-December 2000


Anil Aggrawal's Internet Journal of Forensic Medicine and ToxicologyProfessor Anil AggrawalAnil Aggrawal's Internet Journal of Forensic Medicine and Toxicology

Discussion Forum

Should medicolegal services be thrown open to the Private Sector?


Comments by Dr. George Paul, Malaysia
(Received on November 3, 2000)

Dr. George Paul, Malaysia
Dr. George Paul, Malaysia

Opening up the Forensic Services to private practice is one of the best incentives to induce some competitive elements of the best of doctors, and even other staff, to take up this specialty, especially those, who for monetary considerations, have evaded this option of specialization. Besides, it would also bolster the residency programme, which by virtue of the in-house training of doctors, would also offer sufficient man power in the civil services, to staff the departments/ hospitals in these cases. At present, though many institutions have forensic training postgraduate courses, the number of registrants to these courses are dwindling as the competent are opting for the other specialties that offer opportunities outside the government employment scenario's so that of late the specialty is seeing entrants who hold the residency post only for the purpose of another contractual employment till the end of the 3 or 4 year's tenure. The means to do it are simple. In the first instance, there should be clearing from the government by appropriate amendments in the Criminal Procedure Code or the Evidence Act, to say that any person either serving in these departments, or a member of the registered parent body of Forensic Examiners/Medicine Experts/ Pathologists/ Clinicians, etc. is authorized to examine and report on - postmortems/ clinical examinations, etc. As it is, the forensic expert's evidence is not admissible in many countries, unlike Malaysia. More often than not, doctors conducting postmortems in Malaysia are rarely called to attend court in those cases. Then the government should permit Forensic experts to charge for issuance of reports to insurance companies and relatives of patients for insurance purposes. Besides these, the amended rules should permit forensic Pathologists to conduct postmortems from private hospitals, where they need to find out the cause of a difficult case, to cover their back- so to speak, when they have a death in their hospitals. Of course the charges, if fixed by any public government regulating body, as in the case of Malaysia, the Malaysian Medical Association, would be satisfactory guidelines to charge, not only for expert opinion, but private autopsies, court attendance fees and charges, etc.

Currently these guidelines are being followed at the Forensic Unit of Department of Pathology, where we are often asked to provide a brief summary report of three or so lines of major findings of the postmortem, and the cause of death (as given in the WHO - ICD) for which we have a very nominal charge. If a more detailed or full report is required, then we charge as per the complexity of the postmortem report. Besides, there have been lengthy clarifications asked by a clams adjuster firm on behalf of Insurance company, where I have charged the full amount chargeable for a report/opinion, to clarify some issues of disease, trauma and alcohol, for them to rebut an insurance claim. (The insurance companies make all applicants for insurance cover to sign a waiver authorizing them to ask for records of hospitalization in case of a claim, under which they need not take a consent from the next of kin/claimant).
Dr. George Paul, Malaysia
quote start...The hospital record section on its part ensures, that whenever there is such a claim, they ask for the next of kin/ claimant to sign a consent form for its release to insurance, etc. The record section of the hospital bills them and reimburses us the fee. We have also been doing autopsies at the request of relatives, who might intend to sue either our hospital or some outside private hospital....quote end

The hospital record section on its part ensures, that whenever there is such a claim, they ask for the next of kin/ claimant to sign a consent form for its release to insurance, etc. The record section of the hospital bills them and reimburses us the fee. We have also been doing autopsies at the request of relatives, who might intend to sue either our hospital or some outside private hospital. In the latter case the body is brought from that private hospital just for that purpose, and the relative sign the consent form for the autopsy and also for release of the report, and pay a deposit fee covering all the costs in advance. I have done a few clinical forensic cases here, and in a couple of them, the person accompanying wanted a copy of my report. I charged appropriately for the report, which was billed through the hospital record section, who were the ones issuing the report.

So to conclude, opening up the in-house services to private is the first step, and would in the long run offer us forensic medicine experts, like our other clinical and other brethren, the opportunities to continue in our specialty even after our retirement. For Forensic Pathology to be practiced purely as a private practice by a group of private Forensic Pathologists, as in London, or as part of contractual pathological services of a private group to a county district hospital as near Vancouver, Canada, would either require that, as in the first instance, there be public mortuaries, which anyone can use for a fee, or as in the case of the latter, the contracting agency have its own mortuary facilities. The private Forensic Pathologists would then offer a consolidated fee for the full autopsy charge to the police.

As a start, those of us who have practiced in India should know, that the concept of the mortuary services being the last service to get funding for any development or maintenance needs amending. Bureaucracy gives least importance to forensic, as we have no marketable value. One of the best ways to do that without waging an all out war against bureaucracy to realize that we deal with matters which deal with life and liberty of citizens by the implications of our reports, is to earn not only for ourselves, but by apportioning a small part of those earnings to the institution, but for the institution also, by our private services. By doing so, if we find ourselves strapped for funds, we could use some of the funds we have generated by our practice in bettering our work place.

The following "add-on" comments from George came on November 6, 2000

We also need to do a micro-costing of each component of our services, with regards to the costs/ contribution of each member of our team, in the Forensic Practice, to come at a sum total of what a particular service would cost the exchequer for a single investigation/ examination. For at present it is the exchequer, who finances all the autopsy and other services in most countries. The need for it is already felt when one takes up corporatizing the Forensic Services.
Dr. George Paul, Malaysia
quote start...The fact that no money actually changes hands is not important, for the exchequer can be justified expenses by the department by showing the money owed by some other government department, and therefore accounted for by the treasury in the department's account, is available there for one to spend...quote end

Micro costing means the cost of the contribution of the (clerk + attendant + technician + doctor) x Man hours + consumables + disposables used per case + wear and tear per unit of work of the mortuary, etc. + cost of (electricity + water) for the man hours of the case + cost for the report writing to doctors and stenographer/typist's costs per case, etc. All these should be micro- costed and added up. The rate for the level of difficulty/complexity of the case - whether it needed Biochemical and Microbiological/ virological investigations, extensive histopathology examinations, etc should also be costed in. An additional administrative charge may be budgeted in also. This would serve as the framework for the billing of private services. With corporatization and some element of generation of funds for the running of the departments, it is necessary, when denial of funds and lack of budget starts affecting the running of the department, to consider whether the State/ Crown/ exchequer should also pay for the routine Coroner's/ Police/ Magistrate postmortems which form the bulk of the forensic practice. This service should generate funds that are for running the department. The fact that no money actually changes hands is not important, for the exchequer can be justified expenses by the department by showing the money owed by some other government department, and therefore accounted for by the treasury in the department's account, is available there for one to spend. The exchequer could therefore be asked for the funds generated in the departments account with the treasury, for the running of, and even development and modernization plans of the departments, as is being practiced in a few centers in the west.. One offshoot of it is that the Police would have to pay for the services they ask of us. With a system like this in place, unnecessary postmortems would cost the police/justice department, and by the means of auditing the respective payments of these wings of the executive, the number of these cases would also decline. It may be argued that research would be affected, but from my experience, research usually emanates from educational institutions housed forensic services. Education is a commodity that one cannot charge the full cost to either the student, or the exchequer, and the public should not look for the economic returns from these setups to offset the expenditure. The rewards of investments in educational institutions would see the rewards in the product, its graduate/ postgraduate, and their work in the form of research, etc. would still continue and benefit all without separately budgeting for it.

Readers may want to submit their experiences on this problem either by E-mail or by snail mail at the following address.
(N.B. Kindly submit your views even if this issue is in Archives section, as readers come to the Archives section quite often, and we keep it updated!).

Professor Anil Aggrawal (Editor-in-Chief)
Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology
S-299 Greater Kailash-1
New Delhi-110048
India

If you have interesting questions like this one, please send them over to me, so I can host them over the net. Every one can then contribute his own experiences on the problems posted. It is the web which makes such a lively discussion possible. We all can contribute our own bit of experience and absorb a lot more from the collected wisdom of all the others. This kind of discussion is probably not possible in routine "paper" journals.

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