|Year : 2016 | Volume
| Issue : 3 | Page : 104-107
Expatriate doctors, medical litigations, and overall patient care: Taif study
Sami Abdul Rahman Alkindy
Department of Surgery, College of Medicine, Taif University, Taif 21944, Kingdom of Saudi Arabia
|Date of Web Publication||14-Nov-2016|
Sami Abdul Rahman Alkindy
Department of Surgery, College of Medicine, Taif University, P. O. Box 888, Taif 21944
Kingdom of Saudi Arabia
Source of Support: None, Conflict of Interest: None
Objective: In Saudi Arabia expatriates physicians involved in malpractice litigation process (MLP) risk travel ban, creating immeasurable stress as these procedures are quite lengthy with no insurance company or employer support. A survey study conducted in the city of Taif aimed to demonstrate the outcome of ongoing MLP on overall patient care. Methods: Various grades doctors of both sexes, from different surgical and medical specialties in Ministry of Health Hospitals, Taif city, were surveyed, including mental, pediatric, King Faisal and King Abdul Aziz Specialist Hospitals. The study was conducted between January 25, and May 3, 2015. Saudi nationals and paramedics were excluded from the study. Multichoice questions with space for suggestions were distributed and collected manually. It is a qualitative and cross-section study. Results: A total of 277 responded to the survey, 127/277, (45.84%) were involved in MLP of whom 97/127 (76.4%) were banned from travel. While in Linkert's scale, 96/277 (34.65%) were satisfied with the role of insurance company, 114/127 (89.8%) had little or no support from their employer during MLP, and 218/277 (96.03%) agreed that overall patient medical care will have a negative impact due to the ongoing MLP (P < 0.05). Conclusion: We believe the ongoing MLP is a fertile ground for developing defensive medicine culture. A stress-free environment strategy governed by support and legal protection by employer and insurance company respectively is suggested.
Keywords: Defensive medicine, liability claims, malpractice, medico-legal litigations, Saudi Arabia
|How to cite this article:|
Alkindy SA. Expatriate doctors, medical litigations, and overall patient care: Taif study. Saudi Surg J 2016;4:104-7
| Introduction|| |
"The process of medical litigations in Saudi begins once a patient or one of his/her relative complains of a medical error that from their point of view had a morbid or mortality outcome. Accordingly, it is than directed either to the Ministry of Health (MOH) or the city government. Following which, a letter of travel ban is issued to the medical staff who either had shared the responsibility or attended the event, simultaneously with a local investigation procedure. The Legal Health Organization (LHO) is then assigned, to review all related documents and an interview with individuals from both sides of the claim, based, and governed by Islamic Sharia law. A final decision on the accused is reached."  The process has no limited time frame.
LHO introduced in 1999 looks into these complaints with a mean final accusation verdict value of 49.9-35.8% , indicating that more than 50% and 64%, respectively has been falsely implicated for claims.
With the absence of both employer and insurance company support, the medical fraternity may pursue self-protection by defensive medicine. A survey in the city of Taif was conducted, aimed to demonstrate the number of expatriates involved in medicolegal cases, time taken to reach a final verdict, employer's supportive role, overall medical staff satisfaction with insurance companies, and the negative impact of malpractice litigation process (MLP) on overall patient care. According to our knowledge, there is no similar study in English literature.
| Methods|| |
Doctors of both sexes and various grades (consultants, specialists, and residents), including surgical (general, plastic, orthopedic, otorhinolaryngology, ophthalmology and gynecology) and medical (general internist, pediatrics, neonatology, endocrinology, nephrology, intensivist, pulmonology, and anesthesiology) specialties respectively, from four major MOH hospitals in Taif city, including Mental Health (670 beds), King Abdul Aziz Specialist (500 beds), Pediatric (134 beds), and King Faisal (500 beds) hospitals were surveyed between January 25, and May 3, 2015. Statistics highlighting the specialty with the highest rate of litigations is not part of the study. Saudi nationals and paramedics were excluded from the study. A multichoice seven questions with space for suggestions was circulated and collected manually. It is a qualitative and cross-sectional study. SPSS version 22 (IBM Corporation, Armonk, New York 10504-1722, USA) was used to analyze the data.
| Results|| |
A total of 277 doctors responded to the survey, 127 (45.84%) had had medical malpractice litigations of whom 97 (76.37%) were banned from travel. Fifty-seven (44.88%), 32 (25.19%), 20 (15.7%), 5 (3.9%), and 11 (8.6%) were once, twice, three times, four times, and more than four times involved in litigations, respectively while 2 (1.6%) did not respond. Thirty-nine (30.7%), 57 (44.9%), 23 (18.1%), 6 (4.7%), and 2 (1.6%) took 0-1, 2-3, 4-5, and more than 5 years to reach a final verdict and no response, respectively and 3 (2.4%), 8 (6.3%), 24 (18.9%), 21 (16.5%), 69 (54.3%), and 2 (1.6%) had a very strong, strong, little, very little, and no response, respectively of employer's support employer during MLP. While the overall satisfaction with insurance company was 12 (4.4%), 84 (30.5%), 67 (24.4%), 72 (26.0%), 27 (9.8%), and 15 (5.45%) very satisfied, somewhat satisfied, neither, not satisfied, very unsatisfied, and no response, respectively. The negative impact on overall patient care due to MLP was 88 (31.7%), 92 (33.21%), 38 (13.7%), 38 (13.7%), 15 (5.41%), 6 (2.2%) strongly agree, agree and somewhat agree, disagree, and strongly disagree, no response, respectively [Figure 1].
|Figure 1: Negative impact of malpractice litigation process on overall patient care|
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Sample was obtained in the following manner
According to the annual statistics health book 2012, the average doctor rate per 100 bed is 73.3, i.e. 1.36 doctor per bed.  Accordingly, the calculated beds were 1084 of the total population (1474.24) understudy, of these 75.2% (1108.4) expatriates and 24.8% Saudis (who were excluded) of these only 277 (25.45%) responded to the survey.
| Discussion|| |
Doctors in Saudi Arabia are required by law as elsewhere to have malpractice insurance cover, meant to safeguard patient as well as holding them accountable to their actions and decisions. The MLP in the kingdom is somewhat unique; the involved doctors are subpoenaed to attend multiple lengthy court hearing without legal representatives or counseling to fend for themselves, with expatriates risking travel ban.
Moreover, accused doctors are expected to write clear report, understandable, and with minimum application of technical words and professional jargon.  Such a draft, however, especially in Arabic, may further put him/her in legal pitfalls.
Travel ban exclusively for non-Saudi is a selective decision at the disposal of the initial investigating officer, with no clear criteria, which is later affirmed or reversed by the presiding LHO judge. In our study, more than 44% were involved in at least one litigation, and 8.7% had more than four cases at a time and due to pending cases 76.4% (97/127) were banned from travel of whom 70.1% took more than 2 years to reach a final verdict.
Worth noting was employer's lack of support 114/127 (89.8%) and failure to provide either legal advocate or counseling during MLP. This, however, may also explain the low satisfaction 34.7% (96/277) with insurance company which shared the same responsibility.
The MLC recommendations conclude that "Adherence to the standards of medical practice is required to decrease medical litigations,"  this fair and broad statement; however, do not differentiate between complications, error of decision/practice, or negligence. Furthermore, MLP and its auxiliary regulations have not been addressed to avoid the risk of developing defensive medicine practice.
"Defensive Medicine," which is defined as the deviation from a good practice to reduce complaints and/or criticism without providing additional benefit to the patient. 
In this study, more than 78% (218/277) agreed that the going MLP will negatively affect overall patient care [Table 1], which is in contrast to medical practitioner ethics and professionalism, nevertheless, it has been reported in other parts of the world, ,, however, for other reasons. No matter what justification it holds, the implications include comprising patient safety,  avoiding high-risk patients,  and increasing health-care expenses  by requesting unnecessary and expensive investigations. To curtail its prevalence, some remedies have been suggested, among which is the creation of a supportive and blame-free environment  on the one hand and the application of evidence-based medicine and implementation of sound hospital policy and procedures  on the other hand.
|Table 1: Interpretation of malpractice litigation process negative impact |
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Rate of specialties involved in MLP was not considered here as so as it has been reported  elsewhere Moreover, we felt it would not contribute much to the study. Furthermore, it was not the aim of the study. Although the study is limited to Taif city in the kingdom, we believe the same lies elsewhere; a national survey is required to reveal more of the ongoing MLP implications.
One study limitation is Saudi national exclusion, who shared the same ordeal of MLP, nevertheless exempted from travel ban; this however was the essence of the study. Other limitations included the absence of private and other ministerial health institution (Ministry of Defense) contribution, which was related to bureaucracy and confidentiality policy adopted on the one hand and lack of cooperation, especially from the private sectors that require intimidation-free environment, incentive, and believers of a positive as well as favorable study outcome on the other hand.
The suggested strategy put forward by the surveyed to improve MLP included:
In addition, the author had the following suggestions:
- Proper filtration of complaints by experienced professionals and legal advisors before final submission to LHO, thus minimize errors and falsely implicated cases
- Legal representations authorized by the employer and/or insurance company as so doctors are not trained to write or argue legal matters during the investigation or in the court
- Travel ban, to be replaced by employer and/or insurance sponsorship
- All subpoenas and related legal papers to be translated into English as so as a good number of medical practitioners are non-Arabic speakers.
In summary, Saudi Arabia is a developing nation with an expanding population to meet the challenge there will be an increased demand for expatriates in every sector for many years to come, medicine is no exception. The total Saudi physicians workforce is 24.8%, the rest are expatriates  who are more vulnerable to MLP regulations than nationals. We do need to preserve the right and dignity of these prudent physicians. However, not on the expense of patient's well fare, on the contrary, avoiding defensive medicine culture.
- Claims filed by proxy without legal authorization not to be accepted and processed
- Compensation paid by claimer to doctors falsely implicated
- Administrative fees to be paid by the claimers, refunded once a final verdict proved negligence or malpractice
- Standardizations of informed consents for each specialty by the MOH
- Media publications of cases under review by LHO before final verdict, to be made accountable
- The LHO sitting judge though has expert advisors, will be more advantageous if he had medico-legal background education
- Representations and involvement of the Saudi Medical Council in LHO as it is the sole body accrediting doctors and issuing medical practicing license.
| Conclusion|| |
For optimum patient care and to avoid defensive medicine culture, we suggest the revision of MLP system and a stress-free environment by providing support and the required legal protection by insurance companies and employers alike.
I would like to thank Dr. M. Al Saeed, Dr. Talal Al Kindy, and Dr. M. Murjan for invaluable contribution in collecting data and advice.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Al-Saeed AH. Medical liability litigation in Saudi Arabia. Saudi J Anaesth 2010;4:122-6.
Al-Saeed AH. Revisited: The scope of medical litigations in Saudi Arabia-analysis of closed claims over 15 years. J Health Spec 2015;3:162-5.
Health Statistical Year Book. Saudi Arabia: Ministry of Health; 2012.
Sara B. How to write a medico legal report. Aust Fam Physician 2004;339:66-7.
Solaroglu I, Izci Y, Yeter HG, Metin MM, Keles GE. Health transformation project and defensive medicine practice among neurosurgeons in Turkey. PLoS One 2014;9:e111446.
Ortashi O, Virdee J, Hassan R, Mutrynowski T, Abu-Zidan F. The practice of defensive medicine among hospital doctors in the United Kingdom. BMC Med Ethics 2013;14:42.
Renkema E, Broekhuis M, Ahaus K. Conditions that influence the impact of malpractice litigation risk on physicians' behavior regarding patient safety. BMC Health Serv Res 2014;14:38.
Catino M, Celotti S. The problem of defensive medicine: Two Italian surveys. Stud Health Technol Inform 2009;148:206-21.
Chen J, Majercik S, Bledsoe J, Connor K, Morris B, Gardner S, et al
. The prevalence and impact of defensive medicine in the radiographic workup of the trauma patient: A pilot study. Am J Surg 2015. pii: s0002-9610(15)00248-2.
Tuers DM. Defensive medicine in the emergency department: Increasing health care costs without increasing quality? Nurs Adm Q 2013;37:160-4.
Al-Hajjaj MS. Medical practice in Saudi Arabia, the medico-legal aspect. Saudi Med J 1996;17:1-4.