Doctors: the long march to accountability
BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7261.0 (Published 09 September 2000) Cite this as: BMJ 2000;321:0All rapid responses
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The new Bill of Patients' Rights in Israel is an attempt to enhance
transparency of Physicians performance . It enables patients access to
all medical data related to their health and medical care. This is
supposed to develop more accountability of physicians and institutions.
Unfortunately the results are just the opposite. Doctors and the Israel
Medical Association oppose being exposed to litigations and therefor
instead of improving transparency the result is a growing practice of
concealing information.
Doctors used, in past years, to perform autopsies in about 75% of deaths
in general wards. Now this is almost a non existent procedure. About half
of the general hospitals don't have "mortality conferences" any more. In
many instances such conferences are conducted in restricted forums and no
records are kept. It is even difficult to appoint committees to
investigate mishaps and cases of suspected negligence because members of
such committees were prosecuted for defamation by the involved colleagues.
The IMA and the Ministry of Health even signed a "covenant" which gives
the IMA a power to veto the nomination of such committees. Doctors who are
nominated to such committees are advised to have legal councelling !
Hospital directors and the IMA resent the publication of "comparisons" of
performance results in public for very understandable reasons.
This lamentable situation is the result of the litigations and threats to
doctors and institutions.As long as lawyers and the public in general do
not limit the exposure of doctors to litigations the effects of this trend
is a very "defensive medicine", with all the negative effects that are
related to it . These include not only the avoidance of medical records
and of open discussions by peers. It includes what we know as "dilution
of responsibility" which means over-use of consultations and unnecessary
tests etc. The impact on patients' health is undoubtedly detrimental.
When all this is considered the most effective way to increase
accountability and quality control is through the people at the top . The
case of the Bristol Infirmary should become a turning point. When a
hospital director is paying for uacceptable performance all the echelons
of care givers are effected. A manager who knows he/she will be
accountable for misdeeds of the institution is more effective in making
the organization perform better. This means that the management of such
institutes be medically oriented and not only economically oriented.
In
Israel hospital directors are physicians . But they are obliged to be
qualified in Healthcare Administration. This qualification is achieved
only after a very long and very formal program of training and studies (
minimum 7-8 years for an MD ! ).
Recently the Union of Hospital Directors adopted a resolution to formally
define the responsibility and the authority of the hospital director at
the hospital. This includes general managerial functions as well as
clinical performance. This is a bold and courageous act and may contribute
more to the quality of medical care then trying to expose individual
doctors.
Another step that is needed is to amend the Bill of Patients's Rights and
to restore the Cofidentiality of the files and documents that are related
to the work of Enquiry Committees, Mortality Conferences and all
encounters within the Medical Profession that are related to quality
control and quality assurance. Physicians want to give the best service to
their patients but they don't agree to expose themselves to litigations
and harassments by the Media or lawyers.
Competing interests: No competing interests
Clinical Negligence in the developing world
Fighting a case of clinical negligence is a horrendous task,whether
such an action is initiated in a developed country or elsewhere.As
indicated in this editorial[1],it is harder to pursue a clinical
negligence action in the indian subcontinet.Much of the difficulties are
due to lack of resources, and the ingrained cover-up culture among
doctors;the latter is not at all unusual in the UK either.However,things
are not all that bad in India;a determined group of doctors have started a
campaign against corrupt medical practices and further details can be seen
in their regular online journal titled Issues in Medical Ethics at:
http://www.healthlibrary.com/reading/ethics/april-june2000/index.htm
.
In Sri Lanka too,malpractice litigation is as difficult as
ever,largely due to economic constraints that affect many developing
nations.However,at least one high profile negligence case involving a well
known Professor of Paediatrics has reached the highest Court of Sri
Lanka,and perhaps,this could be a timely reminder to others that proper
accountability cannot be easily evaded in developing parts of the world.
Competing interests:None
(13.09.2000)
REFERENCES
[1]Smith R.Doctors:long march to accountabilty.BMJ 2000;321:0.
Competing interests: No competing interests