M Seraj. Litigations in anesthetic practice in Saudi Arabia: The Picture And The Dilemma Of The Specialty. The Internet Journal of Health. 2007 Volume 7 Number 1.
The anesthesia specialty in KSA is seeing the next generations after the pioneers. It is seeing as well growing engagement with more complicated surgeries.
The level of patient education regarding anesthesia is variable. So, sometime litigation faces the anesthesiologists in his practice. The litigations solving committee's investigations has to clear the view and take its tool.
The author is drwing a strategic view regarding this issue over his practice since the 80s of the last century and proposing for the futures
An article caught my attention recently by Dr Ahmed Alsaddique titled Medical liability. (The dilemma of litigations.) (1). It represents the true picture of litigations against various medical specialities in the health care delivery system in Saudi Arabia. The speciality of anasethesia ranked number seven among cases submitted for litigation. It revives memories of serial article titled, Dilemma of Anaesthesiologist working in Saudi Arabia.
The authors of that article illustrated the daunting facts about the absence of guidelines on the standard of care and of proper monitoring, non-existent policy and procedures, the appalling working facilities in peripheral hospitals, single handed working anaesthesiologist, the unhelpful attitude of administration, who can order any physician to perform certain tasks beyond their capabilities, psychological torture, frustration and agony of being involved in a legal case and being convicted without fair trial. etc (2,3,4,5) That article was14 years ahead of the recent mentioned article. It pointed out that the dilemma is a multi-disciplinary one and shared by three components: The Ministry of Health (the governing body), the Association and the Specialist ( The practitioner).
The authors stipulated all problems encountered by colleagues in their daily work and the cases of mal practice submitted against some members of the speciality. They gathered all necessary and essential information and were advisories to the legal medical court and gave their opinion on several occasions. The authors insist every time they attended these medical legal courts or gave written consultation that a post mortem should be a mandatory part of the investigating procedures. This will provide the ultimate diagnoses to be fair to the speciality, the plaintiff and the accused. The authors indicate western countries are using post mortem to reach the accurate cause of death in obscure illness or unexpected death forming a litigation case.
The litigation discussion in the past took place in one central court which dealt with all cases. The procedure was long and daunting. Some times it took between two-three years or longer until a verdict was reached. The accused during this period could not travel, received less salary and was not allowed to practice anaesthesia at all. Once the verdict was reached, the blood money usually paid, the accused had to leave the country. Two anaesthesiologists who were subjected to this ordeal suffered heart attacks and died during or after their conviction. This was due to overwhelming stress of the enquiry.
The authors ended with these recommendations:
Roles of the governing body GB.(the establishment)
The authors gathered statistics of anaesthetics performed, the number of anaesthetists working in Ministry Of Health MOH and Private Sector PS and Other Government Hospitals OGH. The authors found out that both the MOH and the PS anaesthetists have, more work load per year, they are less qualified with a lower degrees, they are not insured when compared with anaesthetists working in the OGH. In the mean time they discovered that they have more litigations and convictions than Anaesthetists working in other government hospitals. Statistics indicate that the MOH control about 82 % of the health care delivery system in Saudi Arabia and have more litigation cases submitted against them to the legal medical courts. From the above findings we asked our selves. Does it have any roles? Yes it has major roles toward their members of the speciality as it is considered to be the governing body or the guardian of the health care delivery system in the Kingdom. The authors targeted them with specific recommendations aimed to improve the service in the speciality of anaesthesia, the recruitment policy and procedures that have to be implemented and enforced, better salaries for the Saudi and expatriates specialists in order to attract top class personnel, implement our national standard of care and monitoring created by the Saudi Anaesthetic Association SAA and must have detailed policy and procedures for the speciality including administrative, professional and educational. The above mentioned sets of criteria must be implemented and enforced. This also must be coupled with an excellent biomedical department. Mandatory requirement of an ongoing education was indicated by His Excellency Dr Ghazy alQusabi, the former Minister of Health that all members of the speciality and other health providers must be allowed to attend symposia, courses and workshops in order to improve their knowledge and skills. The objective of this exercise is to improve the quality of medical service to the patients. This rule was written but was never implemented by health authorities working in both MOH and the private sector. Finally all hospitals should have proper computerized monitoring in order to reduce or even prevent the poor documentation.
Roles Of The Association
The newly established Saudi Anaesthetic Association invited top consultants and academicians in the speciality to put forward recommendations and input for the anaesthetic service in the kingdom as a whole. The main objective of the exercise is to up date our system and to improve the service in our speciality similar to the western associations who became the guardian of the speciality. The western societies set the standard of care and monitoring and policy and procedures that have been applied through out the health care system world wide. Anaesthetists all around the world are using the American Society of anaesthesiologist's classification and standard of care. We felt obliged that there is a need to develop our own standard of care and it should be slightly different from theirs, not to forget using some of their excellent indices. Our substantial recommendations to the Association is to have a long term national survey on the anaesthesia services in the kingdom. To establish the national standard of care and monitoring that has been applied in the university hospital but not by the majority of hospitals. This was published in two parts in the news letter of the association vol. 1, No.3 and 4 May and July 1990. 88888
The SAA must Aim to put forward the approved policy and procedures for the anesthesia services in the ministry and private sector hospitals. Provide continuous medical education in the form of regular scientific meetings and courses for updating the knowledge and the skills of the working anaesthetists in the kingdom. It should provide top class library. Finally we advise the association to provide mal practice cover known as Al-takaful el-ejtemaei. The system requests each member of the department to deposit S.R. 2000. The collection can be used to pay the blood money in cases of conviction of any member of the department. One of the advantages of the insurance cover is that each member can withdraw the sun of money belonging to him or donated to SAA when he/ she has finished their work in the department. This only applies if blood money has not been paid. This insurance cover was started by the association in the anaesthetic department of the university hospitals and later was offered to all members of the association even to every anaesthetist working in the Kingdom.(6).Once again the higher authority in health care delivery system was never on the same wave length at the time and never advised their staff to join in. The MOH still have the same lack of interest toward the speciality.
The Practitioner (Specialists)
The authors advised the specialists to be fore armed with the following important points that will help them to be the excellent anaesthetists. The precious advices is to follow the ten commandments and how the perfect anaesthetist should be (7,8) the advice is to be safe, punctual, diligent and tactful to all, vigilant, able to perform a wide varieties of anaesthesia without being harmful, never leave your patient unattended, able to solve any problems, expect the unexpected, know one's limitation and seek advice, insist on immediate documentation and proper charting, attend scientific meetings and workshops regularly, accompany patients to the recovery room and see that discharge orders are prescribed, signed and approved by him all the time, and finally be a holder of a valid certificate in BLS and ACLS.
OVER the years, and as the only Professor of Anaesthesiology in the Kingdom, the chairman of the newly established department of anaesthesia in the medical college of King Saud University (KSU) and the university hospitals and president of the SAA. All these positions gave me the right to defend the speciality by writing several submitted documents to His Excellency the previous minister of health Professor Osama Shubokshi detailing the status of the anaesthesia service and the Status of CPR in the Kingdom. Further more I had an audience with His Royal Highness Prince Naif Ben Abdulaziz minister of interior, to enlighten His Royal Highness regarding the critical and important points that were issued and circulated to the health care delivery system in the Kingdom. The aim was to put forward the actual and clear picture of the anaesthetic practice and its pitfalls in the Kingdom.. This ultimately ended with two meetings between several health authorities in the Kingdom mainly representatives of, The MOH, the Saudi Council For Health Speciality (SCFHS) and the SAA. A further report was submitted to His Royal Highness Prince Naif on the out come of these meetings including the future recommendations and the measures that have been taken to improve the service. Suggestion Was put forward to have financial increments in order to encourage new Saudi and expatriates anaesthetists to be recruited to join the speciality, plus other relevant matters that were discussed.
The AAS accomplished to have regular annual scientific meetings, monthly club meetings and most recently started new venture of having out reach programs. All these activities were accredited by SCFHS as Continuous medical education for CME
The author still has several questions would like to have a clear answer. These are as follows:
a. Is there a set of rules and regulations that govern the formation of these various regional courts? b. Who are the members of these medical legal courts?
c. Are there any differences between regions?
d. Are there any differences between our medical legal courts and other countries medical courts? i.e. Overseas medical courts allow lawyers to defend the accused. This is not applied in our courts.
Application of Post mortem
A post mortem is only used some times as the ultimate diagnostic tool in a criminal act. This should be used for all as mandatory diagnoses in order to protect the speciality, the plaintiff and the accused. No legal proceedings should start without a post mortem. This rule will abolish the speculative conviction that has been used widely in the Country. Most of the time, members of the courts have to use their medical expertise to read files notes and be able to solve the medical puzzles that they are facing. May I put it in another phrase; most members are using the magic crystal ball, in order to make the right judgment. This practice is not fair on either the plaintiff, the accused .or the speciality.
How many more years will take for The MOH to make the decision to implement and enforce the following points on the ministry and the private hospitals:
To have detailed policy and procedures (P.P.). Medical professionals can not be judged unless he/ she received the written policy and procedures of the department to read, digest and work by. Most of the MOH and private sector hospitals have no P.P. Without P.P. the governing body can not condemn the specialist and release the guillotine. Again this is unsatisfactory and unjustified.
Apply the newly recommended recruitment policies to recruit top class expatriate professionals.
Request from the highest authority in the Kingdom to approve a different and new scale of salaries for rare specialities and subspecialities. This has been achieved in the western world. I have put forward a few suggestions how this was achieved in my official documents submitted to the above mentioned dignitaries. Why some of the specialities who work only day duty and they are on call at homes and hardly or never attend to any kind of serious and life threatening cases during on call duty. Then the real question is, why they collect the same salaries as those working the same day duty plus nights and week ends on call when actually we are dealing with life threatening emergencies?.
Apply CME credit hours for all medical professionals for ongoing medical education by attending regularly symposia, conferences, and workshop to collect the necessary credit hours needed to obtain the license to practice medicine in the kingdom.
Computerized documentation. Modern technology is available and should be an integral part of practice in monitoring anaesthetized patients all the time and any where in all hospitals. This will reduce or prevent the likely hood of fabrication of the charts in the patient's file, lying and shifting the responsibilities onto innocent staff.
Adopting the national standard of care and monitoring in all hospitals is the responsibilities of The Ministry and the private sector. This national standard of care and monitoring was established by the SAA and implemented in most of the referral of the other government body hospitals.
All major and referral hospitals of the Ministry of Health should submit for accreditation to joint the Saudi Board of anaesthesia and intensive Care residency training program. The aim is to qualify these hospitals with the standard required by the board of SCFHS and have Saudi residents joining the speciality who will be the future specialists responsible to manage supervise and/ or be in charge of running the daily routine work in the departments once they are graduated.
These important measures will ultimately make the difference between lower and upper class of standard of care in medical practice in the kingdom..
In the seventies, medical practice was different as most hospitals were limited with up dated facilities if compared with what have been implemented in the western world where we trained and practiced. I was the only practicing Saudi anaesthetist working in the medical school and university hospitals of King Saud University. The task of introducing modern practice of anaesthesia to the Kingdom was huge and daunting one. Previously another colleague tried ahead of me and introduced a technician training program to produce technician graduates. The country was short of specialists in our field. This limited supply of anaesthetists forced him to establish the technician diploma degree in order to cover the service in the speciality.
In the eighties, a few colleagues returned after obtaining their higher degrees from England, Germany and Canada to the Kingdom. They were the new and added work force in the health care delivery system.
The nineties were considered to be the beginning of the golden area for the speciality. Three higher degrees were established starting with King Saud Fellowship 1989, The Arab board 1993 and finally the Saudi board 1998. The board was established to have a four year resident training program based on the Canadian system of training. The modern arts of anaesthesia teaching were introduced to the country. The resident training program was not very popular with medical graduates as the speciality was known as the Unknown Soldier speciality. Only very few residents joined the program and graduated as holder of one or all three degrees. Recently more than 20 new residents per year for the last 2 years have joined the speciality. The newly graduates took leading posts in different hospitals. At the same time several overseas graduates returned and made the task of implementing and enforcing the excellent practice of anaesthesia much easier. The Saudi anesthetic association (SAA) was also established in 1989.This definitely made a vast and immeasurable difference to the speciality. Finally, I am not alone any more. Recent statistics gathered by the author shows that the numbers of Saudi anaesthetists increased 100 times during the last 20 years to reach 200. Over 80 are with higher degree and 120 are residents, 98 residents are in the local residency training program while the rest are in overseas scholarship.
In the new century, further advancements were established. These were the development of the higher post degrees in the following subspecialities:
a. Cardiac anaesthesia
b. Critical care medicine
c. Peadiatric anaesthesia. Recently discussed and approved by the board.
d. Pain management. This is under preparation.
These fellowships are composed of intensive training programs. The candidate spends two years in a specific sub-speciality and obtain the fellowship degree in the subspeciality. The SCFHS has great impact on the medical field by taking over the major role from post graduate department of the medical schools that started these resident training programs earlier in the eighties. The SCOHS developed a wider spectrum of higher degrees in other specialities, by introducing the ruling that no one can practice medicine in the kingdom with out having his/her degree recognised and equalized, further more they must obtain the actual mandatory CME credit hours in order to obtain the Saudi license to practice in the Kingdom.
I am honored to be an anaesthetist and proud with what I have started, implemented and accomplished through out the past thirty years. I am sure and confident that the new graduates are up to the challenges facing them. They will take the banner and carry on the good work for the speciality.