Sat, Dec 17, 2011 page8

• How to fix Taiwanese medicine?

  • By Chiang Sheng 江盛
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  In recent years, the number of medical disputes has risen rapidly and the industry’s regulatory body now reportedly handles an average of 430 cases every year. One prominent medical dispute in 1996 concluded with record compensation of NT$43 million (US$1.42 million) this year.

  Justice might have been done in this instance, but the reality is that few medical professionals can afford to pay such large settlements. Fear of being sued forces people to behave defensively to minimize their exposure to possible mistakes. As long as such a culture of blame prevails, it is extremely difficult to improve information transparency and encourage medical practitioners to learn from their mistakes.

  It has been established that the risk of being injured in hospital is as high as in daily life. However, while there is mandatory third-party liability auto insurance to cover those involved in traffic accidents, an insurance system to cover medical malpractice remains in its infancy in Taiwan.

  In addition, that medical malpractice can be dealt with under criminal law in Taiwan means that a higher number of medical professionals are convicted of committing crimes than in other countries.

  The most common reaction in a medical dispute is to blame the individual medical workers involved rather than the system. For example, if an obstetrician decides that an urgent Caesarean section is needed, but the hospital fails to provide the resources needed, adversely impacting the baby, who is to blame, the doctor or the hospital? Even doctors themselves tend not to pay attention to systemic problems.

  Lack of medical malpractice insurance, possible criminal prosecution and overtime have undermined the patient-doctor relationship. The result is the practice of defensive medicine. Two common defensive medical practices can be discerned — assurance behavior (positive defense medicine) and avoidance behavior (negative defense medicine). Assurance behavior involves the provision of additional, unnecessary medical services. Avoidance behavior occurs when providers refuse to participate in high-risk procedures.

  According to a report, 93 percent of US high-risk specialist physicians (in such fields as emergency surgery, obstetrics/gynecology, neurosurgery, orthopedics, general surgery and radiology) have employed defensive medicine. The prevalence of defensive medicine also increases medical costs. The convention of medical education that emphasizes compassion, empathy, altruism and responsibility have been replaced by a strong sense of self--protection. In Taiwan, medical students have been dissuaded from pursuing those practices prone to malpractice liability and litigation, resulting in a lack of personnel in the fields of internal medicine, surgery, obstetrics/gynecology and pediatrics.

  Patients and their associates involved in medical disputes often seek maximum media exposure by involving politicians or organizing crowds to demonstrate outside medical establishments.

  According to an -investigation conducted in 1999, an average of 98,000 deaths and 1 million injuries a year in the US can be attributed to medical errors. Researchers estimate that in Taiwan there are about 80,000 such injuries each year.

  The way the aviation industry works to improve flight safety is considered a good model for ensuring patient safety. Aviation designers and other professions believe that “to err is human.” The onus is therefore on guarding against such errors, which involves checking the health of pilots, standardizing procedures and setting up a flight operations quality assurance program.

  If medical institutes can learn from the aviation sector, mistakes can be made more transparent and turned into opportunities for people to learn.

  Improving the deteriorating doctor-patient relationship should be considered a national priority. In addition, national problems require national solutions and it is time to consider introducing no-blame compensation for medical injuries. This is one way to ensure that the truth comes out, that people in the medical system learn from mistakes and that patients receive proper compensation.

  Unfortunately, the current legal system is designed to blame medical professionals and to ignore systemic errors.

  Often a great deal of public resources and personnel are devoted to prosecuting medical professionals who do not intentionally commit errors.

  In the US, medical malpractice lawsuits have made attorneys very wealthy, but have also resulted in an increase of US$55.6 billion in medical costs, accounting for 2.4 percent of total medical cost in 2008.

  Reinforcing rules to improve safety helps to save lives as well as money. Reducing defensive medicine would also reduce healthcare bills. Hence the argument that the existing system of medical lawsuits and compensation in Taiwan should be changed. Establishing a reasonable medical compensation institution would be the first step.

  Medical institutes, government and the public must all play a role in creating a more effective and equitable environment for the practice of medicine.

  With the presidential election next month, both major political parties have called for the establishment of a medical compensation system similar to those in Sweden and New Zealand. Unfortunately, neither party has proved very determined in the pursuit of this goal or adept at communicating to the public why such an outcome is desirable.

  It is time to put an end to the “punitive culture” that dominates medical malpractice and invariably involves identifying those individuals responsible, demanding compensation and seeking punishment. Such a culture provides the strongest incentive possible for medical professionals to cover up their mistakes.

  Only when we finally start to view errors as being systemic is it possible to guarantee positive and constructive feedback from medical practitioners and enhance medical safety. It is time to change the culture of blame once and for all.

  Chiang Sheng is an assistant professor at Mackay Medical College.
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