Talking about passengers suing gliding clubs, this article sums up
succinctly the problem we are facing in our medical system.  After all, we
are all patients.   This could be titled: Carrying passengers in gliders: an
uninsurable risk?

Please circulate this widely as we have to have tort law reform in
Australia.

> Discussion: Medical practice: An uninsurable risk?
>
>
> Good afternoon, ladies and gentlemen.  It is a pleasure to be back at
> the
> National Press Club in Family Doctor Week.
>
> There are many issues affecting medical practice and patient care these
> days, but none more pressing than the crisis in medical indemnity.
>
> We have seen life in Australia as we know it changed forever by the
> farce
> that public liability has become.
>
> When school excursions have to be cancelled, when a local community is
> unable to hold its annual fundraiser, when pony clubs are forced to
> close
> down?or when Bondi Beach has to consider whether it can afford to keep
> providing volunteer lifeguards for the world's most famous beach because
> someone sued the Council when they dived into a sandbank?something is
> very
> very wrong.
>
> But when those same communities are losing their doctors, when we start
> finding it impossible to find trained doctors to deliver babies or
> operate
> on brain tumours?it becomes a matter of life and death.
>
> In Westmead, for example, 18 months ago there were 11 obstetricians
> delivering babies. Today there are five.
>
> Of all the trainee obstetrician/gynaecologists at that hospital, not one
> is
> prepared under the current system to deliver babies when they qualify.
> They will just practice gynaecology.
>
> It takes a medical generation to turn this sort of situation around.
>
> The medico-legal system as it has evolved has provided fertile pastures
> for
> the growing legions of plaintiff and defence lawyers to graze upon over
> the
> years.
>
> The emergence of 'no-win-no-fee' lawyers has created a Lotto mentality
> amongst some injured patients who might otherwise not receive the care
> and
> rehabilitation they need.
>
> So, for some there is a windfall.  For most, it's a massive shortfall.
>
> Medical practitioners have been gob-smacked at some of the judgments
> that
> have emerged from courtrooms.
>
> Lawyers and judges with no understanding of the nature of the practice
> of
> medicine routinely accuse doctors who have been going about their work
> diligently and responsibly of negligence.
>
> They fail to take into account the nature of the clinical setting.
>
> In the cold hard light of a courtroom, they make no effort to explain or
> consider the split-second high-drama decisions that must sometimes be
> made
> in life and death circumstances.
>
> It's not in their interests to do so.
>
> It's a case of 'sue now, and don't ask questions later'.
>
> Even eminent judges have felt compelled in recent months to come out and
> criticise the legal system and the "Santa Claus mentality" that has
> allowed
> this crisis to develop.
>
> In a speech entitled "Negligence: the Last Outpost of the Welfare State,
> NSW Chief Justice, Jim Spigelman, said that some judges have 'got it
> wrong'
> in awarding payouts for negligence over the years.  He has listed a
> series
> of legislative and procedural reforms he sees as necessary
>
> The medical indemnity crisis cannot simply be swept under the carpet as
> it
> has been for the better part of the past decade.
>
> It is an issue that has profound effects on the whole community.
>
> It is a social problem that needs a national solution with national
> leadership.
>
> Despite significant advances in tort law reform in NSW and moves afoot
> in
> other States and an "iron clad guarantee" from the Federal Government,
> medical indemnity premiums are set to rise again by 50 to 100% in the
> next
> six months.
>
> And the Federal government is talking about a levy on top of that for
> the
> next five to ten years.
>
> They want doctors to pay for years of governments failing to heed the
> medical profession's warnings about this crisis.
>
> It's not that the reforms are not working.  We can only imagine the
> situation we would be facing if the NSW reforms were not in place or the
> Federal government had not stepped in at the 11th hour to prop up UMP.
>
> So we have reached the stage where we are forced to ask the question: IS
> MEDICAL PRACTICE AN UNINSURABLE RISK?"
>
> One issue I would like to take up here and now is this concept of trying
> to
> create a commercial marketplace for medical indemnity insurance.
>
> I must say my colleagues and I were stunned at Senator Coonan's
> suggestion
> in April that several commercial insurers were interested in entering
> the
> market.
>
> That, of course, has not eventuated and never was going to in the
> prevailing climate - and UMP limps on under the provisional liquidator.
>
> Medical indemnity should not be treated as a commercial opportunity.  It
> is
> and should be a service for doctors and injured patients, NOT an
> opportunity for commercial insurers to line the pockets of insurance
> company executives and shareholders.
>
> It has been said to me that the interest of commercial insurers in the
> medical indemnity industry would be a sign that stability has returned
> to
> the scene.
>
> I say that the best indication of stability returning to the scene would
> be
> a massive reduction in the number of cases being mounted against
> doctors.
>
> It is worth noting that the main sources of injury in Australia ? motor
> vehicle and workplace accidents ? are covered by statutory schemes with
> only limited recourse to the court system.  That is the only way they
> can
> be sustainable.
>
> There is no open commercial insurance market for compulsory third party
> motor vehicle insurance.
>
> Why should we expect one to develop for medical injury, at least without
> radical change to the legal system.
>
> Even if there were insurance companies champing at the bit to get into
> this
> so-called "market", is childbirth - with all its inherent
> unpredictability
> and potential for disaster - actually insurable?
>
> Is an emergency room overcrowded with the very seriously injured and
> ill,
> and often staffed by doctors-in-training, an insurable risk?
>
> Would any insurance company in a commercial market accept a policy for a
> doctor to remove a deep-seated brain tumour - an operation that might
> prolong life but at the possible price of greater disability?
>
> One of life's great ironies is that the better medical science has
> become
> at treating disease and keeping people alive, the greater have become
> our
> patients' expectations of the perfect outcome.
>
> With this has come the greater likelihood of punishing the doctor for
> less
> than perfect outcomes.
>
> Is medical practice an uninsurable risk?  Today I will explore this very
> question which cuts to the very heart of the debate.
>
> Just over a week ago, I attended the Annual Conference of the British
> Medical Association.
>
> While I was there, I met with the President of the American Medical
> Association.  Like here, the medical indemnity situation in the United
> States is dire.
>
> The American Medical Association has declared that only eight States are
> off the medical liability danger list, and they are the States which
> have
> had meaningful tort law reform?such as California, Hawaii, Indiana and
> Rhode Island.
>
> Twelve US states are in crisis, with another 30 heading that way.
>
> They are seeing physicians retiring early, moving to States where the
> problem has been contained, or giving up high-risk procedures because of
> liability concerns.  Sound familiar?
>
> A woman in Arizona recently delivered her baby in a car on the way to
> hospital 80 kilometres away because her nearest hospital no longer
> provided
> obstetric services.
>
> A man in Texas died from his head injury because it took seven hours to
> find a hospital with a neurosurgeon to treat him.
>
> Mississippi physicians are crossing their fingers because there are no
> 'level 2' trauma rooms north of Jackson.
>
> This is not from the 'only in America' file.  It's happening here, too.
>
> It is important to point out that this is not just about affordability
> of
> medical indemnity premiums, although that is a big factor and the cost
> must
> of course be passed on to patients.
>
> In many cases, a commercial decision is made to settle a case rather
> than
> risk the cost of defending it, even when the doctor has not been
> negligent.
>
> It is also very much about the nature of the adversarial legal system
> that
> relies on a culture of shame and blame?and the trauma for a patient of
> bringing the action, and for the doctor of defending it.
>
> There is also the issue of the cost to the community of a cumbersome and
> inefficient way of providing injured patients with the care they need
> through the courts.
>
> Let's look at some indicative figures.
>
> The average number of private deliveries per obstetrician is about 100
> per
> year.  The average indemnity premium is $80,000. That works out at $800
> per
> delivery.
>
> The MBS rebate for a normal delivery is $425.00.
>
> Estimated legal costs across the board are 45-50% of medical indemnity
> premiums.
>
> So the entire Medicare budget for obstetric deliveries goes to lawyers.
> And we thought Medicare was for patients?
>
> The UK is just starting to look at the impact that so-called 'clinical
> negligence litigation' is having on their health budget and their health
> system.
>
> 'Clinical negligence litigation' is actually a preferable term to
> "medical
> indemnity" because medical accidents are not just about doctors.  They
> are
> also about nurses, administrators, computers, hospital procedures and
> system failures.
>
> According to respected British authority, Professor Sir John Kennedy,
> for
> reasons of safety alone, the only solution for the future is, and I
> quote,
> 'to get rid of clinical negligence litigation'.
>
> Yes, you heard me right ? 'To get rid of clinical negligence
> litigation'.
>
> Why so?
>
> Once again, it is not just about cost, although the cost to the National
> Health Service is currently estimated at 400-500 million pounds per year
> -
> with two to four billion pounds worth of 'tail', plus social security,
> medical care costs and lost productivity.
>
> No, the urgency is because litigation is the enemy of safety.
>
> Let's examine why.
>
> What do supporters of litigation claim are their objectives?
>
> .    Compensation for patients
> .    Accountability of the health professional
> .    Deterrence of the conduct that led to the litigation
> .    Generating a culture of safer care.
>
> Professor Kennedy argues convincingly that litigation fails to achieve
> any
> one of these objectives.
>
> When you look at compensation, very few people who suffer harm from a
> medical accident take legal action, very few who commence an action get
> any
> payout at all, and very few people get very large amounts.
>
> So, a socially just model of compensation is not achieved.
>
> What about accountability?
>
> The shame and blame culture of medical litigation means that doctors are
> advised not to confess to accidents, not to disclose adverse events for
> fear of expensive and traumatic litigation.
>
> The really bad, obvious cases of negligence are settled on the quiet
> because they are not worth defending, and nobody gets to find out
> because
> secrecy is the condition of settlement.
>
> The possibility of litigation actively prohibits open disclosure.
>
> To make headway on quality and safety we need to have a culture which
> values the reporting of adverse events for the opportunity they give to
> improving the system. At the moment the culture is one of terror of the
> legal risk.
>
> So this means that the system learns nothing about its failures because
> there is no routine reporting of adverse events or accidents and
> therefore
> accountability is not achieved - and neither is deterrence.
>
> If there is no system for looking at why things went wrong, there is no
> possibility for improvement to safety in the system.
>
> In fact, litigation works against safety because of the culture of
> defensiveness.  It makes monitoring and data collection impossible.
>
> It also leads to what we call "defensive medicine".  That is where a
> doctor
> changes the way they practice medicine for the purposes of avoiding
> legal
> action rather than what is clinically best practice.
>
> An example of this might be the patient with a simple headache who gets
> a
> CT scan or an MRI of their brain rather than a couple of paracetamol and
> a
> good lie down and see how you are going in a week or so. JUST IN CASE
> that
> headache is a brain tumour or a rare blood vessel malformation once
> described in an ancient Greek text.
>
> This adds not only cost to the health system but also the possibility of
> adverse events related to the investigative procedures themselves.  BUT
> the
> doctor has covered their legal risk.
>
> Even this week we have been treated to yet another threat of class
> action
> against a pharmaceutical company and doctors following the publication
> of
> the Women's Health Initiative study at Harvard.
>
> Following an extraordinary media beat-up which had some media
> commentators
> claiming the study showed that 26 per cent of women who took HRT
> long-term
> develop breast cancer, the medical profession was left to try to deal
> with
> the understandable anxieties of women in total confusion about their HRT
> and whether it was going to kill them tomorrow.
>
> Then along came the plaintiff lawyers saying they were going to have a
> go
> at a class action for women who had taken HRT and developed heart
> disease
> or breast cancer.
>
> For a start, the study showed that the increase for breast cancer was in
> the order of 8 in 10,000 women, and that the risk of heart disease was
> about one-thousandth the risk of being a smoker.
>
> How exactly these lawyers were going to determine which women were going
> to
> get the breast cancer whether they had taken the HRT or not is beyond
> me.
>
> But let's just say in our wildest imaginations that they decided to have
> a
> go and drag this one through the courts.
>
> Are the thousands of doctors who had prescribed HRT in good faith to
> women
> who were presented with all of the available evidence at the time at
> risk
> of litigation?
>
> All would be stridently defended.  Who is likely to win?  The lawyers,
> of
> course!
>
> And what of the pharmaceutical companies who researched and produced the
> HRT?
>
> History gives us the example of the tragedy of thalidomide.  If this
> sort
> of class action proceeded, there is unlikely to ever again be any
> research
> into medication for the treatment of morning sickness in pregnant women.
>
> If such a class action were to proceed under these circumstances it
> would
> plunge medical research and medical practice back into the Dark Ages.
>
> No pharmaceutical company would be prepared to put research funding into
> hormone treatments...just in case it came back to bite them in the rear
> thirty years down the track.
>
> On the one hand the consumer lobby calls for faster, more streamlined
> drug
> approval mechanisms.
>
> Yet research that emerges only after thirty years of experience in large
> populations of women demonstrates a small negative effect.
>
> Rather than being celebrated as a triumph for medical research and a
> valuable addition to the information available to women to make an
> informed
> decision about HRT, it is turned into an opportunity for a few legal
> firms
> to make a killing.
>
> But what could die in the process is medical practice.
>
> We need to 'treasure' medical mistakes as they are the clues to building
> our safety mechanisms.
>
> Without "trial and error" we are likely to perpetuate error because we
> would not know any better.
>
> Is it possible to get rid of clinical negligence litigation?  Is this
> desirable?
>
> Well, they're giving it a go in some countries, some more effectively
> than
> others.
>
> At the AMA National Conference this year we heard from Dr John Adams,
> the
> Chairman of the New Zealand Medical Association, about New Zealand's
> Accident Compensation Corporation ? the ACC - which also handles medical
> accidents.
>
> The ACC administers New Zealand's accident compensation scheme, which
> provides accident insurance for all New Zealand citizens, residents and
> temporary visitors to New Zealand.
>
> In return, people do not have the right to sue for personal injury,
> other
> than for exemplary damages.
>
> In 1989, medical mishap was included in the scheme, and lump sum
> compensation payments were abolished and replaced with periodic
> payments.
>
> Under the ACC scheme, a patient undergoing treatment accepts that there
> are
> certain risks involved.
>
> If a patient is injured as a result of medical treatment they are
> quickly
> assessed
>
> If a complication occurs which is severe or rare (defined as less than
> 1%
> chance), then the patient is assessed and the ACC makes a determination
> whether the injury was a result of medical error or mishap.
>
> A medical error is defined as a failure to observe the standard of care
> and
> skill reasonably expected in the circumstances.
>
> However, medical error does not exist solely because the desired results
> were not achieved or because subsequent events show in retrospect that
> different decisions may have produced better results.
>
> OR the failure in question consists of a delay or failure attributable
> to
> the resource allocation decisions of the organisation.
>
> There is a parallel complaints and discipline system for health
> professionals ensuring accountability.
>
> Our medical colleagues from across the Tasman admit the system has its
> faults but they manage to work with it and pay on average $1000 per
> doctor
> per year.
>
> In the Netherlands, the legal system limits the level of damages payable
> and clinical negligence has been removed from tort law. An arbitration
> board deals with smaller claims.
>
> Physicians in the US are starting to look at a no-fault compensation
> scheme
> to keep malpractice out of the courtroom.
>
> I'll read you an extract from last week's edition of American Medical
> News:
>
>      "Physicians launched an all-out attack on the medical liability
> crisis
>      at the American Medical Association's Annual Meeting in June,
> making
>      liability reform the AMA's 'highest legislative priority'.
>
>      "They're calling for legislation at the state and federal levels.
>      They want a public education campaign geared to help the public
>      understand how the crisis affects access to care.
>
>      "They want a state-by-state analysis of litigation costs under the
>      current tort system.
>
>      "They want grassroots physicians to call and write their
> legislators.
>
>      "They want to study a no-fault liability system.  And, by December,
>      they want a plan for a national liability reform event, perhaps a
>      rally or march."
>
> Sound familiar?
>
> This is a very interesting development and a natural progression of
> action
> already undertaken in individual US States.
>
> A colleague told me last week of an initiative in Florida in the early
> 1990s.
>
> They introduced a no-fault compensation scheme for neurologically
> impaired
> babies.
>
> Babies with cerebral palsy or other problems linked to birth were
> automatically eligible for this scheme.
>
> A Study by Duke University found that under this system people were
> getting
> better services, and that care and rehabilitation services were better
> targeted.
>
> Interestingly, the study found that before the system was introduced,
> lawyers were getting around 45 per cent of compensation payments.  After
> the scheme, this amount came down to five per cent.
>
> Isn't that interesting?
>
> So, where are we in Australia on solving our medical indemnity crisis?
>
> We have three major activities happening and one major deadline.
>
> There is the Prime Minister's Departmental Taskforce led by the head of
> the
> Department of Prime Minister and Cabinet, Max Moore-Wilton.
>
> This involves senior offices of PM&C, Treasury, Finance, Health and
> Ageing,
> and Attorney-General's.
>
> The AMA has been working closely with this group.
>
> Then there is the Eminent Persons Group reviewing the law of negligence.
>
> This is urgently needed because most cases arise out of medical
> accidents,
> not medical negligence.  As medical science advances and new technology
> is
> introduced to save and preserve life, new risks and higher patient
> expectations are introduced.
>
> By definition, doctors are working with sick or injured people, so there
> is
> an inherent risk in everything we do. Yet the expectation of the
> community
> and the legal system is becoming more and more unrealistic.
>
> As a minimum, we should expect the Eminent Persons Group to advocate a
> return to the Bolam principle.  That is, a patient should expect a
> standard
> of care in keeping with accepted professional practice of the time, and
> that it is not open to a court to find that a standard medical practice
> is
> negligent.
>
> One example of the courts ignoring the realities of medical practice and
> redefining negligence is that of Kalakerinos vs Burnett.
>
> In this case a country GP referred a patient to a gynaecologist in a
> nearby
> town. The patient was reluctant to make the trip. The GP was
> subsequently
> sued because the patient's condition was not treated and the GP,
> according
> to the judgment, did not make sure the patient had attended their
> appointment.
>
> The GP was effectively sued for the complacency of the patient.
>
> And then we have the work of Mr David Lombe, the provisional liquidator
> of
> United Medical Protection.  We have yet to discover whether UMP is
> viable
> in the longer term.
>
> Facing them all is the deadline of 31 December 2002.
>
> This is when the Government's UMP guarantee expires and it's also around
> the time when more than 20,000 doctors will have received their UMP
> insurance renewals ? with the huge premium increases expected to be in
> the
> range of 50 to 100%.
>
> For some doctors, however, their personal deadline will have already
> passed.  They will have made their career choices.  Some will leave the
> profession.  Others will steer away from high-risk procedures.
>
> As I said earlier, any significant change to the make-up of the medical
> workforce can take a generation to turn around.
>
> Patients and communities would become significantly disadvantaged.
>
> Both the Eminent Persons Group and the UMP provisional liquidator are
> due
> to report by the end of August.
>
> What progress will we have by then, I wonder?
>
> Despite these groups working on solutions, little progress is being
> made.
> As the Roman historian, Suetonius, put it, things are 'hastening
> slowly'.
>
> Progress is stalled ? due mainly to differing priorities.
>
> The AMA sees the urgent response based around:
>
> .    A national reform of the law of negligence, with as a minimum the
> return of the Bolam test
> .    Consistent and coordinated tort law reform in all States and
> Territories
> .    A national standard Statute of Limitations of three years for
> adults
> and six years for minors
> .    Assessment of liability by properly accredited experts
> .    Removing Medicare payments and hospital costs from any awards
> .    And a proper community-funded national care and rehabilitation
> scheme
> as a minimum for the severely disabled at a set level of impairment [the
> problem with our current care and rehabilitation arrangements is that
> they
> do not provide a disincentive to sue].
> .    Effective management of the so-called "tail". Until now the tail
> has
> been looking for a donkey to pin itself onto. Unfortunately the Federal
> government has picked the medical profession as that donkey with its
> suggestion of a levy.  This puts the tail before the donkey.
> .    There are many reasons that the "tail"?that is the estimate of the
> cost of injuries that have never been reported?has in essence become the
> big problem.  Without uniform and strictly enforceable statute of
> limitations, severely injured patients have an indefinite time, at least
> 25
> years in some states, to bring a legal action against a doctor.
> .    No actuary could ever predict what a cerebral palsy case might be
> awarded by a court in a quarter of a century, yet the medical profession
> is
> expected to both estimate and fund that amount today.
>
> While the Government is prepared to look at much of this agenda, their
> priorities at the moment seems to be a levy on doctors and a subsidy for
> high-risk specialties.  But no detail.
>
> The AMA believes it is imperative that any discussion of a levy be put
> off
> until we have done all we can on tort law reform in every State and
> Territory and introduced the national care and rehabilitation scheme.
>
> For doctors to agree to any levy at this time would be throwing
> money into a black hole.
>
> If the Government drives its Chevy up to this levy, it will find that
> the
> levy is dry.
>
> Downward pressure must be placed on premiums, and this is just not
> happening yet.
>
> While the tort law reforms in NSW are yet to slow premiums, I shudder to
> think how high they might be without these reforms.
>
> It is vital that all the other States catch up with NSW.  Nationally
> harmonised tort law reform must proceed, particularly statute of
> limitations.
>
> As it stands, from the point of State reforms, NSW is leaps and bounds
> ahead of the pack.
>
> Queensland has now taken some AMA advice and is getting there.
>
> South Australia has gone for the soft option.
>
> But Victoria has not even stepped up to the starting blocks.  Perhaps
> the
> starter's gun is held by the plaintiff lawyers in Victoria.
>
> So where are we if State tort law reform is not achieved and legislated
> by,
> say, the end of October?
>
> Where are we if the Government hasn't legislated for a suitable
> community-funded care and rehabilitation scheme for the severely
> disabled?
>
> Where are we if medical indemnity premiums continue to spiral out of
> control?
>
> I'd say we'll all be in big trouble.  There'll be chaos.
>
> It's time to fast track or change tack.
>
> Australia must have a back-up plan.
>
> For a start, we can't wait until December 31 to make decisions.
>
> The Government must be prepared to extend its guarantee to give the
> States
> and Territories enough time to get their reforms through and for
> premiums
> to start coming down.
>
> This extension must not be conditional on the imposition of a levy on
> doctors.
>
> And, given the overseas experience, a national debate must begin on the
> possibility of a national medical accident scheme.
>
> Different versions of a scheme have been raised by both sides of
> politics,
> Bob Carr and Joe Hockey the most notable.  In an editorial this week,
> the
> Australian Financial Review also backed such a scheme.
>
> We need to go forward.  We need an alternative to the current
> adversarial
> legal system for medical negligence.
>
> As a community we need to put an end to the notion that patients have
> the
> basic right to sue their doctors.  That does not appear in any human
> rights
> charter.
>
> Instead, we should promote the concept that patients have a right to
> safety
> and good care, and support if they are harmed.
>
> The litigation system stands in the way of many people accessing that
> right
> to care and support which should depend on patient need, not proving
> some
> form of conduct by the doctor or the system. And it stands in the way of
> improving safety in the health system.
>
> To cover all bases, the AMA is prepared to explore a National Medical
> Accident Scheme.
>
> Such a scheme would support the needs of people who suffer impairment as
> a
> result of medical accident.
>
> The scheme would:
>
> .    Be Government funded
> .    Provide services for long term care of the severely impaired
> .    Be governed by an impairment threshold.  Anyone who suffers
> significant impairment from a medical accident who needs support should
> be
> entitled to the benefits of the scheme.
> .    Allow small claims to be handled through a non-adversarial
> complaints
> mechanism with genuine cases of negligence, properly defined, referred
> to
> appropriate professional review.
> .    Provide effective risk management aimed at improving safety in the
> health system.
> .    Support Medical Defence Organisations to remain as providers of
> membership services like complaint review, representation at inquests
> and
> tribunals, disciplinary matters ? the so called 'road service' matters
> relating to legal compliance.
> .    Support Open Disclosure in a non-adversarial environment.  Open
> disclosure is only possible in the absence of litigation.
>
> The medical indemnity crisis makes it necessary for us to at the very
> least
> closely examine such a Scheme for Australia.
>
> As the Fin Review so neatly put it, 'it is worth considering as part of
> broader reforms'.
>
> Time is running out to fix the medical indemnity crisis.  I hope I have
> been able today to bring the enormity of the problem into focus for you.
>
> I began this address by posing the question: Is Medical Practice an
> Uninsurable Risk?  The answer to that question is inevitably yes.
>
> I'm happy to take any questions on medical indemnity or other medical
> issues.
>
> Thank you.
>
> 17 July 2002
>
>
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