Why specialists won’t deliver babies

Huge insurance costs, possible lawsuits fuel exodus of obstetricians

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Escalating indemnity costs of up to R1m a year are forcing obstetricians to abandon their private practices and scaring off doctors from entering the specialist field.
In Nelson Mandela Bay, the drain of these specialists has raised fears of the pressure it will place on the metro’s state labour wards which are already battling to cope.
The indemnity costs for obstetricians in private practice have increased by about 700% in the past nine years, with specialists saying that the payment they receive for the first 20 deliveries they perform each month goes towards paying their insurance.
Just eight obstetricians remain in private practice in the metro.
Netcare Greenacres Hospital has just one after losing three since 2016, while Life St George’s has five and Life Mercantile two.
In 2017, a survey done by the South African Society for Obstetricians and Gynaecologists showed that only 12% of the 201 obstetricians in the country were sure they would be practising obstetrics in five years’ time, with 21 saying they were planning to quit.
The doctors in the survey cited high indemnity costs and the stress of a potential lawsuit as reasons for their decisions.
Walter Sisulu University department of obstetrics and gynaecology head Prof Mfundo Mabenge said the potential closure of any maternity ward would negatively affect the already overburdened labour wards at Port Elizabeth’s Dora Nginza Hospital.
“We already deliver more than 800 babies a month.”
The state hospital has three obstetricians, who do not pay indemnity costs.
However, Mabenge, who apart from several medical degrees also holds legal qualifications, said the problem was much wider.
“Doctors are shunning the speciality in general due to high indemnity costs and the general attitude of patients.
“Nobody wants to discuss complications or what will be done if something goes wrong.
“Instead, they just run straight to their lawyers.
“It is not about patient care. It has become a money-making scheme,” he said.
Many of the legal claims involve brain damage.
Mabenge is backed up by research presented at a highlevel conference on the issue in 2018 showing many adults who receive lump-sum damages payments on behalf of children go bankrupt a few years later, putting the children’s care at risk.
“Someone should tell these patients that every time you sue a doctor for nothing, your lawsuit is taking services away from patients,” he said.
Mabenge said doctors were also turning away complicated gynaecological cases as they too were deemed too risky.
Dr Graham Howarth, the head of Medical Services, Africa at the Medical Protection Society, said it was aware of the impact that high indemnity payments were having on the profession.
“We want to be part of the solution and are taking steps to help tackle the long-term escalation of costs associated with clinical negligence.
“The reforms we recommend include the introduction of a pre-litigation resolution framework and the development of a patient-centred complaints process that allows for local resolution.
“In a legal system that can at times be unduly complex and potentially inaccessible, we believe there is value in exploring alternative dispute resolution, similar to the South African Dental Association’s effective mediation process.”
Howarth did not want to disclose the annual payments that are made by specialists, but practitioners have confirmed that they are each paying close to R1m annually.
They indicated that this meant the payment for the first 20 deliveries they did each month just went to paying their insurance.
General practitioners said their indemnity costs were generally between 10% and 20% of that of obstetricians.
“I can tell you that from 2008 to 2017, the number of medical claims against MPS members increased by 57%, while the average cost of a medical claim increased by 42%,” Howarth said.
“Large claims, which include obstetric and paediatric claims, in particular, are on the rise.
“We have seen an increase of 121% in medical and dental claims valued at over R1m.
“We believe whole system legal reform is essential and would have the biggest impact.”
A panel of experts writing for the South African Medical Journal said earlier this year that litigation was an expensive, time-consuming and emotionally draining and lengthy process to resolve disputes.
The majority of cases took five years and mediation would prove to be a better alternative.
The South African Law Reform Commission is also investigating a potential legislative change to facilitate mediation rather than litigation.
The maternity ward at Netcare Greenacres stands empty as the hospital is down to its last obstetrician, but management is adamant the unit will not be closed.
“The maternity unit will remain open and fully staffed,” hospital manager Andre Bothma said.
“Obstetricians determine the number of patients they can manage, and hence having one obstetrician on call should not present a problem.”
Bothma said it was hoped to have more obstetricians at the hospital soon.
Dr Usen Akpan, 51, is the sole obstetrician at the hospital.
Despite indemnity payments totalling R1m a year, he said his motivation to keep on caring for women and babies came from a deep conviction.
“If you care for a pregnant woman, your care reverberates throughout a community.
“You look after her, her family who are expecting a new member and the community which is looking forward to a new child.
“There is so much happy expectation.”
Akpan originally qualified as a doctor at the University of Calabar in Nigeria, but specialised in gynaecology and obstetrics at the University of KwaZulu-Natal in 2010.
“Every speciality has its problem,” he said.
“About R5,000 of each delivery I do goes to paying for insurance.
“Since 2010, our insurance has increased by 700%.
“It is a stressful job. Things can change with a pregnancy in a few seconds.
“That is why I tell my patients I am here for them 24 hours a day.
“Despite the high insurance, I will carry on doing what I do.
“When a happy mom crashes your phone with all the pictures of the happy, healthy baby she had after eight miscarriages, it makes it all worth it.”
Doctors have expressed concern at a new rule introduced by Discovery medical aid in 2019 that some of their members have to use day clinics for certain procedures.
Members of the Discovery saver, smart, keycare, core and priority plans have to use day hospitals – where patients cannot stay overnight – or pay hefty co-payments to go to an ordinary hospital.
Discovery CEO Jonathan Broomberg said in an e-mail: “In the US, for example, up to 90% of all surgical procedures are performed on a same-day basis, whereas the equivalent figure in South Africa is below 15%.
“South African private healthcare is lagging well behind global trends in moving surgery to more cost-effective settings.”
But doctors say the healthcare system here cannot be compared to the US.
The main concerns about day hospitals are that patients cannot be monitored overnight after procedures, the day hospitals do not have intensive care units, and many are not equipped to do blood transfusions.
Doctors say they were not consulted before the decision was made, while many of the day hospitals are not up to the appropriate standard to ensure operations take place safely, or even have the equipment needed.
Wits University professor and ear, nose and throat (ENT) specialist Chris Joseph said: “Patients should feel abused and exposed to possible risk.”
He said Discovery did not assess whether the day hospitals had the correct equipment or staff for a procedure.
“ENT theatre requires very expensive instruments and trained staff.”
Joseph explained that doctors must observe patients who have had surgery on their airways to ensure they do not have complications that compromise breathing.
This means the operations at a day hospital must be done in the morning, so patients can be watched closely in the afternoon.
“Discovery did not check whether the day clinics have morning lists [availability].
”A Facebook post by paediatric pulmonologist Fiona Kritizinger, which has been widely circulated among doctors on WhatsApp, drives the point home.
“We do airway endoscopies in babies and children because their airway is at risk or because they have significant lung disease,” she wrote.
“Performing such high-risk in babies and children in a facility with no aftercare and no ICU back-up will never be safe no matter how Discovery spins this story regarding what happens in other countries.”
She said there was not a single day hospital in the Western Cape with equipment to perform the surgeries Discovery wanted to be done in day hospitals.
In response, Discovery’s Broomberg said doctors could ask for exceptions to be made in these cases.
Specialist physician Adri Kok said there was a real risk that complications from surgery could not be dealt with by a day hospital.
“We are very worried about what is happening. This is about a risk to patient care, not about [unhappy] doctors.
“What if a child has a tonsillectomy and bleeds to death?
“This happened last year in a day hospital. We hear anecdotes [about incidents at day hospitals] all the time.”
A day hospital did not always have skilled resuscitation staff or an ICU and might even not have blood for transfusions, she added.
Surgeon Stefaan Bouwer said equipment for ear, nose and throat surgery cost up to R3m and some day hospitals could not afford it.
However, Discovery said this was not true.
“Day clinics are accredited in South Africa, and the procedures on the Day Surgery Network list are aligned with those of the Day Hospital Association of South Africa
“Day surgery centres have been shown to be safer and more cost-effective when operated efficiently.
“The list of procedures that are performed in the Discovery Health medical scheme day surgery network has been approved by the Council for Medical Schemes before implementation.”
Joseph said: “Ear, nose and throat societies are not opposed to day clinics. We use many currently. [But] we need to ensure that the day clinic can deliver on quality care.
“The Discovery modus operandi is to expose patients to risk and/or poorer quality and rely on specialists to correct this by checking the day clinics’ services and facilities.”
Broomberg said it was adjusting its approved hospital list in consultation with doctors.
“Discovery Health has consulted and continues to consult the relevant specialist bodies, and we will continue to make adjustments to the procedure list based on these interactions and the advice of these bodies.”
Broomberg said doctors could apply for exemptions if they needed to perform surgery on a patient in an acute hospital owing to the risks.
“The entire process has been designed to ensure that any doctor who believes that their patient is not suitable for a day-surgery setting can easily request an exception,” Broomberg said...

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