Medical liability: an international concern

Medical liability: an international concern

By Mary Ann Porucznik

Each year at the AAOS Annual Meeting, the presidents of orthopaedic societies from around the world meet together. Language barriers disappear, and common concerns surface. At yesterday’s International Presidents Breakfast, the common concern was the increasing impact of medical-legal (medical liability) issues.

After opening remarks by AAOS President Richard F. Kyle, MD, the chair of the International Committee, Miguel E. Cabanela, MD, outlined a new AAOS initiative “Global Orthopaedic Opportunities” (formerly the International Center for Orthopaedic Education). This free, user-friendly service on the AAOS Web site ( provides a central location for listing short- and long-term musculoskeletal healthcare-related positions around the world. The site opens to position seekers on April 2.

Guest Nation: Thailand

Drs. Kyle and Cabanela then presented the Guest Nation Award to the Thai representatives, who lead the remainder of the program. Dr. Thamrongrat Keokarn, of the Royal College of Orthopaedic Surgeons of Thailand, provided a short history of orthopaedics in his country.

Before World War I, said Dr. Thamrongrat, medical practice in Thailand was much different than in Europe or North America. But the efforts of “the great father of modern medicine,” His Royal Highness Prince Mahidol of Songkhla (1892-1929), resulted in many changes.

The first Thai Orthopaedic Society was established just over 40 years ago, in 1966. “Since then, we have followed the educational model set by the Academy,” said Dr. Thamrongrat, with specialized orthopaedic training and a board certification process. The first Journal of the Thai Orthopaedic Association was published in 1976 and continues to be published today. In 1996, the group was reorganized as the Royal College of Orthopaedic Surgeons of Thailand (RCOST), and with royal backing, began a number of outreach programs to poor, rural areas.

RCOST and the AAOS held their first joint instructional course lecture in Bangkok in 2000; the most recent joint program was in 2006. The cooperative efforts are crystallized in the Guest Nation award, which recognizes “friendship, collaboration, education.”

Dr. Wichien Laohacharoensombat, current president of the Royal College of Orthopaedic Surgeons of Thailand, asks for a show of hands in answer to his question: Is the medical-legal issue in your country a significant problem?

A world-wide crisis?

AAOS members are well aware that medical liability concerns are having an increasing impact on the practice of medicine. What may be less well-known is that the crisis is not confined to the United States. Dr. Wichien Laohacharoensombat said that concerns about medical liability are also being felt in Thailand, where the incidence of reporting has increased from practically none to an average of one per week.

In Thailand, reports are made to the RCOST Ethics Committee, and frequently involve a second surgeon. The most common reasons for filing a complaint are the following: patient dissatisfaction with the result; unexpected complication; missed diagnosis; treatment issues (over-treatment; under-treatment; delayed treatment). The audience response to Dr. Wichien’s question, “Is the medical-legal issue in your country a significant problem?” was almost unanimous.

He received a similar response to his follow-up question, “Do you always keep this issue in mind in your daily practice?” Although surgeons may consider medical liability concerns daily, they don’t let the issue influence their course of treatment.

Reasons that patients sue are similar around the world. Unexpected complications led the list, followed by treatment issues and patient dissatisfaction with results. Other reasons cited by the international group included communication, problems with continuity of care, and “overenthusiastic indications for surgery.”

While following the standard of care and remaining united as orthopaedic surgeons were among the option for avoiding medical-legal problems, most in the audience thought that improved information to the patient and building a stronger relationship with the patient would be more effective strategies. Dr. Kyle pointed to the Academy’s efforts to improve patient-physician communication, particularly through the Communication Skills Mentoring Workshops.

International experiences

The discussion that followed uncovered both similarities and differences among the nations represented. Sweden, for example, has a national insurance program for hospitals and physicians, with hospitals paying the premiums. A patient who files a claim automatically receives a payment under the program. As a result, the number of lawsuits against physicians is small and limited to gross acts of malpractice, and lawyers “have other ways of earning money than suing doctors.”

Workers compensation claims are a major problem in Costa Rica, which also has a national insurance system. Unfortunately, patients “try to get as much money as possible” through the system. Physicians there are looking at the possibility of establishing a review board to filter cases before they go to court.

Ireland, it was pointed out, has the second highest malpractice rates in the world. As in the United States, contingency arrangements between plaintiffs and attorneys are common.

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