BEIRUT: Conditions in Lebanon’s health care system leave the public exposed to the risk of medical malpractice, according to the investigative team of the Order of Physicians.
Members of the team say that a lack of staff and equipment – particularly at hospitals in rural areas – increases the odds that medical errors and complications will occur and go unreported.
The assertion is consistent with findings of a November 2014 report on medical malpractice in the country by the Lebanese Transparency Association. As stated in the report, “most cases of medical errors remain well-kept secrets,” as physicians fear humiliation and potential job loss.The Lebanese Order of Physicians’ Professional Investigation Committee is responsible for investigating malpractice cases.
Committee member Dr. Chawki Danaf said that physicians review complaints brought by the patients themselves or their legal representation. The goal is to discern whether a medical error or medical complication occurred.
Medical errors are violations of professional ethics, where doctor negligence and inappropriate treatment methods have been used. Here, the doctor is at fault. By contrast, complications are not the fault of the doctor. Surgical procedures account for most medical error cases.
Danaf said that each year, 30 percent of cases reviewed are found to have medical errors. Complications account for the remaining 70 percent.
“Sometimes there is a thin line between medical fault and medical complications,” and discerning between the two is “not so easy, ” Danaf said.
If the doctor is at fault, then the Order’s disciplinary board reviews and verifies the ethical violations before determining punishment. The judiciary relies on the expertise of the Investigation Committee and the Disciplinary Board to interpret the scientific knowledge necessary to determine guilt in cases of malpractice.
According to the LTA report, to convict a physician the error must be “the result of neglect, lack of attention or caution, must be unintentional and serious.”
As cited in the same report, Charles Ghafari, the legal adviser of the Order, said that “more than 1,000 complaints were reported at the Order of Physicians from 1996 to 2013.”
Of these, 300 received disciplinary sanctions. For 50 of the 300 issued verdicts, physicians were suspended from work for periods ranging between two and six months. The year 2001 saw the permanent ban of one physician due to malpractice.
On a yearly level, Ghafari told The Daily Star that approximately 100 cases are reviewed by the Professional Investigations Committee. Around 20 of those are classified as medical errors and then referred to the disciplinary board.
Danaf and his investigations colleague Sami Kawas explained that human resources and facility deficiencies increase the risk that malpractice will occur.
Kawas likened the experience of doctors in Lebanon to that of pilots flying planes under precarious conditions and under multiple constraints.
“It’s like asking [the pilot] to land his 300 passenger plane with only one engine out of four, while trying to overcompensate for a strong side wind,” he said.
Danaf added: “We have very large differences between hospitals in Beirut and large cities, and small towns, where hospitals cannot do everything necessary for the patient.” He said that government health insurance schemes are slow to refund hospitals, which can result in shortages in equipment and staff.
Atallah al-Salim, the main researcher for the LTA report, told The Daily Star that malpractice incidences often go undocumented by health care staff due to “the fear of reporting errors.”
The LTA report cited a 2012 study by public health professor Fadi El-Jardali of the American University of Beirut, which found that 81.7 percent of hospital staff feared repercussions if they were to report medical errors.
Danaf confirmed this fear, saying that sometimes doctors are afraid of the consequences. He added that, in some cases, doctors lack awareness of wrongdoing.
Salim cited the need to pass a whistleblower protection law that would encourage health care staff to report medical errors. He also recommended “a mechanized system for tracking, reporting and communicating medical errors, in both government and private hospitals.”
Further, Salim’s recommendations included boosting human and financial resources, particularly within the public health care sector, and empowering patients to recognize when errors have occurred.
Physicians on the Investigative Committee expressed great concern over how media outlets handle malpractice stories.
They cite a pattern of prematurely targeting doctors accused of malpractice, causing unfair damage to their reputations.
“Anyone can go to the media and say whatever he wants, there is no limit. But does that mean everything that has been said in the media is true?” Danaf asked.
He and Kawas pointed to a range of reports where doctors’ names were published in a defamatory way prior to determination of guilt.
One example was last year’s reporting on 4-year-old Celine Rakan. On Oct. 8, 2014, local media outlets reported that she died shortly after receiving a vaccination. The heavy press coverage was quick to cite the vaccine as the cause and point to the administering doctor, M.Z., as responsible. Two news websites both published the full name of the physician responsible, although no fault had been found at the time of reporting. Rakan’s death was subsequently attributed to another cause than the vaccine.
“The media took this announcement and spread it,” said Danaf, who explained that the death had nothing to do with the vaccination from the doctor, though the damage had been done.
Another example is that of S.K., a family medicine physician and forensic medicine expert. The physician refused to comment on specific cases, but research revealed that in January 2014, he was part of a forensic team tasked by the judiciary to investigate the death of Al-Qaeda offshoot leader Majid al-Majid.
The judiciary prohibited the team from performing an autopsy, relying on other documentation to determine the cause of death. Shortly after, on Jan 13, 2014, a local newspaper published an article with the full names of this committee, and suggested that members of the investigatory team were deficient in qualifications to practice forensic medicine.
On Feb 7, 2014, S.K. fired back in a letter to the editor, defending his credentials and explaining the judiciary’s control over the autopsy decision. In a recent interview, he presented The Daily Star with documentation of his education credentials as evidence of his forensic training and experience in the field.
Jad Melki, assistant professor of journalism and media studies at the American University of Beirut, lent insight into the media’s treatment of malpractice. He said that while the law allows for those defamed to take responsible media outlets and journalists to court, such cases are treated in an inconsistent manner by the judicial system.
Melki described a trend of sensationalized news coverage in Lebanese media, “mainly aimed at seeking larger audiences and higher ratings in order to attract more advertising revenues.”
With respect to covering medical malpractice, Melki said that such coverage may result in exaggerated accusations and the news being “released prematurely before ascertaining the facts and waiting for a court decision ... the situations are simplistically reduced to a good versus evil tale. The result is that the targeted professional could lose their job and reputation – regardless of the complexities and the stakes of the matter.”
He explained that media outlets are reticent to cover instances where physician is cleared of wrongdoing, as corrections are “embarrassing,” and such a story lacks audience appeal.
Melki advised reporters to solicit information from all sides of a story and to weigh the risks of individual harm against the benefit to the public interest.
“Not all medical errors or deaths in hospitals are the results of malpractice,” he said. “The issue is often much more complex than a tale of an ‘irresponsible doctor.’”
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