AFJOG

and have sparked intense debate within the medical and legal communities. The 81-year-old Dr Elliot Shevel, a maxillofacial and oral surgeon and founder of The Headache Clinic in Johannesburg, is the latest specialist facing criminal charges linked to allegations of unsafe professional practices that led to serious patient harm. This criminalisation fosters a culture of fear, discouraging specialists fromperforming complex procedures and driving some to leave the profession entirely. The sensational media coverage of these cases further complicates these matters by negatively affecting the psychological well-being of these practitioners and by causing serious and irreparable reputational damage. The tragic murder of Dr. Munshi has sparked widespread concern within the South African medical community, particularly regarding the increasing criminalisation of medical professionals and the risks they face under contentious circumstances. The South African Medical Association (SAMA) has expressed concern that criminalising medical errors could create a punitive and fear-driven environment. This might deter doctors from performing high-risk procedures or entering specialisations seen as legally hazardous. SAMA has advocated for distinguishing between true criminal negligence and unintended medical outcomes despite adherence to standards of care, emphasising the need for legal reforms to balance patient safety and professional accountability. THE CONSEQUENCES The litigation explosion has resulted in soaring indemnity insurance premiums, with some practitioners paying well over R1.3 million annually. For many, this financial burden is unsustainable, forcing early retirement, career changes, or the abandonment of high-risk cases altogether. While the right to legal recourse for genuine harm must be acknowledged and protected, the escalating frequency and magnitude of claims are unsustainable. One of the most inconspicuous unaddressed and seldom talked about consequence of the medico-legal storm is the effect it is having on the mental health of medical practitioners involved in civil litigation or criminal prosecution. The litigation process is almost always prolonged for many years, and emotionally taxing, causing significant stress and anxiety for practitioners. The fear of reputational damage and professional censure adds to the pressure. The protracted processes of litigation contributes to burnout, with specialists feeling demoralised and undervalued despite their commitment to and their track record of mostly good and professional patient care. Extended legal battles and public scrutiny can lead to depression. In our own discipline there has been isolated reports of colleagues committing suicide, with malpractice litigation being cited as a contributing factor. Even unproven allegations can tarnish a specialist's reputation, affecting their professional standing and future opportunities. Faced with mounting legal and financial pressures, some specialists choose to retire early or switch to lower-risk practices. Others have been forced to retire or close their practices due to severe reputational damage. Specialists may adopt defensive practices, ordering unnecessary tests or procedures to avoid litigation, which increases healthcare costs and can strain patient-provider relationships. Some specialists, particularly in obstetrics, may avoid taking on high-risk cases, leaving vulnerable patients without access to skilled care. The impact on the public health system is catastrophic. Funds meant for improving maternal and neonatal care are instead funnelled into settling exorbitant claims, as the provincial healthcare departments do not have separate medical litigation budgets. Successful claims against the state is settled using funds allocated to the penicillin-and- paracetamol budget. Hospitals in resource-constrained settings, already struggling with staff shortages and inadequate infrastructure, are consequently further crippled by the financial drain of medico-legal liabilities. The current moratorium on filling posts in the public sector will exacerbate the problem, and the limited savings on salaries in the short-term will undoubtedly manifest in higher order medico-legal litigation pay-outs years later. The vicious cycle of overburdened practitioners and underfunded systems creates a fertile ground for errors, further fuelling litigation. For the discipline of O&G, the implications are profound. Rising indemnity premiums which are among the highest for any specialty, are deterring talented younger doctors from entering the field and driving seasoned practitioners into early retirement. This exodus exacerbates existing workforce shortages, especially in underserved rural areas, leaving many women without access to skilled professional care. The cumulative effect of litigation pressures contributes to a shrinking pool of specialists willing to practice in high-risk fields, particularly in underserved areas. This exacerbates healthcare inequities, especially in resource-constrained systems like South Africa's public health sector. ADDRESSING THE CHALLENGES Addressing these challenges requires a multifaceted approach, and there is no quick fix available or a single intervention that will impact significantly. Unfortunately, most of the solutions that can have an impact will include structural and legal reform. There is an urgent need to improve patient safety through enhanced continuous training, better clinical governance, and the implementation of evidence-based protocols in both the public and private sectors. Strict implementation of SASOG initiatives such as BetterObs® and BetterGyn® can go a long way to contribute to lower indemnity premiums in private practice. Ultimately, the court and the legal process is not the place to adjudicate what is in essence a difference of opinion between two expert witnesses. The legal system is sub- optimally equipped to manage medical negligence cases, and the winner vs loser outcome does not recognise the adverse experience of patients or that of the practitioner being subjected to the legal process. Court rules with the objective of facilitating alternative dispute resolution (ADR) such as mediation, have not produced the desired effect. Legislative frameworks to cap medico-legal payments and mandate alternative dispute resolution mechanisms as a first step prior to litigation is urgently needed. Structural and policy reform resulting in a model as proposed by SASOG to the law reform committee where, after failed mandatory ADR, claims are dealt with outside of the courts and legal system through a legislative “Independent Medico-legal Regulatory Authority” is preferable compared to the courts to address medico-legal claims. EDITORIAL African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 3 | 2024 | 02