Doctors knowingly fail to cooperate to make medicine safe because they would then be required to practice safe medicine, and be held accountable if they fail.

In the recent issue of Obstetrics and Gynecology,[1] Drs. Strunk and Queenan in their advocacy for an administrative compensation plan to replace the tort system in providing compensation for adverse medical outcomes, liken the performance of a physician to that of a professional golfer or bowler.  Since a professional golfer does not always shoot par, and a professional bowler will not always have a perfect score, the authors  reason similarly doctors should not be expected to have perfect results.

“To Err is Human”.  But the fact that all humans are in some circumstance or at some points subject to err, does not mean that they should not be held liable for negligence.  The authors claim without any offer of proof that the most important reason for adopting an administrative compensation model for adverse medical outcomes is that somehow such a system would improve patient safety and the quality of care.  They also claim that there is such fear of litigation that it somehow impedes the investigation and analysis of adverse medical outcomes.  A remarkable claim suggesting doctors are so self-absorbed they knowingly fail to cooperate in efforts to make the health system better because they assume cooperation will reveal that they agree something is unsafe and such agreement might have personal consequences.  Certainly, if doctors were so affected by their egos, making them unaccountable for error would not convert them to patient centered saints.

There is and can be no evidence that litigation interferes with root cause analysis.  What most interferes with analyzing how needless harms have occurred is the unwillingness of doctors or other healthcare providers to admit they have done something wrong.  If a person has been careless and has hurt another that is wrong.

There was a time in this country when there was little litigation and there certainly were no malpractice suits available when there were doctors who continued to treat people with leaches long after their better informed brethren recognized the absurdity of such a practice.

The tort system particularly in Pennsylvania provides effective investigative tools, which in the hands of competent lawyers enable injured patients to determine with a reasonable degree of confidence whether an injury was avoidable or not.

Physicians object to the litigation system as they object to any system in which their conduct can be criticized.  One need only examine the existing peer review mechanism and how they operate within hospital systems when no litigation has been threatened.

A Bogie occurs because a person trying as hard as they can is unable to complete a hole in the prescribed number of strokes.  It does not occur because of negligence.  It occurs because of a lack of required skill.  If a golfer were to choose a putter to drive from the tee on a five par course, that would be negligence but only the golfer’s reputation would be at stake, not the life and welfare of a newborn.  A bogie is not a matter of life or death.

News-Medical.net also reports on the trial confirming the neuro protective effect of magnesium sulfate I earlier discussed in “If Mother Only Knew.”  This report misses the point that many physicians still think the standard of practice still does not require that magnesium sulfate be administered to mothers threatening preterm delivery prior to 32 weeks.   Rouse was the lead author for the published study findings N-M.net reports.  However, Rouse wrote an opinion piece in the same issue of the New England Journal of Medicine lamenting that the beneficial effects of magnesium sulfate have not,  for some authorities,  been sufficiently established to recommend its use.  Rouse opines that the neuroprotective effects of magnesium sulfate could spare 1000 children a year from suffering cerebral palsy.

The first study to demonstrate the beneficial effects of magnesium in this setting was published in 1995.  The Rouse trial first reported upon in 2008 was the largest to date and those findings were again confirmed by Constantine and Weiner in their impressive meta-analysis “Effects of Antenatal Exposure to Magnesium Sulfate on Neuroprotection and Mortality in Preterm Infants” (Obstet Gynecol 2009; 114:354-64).

Weiner and Constantine, though concluding “magnesium sulfate…significantly reduces the risk of cerebral palsy without increasing the risk of death,” still fall short of insisting upon its use.   This vacillation evades the the kind of pronouncement that assures obstetricians of the need to change their practices.

How many further children must needlessly suffer until a new standard of practice is pronounced?  I think a new standard of practice has been announced and if obstetricians choose otherwise and cerebral palsy results,  those obstetricians will suffer consequences.

In an opinion piece published in the June issue of the American Journal of Obstetrics and Gynecology, Dr. Dwight J. Rouse from the Center of Women’s Reproductive Health at the University of Alabama at Birmingham, suggests that a thousand fewer children each year would suffer from handicapping cerebral palsy if magnesium sulfate were uniformly administered to mothers prior to delivery of children born prematurely at 32 weeks gestation or sooner.

Indeed, a debate has been ongoing about the use of magnesium sulfate to lower the risk of cerebral palsy for many years.  Between 2003 and 2008 three large studies of magnesium sulfate used to protect the infant brain were reported.  Individually and collectively the results of the studies justify the administration of magnesium sulfate to pregnant women threatening delivery prior to 32 weeks to protect their babies who survive their preterm birth from developing cerebral palsy.

In spite of the published studies and the opinion piece by Dr. Rouse and others, magnesium sulfate remains, “unproven” and its use is not the standard of practice for preventing cerebral palsy though it is regularly used by obstetricians for the treatment of other conditions.

Where are the voices of mothers and mothers to be in this debate.  For those who know the hardships faced by children with cerebral palsy and their families, the lack of action by leaders in obstetrics to bring about a change is inexplicable but not uncommon.

Many children died needlessly from neonatal respiratory distress syndrome during the 22 year period between the first individual trial which demonstrated in 1972 that steroids given to the mother prior to birth would be effective in preventing the syndrome until 1994 when the National Institutes of Health consensus guidelines were published making the administration of steroids prior to early preterm birth standard.