OB/GYN practitioners are frequently confronted with critical and medicolegal situations. Investigations of malpractice-related issues are the first step in protecting physicians with high-risk specialties. Also, evaluation of MLC management guides future readjustment of potential defects in this context [1, 11]. Therefore, this study had an in-depth look at the handling of obstetricians and gynecologists of MLC in Egypt.
More than three-quarters of the respondents had a master's degree in OB/GYN. The highest percentage of the participants were aged between 30 and 40 years. The high participation of middle-aged physicians is attributed to their high accessibility to online pages through which the questionnaire was distributed. More senior doctors were often less skillful in accessing web-based sites than junior staff [20].
In the present work, nearly a third of respondents were previously accused of malpractice claims that denote that OB/GYN is a highly litigious specialty in Egypt. It is worth mentioning that Azab 2013 analyzed malpractice claims investigated by the Egyptian Medical Syndicate and found that obstetricians and gynecologists were the most sued physicians [21]. Similarly, Mashali et al. 2020 [22] denoted that OB/GYN practitioners were the most accused physicians of malpractice in Alexandria, the second biggest city in Egypt. In Saudi Arabia, AlDakhil 2016 declared more litigation against obstetricians and gynecologists in relation to other specialities [23].
In the United Kingdom, it was reported that 76% of OB/GYN practitioners faced a claim at least once [24]. Similarly, in USA, literature revealed that all obstetricians and gynecologists had been accused during their medical practice [25]. The restriction of these studies to senior practitioners with a long duration of medical practice explains the relatively high fraction of accused physicians in relation to the present study.
In the current research, the percentages of accused physicians with an experience more than 10 years are high compared with more junior staff. It seems that longer practice is associated with managing a larger number of cases with a subsequent higher probability of malpractice claims.
A higher scientific degree positively impacts the physicians' competency in managing complicated cases. Therefore, in the present work, the percentage of accused physicians is higher among those with a bachelor's degree than those who have master's and doctorate degrees. Regarding job level, the percentage of accused specialists was higher than that of consultants and resident doctors. The consultants' experience decreases the liability of their accusation of malpractice. Regarding resident doctors, they are unlikely to manage complicated cases without supervision, whereas the management of high-profile cases is the utmost duty of the specialists.
In this study, 87.3% of the respondents reported an increased rate of malpractice claims against OB/GYN practitioners in Egypt in the last few years. Nearly two-thirds of the participants attributed increasing claims to the false allegations of some patients to obtain compensation. Similarly, other Egyptian studies previously reported unjustified claims against physicians to obtain financial indemnity [21, 22]
In the present work, 43.3% and 32.7% of the participants mentioned that the limited awareness of patients regarding the doctors' role in their management and the inadequate doctor-patient communication cause increased malpractice litigations. It is worth mentioning that a considerable sector of Egyptian society encourages a large family size. The concept of high parity is prevailing among populations with low educational standards that explains their misperception and limited communication skills with healthcare providers [26].
Regarding medical errors, the study participants denoted that operative problem, unsuccessful management of complications, and failure to obtain valid consent are the commonest pitfalls associated with malpractice claims. Similar medical errors were previously reported by Gowda et al. 2016 [27] and Mashali et al. 2020 [22].
Considering the sequelae, the respondents pointed to neonatal deaths, fetal injuries, and maternal deaths as the commonest consequences of medical errors. Human suffering pushes the patients or relatives to take legal actions against healthcare providers and their institutes. AlDakhil 2016 mentioned similar maternal and fetal morbidities and mortalities in relation to medicolegal litigations against OB/GYN practitioners [23].
The participants' awareness of malpractice elements was unsatisfactory in the current study. The personal and professional characteristics didn't influence the knowledge regarding medical malpractice. It could be concluded that malpractice-related knowledge is neither included in postgraduate curricula nor acquired by clinical practice. Regarding healthcare institutes, serious defects were recorded in the measures taken to guard against malpractice claims. Ensuring proper medical documentation is mentioned by less than two-thirds of participants as the main protective action in Egyptian hospitals. Less identified protective measures include raising the medicolegal awareness of health care providers, discussing complicated cases in periodic meetings, enhancing the educational level of physicians, using quality standards in case management, and implementing medical insurance.
In oriental societies, including Egypt, the medical opinion regarding hymen integrity is associated with serious social and legal consequences [28]. Women might attend to obstetricians and gynecologists following sexual assaults or premarital sexual activities. Assessment of the hymen requires experience and must be done with caution. The inexperienced eye could perceive the normal variations such as hymenal notches and folds as defloration evidence [29, 30]. Therefore, in the current study, only 18.7% of participants handle cases of sexual assault or premarital relations. The management of these cases was mostly carried out by consultants and senior physicians with doctorate degrees.
Egyptian society valorizes premarital sexual purity due to religious and cultural beliefs [28, 30]. The current study pointed to the assessment of hymenal integrity and termination of pregnancy as the main concern of unmarried females. Also, restoration of hymen integrity could be requested if a medical assessment revealed hymenal defloration.
The practice of hymen restorative surgeries arouses religious and ethical controversies [5, 28, 31]. The current results reflect such a debate where more than half of the participants did not justify hymen restoration surgery under any circumstances. Other participants agreed on hymenal repair following sexual assault and accidental injuries. On the other hand, only a tiny fraction of the participants accept hymenal repair following consensual sexual acts.
Worldwide, medicolegal and ethical rules of termination of pregnancy are variable from total prohibition to unconditional permission. The international and national legislations are adapted to balance the right of the fetus to live and maternal autonomy to terminate pregnancy [32, 33]. In Egypt, the ethical clinical decision regarding the induction of abortion is regulated by the national medical practice law inspired by religious doctrines. Therapeutic abortion is permitted when the pregnancy endangers the mother's life or when fetal death is inevitable. Importantly, strict medicolegal precautions should be considered by the physician performing therapeutic abortion [3, 15]. In the current study, the awareness of most of the participants is satisfactory regarding the appropriate medicolegal precautions of induction of therapeutic abortion.
Some contemporary Islamic scholars permit the induction of abortion before 16 weeks of pregnancy in the absence of medical indication [3, 15]. However, only 3.3% of the current study participants justified induction of non-therapeutic abortion within the first 16 weeks of gestation. Refusal of the induction of abortion by the majority of the participants points to the sacredness of fetal life in Egyptian society.
Recommendations
This study serves as a valuable reference that reflects the handling of MLC by Egyptian OB/GYN practitioners. In view of the current results, there is a necessity to enhance measures that protect physicians against malpractice claims, including providing training workshops and inclusion of medicolegal courses in OB/GYN curricula, improving communication with patients, and adopting medical insurance system. In addition, this study reflects controversies in managing cases with medicolegal significance in OB/GYN practice in Egypt. Subsequently, it is recommended to adopt a standardized policy that regulates the management of these cases. Also, it is recommended to carry out similar studies in different countries so that the comparability of the results with that of other nations could be possible.
Limitations
The present work adopted a simple questionnaire to investigate OB/GYN practice in Egypt, the questions were either single correct answer per question or multiple correct answers per question. The relatively limited number of respondents and the absence of advanced question forms, such as Likert Scale questions, hindered more sophisticated statistical analyses; thus, there is a need to conduct a national study on a larger scale in Egypt following the enhancement of the survey instrument.