What do doctors talk about when they get together? Probably bosses, interesting cases, salaries and nurses, among other subjects. At the second Israel Medical Convention held recently at Jerusalem's International Convention Center, some 1,000 physicians and others came to hear eight hours of lectures on the hospital of the future, medical ethics, the growing threat of malpractice suits and challenges in human genetics.
Octogenarian Health Minister Ya'acov Ben-Yizri, who greeted the audience and received only a minimum of applause, struck a pessimistic note: In 2020, Israel's population will reach almost nine million, but at the current pace of development, there will not be enough medical institutions and qualified personnel.
"We will not be ready," he said, hinting at constant Treasury efforts to cut health spending. "We are working to include psychiatric and geriatric care in the basket of health services," said Ben-Yizri, but while this has been promised by Ben-Yizri's predecessors over the years, there is not even a target date. "We struggle against the Treasury," he said, adding that the ministry must also prepared for possible emergencies such as earthquakes, terror attacks and pandemics, along with now-routine violence against medical personnel and the need for preventive medicine. "We need a coalition for health, with all factors working together so we can give the public what it justifiably demands."
ISRAEL MEDICAL Association chairman Dr. Yoram Blachar - who does not get along professionally with the minister - nevertheless had the same pessimistic approach: "Medical research has been in crisis in recent years," he said. "The state hardly supports it. The Health Ministry's chief scientist's office has only NIS 7 million to allocate this year - and that's twice what it was. Medical research is in danger of losing its status. In the US," noted Blachar, "when a decline in medical research was noted, the state realized it had to fund doctors' time spent on research, and now the trend has been reversed. We must do that too, before it's too late."
The host of the event, Hadassah Medical Organization director-general Prof. Shlomo Mor-Yosef, was more heartening. "Hadassah and all other hospitals are interested in providing medical care to Arab neighbors who seek it. We won't bring peace, but we will improve understanding. As for our Israeli patients, thanks to advances in medical research, we can tell them what they can hope for, what's in the pipeline, even if a treatment is not yet available."
While many changes in diagnostics and scanning have already become routine, said Mor-Yosef, bigger changes are on the way. "Everything is computerized. You can see tiny details of organs and perform virtual examinations of the colon, heart and tendons. Some three-dimensional functional - and not only anatomical - imaging is already being performed with Positron Emission Tomography [PET]. We have tools to show the effects of only one or two cigarettes." Catheters threaded through a vein in the groin, he continued, will be able to reach almost any organ. Computers are becoming an inseparable part of operations, with digital navigators telling surgeons at what angle to insert implants.
"This is only the beginning," said Mor Yosef. "There are pacemakers for the heart, but there will be electronic pacemakers for the brain as well." Mor-Yosef predicted that computerized robots would become good enough so that surgeons will be able to manipulate joysticks and perform surgery not only in another room, but in another country.
Individualized medicine will offer customized treatments for patients. "One patient will get a drug because it will help him but it won't do anything for another patient," said the Hadassah chief. "And medical education will be revolutionized by simulators that enable students and doctors to train over and over before touching their first patient."
ALL ISRAELI hospitals currently building new facilities - including Hadassah's Ein Kerem campus that is constructing a 12-floor hospitalization tower - are preparing improved "hotel services"- more privacy and esthetics "so patients and their families are more comfortable. Doctors will monitor the conditions of their patients over cellphones. More patients will want to be at home. We will have to be ready for this."
Prof. Mark Glazerman, head of obstetrics and gynecology at the Rabin Medical Center in Petah Tikva, quoted an expert who told medical students, half jokingly: "Fifty percent of what you learn in medical school will be found to be wrong in 10 years. The problem is that your teachers don't know which half." Also an expert in medico-legal subjects, Glazerman complained about physicians who have turned into "for-hire professional witnesses" in medical lawsuits, even though they lack the credentials. Ob/gyn specialists are the most-sued in Israel, he said. "There were efforts to reduce costs on lawsuits, but the issue is a hot potato. Fearful of lawsuits, doctors around the world tend to perform unnecessary cesarean sections." The rate, he said, is 80 percent in Brazil, 40% in Italy and an average of 20% in Israel. No one has been sued for doing a cesarean instead of a vaginal delivery, he said, but many are sued for not doing a cesarean, which can result in significant complications for the mother. Half of Israeli obstetricians polled said they would perform a cesarean on a woman who insisted on it, even if there were no medical indications. But when asked if they would do this for close relatives, few would agree. "This is not defensive medicine, but frightened medicine. With a sensational press, a growing number of lawsuits and doctors ready to testify for clients on any side, it's a big problem."
SINCE 1992, the number of lawsuits against doctors has multiplied by 13, said Prof. Shimon Pollack, a Rambam Medical Center immunologist with expertise in medio-legal issues. The amount of money granted patients by the courts has multiplied by 82 during that period. Between NIS 500 and 700 million in payments for medical malpractice are won by patients in an average year. "The Israel Medical Association says medicine is not an exact science; there can't always be a positive result. Sometimes there are unintentional results, and they don't always come from a doctor's errors. Mistakes often can't be prevented, said Pollack, who is chairman of the department of immunology at the Technion's Rappaport Medical School. "At Rambam, I found that 40% of lawsuits against our doctors were unjustified. Of the latter, 70% were errors and only 30% were mistakes, in which the doctor did not do what he should have done according to accepted medical protocols."
The growing number of malpractice suits forces doctors to adopt defensive medicine, he continued. Patients are sent for unnecessary tests and expensive scans, and more cesarean sections are performed to minimize the risk of lawsuits, Pollack said. Obstetrics cases worth NIS 200 million in damages each year comprise 35% of all negligence cases here. Israeli malpractice lawyers' annual earnings reach a total of about NIS 150 million. All this comes at the expense of state health expenditure and the Health Ministry's official basket of health services, the contents of which do not keep up with available technologies.
Pollack urged unraveling "the Gordian knot between proof of a doctor's responsibility for harm and compensation to the patient who was hurt. As in Scandinavia, no-fault insurance would minimize lawyers' fees and speed up the conclusion of cases. In two US states, limits set on payments for negligence and errors reduced the number and size of lawsuits. Our Treasury claims that no-fault insurance would cause the health system to collapse, but experience abroad shows that it actually lower costs," Pollack insisted.
Newspaper ads placed by lawyers offering "free consultations" to patients who believe they have been harmed have encouraged needless lawsuits that are later thrown out by the courts, said Prof. Moshe Feigin, head of obstetrics/gynecology and the genetic institute in Meir Medical Center in Kfar Saba. There are also some physicians who spend 100% of their time serving as "expert witnesses" in lawsuits even though they are not necessarily qualified. "In the US, for example, there are strict criteria for who can serve as witnesses in medical cases," said Feigin.
The constant pressure of potential lawsuits "encourages doctors to avoid difficult cases. Some obstetricians have even stopped delivering babies because of the fear of litigation," said the Meir physician. "In obstetrics, the gap between success and failure is very small. A case can move from low to high risk in just a few minutes, and compensation payments for death or harm to a baby are high. But the situation has produced some benefits, including more protocols for treating diseases, hospital position papers and improved terminology in describing cases, he explained.
Turning to the subject of ethics in genetics, Dr. Vardiella Meiner - head of Hadassah-Ein Kerem's clinical genetics center, said the field has developed so much that it is referred to as "Gen-Ethics." The mapping of the human genome gave a great boost to genetics but also introduced problems such as the use of stem cells, diagnosing incurable diseases that could appear decades later (like Huntington's), conducting genetic research and intellectual property. "There are diagnostic, predictive and carrier tests," she said. "If there is Alzheimer's in a family, should my patient and his children be tested for a gene? There may be a wife who wants to know before pregnancy if she will pass a Huntingon's gene to a future child and the husband doesn't want to know."
Commercial firms now offer individual genome mapping, said Meiner. She urged more public debate of Gen-Ethics issues, and recommended keeping genes in perspective, as environmental influences are still very important in the development of disease.
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