Malpractice knowledge, attitudes, and practices among physicians at a University Hospital in Saudi Arabia

Raneem Alghamdi; Doaa Maher Abdelaziz; Elham Abdullah Alobaid; Ghadah Almazrua

doi:10.4103/sjl.sjl_6_21

ORIGINAL ARTICLE

Year : 2022 | Volume : 7 | Issue : 1 | Page : 1-6

Malpractice knowledge, attitudes, and practices among physicians at a University Hospital in Saudi Arabia

Raneem Alghamdi, Doaa Maher Abdelaziz, Elham Abdullah Alobaid, Ghadah Almazrua
College of Medicine, King Saud University, Riyadh, Saudi Arabia

Date of Submission	14-Dec-2021
Date of Acceptance	23-Jan-2022
Date of Web Publication	16-Nov-2022

Correspondence Address:
Dr. Ghadah Almazrua
King Saud University, Riyadh
Saudi Arabia

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/sjl.sjl_6_21

Abstract

Objectives:

To assess knowledge, attitudes, and practices of physicians regarding medical malpractice at King Khalid University Hospital
To assess the possible factors that affect malpractice knowledge, attitudes, and practices among physicians.

Methods: A cross-sectional questionnaire-based study was conducted in King Khalid University Hospital between November and March 2019. Both medical and surgical physicians were included. A convenience sampling technique was used with a sample size of 336. The questionnaire contains four sections: demographics, knowledge, attitudes, and practices.
Results: A total of 293 out of 336 questionnaires were returned giving a response rate of 87.2%. The comparison of the levels of knowledge of the respondents for each form of malpractice showed a statistically significant correlation with gender where female high knowledge score was 73 (62.9%) and male high knowledge score was 50 (35.5%). Another variable that showed statistical significance is specialty where medical specialty doctors scored 81 (54.7%) high knowledge, surgery doctors scored 25 (34.7%) high knowledge, and other specialties scored 17 (45.9%) high knowledge. Other variables showed no statistical significance. About the other two outcome variables, both attitudes and practice showed no statistically significant correlation with all included study variables.
Conclusion: The research results show good and bad aspects. The overall knowledge among physicians was good. Moreover, there was no significant difference in knowledge among physicians from different rankings, nor among physicians with different years of experience. Regarding attitude and practice, the results showed no statistical significance. Overall these results can contribute to the quality of healthcare.

Keywords: Knowledge attitudes and practices, malpractice, medical error, physician, quality improvement, Saudi Arabia

How to cite this article:
Alghamdi R, Abdelaziz DM, Alobaid EA, Almazrua G. Malpractice knowledge, attitudes, and practices among physicians at a University Hospital in Saudi Arabia. Saudi J Laparosc 2022;7:1-6

How to cite this URL:
Alghamdi R, Abdelaziz DM, Alobaid EA, Almazrua G. Malpractice knowledge, attitudes, and practices among physicians at a University Hospital in Saudi Arabia. Saudi J Laparosc [serial online] 2022 [cited 2023 Jun 9];7:1-6. Available from: https://www.saudijl.org/text.asp?2022/7/1/1/361357

Introduction

The medical malpractice concept, which is defined as “professional negligence by act or omission by a health care provider in which the treatment provided falls below the accepted standard of practice in the medical community and causes injury or death to the patient, with most cases involving medical error (ME)”^[1] is a recently recognized term that has been highlighted due to increased awareness of patients' rights. The literature shows that medical malpractice incidence is globally expanding despite the presence of well-established medico-legal systems in many countries including Saudi Arabia. Physicians' perception of the concept is central for promoting ideal physician-patient's relationship that subsequently would increase patients' trust and satisfaction with the health care provided. Previous data find out physicians' level of understanding of malpractice and their ability to differentiate it from other similar concepts such as adverse events is extremely low.^[2] Therefore, the need for an understanding of malpractice is essential to be able to prevent it in the first place.

A study that was conducted to evaluate physicians' knowledge, attitudes, and practices regarding malpractice at a university hospital in Pakistan, the outcomes were poor.^[2] Although the Pakistani study considers non-existent laws as a cause of malpractice; in the United States, where the medico-legal system was established years ago,^[3] both the physicians and public are still concerned about medical malpractice.^[4] This indicates that malpractice is a multifactorial problem where its legal consequences result in making the medical profession risky for practitioners world-widely.^[5] Moreover, the malpractice litigations can reflect the level of quality of care as demonstrated by a study conducted in China, where it found that the incidence of medical malpractice litigations is considered as an indicator to assess the quality of health care; the researchers noticed that many of malpractice cases caused by inadequacies in the quality of healthcare.^[6] These factors may represent the motive behind many studies conducted to evaluate physicians' knowledge, attitudes, and practices regarding medical malpractice.

Another study that aimed to evaluate knowledge of malpractice concepts among physicians was done in Pakistan. It was found that 31.3% of participants can define and recognize the different forms of malpractice.^[2] A local study was conducted in Jeddah to measure the level of knowledge of the medical students about the medical international and national laws. The results showed a low level of knowledge about the laws. This encourages the researchers to highlight the significance of having a curriculum that introduces undergraduates to the rights and laws related to medical practices.^[7]

In addition, other researches study physicians' attitudes and practices regarding malpractice based on different variables which are disclosure, defensive medicine, ME reporting, and discussion of ME among colleagues.

A national study showed that only 6% of physicians working in tertiary hospitals are willing to disclose their MEs.^[8] This percentage is small in comparison with the Pakistani study which has shown that 67.7% of the participants are willing to disclose their errors to their patients.^[2]

A study involving three hundred hospitals in the United Kingdom showed that 78% of physicians practiced at least one type of defensive medicine such as ordering unnecessary tests or prescribing unnecessary medications.^[9] In our local working environment, medical malpractice litigation may possibly result in the practice of defensive medicine. This has been emphasized by a local study that demonstrated the outcome of ongoing malpractice litigation. The researchers reported that these outcomes may be the base for the development of defensive medicine culture.^[10] Moreover, another study was done in Saudi Arabia found that Obstetrics and Gynecology liability claims led to the practice of defensive medicine.^[11] Up to our knowledge, there is no study conducted on the prevalence of defensive medicine.

A research studied the attitudes toward reporting MEs in Saudi Arabia found that 43% of physicians are not willing to report their MEs.^[12] In addition, another local study found the low rate of ME reporting is due to the blame culture. Ultimately, this would negatively affect the level of patient safety.^[13]

A research conducted in a teaching hospital in the United States reported that 73% of physicians are willing to discuss their medical mistakes with colleagues to share knowledge and obtain support.^[14] There is no doubt that the discussion of malpractice cases among colleagues needs a blame-free environment.^[14]

World-widely, all previous data have generally focused on prevalence, disclosure, or reporting alone.^{[8],[12],[14],[15]} Moreover, most studies have been done on certain specialties which limit the generalizability of the results.

In this research, we aim to assess the knowledge, attitudes, and practices regarding medical malpractice among physicians; In addition, to discover the factors that lead to malpractice incidence. The lack of researches related to the malpractice field in Saudi Arabia encourages applying this research.

Methods

This cross-sectional study was conducted in King Khalid University Hospital (KKUH), a tertiary hospital, during a 5-month from November 2018 to March 2019. The study was approved by the College of Medicine Institutional Review Board. The study included all physicians working in KKUH who are specialized in internal medicine, general surgery, plastic surgery, neurosurgery, thoracic surgery, pediatrics and obstetrics, and gynecology. The study subjects were chosen using a convenience sampling technique. The complete lists of physicians' names and emails were obtained from the data-base of each department. Single population proportion formula with 95% confidence interval; Z = 1.96, P = 31.3%,^[15] d = 0.05, and non-response rate is 10%; the final sample size for this study is 363. However, we were able to collect 291 due to the limited time. The study subjects included consultants, fellows, and residents. Interns were excluded. The data were collected through an electronic self-administering questionnaire that was adopted from the study conducted in Pakistan.^[2] The questionnaire contains 4 main sections which are demographic characteristics, knowledge, attitudes, and practices of physicians toward medical malpractice. The survey was sent via email in English language. The demographic data included gender, doctor's title, years of experience (for consultants), specialty (area of practice), and nationality. The knowledge questions assessed the agreement on eleven different forms of malpractice using a 5 Likert scale ranging from strongly agree to strongly disagree. The participants were asked about their attitudes regarding taking informed consent, disclosure of MEs to patients, and reporting MEs. Moreover, they were asked about their practices of taking informed consent and defensive medicine.

A pilot study was done on 30 physicians and the questionnaire was edited accordingly. The participants were informed about the study content and purpose prior to their participation. Participation in this study is completely voluntary, with no rewards, and they have the right to withdraw from answering the questionnaire at any point of time. Confidentiality was maintained and no identifiable data were requested.

The data were arranged in Microsoft excel tables, then analyzed using the software IBM SPSS version 22.0 (IBM® SPSS® Statistics Desktop V22.0.0. PID number 5725-A54). Percentages were used to describe the quantitative and categorical variables. The data were processed based on the Chi-square test.

Results

The results were compared between the variables in the study; however, our data have some missing values. P values were calculated to determine the significant difference between variables and outcome, and they were based on the Chi-square test. A P < 0.05 was considered to be statistically significant.

Demographics

A total of 293 out of 336 questionnaires were returned giving a response rate of 87.2%. Hundred and sixty-four (56.2%) respondents were male, whereas 128 (43.8%) were females. Ninety (30.7%) respondents were junior residents, 49 (16.7%) were senior residents, while 58 (19.8%) were fellows, and 96 (32.8%) were consultants. Medicine (167 (57.0%)) was the most common specialty, followed by surgery (85 [29.0%]), then comes other specialties (41 [14.0%]). Two hundred and thirty-eight (81.2%) are Saudis and 55 (18.8%) are non-Saudis. For consultants, we asked about years of experience and 30 (31.3%) have <5 years experience, 18 (18.8%) have 5 to 10 years experience, 30 (31.3%) have 11 to 20 years experience, and 18 (18.8%) have more than 20 years' experience. [Table 1] provides a representation of these data [Table 1].

Table 1: Demographic characteristics of study subjects (291)

Click here to view

Knowledge

[Table 2] shows a summary of the comparison of the levels of the knowledge of the respondents for each form of malpractice. Gender differences showed a statistical significance where the female high knowledge score was 73 (62.9%) and male high knowledge score was 50 (35.5%). Another variable that showed statistical significance is Specialty/Areas of practice, where medical specialty doctors scored 81 (54.7%) high knowledge, surgery doctors scored 25 (34.7%) high knowledge, and other Specialties scored 17 (45.9%) high knowledge. Other variables showed no statistical significance regarding knowledge [Table 2].

Table 2: The comparison of knowledge score levels in relation to the study variables

Click here to view

Attitude

There is no statistical significance in the difference between variables in relation to the attitude of respondents to malpractice. [Table 3] summarizes the scores of different variables according to attitude [Table 3].

Table 3: The comparison of attitude score levels in relation to the study variables

Click here to view

Practice

[Table 4] summarizes the respondents' practices in regard to malpractice and its relation to the study variables. However, it shows no statistically significant difference [Table 4].

Table 4: The comparison of practice score levels in relation to the study variables

Click here to view

Discussion

Although the literature indicates that physicians' knowledge regarding medical malpractice is poor, our research found that 62.9% of female doctors and 35.5% of male doctors exhibited a high level of knowledge. This may be attributed to the prudent and detail-oriented nature of women. However, physicians showed no difference in their attitudes or practices in terms of gender.

Furthermore, we found out that there is no difference in the level of knowledge among physicians of different titles and different years of experience. This is somewhat reassuring and can be attributed to two factors. One of which is that older physicians have built their knowledge from their experience, while the other is that younger physicians may have built their knowledge from the recent introduction of medical ethics in the pregraduate medical curriculum. The authorities can enhance it by introducing courses or workshops for physicians in postgraduate programs.

Certain aspects of the practice seem to be neglected possibly because physicians are not familiar with the reporting process or they would like to avoid creating a malpractice record of any kind. Even though women score high in knowledge, they do not score as well in practice as they are unlikely to report malpractice in a male-dominated field for fear of partiality in decisions made regarding their errors. This can be improved by implementing educational programs targeting physicians at all levels to improve their knowledge about both physicians' and patients' rights and responsibilities that would ultimately be reflected positively on the quality of health-care provided.

Despite that, the findings suggest a significant difference between medical and surgical specialties, in a ratio of approximately 2:1. The medical specialty demonstrated higher levels of knowledge compared with their counterparts in the surgical specialty. Having said that, both specialties exhibited similar attitudes or practices. Surgeons are more vulnerable to MEs than medical physicians, therefore the former score well in terms of attitudes while scoring noticeably poorer with respect to practices and knowledge and the latter were found to have the basic knowledge required of any physician.

Since our sample was not representative, we would suggest a larger sample size that includes other medical specialties to be able to generalize the results. A longer duration of time would help the investigators to use a paper-based questionnaire instead of an electronic questionnaire that would result in their ability to reach the physicians and subsequently improve the response rate. Designing two forms of the questionnaire that vary by specialty (surgical vs. medical) may result in more accurate results. It is important to point out that we have some missing data.

Conclusion

The research results show some good and bad aspects. Regarding knowledge, the overall knowledge among physicians was good; however, it needs to be enhanced more through educational sessions and raising awareness toward medicolegal terms. Moreover, there was neither significant difference in knowledge among physicians from different rankings, nor among physicians with different years of experience; this is good because it shows that these differences do not affect the level of knowledge about medical malpractice. In regard to attitude and practice, the results showed no statistical significance; this also implies that attitude and practice are not affected by the demographics included in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Awati AM, Mudda V. Professional liability in medical practice: A20 years retrospective study at district consumers' forum Gulbarga (1991-2011). journal of Dr. NTR University of Health Sciences 2014;3:15-8.
2.	Sheikh A, Ali S, Ejaz S, Farooqi M, Ahmed SS, Jawaid I. Malpractice awareness among surgeons at a teaching hospital in Pakistan. Patient Saf Surg 2012;6:26.
3.	Wecht CH. The history of legal medicine. J Am Acad Psychiatry Law 2005;33:245-51.
4.	Robinson AR, Hohmann KB, Rifkin JI, Topp D, Gilroy CM, Pickard JA, et al. Physician and public opinions on quality of health care and the problem of medical errors. Arch Intern Med 2002;162:2186-90.
5.	Shreemanta Kumar Dash. Medical Ethics, Duties & Medical Negligence Awareness among the Practitioners in a Teaching Medical College, Hospital-A Survey. Journal of Indian Academy of Forensic Medicine 2010;32.
6.	Wang Z, Li N, Jiang M, Dear K, Hsieh CR. Records of medical malpractice litigation: A potential indicator of health-care quality in China. Bull World Health Organ 2017;95:430-6.
7.	Al-Amoudi SM, Al-Harbi AA, Al-Sayegh NY, Eldeek BS, Kafy SM, Al-Ahwal MS, et al. Health rights knowledge among medical school students at King Abdulaziz university, Jeddah, Saudi Arabia. PLoS One 2017;12:e0176714.
8.	Al-kaabba AF, Hussein GM, Kasule OH, AlhaqwiAI. Disclosing medical errors in tertiary hospitals in Saudi Arabia: Cross-sectional questionnaire study. International Journal of Applied Science and Mathematics 2016;3:75-83.
9.	Ortashi O, Virdee J, Hassan R, Mutrynowski T, Abu-Zidan F. The practice of defensive medicine among hospital doctors in the United Kingdom. BMC Med Ethics 2013;14:42.
10.	Abdul S, Alkindy R. Expatriate doctors, medical litigations, and overall patient care: Taif study. Saudi Surgical Journal 2016;4:104-7.
11.	AlDakhil LO. Obstetric and gynecologic malpractice claims in Saudi Arabia: Incidence and cause. J Forensic Leg Med 2016;40:8-11.
12.	Alsafi E, Bahroon SA, Tamim H, Al-Jahdali HH, Alzahrani S, Al Sayyari A. Physicians' attitudes toward reporting medical errors-an observational study at a general hospital in Saudi Arabia. J Patient Saf 2011;7:144-7.
13.	Alahmadi HA. Assessment of patient safety culture in Saudi Arabian hospitals. Qual Saf Health Care 2010;19:e17.
14.	Kaldjian LC, Forman-Hoffman VL, Jones EW, Wu BJ, Levi BH, Rosenthal GE. Do faculty and resident physicians discuss their medical errors? J Med Ethics 2008;34:717-22.
15.	Bell SK, White AA, Yi JC, Yi-Frazier JP, Gallagher TH. Transparency when things go wrong: Physician attitudes about reporting medical errors to patients, peers, and institutions. J Patient Saf 2017;13:243-8.