Increasingly, the specter of medical liability threatens humanitarian missions

Humanitarian missions to developing nations are both personally and professionally rewarding. Whether through secular or faith-based organizations, physicians perform a noble service in caring for the poor in countries with few doctors and scarce resources.

In the past, many volunteers have remarked on the gratitude expressed by patients and the relief they, as physicians, felt while practicing in societies that are less litigious than the United States. Although medical negligence lawsuits are not currently a significant problem for humanitarian medical groups, many are becoming more concerned that such lawsuits may soon have an impact on their missions.

The problem appears to be a globalization of the medical liability crisis in the United States. Patients who think that they should always have an ideal outcome after an injury or surgery will frequently blame the physician for a lesser result. Mission hospitals, medical missionaries, and sponsoring organizations are perceived to have deep financial pockets—while the reality is quite different.

As a friend who is in leadership in a faith-based mission organization told me, “Malpractice is slowly beginning to rear its ugly head as the lawyers look with envy at what the American legal system has gotten away with. What they fail to realize is that you can’t get blood out of the turnip—you just end up with a smashed and nonfunctional turnip.”

Full-time, foreign-based missionaries usually need to raise financial support from their fellow Americans to support their families while they serve overseas. Mission hospitals and organizations are rather limited in their financial capital, and lawsuits against these organizations are unlikely to be the “cash cow” that a plaintiff may be pursuing. Short-term missionaries, however, may have significant assets. Although a medical liability lawsuit arising out of a short-term medical mission is unlikely, the concern that this could happen is increasing.

It could happen—and has
A recent survey of full-time medical missionaries, serving in 29 different countries as part of a Christian organization, is insightful. Of 56 physicians who were surveyed, 20 percent stated that they had liability coverage, either through the organization or through conventional medical liability insurance. One in five also stated that he or she had been sued while working in the mission field. Settlements in these cases were generally in the thousands of dollars; cases settled for more than $100,000 were extremely rare. Surprisingly, almost all of the respondents thought that they would be involved in a medical negligence lawsuit within the next 5 years.

Because the personal experience of serving as part of a foreign medical mission is so incredible, concern about medical liability should not deter volunteers. Another friend who is a leader in missions told me, “Although the sense of risk is increasing, there have been few claims. The general consensus is that short-term groups have much less risk.”

The orthopaedic surgeon who wishes to participate in a short-term humanitarian medical mission in the developing world should consider the following points before traveling to minimize potential complications and liability.

Local legal systems
Needless to say, an elaboration of the different legal climates within the developing world is well beyond the scope of this article. Laws on medical negligence differ in every locale, and the visiting orthopaedic surgeon should discuss this issue with local physicians and the sponsoring organization. Although situations where medical liability is a significant problem are rare, it is wise to inquire about these issues. A visiting surgeon who is named in a foreign lawsuit may be able to leave the country and escape the legal system, but will damage the opportunity for others to serve there.

Practice within reason
Depending on the country, the conditions and abilities of the local healthcare system may be substantially different from those encountered in the United States. The local orthopaedic surgeons I have met on humanitarian missions are some of the most wonderful and caring physicians that I have ever encountered. They crave our techniques and technology, and they are extremely eager to learn all that they can. They offer genuine friendship and sincere camaraderie. Nonetheless, a visiting physician, especially a surgeon, can quickly get in over his or her head.

When I was in eastern Europe, for example, I saw a patient with an unstable pelvic fracture. In the United States, surgical care would be the norm. The local orthopaedic surgeons were very eager to see the techniques of pelvic reduction and fixation, and my ego was screaming to save the day. Without quality fluoroscopy, modern fixation, pelvic reduction instruments, and a team accustomed for caring for these patients, however, surgery would have been recklessly inappropriate. I later learned that the patient had an uneventful, though prolonged, nonsurgical recovery.

Many hospitals in the developing world do not have the instruments and implants that are common in U.S. hospitals. A visiting orthopaedic surgeon must determine exactly what instruments, imaging equipment, and implants are available. The local orthopaedic surgeons are usually eager to be gracious, and they have significant respect and expectations for the abilities of their visitors. They do not know how much U.S. surgeons rely on technology and systems. I recommend that visiting surgeons ask to see the implants as well as any special equipment needed prior to the surgery.

A common problem is the temptation to perform many complex operations during a short-term humanitarian mission. Local physicians, however, may then have to deal with complications that they do not have the knowledge or expertise to properly treat from surgeries that they cannot perform. Infections, failures of fixation, and failed arthroplasties become disasters that the local system cannot handle.

It is better to do simpler procedures within the abilities of the local system and to teach these procedures to local surgeons. Total joint arthroplasty and complex reconstruction have a place in the developing world, but I have also seen the disastrous results of a well-meant procedure that the local system cannot handle.

Politely refusing to do any surgery that is beyond the scope of the local system is clearly in the best interests of the patient, the hospital, and the local doctors. In the grand scheme, it is far better to exhibit restraint and practice within the abilities of the system.

Medical liability insurance
Some insurance providers are now providing coverage for both short-term and long-term medical missionaries. Companies such as Adams and Associates International (http://www.aaintl.com) are developing new products to help protect those serving the underprivileged in the developing world. Interestingly, many surgeons carry this insurance to protect themselves not from the foreign nationals but more from the other expatriate citizens working in the country.

Adams and Associates estimates the cost of this insurance is $4.35 to $8.75 per day on a per diem basis. The cost of insurance for those stationed abroad is $700 to $1,800 per year. The company also offers travel, medical, and other insurance products to the traveling orthopaedic surgeon.

Lloyd’s of London offers “claims-made” coverage to humanitarian organizations, but this often costs several thousand dollars. The insurance is backed by a trust through the International Helpers (Guernsey) Trust. They will insure physicians, other medical personnel, and mission-sending organizations.

Don’t let it stop you!
Orthopaedic surgeons are in a unique position to help the underprivileged around the world. With our talents, we can help restore the function and livelihood of many injured and debilitated people so that they can support their families and return to a productive life. The need is so great, any effort that we make will have an incredible impact—especially when a visiting orthopaedic surgeon teaches techniques to the local surgeons.

I have been to developing countries in Asia, eastern Europe, and Africa, and I would not trade those experiences for anything! Although medical liability may be an increasing problem in the developing world, I encourage you to participate in these opportunities whenever you can.

Douglas W. Lundy, MD, FACS, is a member of the AAOS Medical Liability Committee and editor of the Orthopaedic Risk Manager articles in AAOS Now. He can be reached at lundydw@resurgens.com

The AAOS Medical Liability Committee welcomes your comments and input on Orthopaedic Risk Manager articles. E-mail them to feedback-orm@aaos.org or contact this issue’s contributors directly.