SAMA Insider - 2015 Feb

SAMA

INSIDER

FEBRUARY 2015

SAMA welcomes 2015 interns Fraud in the medical industry

PUBLISHED AS A SERVICE TO ALL MEMBERS OF THE SOUTH AFRICAN MEDICAL ASSOCIATION (SAMA)

SOUTH AFRICAN SOUTH AFRICAN MEDICAL ASSOCIATION MEDICAL ASSOCIATION

FEBRUARY 2015

CONTENTS

“Sun – the source of life” – Dr Syed Fatmi

3

5

9

SAMATU disappointed at comserv shambles

Conrad Strydom

SAMA Trade Union

FROM THE PRESIDENT’S DESK 9 Improve doctor-patient relations

Prof. Lizo Mazwai

FEATURES 5 Fraud in the medical aid industry

EDITOR’S NOTE Don’t disenchant the youth

SAMA Private Practice Department

JUDASA demands placement of unemployed community service doctors

Junior Doctors’ Association of South Africa

11

Back to School campaign visits Jeppes Reef

SAMA Trade Union

14

7

SAMA welcomes 2015’s new intern doctors

11

Member profile

Dr Mzukisi Grootboom

Dr Winston Mkhonza

7

SAMATU supports 2015 interns

SAMA Trade Union

MPC’s Practice Cost Calculator makes practice management a breeze

Medical Practice Consulting

8

8

CMS versus SAMA, SAPA and SACTSA – the saga continues

17

Three Jacks

SAMA Governance and Legal Department

Dr Henry Davel

SAMA Medical Doctors’ Coding Manual (eMDCM) for 2015 now available SAMA Private Practice Department

19

MEDICINE AND THE LAW High expectations

Medical Protection Society

20

GENERAL NEWS

Alexander Forbes

Herman Steyn 012 452 7121 / 083 389 6935 | steynher@aforbes.co.za

Offers SAMA members a 20% discount on motor and household insurance premiums.

Automobile Associa6on of South Africa (AA)

AA Customer Care Centre 0861 000 234 | kdeyzel@aasa.co.za

The AA offers a 12.5% discount to SAMA members across its range of AA Membership packages.

Barloworld

Lebo Matlala (External Accounts Manager: EVC) 011 052 0167 LeboM@bwmr.co.za

Barloworld Retail Digital Channels offers compeRRve pricing on New vehicles; negoRated pricing on demo and pre-­‐owned vehicles; Trade in’s; Test Drives and Vehicle Finance.

Legacy Lifestyle

Patrick Klostermann 0861 925 538 / 011 806 6800 | info@legacylifestyle.co.za

SAMA members qualify for complimentary GOLD Legacy Lifestyle membership.

Gold membership enRtles you to earn rewards at over 250 retail stores as well as preferred rates and privileges at all Legacy Lifestyle partnered hotels and further rewards back on accommodaRon and extras. Claim your membership at www.legacylifestyle.co.za/SAMA, all you need is your mobile number to earn or redeem rewards. Travelling SAMA members can book their travel online or speak with our concierge service at Travel By Lifestyle (www.travelbylifestyle.co.za) Legacy Lifestyle, the rewards you’ve earned will pay for the Lifestyle you deserve.

Medical Prac6ce Consul6ng

Werner Swanepoel 0861 111 335 | werner@mpconsulRng.co.za

20% discount on assessment of PracRce Management ApplicaRons (PMA) and Electronic Data Interchange (EDI) systems.

SAMA and Merck Serono are offering SAMA members a first-­‐of-­‐a-­‐kind and FREE FPD online CPD courses on FerRlity and Hyperthyroidism on www.mpconsulRng.co.za. Each course is worth 3 CPD points. The benefit is a saving of R465.00 per member per course.

Medport

Shelly van Dyk

087 550 1715 | support@sosit.co.za

A personalised portal website; an opRonal public webpage to make their services known (Private PracRce); access to a HPCSA accepted CPD Manager; a consolidated e-­‐ mail account; online data storage space; unique applicaRons to manage their medical career; addiRonal applicaRons to download onto your portal page; easier and user friendly access to the internet; lisRng of your Private PracRce on the SAMA Geomap Directory.

EDITOR’S NOTE

FEBRUARY 2015

Don’t disenchant the youth

T

Conrad Strydom Editor: SAMA INSIDER

Editor: Conrad Strydom Head of Sales and Advertising: Diane Smith Production Editor: Diane de Kock Editorial Enquiries: 012 481 2041 Advertising Enquiries: 012 481 2069 Email: conrads@samedical.org

he holiday season ends rather promptly for final-year medical students. Having book-learned their way through five to six years of medical school they find themselves drafted into the public health sector on the very first day of January. The nittygritties of medical practice are rather more visceral than the nittygritties of other professions, to say the least, and many a young intern surely re-evaluates their career choice before the first week of January is done.

A disturbing number of these young professionals end up exporting their knowledge overseas once they have qualified, and one must wonder if their experiences during their internships contributed to that decision. The South African public health sector is a disorganised, dangerous environment to work in, one which surely breeds cynicism in many young doctors and makes pessimism a part of their curriculum. If the Department of Health really wants to increase the number of doctors produced by our country, they should concurrently improve the state of the hospitals they will send young graduates to. The current state of public hospitals regularly tests the limits of seasoned doctors – imagine how much harsher the experience is for an untested intern?

SAMA takes an active role in intern orientation programmes at hospitals throughout the country. You can read SAMA’s welcoming notices to the new crop of interns on page 7. Some of the other highlights of this edition include a look at fraud in the medical industry (see pages 5 and 6) and urgent notices regarding the placement of community service doctors (page 9).

Design: Health & Medical Publishing Group (HMPG) Block F, Castle Walk Corporate Park, Nossob Street, Erasmuskloof Ext 3, Pretoria Published by the Health & Medical Publishing Group (HMPG) www.hmpg.co.za | publishing@hmpg.co.za | Printed by Creda Communications

DISCLAIMER Opinions, statements, of whatever nature, are published in SAMA Insider under the authority of the submitting author, and should not be taken to present the official policy of the South African Medical Association (SAMA) unless an express statement accompanies the item in question.

The publication of advertisements promoting materials or services does not imply an endorsement by SAMA, unless such endorsement has been granted. SAMA does not guarantee any claims made for products by its manufacturers. SAMA accepts no responsibility for any advertisement or inserts that are published and inserted into SAMA Insider.

All advertisements and inserts are published on behalf of and paid for by advertisers.

LEGAL ADVICE The information contained in SAMA Insider is for informational purposes and does not constitute legal advice or give rise to any legal relationship between SAMA or the receiver of the information and should not be acted upon until confirmed by a legal specialist.

Mercedes-­‐Benz South Africa (MBSA)

Lebo Selumane 012 677-­‐1855/082 412 7229 Lebogang.matlhare@daimler.com

Mercedes-­‐Benz offers SAMA members a special benefit through their parRcipaRng dealer network in South Africa. The offer includes a minimum recommended discount of 3%. In addiRon SAMA members qualify for preferenRal service bookings and other aeer market benefits.

MTN Service Provider

Oswin LoPering Melissa Adriaanse 083 222 1954 083 212 3905 Lofer_o@mtn.co.za Adriaa_m@mtn.co.za

We are pleased to offer SAMA members 18% discount. The discount however only applies to new addiRonal contracts and also when the user is due for upgrade. Discount will not apply to InternaRonal Roaming and Dialling, SMS’ and Data packages. Please note that this is extended out to the family and the discount is on VOICE packages only as well.

Monthly Service Charge: less 18% (eighteen percent) discount.

Usage Charge: less 18% (eighteen percent) discount (excluding internaRonal calls, internaRonal roaming, SMS, MMS and data Usage Charges).

SAMA eMDCM

Zandile Dube 012 481 2057 | coding@samedical.org

67% discount on the first copy of the electronic Medical Doctors Coding Manual (previously known as the electronic Doctor’s Billing Manual).

SAMA CCSA

Leonie Maritz 012 481 2073 | leoniem@samedical.org

CCSA: 50% discount of the first copy of the Complete CPT® for South Africa book.

SOSiT

Shelly van Dyk 087 550 1715 | support@sosit.co.za

20% discount on InformaRon Technology support and a 24/7 callout service.

Tempest Car Hire

Corinne Grobler 083 463 0882 | cgrobler@tempestcarhire.co.za

SAMA members can enjoy discounted car hire rates with Tempest Car Hire.

V Professional Services

Gert Viljoen 083 2764 317 | gert@vprof.co.za 10% discount on medical pracRce bureau service through V Professional Services.

Vox Telecom

DJ Viergever Sales -­‐ 087 805 0003 / Technical -­‐ 087 805 0530 | sales@voxtelecom.co.za/ help@voxtelecom.co.za

Provide email and internet services to members. Through this agreement, SAMA members may enjoy use of the samedical.co.za email domain, which is reserved exclusively for doctors.

FROM THE PRESIDENT’S DESK

Improve doctor-patient relations I thought I might start the year by conscientising us about who we really are and what the nature of our vocation really is

Prof. Lizo Mazwai, President, SAMA

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bring new year’s greetings to all of you for 2015. Having read the last article submitted to these pages by the outgoing president, Prof. Ames Dhai, I am moved to thank her for the kind comments she made regarding expectations on my leadership.

As I stated in my welcome speech in November 2014, I hope I will be equal to the leadership tasks SAMA requires during these challenging times.

During my stint as President of the Colleges of Medicine of South Africa (CMSA)

I had the wonderful privilege to be part of the International Association of College and Academy Presidents (IACAP). The most challenging issue that demanded our attention at the IACAP back then was professionalism.

The impression was that professionalism was diminishing within the medical field.

Evidence of this was based on the increasing number of complaints made by patients either publicly or to national medical councils, including calls for disciplinary action for unprofessional conduct. At the doctorpatient level, the most fundamental level of communication, there is often a breakdown. In some cases this has gone beyond complaints to councils, but often litigation is the direct result of a breakdown in communication, as medical insurers can attest.

Fundamentally patients want a caring doctor associated with the age-old qualities of respect, empathy and compassion.

Notwithstanding that medical ethics is an integral part of the medical curriculum, or that the HPCSA and SAMA have guidelines on professional conduct, there is still a

serious need for workshops on the doctorpatient relationship to update doctors on current ethical issues. Has the advent of new technology in diagnosis and management replaced the In-Touch doctor with a High Tech doctor?

Without stirring the generation gap controversy, it also appears that motives for joining the profession are changing from being vocational to being more materialistic.

This may be a trend of modernism which might be a threat to the profession. My view is that having joined the medical profession you have an obligation to think, act and behave professionally. The basis of this obligation is underpinned by the four fundamental principles of bio-medical ethics. Added to this is the obligation of the OATH or DECLARATION. Bring in the scientific knowledge and skills for the benefit of your patient. This should be binding on your conscience in the form a social contract and responsibility.

I thought I might start the year by conscientising us about who we really are and what the nature of our vocation really is.

Fraud in the medical aid industry SAMA Private Practice Department

F

raud is a multi-cephalic monster that rears its ugly heads in all sectors of our society. It is ubiquitous in nature and no industry is spared. The South African medical aid industry is no exception.

Fraud management goes through stages of Prevention, Detection, Investigation, Litigation and Recovery. The stages are listed in order of importance, based on the principle that ‘prevention is better than cure’. The discussion that follows will deal with the individual stages and will help provide insight into how the industry approaches this scourge.

Prevention What has been prevented from occurring will result in there being no losses and therefore no need to institute recovery processes. This is therefore the ideal situation and ranks senior to

all fraud management interventions. The truth is, however, that for every rand that is stolen only a fraction gets recovered. Central to our industry’s fraud prevention drive is the unwavering need to adhere to the following guidelines: • Adherence to the Medical Schemes Act, the Regulations and the registered Rules of the various medical schemes.

• The industry needs to embark upon an aggressive fraud prevention education drive.

• Properly structured and workshopped peer review mechanisms and programmes.

• The industry agreeing on medical billing codes prior to publication to avoid the generally held view that the industry has a ‘cheat’ list and thereby creating a witchhunt.

• Representation of providers on the industry’s forensic management units.

Detection Fraud that has escaped prevention and has occurred should be detected. Detection will help reduce or eradicate losses emanating from the occurrence. Fraud detection

Over-recovery as a punitive measure is in itself fraud in reverse and should be investigated and be made punishable SAMA INSIDER

FEBRUARY 2015

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FEATURES

is obviously better than fraud that goes undetected as undetected fraud often leads to the demise of organisations.

The following are the tools that are often used by funders in detecting suspected or blatant fraud: • Data Analytics and predictive modelling • TIP-OFFS (often anonymous) from disgruntled spouses, patients or employees • Informers • Shared data from the BHF Forensic Management Unit (FMU) and other stand-alone Fraud and Forensic Units. For example: Discovery, GEMS, etc • System alerts using Fund administrators’ Rules engines and Assessing staff.

Investigation All detected, suspected or reported fraud, gets investigated. The investigations are often outsourced, largely due to lack of capacity within schemes or Third party Administrators (TPAs). These investigations are normally carried out by: • Retired police detectives • Police detectives • Trapping agents • Entities that specialise in fraud and forensic investigations.

The truth is, however, that for every rand that is stolen only a fraction gets recovered Litigation and recoveries Once having confirmed fraud, avenues that are available to defrauded entities are: • Laying criminal charges • Instituting civil proceedings and suing for damages • Reporting the suspected fraudster to the HPCSA • G e t t i n g t h e s u s p e c t t o s i g n a n Acknowledgement of Debt ( AOD), or • Embarking on one or more of the above.

Important considerations Medical Schemes and TPAs prefer AODs in that recovering lost revenue tends to be their primary concern, ahead of anything else. It

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also serves as a low hanging fruit because it helps avoid costs related to civil litigation and is a lot easier to enforce.

AODs are often seen as an easier way out of being charged criminally by medical practitioners accused of fraudulent behaviour.

They rush into signing, without knowing the full implications of signing such agreements.

They do so, even when they know that they never had any intentions of defrauding, the quantum arrived at is inaccurate and thumb sucked. They go on to default and end up with summary judgements, warrants of execution, attachments and ultimately liquidations.

The following excerpt has been extracted from a submission made by our legal department: ‘’Acknowledgement of Debt An acknowledgement of debt, commonly referred to as an “AOD”, is a document which contains an unequivocal admission of liability by the debtor. In it the debtor acknowledges that he or she owes a particular sum of money to the creditor and undertakes to repay what is owed.

An AOD requires no more than this in order for it to be legally valid and binding on the signatory. All other terms that may be inserted in the document are incidental but generally they will be designed to protect the interests of the creditor. For instance the AOD will usually provide that if the debtor fails to pay any one instalment of the debt, the whole amount will immediately become payable.

Thus an AOD is a tool commonly used by creditors when debtors owe them money because, chief among its strengths, is that it is a ‘liquid document’, one which proves a debt without any extraneous evidence.

Accordingly an AOD should enable the creditor to obtain a speedy judgment against the debtor without having to endure a lengthy trial in which all the facts relating to the original credit agreement may have to be proved by the creditor. Judgment can simply be taken for the full amount reflected in the AOD because the court is faced with a document in which the debtor has expressly acknowledged that he owes the money.

Armed with the judgment the creditor may then issue a writ of execution against the debtor’s property to the value of the judgment debt and may have the debtor’s property attached to satisfy it. All of which arises directly out of the AOD signed by the debtor.

The AOD is thus a very powerful document which, once signed is extremely difficult to

set aside. An AOD can only be set aside by a competent Court on application by the party wishing to have it set aside (or varied). The applicant bears the onus to prove that there is a valid legal reason to void the AOD and provide the court with a satisfactory and persuasive explanation as to why the applicant signed the AOD in the first place.

In shor t, the AOD can be seen as a ‘confession’ of sorts in which the debtor admits that he/she owes a particular sum of money to a creditor.’’

Our members should be wary of signing AODs. Members should contact SAMA legal department when confronted with a fraud accusation by schemes or TPAs. This should be done BEFORE anything is signed which will help to curb over-recoveries, which are pathognomic of these fraud recovery agents, some of whom get paid a percentage of what is recovered – thereby creating a perverse incentive.

AODs are often seen as an easier way out of being charged criminally by medical practitioners accused of fraudulent behaviour In summary • Fraud is abominable and should be discouraged and be made punishable.

• It affects all sectors of the economy.

• It is a scourge that is doing the industry more harm than good and should, wherever possible, be prevented before it occurs.

• Funders and TPAs should go on an education drive and functional peer review mechanism should be put in place.

• Fraud once detected and confirmed should be made punishable.

• Over-recovery as a punitive measure is in itself fraud in reverse and should be investigated and be made punishable.

• Members should get legal advice before signing AODs.

FEATURES

SAMA welcomes 2015’s new intern doctors Dr Mzukisi Grootboom, Chairperson: SAMA

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he South African Medical Association (SAMA) wishes to welcome all intern doctors as they take their first, tentative steps in our profession. After long hours spent internalising the theoretical basis of medicine, you are finally ready to receive practical training in our ancient and respected science. Make no mistake – all of your preparation has built to this point, where you have the privilege of improving the health of your fellow people and preventing the occurrence of illness and death.

Being a doctor is a very special honour. In a country like South Africa, which faces many healthcare challenges, it is as much a calling as a profession. Our unique burden of disease as well as the poor state of our public healthcare system make working conditions difficult, but take heart – in facing adversity you will experience the proudest moments of your career. SAMA hopes that all medical interns will live up to the spirit of the Hippocratic Oath, which states that a doctor must have the “utmost respect” for human life.

Nothing can prepare you for those first tentative steps that you take as a doctor during your internship. The constant sight of real injuries and illnesses and the long hours that you often have to work are the polar opposite of your experiences within the walls of your medical school. However, being thrown in the deep end, as it were, is an experience you are sure to look back on with gratitude. When it comes to saving lives, there really is no substitute for experience.

As an intern, you will often have to deal with very adverse conditions, especially since you will find yourself in our country’s beleaguered, but vital, public health system. SAMA has a subsidiary structure, the SAMA Trade Union, that was formed specifically to deal with the rights of doctors in the workplace. If you are treated unfairly at any point during your internship, SAMA’s respected group of industrial relations advisors will be there to represent you. Do not hesitate to phone (012) 481 2000 if you have any queries in this regard.

SAMA wishes you the best of luck with your internships, in the hope that you will become the kind of tough, disciplined, compassionate and ethical doctors our country requires you to be SAMA wishes you the best of luck with your internships, in the hope that you will become the kind of tough, disciplined, compassionate and ethical doctors that our country requires you to be. May you be a credit to your profession and your patients!

SAMATU supports 2015 interns SAMA Trade Union

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ttention all new doctors and interns!

The following is an important notice on remuneration and associated issues from the South African Medical Association Trade Union (SAMATU).

SAMATU would like to welcome our interns throughout the country and congratulate all those who will be new appointees. Some of you have completed community service and some have finished their terms as registrars, while others are specialists and medical officers new to the field of public health. You are about to enter one of the most exciting stages of your career, during which you will experience a baptism of fire, as it were, that will teach you what it really means to be a doctor.

The following information has been compiled by SAMA as a service to all newly appointed doctors, including those transferred from one province to another and from one institution to another.

Please note that it has been our common experience that doctors don’t get paid correctly or at all during their first month of

employment. Therefore SAMATU is advising all members to make sure they have the following documentation on hand in order to counter the excuses that public hospitals’ HR managers always have when you confront them.

Critical checklist • Valid, current registration with HPCSA. • Completed forms obtained in your HR office, signed and stamped by your bank on your first day.

• Qualification certificates (interns should provide an oath-taking letter if they have not yet graduated).

• A valid ID document (passport and working permit for non-citizens).

• SARS registration documents.

• An updated curriculum vitae.

• Commuted overtime forms, recommended by your clinical manager and approved by the hospital CEO, should be filled in before mid January 2015 before Persal closes.

• A rural allowance must be captured – where applicable early January 2015.

• Keep your job offer and acceptance letters handy and make sure your clinical manager submits your assumption of duty letter to the HRM. • Ensure that you keep all copies of submitted documents.

Important advice In order for you to be paid your salary with all the benefits that are due to you, make sure you visit your HRM or salary department during January 2015. If you don’t appear in their system you won’t be paid your salary.

Please contact us on (012) 481 2000/ 90/ 92 so that we can intervene urgently.

It is very important that you ensure that these matters are attended to as soon as possible, or else your internship might end up being plagued by labour issues, as has happended far too often in the last few years.

For further information and/or assistance with regard to remuneration and other employment issues, kindly contact the SAMA Trade Union on (012) 481 2090/2092 or labour@samedical.org

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CMS versus SAMA, SAPA and SACTSA – the saga continues SAMA Governance and Legal Department

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n May 2012 the Council for Medical Schemes (CMS) decided to file two complaints with the Competition Commission (the first against the South African Paediatric Association and SAMA and the second against the Society of Cardiothoracic Surgeons of South Africa and SAMA) alleging that the determination and publishing of the codes in the SAMA Medical Doctors Coding Manual (which they referred to as the ‘Billing Guide’) amounted to horizontal price-fixing, in contravention of Section 4(1)(b)(i) of the Competition Act. A year later, in May 2013, the Competition Commission issued notices of non-referral in both instances (i.e. decided not to refer these matters to the Competition Tribunal) because the Competition Commission was of the opinion that these matters would, in due course, be addressed comprehensively as part of the Healthcare Market Inquiry.

The CMS was not satisfied with the Competition Commission’s decision of non-referral and continued to self-refer both matters to the

Competition Tribunal. Despite various efforts to convince the CMS not to pursue this course of action in an ill-timed fashion, resulting in unnecessary and vast legal expenses to all parties concerned, the CMS persisted in its course and SAMA was left with no choice but to oppose the self-referrals by instituting a High Court review application to contest the authority of the CMS to self-refer the complaints to the Tribunal.

The CMS was again not prepared to solely participate in the High Court Review in order to ascertain its locus standi (as an organ of state established under the Medical Schemes Act) in respect of self-referrals to the Competition Tribunal, but preferred to continue with both parallel legal processes, forcing SAMA to apply for a Stay in the Competition Tribunal pending the High Court review. The Stay Application was heard by the Tribunal in November 2013 and the Tribunal issued its Ruling in SAMA’s favour on 1 December 2014, granting SAMA

the Stay Application pending the outcome of the Review Application launched in the High Court. The Tribunal was inter alia of the opinion that SAMA raised a valid and fundamental question in respect of the competency of a regulatory body such as the CMS to self-refer a complaint to another regulatory body, in this instance the Competition Tribunal, the answer to which might have consequences for all regulatory bodies in similar circumstances.

With the ink on the ruling barely dry, however, the CMS once again showed its propensity for litigation and incurring legal costs, and continued to file a Notice of Appeal against the Competition Tribunal ruling at the Competition Appeal Court on 19 December 2014. SAMA has to date spent more than R3 million in legal fees on these matters and does not intend to file a cross-appeal, which would, in SAMA’s opinion, be counter-productive.

We will keep our members informed of the next chapter in the CMS saga in due course.

SAMA Medical Doctors’ Coding Manual (eMDCM) for 2015 now available SAMA Private Practice Department: Medical Coding Division

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he 2015 release of the South African Medical Association’s Electronic Medical Doctors’ Coding Manual (eMDCM) is now available for download. The eMDCM is the most respected medical coding manual in the South African market and is the acknowledged industry standard. SAMA has long been at the cutting edge of coding issues in South Africa and the latest edition of the eMDCM continues to bring you the latest and most up-to-date codes to assist you in your daily practice.

The 2015 edition will cover all of this year’s Procedural Billing Codes and the easy-to-use functionality that the eMDCM has become known for. The manual also covers PMB lists and guidelines for code interpretation. The knowledge contained in the eMDCM is the distillation of SAMA’s vast amount of experience at the forefront of the South African billing environment, having been the custodian of doctors’ procedural codes since 1944.

Be sure to visit the SAMA website on http:// www.samedical.org to qualify for a discount on

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The prices for the 2015 eMDCM SAMA members (First licence only) SAMA Members/Non-Members: First licence 2nd – 10th licences 11th – unlimited number licences the first product purchased. SAMA members should log in with their username and password and go to the products tab and select the product they are interested in.

An online, internet-based version of the Medical Doctors’ Coding Manual (eMDCM) programme is also available. It is for notebooks, tablets, smart phones, iPads and other platforms. Please note that you will only be able to use one activation licence per user linked to Windows. This is not a stand-alone product, but is free of charge with the purchase of your eMDCM. The same activation key will be used.

Each individual user needs to apply for a licence, since the price is based on a ‘per user’

R238.00/per licence (VAT incl.)

R719.00/per licence (VAT incl.)

R598.00/per licence (VAT incl.)

R361.00/per licence (VAT incl.) basis. Please note that the printed version (hard copy) of the eMDCM will only be published by the end of March 2015. The SAMA Private Practice Department realises that there is a great demand for both electronic and physical copies of the eMDCM and will endeavour to place the hard copy version in the hands of professionals at the earliest possible date.

Please direct any coding queries to the SAMA Private Practice Department’s Medical Coding Unit on 012 481 2073 or email coding@samedical.org.

For any computer/IT related queries, please contact SOSiT on 087 550 1715 or email support@sosit.co.za.

SAMATU disappointed at comserv shambles SAMA Trade Union

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he South African Medical Trade Union (SAMATU) is deeply disappointed at the shambolic manner in which the Department of Health (DoH) is managing the placement of community service doctors for 2015. SAMATU has received reports that about 180 community doctors remain unemployed despite relentless efforts to prevent this fiasco.

We would like to inform the affected community service doctors that the SAMATU is working around the clock to resolve this crisis. We have demanded that the national Minister of Health intervene immediately.

For a speedy resolution, refer to the following list of community service posts and contact the coordinators immediately.

If you are to be posted to Limpopo, to Thabazimbi, Ellisras, Witpoort, Voortrekker, George Masebe, Mokopane, Helene Franz, Botlokwa, Thabamoopo, Donald Fraser, Siloam, Messina, Tshilidzini, Dr CN Phatudi, Sekoro, Kgapane, Maphutha L Malatji, Letaba, Jane Furse, Dilokong, Mecklenburg, Matlala or St Ritas, please contact the regional coordinator Dr N Ndwamato on 015 964 1061 or 078 800 5564.

If you are to be posted to the Free State, to Dihlabeng, Manapo, Bongani, Boitumelo, Mantsopa, Embekweni, Stoffel Coetzee, Thusanong, Mafube, Tokollo, Itemoheng, Phuthuloha, JD Newsberry, Nketoana or Phumelela, please contact the regional coordinator Ms B Coetzee on 051 408 1814.

If you are to be posted to the Northern Cape, to Springbok, Abraham Esau, Joe Slovo, Kakamas, Postmasburg, Connie Vorster, Tshwaragano, Kuruman, Manne Dipico or Prieska, please contact Dr Joubert on 053 802 2147.

If you are to be posted to Mpumalanga, to Lydenburg, Mapulaneng, Matibidi, Matikwane, Shongwe, Themba, Tintswalo,

SAMATU has received reports that about 180 community doctors remain unemployed despite relentless efforts to prevent this fiasco Tonga, Amajuba, Elsie Ballot, Embhuleni, Ermelo, Piet Retief or H.A. Grove, contact regional coordinator Ms T Zondo on 013 766 3316.

If you are to be posted to the North West Province, to Matlosana, Klerksdorp, Maquassi Hills, Nic Bodenstein, Ventersdorp, Mafikeng Provincial, Bophelong, Gelukspan, Ditsobotla, Gen de la Rey, Sannieshof, Ottosdal, Ramotshere Moiloa, Zeerust, Lehurutse, Ratlou, JS Tabane, Koster, Kgetleng Rivier, Moses Kotane, Vryburg, Reneke, Lekwa Teemane, Bloemhof, Ganyesa, Piet Plessis or Taung, please contact Mr S Lenong on 018 391 4202.

If you are to be posted to KwaZulu-Natal, to Untunjambili, Hlabisa, Mosvold, Ekombe, Nkandla, Benedictine, Ceza, Edumbe, Itshelejuba or Nkonjeni, please contact regional coordinator Ms R Erasmus on 033 846 7161.

For more information, call SAMA directly on (012) 481 2000 or email the SAMA Trade Union’s industrial relations experts at DanielM@ samedical.org, WandileM@samedical.org, SimonB@samedical.org, ModisaneL@samedical.org, polelon@samedical.org or LaetitiaN@ samedical.org.

JUDASA demands placement of unemployed community service doctors Junior Doctors’ Association of South Africa

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he Junior Doctors’ Association of South Africa (JUDASA) is disappointed by the failure of the Department of Health (DoH) to appoint dozens of community service doctors in the country.

Many doctors are currently unemployed after applying multiple times to the DoH to start their compulsory year of community service. These doctors were allowed to apply and reapply for posts only to find out after several months that there were limited funded posts in certain provinces such as Gauteng.

We are of the view that this is a result of the disorganisation of the DoH which started the application process very late and did not take

into account the views of the affected people when they made decisions. Since community service is meant to help rural hospitals, the department should not wait for so long to tell doctors that they have few posts in the cities.

As an organisation JUDASA has tried multiple times to prevent this situation and communicate with the DoH in order to be part of meetings that affect the placement of doctors. However, the DoH did not involve any organisation that represents doctors and as a result doctors are left unemployed in a country that is facing a serious shortage of doctors.

It is quite shocking that every year the DoH seems to be surprised that there are new

doctors who are due to start work in various provinces; either doctors are not appointed in time or those appointed are not paid in time.

This makes us wonder if the DoH understands that many people’s lives are endangered because there are no doctors to attend to them when they are sick. We plead with the department to take the lives of our citizens seriously and stop mistreating their doctors.

We have taken up the issue with the Minister of Health and would like all affected doctors who have not yet reported their unemployed status to email Dr G Mashele (gemashele@gmail.com) and copy Dr CM Khoza (couragemkhoza@ gmail.com) for assistance.

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FEATURES

Back to School campaign visits Jeppes Reef SAMA Trade Union

T

he South African Medical Association (SAMA) through its Trade Union arm, the South African Medical Association Trade Union (SAMATU), visited Tinhlohla Secondary School in Jeppes Reef, Mpumalanga, on Wednesday 14 January 2015. SAMATU was there to witness the distribution of essential school and lifestyle supplies as part of its Back to School campaign. Jeppes Reef, an impoverished area close to the border with Swaziland, is a remote part of the country and the residents suffer from a lack of adequate sanitation and infrastructure. Despite these

SAMATU’s Mpumalanga PEC, from left to right: Dr Malumane, Dr Lokothwayo, Dr Maritz and Dr Sihlangu

drawbacks, Tinhlohla Secondary School maintains a 91% pass rate.

As part of its Back to School campaign, SAMATU decided to sponsor the Imbumba Foundation’s Caring4Girls programme.

Caring4Girls is an initiative that provides sanitary towels to girls in rural communities where menstruation is often stigmatised.

Many girls have been known to drop out of school when they start to menstruate, a situation which Imbumba Foundation founder Richard Mabaso has sought to alleviate by educating girls on menstrual hygiene and puberty. “The supplies we provide help girls at a crucial period in their lives, but we still need to do more to reach out,” Mabaso said.

Members of the SAMATU provincial executive committee (PEC) in the area assisted SAMATU general secretary Dr Mahlane Phalane in addressing the crowd of students. They were educated on matters related to puberty and were also motivated to become whatever they could dream of being. “Many of us came from even more impoverished backgrounds than you,” Dr Phalane said, “yet we worked hard

and became doctors.” Dr Phalane concluded that if he and the members of the PEC could become doctors despite their circumstances, the students were capable of the same.

Learners at Tinhlohla Secondary School were overjoyed to receive their sanitary towels Tinhlohla Secondary School principal Herrick Nkosi was overjoyed at the visit, praising SAMA and the Caring4Girls initiative for their willingness to help the local community. “It is particularly good to see people coming to motivate the students,” he said. SAMATU will also engage in health-related activities at the school in the coming year, speaking to students about health issues such as HIV/AIDS and medical male circumcision, among other issues.

Member profile: Dr Winston Mkhonza with one such doctor, Dr Winston Mkhonza, a general practitioner who practises in the region of Vryheid in northern KwaZulu-Natal.

R

ural doctors are often the unsung heroes of South African medicine, spending long stretches of time labouring in less than adequate conditions for very little pay. However, the services they render to often impoverished areas make a profound impact in communities where the very idea of seeing a doctor was impossible a few decades ago. SAMA Insider caught up

What is the average day in the life of a doctor in Vryheid like?

I get up very, very early and head directly to Vryheid Provincial Hospital where I start seeing patients from 07:30 onwards. I am currently working with outpatients and I see a lot of chronically ill people who one gets to know quite well.

In addition, we get many patients referred to us by local clinics, as well as those who invariably refer themselves. Once that is done, I usually go to my practice rooms or the local community health centre in nearby Paul Pietersburg and see patients for the rest of the day.

What misconceptions do people have about rural doctors?

People, even some colleagues, seem to think that we enjoy a more relaxed lifestyle, when in fact we work just as hard – if not harder – than doctors in urban areas. There is a severe shortage of doctors in the rural areas but just as many diseases, so we are forced to see a

great number of patients on any given day, particularly in the public hospitals. On top of that, we also suffer from poor infrastructure in these areas and it is almost impossible to get the equipment you need. People also seem to think we are easy to exploit; medical aids in particular. If I want to transfer a patient, I first have to contact the medical aid and ask them for an authorisation number! They have far too much control over what doctors do.

One doesn’t know who they trust less – the doctor or the patient.

What can be done to remedy the situation?

The challenges in rural and semi-rural areas have to do with a lack of capacity. In our area, there are not enough clinics and the clinics that we have are not good enough. To remedy this, I think we need to invest in mobile clinics that can travel to hard-to-reach communities and help them. We need greater access and need to establish at least six clinics in our area alone. SAMA can do their part by keeping doctors informed. We need more access to CPD events.

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FEATURES

MPC’s Practice Cost Calculator makes practice management a breeze Medical Practice Consulting

T

he effect of the 2004 Competition Commission ruling is that collective negotiation on healthcare tariffs is outlawed. Healthcare professionals must negotiate tariffs with medical schemes individually and trade unions and representative associations are not permitted to negotiate tariffs on behalf of their members.

This ruling has forced healthcare professionals in the private sector to increase their awareness of the financial reporting function of their practice.

The role of medical schemes in the setting of tariffs The medical scheme tariff model represents an application of the Resource-Based Relative Value Scale (RBRVS) model, where medical schemes have assessed their claims risk profile based on number of claims processed during prior periods, the risk of the re-occurrence of the number of claims during current periods as well as available funds. This resulted in medical schemes offering healthcare professionals tariffs that schemes could afford, without healthcare professionals being able to assess whether they could deliver sustainable healthcare services at the offered prices.

This does not mean that schemes have been offering tariffs that would necessarily result in a low profit margin or even a loss for the healthcare professional. The healthcare professional enters into a legal contract with the patient and may choose to accept payment from a third party (the scheme) with the scheme offering direct payment to the healthcare professional through a separate legal contract between the healthcare professional and the medical scheme.

The only guidelines that currently exist are from the Health Professions Act 56 of 1974, which states: “the patient may, within three months after receipt of the account from the healthcare professional, apply in writing to the professional board to determine the amount which in the opinion of the professional board should have been charged in respect of the services to which the account relates, and the professional board shall, as soon as possible after receipt of the application, determine the said amount and notify the

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SAMA INSIDER

practitioner and the patient in writing of the amount so determined: Provided that before the professional board determines the said amount, it shall afford the practitioner concerned an opportunity to submit to it in writing his or her case in support of the amount charged.”

What the Health Professions Act is alluding to, is that the tariff charged should represent a fair value, which is why the practitioner is awarded the opportunity to submit support for the amount charged.

Healthcare professionals must negotiate tariffs with medical schemes individually and trade unions and representative associations are not permitted to negotiate tariffs on behalf of their members What represents a fair value?

We can conclude that a fair value is not below the cost to deliver the service and where tariffs are offered to healthcare professionals that result in a loss, additional fees should be recovered from the patient to support a sustainable business. We also know that a fair value should not be charging exorbitant markups that do not represent a true reflection of the level of skill and risk of the procedure.

As with most professional occupations, discretion should be applied when billing for services rendered.

Regardless of the pattern of thought it becomes evident that one constant remains – the healthcare professional requires valid and accurate information to base his/her decisions regarding whether or not to accept tariffs under a contract to receive direct payment from the medical scheme and if not, whether or not his/her assessment of the value of their services is fair, as required by the Health Professions Act. Current financial tariff models Significant focus is placed on practice cost studies throughout South Africa, in an attempt to develop reasonable tariff guidelines for the delivery of healthcare services in the private sector. The fact of the matter is that where practice cost studies are used to calculate tariff guidelines, these tariff guidelines are more often based on the stratification of averages across different professions and specialities, than not.

The averages also include extrapolated costs to deliver healthcare services over different geographical locations where the average income of patients varies greatly.

A private healthcare practice is a business, just like any other company registered to make a profit. The practice has direct costs and indirect costs to deliver services and the healthcare professional has to be aware of the income potential of the patients in his/ her area, including the type of healthcare services delivered, whether essential or luxury healthcare services. What makes the costing of healthcare services delicate is that a healthcare professional’s services should be offered at a cost that makes it possible for patients in their area to have financial access to the services.

A model based on the application of averages to calculate tariffs could be used effectively in an active market within a developed country but poses significant challenges when applied within a developing country. The following conditions within the South African healthcare industry represent significant challenges for the implementation of an average-based-tariff-model: • The forces of supply and demand costing are not active in the South African healthcare industry, as healthcare professionals are

FEATURES

not truly awarded the opportunity to set the prices of supply when entering into supplier contracts with medical schemes; • These principles were designed for a developed country – not a developing country and are based on the assumptions that: • The costs to deliver procedures over a country are purely based on specialty and can be quantified and averaged to deliver a pure Rand Conversion Factor; • The demographics of a country and the household income of patients do not have a significant impact on the setting of tariffs and • The vast majority of the population earns comparable salaries (South Africa has a 24.9% unemployment rate).

What could however not be quantified is what effect the geographic location of healthcare professionals in a developing country would have on the setting of tariffs.

Tariffs and costs within the South African healthcare industry are not only governed by private sector conditions but also by public sector conditions as well as a demographic distribution that sees significant differences in the household income of South Africans in different areas and ethnic groups: • The costs to manage a practice within South Africa can be seen to fluctuate significantly even within the same province when comparing areas such as Sandton and Diepsloot, which are both within Gauteng.

• The fluctuations in the procurement of goods and services are much lower in developed countries than those in developing countries.

• The average household income also fluctuates significantly within developing countries, when compared to developed countries.

It can also be said that the use of extrapolated data does not take into consideration the conditions under which doctors in township and rural areas practise medicine, including the qualitative factors such as stress and the lack of infrastructure and support services associated with their environment. These qualitative conditions have a severe impact on the quality of life of the doctor, including the sheer number of patients that the doctor is required to consult, while consciously trying to manage the clinical risk of the patients.

All this information leads us to one question: “How do we solve the problem?”

The only sustainable solution for private healthcare in South Africa to introduce a true

supply force to the equation, is for private healthcare professionals to start running their practices as a business. This means that you need to be able to calculate what it costs you to deliver a procedure – including the allocation of direct costs and reasonable allocation of indirect costs, just like any other business with the aim of generating a profit would. When tariffs are negotiated with medical schemes for the delivery of a procedure, you need to be able to calculate a profit on the delivery of the procedure, taking into consideration all relevant costs, and you should be in a position to say ‘no’ to tariffs where the delivery of the procedure is not financially viable for your practice.

You should create and manage dynamic budgets and forecasts that reflect a

budgeted profit of your practice, based on actual financial data that has been taken from your practice, which reflects the true cost of delivering procedures in your geographical area. The budget should take into consideration qualitative factors of your geographical area that is not reflected in tariffs offered by medical schemes, including the percentage of household income of patients that can be spent on healthcare services in your area.

Medical Practice Consulting will be assisting private healthcare professionals in calculating the cost to deliver services in their practice through the launch of the online MPC Practice Cost Calculator. Register a free profile on www.mpconsulting.co.za to access the Practice Cost Calculator.

With GEMS every member matters, and it shows GEMS members are positive about their medical scheme and its future.

Our most recent member survey revealed that 83% of members were highly satisfied with the Scheme while 90% agreed that GEMS was ‘here to stay’.

As the second largest medical scheme in South Africa, there is nothing small about GEMS and yet we have kept our service levels highly efficient and personal. At GEMS we offer big scheme security, affordability and caring service levels.

Nothing is more important to us than our members. We call this the ‘GEMS difference’.

If you are a government employee and are looking for a medical scheme where every member matters, contact us today by dialling *120*4367# or visit m.gems.gov.za. Remember you will need to have your PERSAL number handy.

T&Cs and cellphone rates apply.

Her heart is in her work.

Our heart is in her health.

SAMA INSIDER

FEBRUARY 2015

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FEATURES

Three Jacks The following story was sent to us by Dr Henry Davel. For the last 43 years, Dr Davel has been practising as a GP in Springs. He was also formerly a director at Springs Parkland Hospital and SAPPI’s Occupational Health Practitioner for 25 years. He is currently busy writing his memoirs.

J

ack Hogan sat opposite me with his one arm nonchalantly over the backrest of the chair. He had a could-not-care-adamn attitude accompanied by Rhett Butler’s bushy black hair in the movie Gone With the Wind. Two perpendicular puckers separated his thick eyebrows. A lower lip orbicularis oris muscle encroached over his upper lip. An aura of respect surrounded him, when he spoke in a precise British accent.

But today he said nothing. Jack was in his mid-thirties, owned an engineering firm, and stayed in a house his wife had designed and he had built. He drove a two-door BMW, and his wife had the latest BMW 4x4 to take the children to their various extramural activities. He did not smoke, and drank the odd fine champagne or cognac for medicinal reasons.

“Hullo Jack. Hullo Helen. How are you this morning?” Jack was displeased; he said nothing. His wife had contrived and organised and he had agreed to see me for a continuous cough. That was what he was here for. She was the manager at home, the first to rise and the last to retire. He was waiting for her to tell me how he was. We were both waiting for her to say something.

“Hi doctor, Jack is sulking now, but at home he coughs us out of the house. Not one day will pass without episodes of cough-coughcough. Even his secretary phoned to tell me about his continuous cough at board meetings, in the plant and in his office. I have noticed that he has lost weight by the holes that he uses in his belt, but he eats more than ever. I know I am a nagging wife, but I am worried. Doctor, I lie awake each night, listening to him coughing.”

“J a c k , h o w l o n g h a ve yo u b e e n coughing?”

Helen replied: “For two months, doctor.”

“You have any pain when you cough, Jack?”

“I can see it is painful when he coughs, doctor,” Helen said. “I do not have pain when I cough, doctor,” Jack said.

“Do you cough up phlegm, Jack?”

“No, doctor.”

“Yes, doctor, he does,” Helen said, and looking at him, “you cough up phlegm every morning when you shower Jack, because the

humidity loosens the phlegm. And then you spit it out in the shower.”

“Yes, doctor, I cough up phlegm every morning. So please examine me, so that we can leave. I have lots of work waiting.”

I examined Jack according to the book; his blood pressure, pulse and temperature were normal. I listened with my stethoscope, then percussed his lungs and measured his inspiratory and expiratory chest circumference. I did an expiratory flow measurement, including an electrocardiograph. I could find nothing wrong with Jack.

What concerned me was Helen’s paradoxical pathological concern and feminine intuition that something was horribly wrong with her mate and the father of her four children. I believe in feminine intuition so I sent him for X-rays and routine blood tests.

The radiologist phoned the same day to give me the report which shocked me. My receptionist phoned them and they returned to my rooms the same day.

“Jack, I’m sorry but the X-ray findings are negative. I want you to see a thoracic surgeon today. I will phone now to make an appointment.”

He did not protest. Helen was quiet.

The specialist confirmed an aggressive, rapidly-spreading lung cancer on biopsy.

The prognosis was poor. Jack had surgery

to his lungs, followed by ex tensive chemotherapy. His bushy hair converted into a Yul Brynner hairstyle from The King and I. His trousers became loose around his waist. We knew the treatment caused all this. Our hope that the surgery and chemotherapy would be successful soon disappeared. There was no alternative, except palliative treatment, focused on relieving and preventing Jack’s suffering.

The reality was that Jack had time to prepare himself for the inevitable. We respected his wish to spend his last days in the house that he had built, in an environment that he had created, and where he was comfortable and at ease. I did house calls to monitor his progress, and gave intramuscular morphine injections to relieve his pain. I often stayed for a cup of tea or coffee. His Jack Russell was ever present, and a bond developed between me and the dog. One day while having tea with them I explained to Jack and Helen the possible scenarios if the cancer spread.

Helen agreed it would be traumatic and unfair to put the three young children through these ordeals. Jack refused to have a registered nurse look after him. l suggested he phone me if he was ready to be admitted to hospital. I still did house calls once or twice a week. I got to know

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FEATURES

the family well. My duty was not to prolong his life, but to relieve his suffering.

I believe in feminine intuition so I sent him for X-rays and routine blood tests One day Jack phoned me at dawn. “Doc, can you please come and see me at home today.” I hadn’t seen Jack for a week. Helen, the children, and his mother all left the bedroom when I entered. The Jack Russell stayed on his bed. Jack’s eyes had a sunken appearance. He smiled to show greetings and appreciation; all I saw was a grimace, his teeth exposed like the perfect keys of their Steinway piano, with atrophied lips surrounding them. His emaciated facial muscles showed no dimples or wrinkles of emotion. I knew his brain did not reflect what I saw. His arms were sinewy and thin, and he lifted them slowly to greet me. I sat on his bed and clasped his hands with both my hands. His eyes filled up with tears.

“Jack, I’m going to give you an intravenous injection of morphine for your pain.”

I knew this was my last house call. Helen knew too. I’m sure his dog knew. I arranged an ambulance to transport him to the hospital.

The children were there, and Helen decided they could stay until the ambulance arrived.

Jack’s mother was there. The most difficult death to digest is that of a child. I hugged her. She wouldn’t let me go. I felt sad, and had tears in my eyes. I left them alone with him at home, for the last time.

The more intensive specialised treatment in the hospital resulted in a temporary improvement in his general condition. I saw him daily. His room had two reclining chairs for the family if they wanted to stay over.

Helen brought in fresh flowers daily.

“Good morning, Jack, how are you?” The question was a mere platitude – there was nothing good about the morning. I had just completed a busy twenty-four-hour casualty session at the hospital “Good morning, doc. I am well and how is my dear doc this morning.” He spoke in a whisper.

“Well Jack, I haven’t slept for twenty-four hours and will grab a quick shower, because I

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have appointments at my rooms.” I wasn’t sure if I was fishing for compliments or sympathy from this dying man in front of me. “But if there is anything I can help with or do or anything that you need, please tell me, and I will do my best.” There was nothing more that I could assist him with.

“Yes, doc, you can do me one last favour. I would like to see my dog, my little Jack Russell.”

I remember him, always present whenever I did a house call.

“But Jack, the matron said she will push you with the bed and intravenous fluids and monitors and all into the street if you dare think of such a thing!” said Helen, waking up in the reclining chair next to his bed.

“Jack, it is not possible to bring a dog into a hospital. It is against all rules and regulations. Our matron has a gestapo attitude when it comes to rules and regulations, and there is no way in a million years that she’ll allow it.”

When I left his room, I did not go to my rooms. I went straight to the sister in charge of the ward. I knew her well. I asked her about the nurses’ tea break in the mornings. There was a security fire door around the corner, down the corridor from Jack’s room. It was not visible from the nurses’ duty station. The lock could only be unlocked from inside to get access from outside. It took me a while to decipher the mechanism. Helen and the boys had to get the dog through the main hospital entrance security gate, to the parking area of the hospital grounds. There was an enormous tree on the parking area next to the hospital security gate entrance.

We reserved this parking with two portable poster signs.

Next, we had to get the key to the gate in the security fence. The matron had the key among her bunch of keys that she carried with her. She managed her medical and administrative staff with affection and dedication. The patients loved her, and the nursing staff respected her dedication and professionalism. But she was on guard against anybody who transgressed any hospital rules or regulations. She was a Florence Nightingale with a military-like penchant for order.

I explained my devilish humanitarian plan to the sister. She knew the matron well. We needed the security gate key, and this sister procured it. How she got hold of the security gate key, is still a secret. I used one of Jack’s shirts to cover the dog.

Everything fitted in, like a jigsaw puzzle. And

SAMA INSIDER

that is how we arranged to smuggle Jack Hogan’s Jack Russell into his private room.

It was his dying wish and we were able to do it for him and few would ever know.

As I entered Jack’s room, he was asleep. I slammed the door shut with my foot. The sound woke him. Jack looked at me holding the wriggling parcel wrapped up in his shirt.

He looked tired, emaciated. They were both unaware of each other’s presence. All Jack said was “Hi doc” and stared out in front of him. He did not notice the movement in my arms. Then the Jack Russell heard and smelt his owner, and the wriggling kicking parcel became impossible to control. He forcibly freed himself from my grip and catapulted himself towards Jack’s voice like an arrow released from a bow. He flew through the air with ease. Halfway to the bed Isaac Newton’s laws of gravity took effect; the dog tumbled to the floor like a log, only to be propelled from the floor by his hind legs, jumping like a jack-in-the-box straight onto Jack’s bed. The speed at which he got between the sheets on Jack’s bed was mind-boggling. It was heart-breaking to see the camaraderie between Jack and his dog. The Jack Russell showed his affection with high-pitched pipsqueak talk under the blanket. He unashamedly licked the tears from Jack’s face. He wormed himself back under the blankets. Jack died that very day.

“Yes, doc, you can do me one last favour. I would like to see my dog, my little Jack Russell.”

A few months later, I had a cup of tea with the matron in her office. I was on the hospital board, and confessed to all that had happened on that day. I did not have any regrets, and thought nobody knew.

“Yes,” she said, “and I had to do a courtesy call to a neighbouring hospital’s matron which wasn’t on my schedule for the day. How could I be present when all these unholy, devilish acts of unlawfulness played themselves out in my hospital? I sold my soul and keys so that you may smuggle in a damn dog that messed up everyone’s tea break, left the nurses nervous wrecks, and peed in the patient’s bed.”

MEDICINE AND THE LAW

High expectations The Medical Protection Society shares a case report from its archives

M

r O was a 24-year-old man who h a d j u s t e n j oye d a h o l i d ay overseas. On the return journey he started vomiting. The nausea and vomiting continued after he arrived home and he began to lose weight because of it. When his symptoms did not abate he made an appointment with his GP. H is GP documented a four-week history of nausea and vomiting and, after reviewing normal blood tests, referred him to gastroenterology. The gastroenterologist wrote back concluding that he had found no significant pathology on endoscopy or ultrasound, and that he thought that anxiety was contributing to his ongoing symptoms.

Irritable bowel syndrome was also considered to be a factor.

Mr O asked his GP for a private referral to neurology, which he agreed to. The neurologist arranged an MRI scan, which was normal, and he felt that Mr O was suffering from a significant depressive illness from which he had partly recovered. Mr O did not agree with this diagnosis and felt that his symptoms had a physical rather than a psychological cause. He did, however, agree to see a psychiatrist, who concurred that his symptoms were due to anxiety and depression. He prescribed venlafaxine and arranged cognitive behavioural therapy (CBT).

Mr O was struggling with fatigue in addition to the nausea and was not coping at work, so he visited his GP again. His GP referred him to a specialist in chronic fatigue who wondered if he may be suffering with post-viral fatigue syndrome.

Mr O was convinced that there was a physical cause for his symptoms and demanded a second neurological opinion.

This was sought but nothing abnormal was found on examination, repeat MRI or lumbar puncture. He had mentioned some dizziness and had an audiometric assessment showing abnormal canal paresis to the right. The neurologist concluded in a letter to the GP that “the only abnormality found in spite of extensive investigations was a mild peripheral vestibular disorder”. The letter detailed that he had been seen by a physiotherapist who had instructed him in Cawthorne-Cooksey exercises and that he had been asked to continue these at home.

Despite doing the vestibular rehabilitation exercises at home, Mr O failed to improve.

He still felt weak and light-headed and had moved back in with his parents who were worried about him. They made another appointment with his GP who referred him for an ear, nose and throat (ENT) opinion.

The ENT consultant took a detailed history and noted the absence of tinnitus, vertigo or deafness. She could not find anything abnormal on examination and thought that a labyrinthine problem was unlikely to be the problem. She repeated the balance tests, which were normal.

Years went by and Mr O became very focused on his symptoms, feeling sure that a diagnosis had been missed. Opinions were sought from an endocrinologist, a professor in tropical diseases and a private GP. Nothing abnormal could be found and no firm diagnosis was made.

A neuro-otologist thought that his symptoms were due to a combination of “anxiety with an associated breathing pattern disorder, a migraine variant and physical de-conditioning”. A joint neurootology/psychiatry clinic concluded that it was “a confusing story with nebulous symptoms but it was probably a variant of fatigue disorder with a depressive element and derealisation”.

Mr O was very frustrated at the lack of diagnosis or improvement in his symptoms.

He felt that the sole cause of his symptoms was a peripheral vestibular disorder. He made a claim against his GP, alleging that he had failed to make the diagnosis and that he had also failed to arrange vestibular rehabilitation.

MPS instructed expert opinion from a GP and a professor in audiovestibular medicine. The experts felt that Mr O’s GP had not been at fault.

The professor in audiovestibular medicine was sceptical regarding the diagnosis of a vestibular disorder. He noted that repeat audiograms and tympanograms had been normal and felt there was no robust evidence that he had a peripheral vestibular disorder.

He stated that there was no clinical history suggestive of vestibular pathology at the onset of Mr O’s illness. He also commented that there had been no consensus among various specialists as to the true cause of Mr O’s symptoms and that to claim that a peripheral vestibular disorder was the sole cause was an overly simplistic view.

The GP expert noted that the neurologist’s letter to the GP referred to Mr O having been instructed by the physiotherapists in Cawthorne-Cooksey exercises. These are vestibular rehabilitation exercises so it was wrong to say that there had been a failure to arrange the exercises or that this was the responsibility of the GP. The expert explained that GPs are not trained to instruct a patient in vestibular rehabilitation exercises and are not likely to have direct access to specialist physiotherapists who could arrange these.

The expert noted that a large number of specialists saw Mr O over a prolonged period, all of whom failed to reach a consensus on the cause of his symptoms. The expert’s view was that the treatment provided was reasonable and that the standard that the claimant sought to apply was too high.

Mr O withdrew his claim before it went to court.

Learning points: • The defence of this claim was helped by the contents of the correspondence to and from specialists, which were relied upon to disprove some of the allegations made. It is important to take the time to write comprehensive referral letters and to read letters from specialists carefully. Correspondence is an important part of the medical record, as well as being important communication between clinicians.

• Mr O clearly had a very difficult time. There had been a protracted period of time with no clear diagnosis. However, in the circumstances of this case, this did not equate to negligence.

• This case highlights the standard doctors must meet in order to refute negligence claims – that of a responsible body of their peers (GPs in this case), rather than a specialist in the condition in question.

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GENERAL NEWS WMA welcomes strongest statement yet on violence against health workers World Medical Association

C

ommenting on the recent United Nations General Assembly resolution urging governments to act to ensure the safety of health workers, the World Medical Association (WMA) President Dr Xavier Deau welcomed the new UN Resolution on ‘Global health and foreign policy’.

“I welcome the fact that we are ending the year with the strongest statement yet from the UN on the issue of attacks on health workers,” he said. “The past year has seen yet more deaths and injuries among health workers whose only job has been to care for patients in often extremely difficult circumstances.”

He said that whether under conditions of war or in peace healthcare facilities must be free from violence. They should never be under attack and health personnel should never be threatened or intimidated. The UN resolution was in line with recent initiatives of the International Committee of the Red Cross and the World Health Organization to protect healthcare against violence, which the WMA strongly supported. Dr. Deau added: “Although this resolution is a step in the

right direction – a step the WMA has lobbied for – much more needs to be done.

“It is important that in the year to come we continue to monitor these attacks wherever they occur and collect data so that governments and other conflict parties can maximise their efforts to protect health workers, health facilities and patients. In this way we can help to bring to justice those responsible for these appalling attacks.

“The G20 Leaders’ summit last month acknowledged the need to address Ebola and strengthen health systems. That requires a safe environment for health providers and their people requiring care. The preceding WMA H20 summit heard of the challenges for health of armed conflict and the grim, dangerous tasks of aid organisations like the ICRC in providing this.

“Unless governments and other conflict parties take immediate action, health systems and health facilities around the world will be further weakened and as we have seen with Ebola in West Africa, this can have disastrous consequences across the world.”

Free State mourns loss of Dr Grant Ebenezer van der Merwe Dr Dirk Hägermeister

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t is with great sadness that the SAMA Free State branch has learned about the untimely passing of our colleague Dr Grant Ebenezer van der Merwe. Dr van der Merwe, a general practitioner in Willows, Bloemfontein, died in a tragic accident in the early hours of 18 November

2014 while on the way to work. The medical community in the Free State has lost a bright young mind and a source of inspiration is gone. Our thoughts are with his family. We join his parents, siblings and spouse, also a colleague of ours, in mourning this incredible loss.

SAMA KZN Coastal branch grieves over passing of Dr Kevin Nankissor

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t is with great sadness that we inform you of the passing of Dr Kevin Nankissor. Dr Nankissor was a highly respected member of the Durban medical community and a pillar of strength to his many patients. Dr Nankissor, a specialist nephrologist, operated a practice in Berea and also

treated patients at Capital Hospital. A leading light in his field, Dr Nankissor will be remembered as much for his medical expertise as for his willingness to go the extra mile for his patients. He will be sorely missed by his colleagues at the KZN Coastal branch and in the broader medical community.

Eastern Highveld branch to host AGM

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AMA’s Eastern Highveld branch invites all its members to attend its annual general meeting. The event will double as a CPD meeting and lecture. The branch’s leadership will also provide feedback on the branch’s activities throughout the course of the previous year.

When: 18 February 2015 Where: The Venue, 14th Avenue, Northmead, Benoni

When: 16:00 - 19:00 Speakers: Dr A Ranshod, specialist radiologist on the topic of the ‘Cardiac Angiogram’ and Dr S Hirschowitz, specialist gynaecologist on the topic of ‘Vaginal Prolapse’.

To RSVP, contact Alex Graham on 083 449 3556 or send an email to samaeast@mweb.co.

Border Coastal hosts intern orientation

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embers of SAMA’s Border Coastal branch were at work on 1 January to welcome new interns to Frere Hospital in East London, Eastern Cape. The new interns were introduced to the basics of daily life in a public hospital. Although most were understandably nervous, the

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orientation proceedings did noticeably calm their nerves a bit. SAMA branches regularly participate in intern orientation at hospitals throughout the country and are ready to assist interns with any issues they may face in their first couple of years as doctors.

SAMA INSIDER

Border Coastal branch’s Dr Kruger participating in an intern orientation presentation

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