The document attached has been archived with permission from the editor of the Medical Journal of Australia (10 January 2008). An external link to the publisher’s copy is included.Objectives: To assess the intentions of Australia's specialist obstetricians to cease practice and their reasons for abandoning this specialty. Design: A structured questionnaire posted to Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), issued 11 July 2001 with a return date of 31 July 2001 (in practice, responses were accepted up to 31 August 2001). Participants: Australian specialists holding a Fellowship of the RANZCOG. Main outcome measures: Demographic data (eg, age, sex); type and location of practice; past, current and intended future obstetric practice; reasons for stopping practice; cost of indemnity premiums; experience of litigation and its influence on practice; and experience in giving medicolegal opinion. Results: The response rate was 74% (829/1116), with 826 responses fulfilling our selection criteria. The median number of years since admission as a Fellow was 17 (range, 1–47 years), and 19% (158/817) of respondents were women (9 people did not specify their sex). Of the 826 respondents, 596 (72%) were currently practising obstetrics, 548 (66%) intended to still be practising after one year, 365 (44%) intended to be practising after five years, and 196 (24%) intended to be practising after 10 years. The median indemnity premium in 2001–02 was $35 515 (range, nil to $156 000) for practising obstetricians. The main reasons given for ceasing obstetrics were intention to specialise in gynaecology, fear of litigation, high indemnity costs, family disruption, and long working hours. About two-thirds of respondents (557/818) had experienced the threat of litigation, and almost all (768/803) desired some type of "no-fault" indemnity scheme. Thirty-three of the 314 respondents who had given medicolegal opinions accounted for 71% of the total number of opinions. Many of these were non-practising obstetricians who were not accredited RANZCOG expert witnesses. Conclusion: There will soon be a shortage of experienced practising obstetricians in Australia.Alastair H MacLennan and Michael K Spence

MacLennan, A.

Spencer, M.

The Medical Journal of Australia

Adelaide Research &amp; Scholarship

 PUBLISHED VERSION    MacLennan, Alastair Harvey; Spencer, Michael Keith  Projections of Australian obstetricians ceasing practice and the reasons Medical Journal of Australia, 2002; 176 (9):425-42  This article is available from the Medical Journal of Australia at: https://www.mja.com.au/journal/2002/176/9/projections-australian-obstetricians-ceasing-practice-and-reasons                          http://hdl.handle.net/2440/8364    PERMISSIONS   This document has been archived with permission from the editor of the Medical Journal of Australia, 26 April 2007.    MJA Vol 176 6 May 2002 425HEALTHCAREThe Medical Journal of Australia ISSN:0025-729X 6 May 2002 176 9 425-428©The Medical Journal of Australia 2002www.mja.com.auHEALTHCAREIN 2001, the President of the RoyalAustralian and New Zealand College ofObstetricians and Gynaecologists esti-mated that 30% f specialist obstetri-cians did not practise obstetrics.1 Todate, the cessation of obstetric practicehas been particularly high among gen-eral practitioners and rural specialists —in a survey conducted in 2000, 34 of200 rural Australian specialist obstetri-cians had recently left rural practice and46 of the remaining obstetriciansplanned to move on within five years.2Furthermore, in a 2001 survey, 24% of109 new Fellows and Members in theirfinal two years of training stated thatthey did not intend to perform anyobstetric work.3 The main reasons citedfor choosing to avoid obstetric practicewere the cost of medical indemnity(25%) and fear of litigation (20%).An impending crisis in obstetricsowing to a shortage of practitionershas been foreshadowed for manyyears.4 Many factors may contributeto the decline in the number of practi-tioners, including long and unsociablehours, disruption to family life andlack of adequate backup by otherpractitioners.3More recently, the rapidly escalatingcost of medical indemnity insurance hasbecome a major precipitating factor. In1980, indemnity to practise specialistobstetrics and gynaecology could beobtained for $100. In 2001, the baserate for indemnity offered by Australia’slargest indemnity provider, UnitedMedical Protection, ranged from$20 970 in the Northern Territory to$54 315 in New South Wales (RichardWilson, Senior Medical Advisor,United Medical Protection, personalcommunication).There is a lack of current data abouthow Australian obstetricians are copingwith their current working conditions.We report here the outcomes of a surveyof Australian Fellows of the Royal Aus-tralian and New Zealand College ofObstetricians and Gynaecologists(RANZCOG) to determine their rea-sons for ceasing obstetric practice. Asinformation on litigation and its out-comes is not readily available, we alsosought details of specialists’ personalexperience in this area.METHODS1.MethodsA structured questionnaire was postedon 11 July 2001 to 1116 Fellows of theRANZCOG who had an Australianpostal address, as obtained from theRANZCOG. The cut-off date for thereturn of responses was 31 August 2001.The questionnaire asked about demo-graphic information, the extent ofobstetric practices, when respondentsexpected to cease practising (and, if theyhad ceased practising, when and whythey did so). Further information wasProjections of Australian obstetricians ceasing practice and the reasonsAlastair H MacLennan and Michael K SpencerDepartment of Obstetrics and Gynaecology, The University of Adelaide, Women’s and Children’s Hospital, North Adelaide, SA.Alastair H MacLennan, MD, FRANZCOG, Professor; Michael K Spencer, BSc(Hons), LLB(Hons), Barrister and Solictor, and Academic Visitor. Reprints will not be available from the authors. Correspondence: Professor Alastair H MacLennan, Department of Obstetrics and Gynaecology, The University of Adelaide, Women’s and Children’s Hospital, 72 King William Road, North Adelaide, SA 5006. alastair.maclennan@adelaide.edu.auABSTRACTObjectives:  To assess the intentions of Australia’s specialist obstetricians to cease practice and their reasons for abandoning this specialty.Design:  A structured questionnaire posted to Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), issued 11 July 2001 with a return date of 31 July 2001 (in practice, responses were accepted up to 31 August 2001).Participants:  Australian specialists holding a Fellowship of the RANZCOG.Main outcome measures:  Demographic data (eg, age, sex); type and location of practice; past, current and intended future obstetric practice; reasons for stopping practice; cost of indemnity premiums; experience of litigation and its influence on practice; and experience in giving medicolegal opinion.Results:  The response rate was 74% (829/1116), with 826 responses fulfilling our selection criteria. The median number of years since admission as a Fellow was 17 (range, 1–47 years), and 19% (158/817) of respondents were women (9 people did not specify their sex). Of the 826 respondents, 596 (72%) were currently practising obstetrics, 548 (66%) intended to still be practising after one year, 365 (44%) intended to be practising after five years, and 196 (24%) intended to be practising after 10 years. The median indemnity premium in 2001–02 was $35 515 (range, nil to $156 000) for practising obstetricians. The main reasons given for ceasing obstetrics were intention to specialise in gynaecology, fear of litigation, high indemnity costs, family disruption, and long working hours. About two-thirds of respondents (557/818) had experienced the threat of litigation, and almost all (768/803) desired some type of “no-fault” indemnity scheme. Thirty-three of the 314 respondents who had given medicolegal opinions accounted for 71% of the total number of opinions. Many of these were non-practising obstetricians who were not accredited RANZCOG expert witnesses.Conclusion:  There will soon be a shortage of experienced practising obstetricians MJA 2002; 176: 425–428in Australia.HEALTHCARE426 MJA Vol 176 6 May 2002HEALTHCAREsought about the number of occasionsthat the respondents had been involvedin the litigation process (and how far intothe process they went on each occasion)and their involvement as an expert wit-ness. As the replies were anonymous, itwas not possible to follow up those Fel-lows who failed to respond.RESULTS1.ResultsDemographic informationQuestionnaires were returned by 829Fellows (a response rate of 74%). Threesurveys were excluded for not stating anAustralian practice address, leaving atotal of 826 surveys from which datacould be drawn.Of the respondents, 72% (596/826)were currently practising obstetrics, and19% (158/817) were women (9 peopledid not specify their sex). The mediannumber of years since the respondentwas first admitted as a Fellow (of anycollege of obstetricians and gynaecolo-gists) was 17 (5th and 95th percentileswere 2 years and 34 years, respectively).Ceasing practiceThe reported intentions of the respond-ents suggest that the number practisingobstetrics will fall over the next 10 yearsfor both public and private practice(Box 1) and across all age groups,although the proportion intending tocease practising was higher among olderrespondents (Box 2).Of the 388 respondents who hadalready ceased public practice, themedian time since ceasing was six years;of the 349 respondents who had alreadyceased private practice, the median timesince ceasing was five years. The rea-sons given for ceasing public and privatepractice were, respectively, to specialisein gynaecology (34% and 38%), fear ortrauma of litigation (25% and 39%),indemnity insurance cost (20% and41%), practice cost (10% and 27%),disruption to family (37% and 21%),and long and late hours (37% and 40%)(more than one reason could be givenby each respondent).Medical indemnity insuranceIn Australia, in the 12-month periodprior to our survey, the median annualinsurance premium for those practisingobstetrics was $35 515 (taking intoaccount any extra call made by theinsurance or indemnity organisation),and varied according to the State orTerritory in which they practised (Box3). Of the 432 respondents who had apublic practice, 143 paid their owninsurance, 58 were partially subsidisedand 231 did not pay for insurance. Ofthe 477 respondents who had a privatepractice, 449 paid their own insurance,14 were partially subsidised and 14 didnot pay for insurance.Threatened or actual litigationSixty eight per cent (557/818) of obste-tricians were aware of the possibility oflitigation against them at some point intheir obstetric careers.Among the 32% (262/815) ofrespondents who had at some timereceived documents from a court for-mally initiating an obstetric claim, therewere 401 claims reported (Box 4). Thefull outcomes were not provided for allclaims reported, as some are ongoing.After receipt of documents formallycommencing a court action againstthem, 46% of respondents had experi-enced depression and 3% had consid-ered suicide, and 37% stated that itinterfered with their work. Seventy-seven per cent of respondents currentlypractising obstetrics indicated that thepresent state of litigation encourageshigher rates of caesarean section. Forty-five per cent of respondents would like ano-fault publicly funded scheme intro-1: Respondents’ projected intention of practising obstetrics050100150200250300350After 10 yearsAfter five yearsAfter one yearCurrentlyNumber of respondentsPrivate practice onlyPublic practice onlyBoth private and public practicePractising2: Respondents’ intention to practise obstetrics at various years, by age*ND=Not disclosedNumber of respondents020406080100120140Currently practisingNumber of respondents020406080100120140160ND*8075-7970-7465-6960-6455-5950-5445-4940-4435-3930-34Age distribution of all respondentsNumber of respondents020406080100120Intending to practise after one yearNumber of respondentsNumber of respondents020406080100Intending to practise after five years020406080Intending to practise after 10 yearsND*8075-7970-7465-6960-6455-5950-5445-4940-4435-3930-34ND*8075-7970-7465-6960-6455-5950-5445-4940-4435-3930-34ND*8075-7970-7465-6960-6455-5950-5445-4940-4435-3930-34ND*8075-7970-7465-6960-6455-5950-5445-4940-4435-3930-34Age groupMJA Vol 176 6 May 2002 427HEALTHCAREduced to compensate patients for anyadverse medical event or condition; afurther 17% would approve of a suchscheme if limited to obstetric eventsonly. Others would prefer a schemelimited to children with a disability frombirth (18%), children with a severe neu-rological disorder (8%), or children on acerebral palsy register (4%), and 4% areopposed to introducing any no-faultcompensation scheme.Expert opinionOf the respondents, 314 (38%) hadbeen asked to supply a written expertopinion in an obstetric case. Thirty-three (11%) of the respondents who hadsupplied a written opinion had supplied25 or more opinions and these com-prised 71% of the total number of opin-ions given; 6% of the total number ofwritten opinions supplied by these 33respondents resulted in testimony givenin court. Eleven (33%) of theserespondent s  were  no t  on  theRANZCOG’s list of approved expertwitnesses for obstetric cases and 14(42%) did not currently practise obstet-rics.DISCUSSION1.DiscussionThe results show an aging obstetric work-force. Nineteen per cent of respondentswere women, corresponding with a 19%female Fellowship of the RANZCOG in2001 (source: RANZCOG database).However, 55% of trainees in 2001 werewomen (source: RANZCOG database)and their equivalent full-time contribu-tion to the future workforce is likely to beless than that of male trainees.In the years 2000 and 2001, 46 and49 trainees, respectively, finished theirtraining in obstetrics and gynaecology(source: RANZCOG database). How-ever, given that 24% of all traineesnewly elevated to Fellowship say thatthey do not intend to practise obstetricsat all,3 this leaves about 35 trainees peryear intending to practise obstetrics. Ifthis continues, there will be a shortfallin the number of practitioners availableto replace those planning to retire overthe next 10 years. If the respondents’predictions of the timing of their with-drawal from obstetrics are correct, thena retirement rate from obstetrics ofabout 50–60 practitioners per year canbe expected over the next 10 years.There is likely to be regional variation,with higher retirement rates in NewSouth Wales, where indemnity costs arehighest.Rates of retirement from obstetricsmay rise even further if an increasingworkload falls to those still practisingobstetrics and if indemnity premiumscontinue to rise. The private sector maylose practitioners more quickly than theparts of the public sector in which theemployer pays for indemnity insurance.However, our survey showed that about44% of currently practising specialistobstetricians in both sectors proposed tocease practice within five years.Most obstetricians are self-employed,work in private practice and must paytheir own indemnity premiums, butindemnity costs are not uniform. Staffspecialists employed by the State healthdepartments generally have theirindemnity premiums paid for both pub-lic and private patients (Richard Wil-son, Senior Medical Advisor, UnitedMedical Protection, personal communi-cation),  but cl inical  academicsemployed by universities often have topay their own indemnity costs to con-duct private practice. Premiums alsovary from State to State. Much higherpremiums have been foreshadowed for2002–03. The base rate in New SouthWales will be $97 412 in addition to acall (Richard Wilson, Senior MedicalAdvisor, United Medical Protection,personal communication).With such high indemnity premiumsand low Medicare schedule fees, theeconomic difficulties of running a pri-vate practice become great. These areespecially onerous when commencingpractice, taking leave, or reducing work-load in later years.Of great concern is the number ofobstetricians who felt depressed or con-templated suicide following initiation ofa court action, as well as the extent thatpotential litigation is influencing theirwork and decisions to perform caesar-ean sections.Most respondents would prefer towork under some type of “no-fault”scheme. Many expressed a preferencefor a publicly funded compensationscheme for all adverse medical eventsand conditions, along the lines of theNew Zealand government’s accidentcompensation scheme. However, ascheme covering all adverse outcomesmight increase the number of claimsand, unless compensation was capped,4: Outcome of litigation commenced against respondents (between 1978 and 2001)Number of claims commenced in the courts 401Number of claims settled before trial 256Number of claims settled during trial 23Number of claims in which a trial was completed26Number of claims in which trial verdict was in favour of defendant19Number of claims in which trial verdict was in favour of plaintiff4Median value of settled claims (range) $60 000 (nil to $4  million)3: Indemnity premiums for obstetric practitioners over the previous 12 months, by State/Territory (based on participants’ responses)State/Territory 25th percentile Median 75th percentile MaximumNew South Wales $35 750 $55 000 $67 000 $138 000Victoria $32 000 $35 530 $45 000 $80 000Queensland $1 500 $31 800 $39 250 $70 000South Australia $4 850 $28 000 $33 000 $35 000Western Australia $24 250 $48 000 $52 580 $60 000Tasmania $14 850 $15 000 $15 000 $16 000Northern Territory $763 $11 900 $24 500 $25 000Australian Capital Territory $47 750 $61 000 $73 000 $156 000Total $20 000 $35 515 $52 000 $156 000428 MJA Vol 176 6 May 2002HEALTHCAREcould prove expensive. In the UnitedStates, it has been estimated that up to88% of the cost of indemnity and litiga-tion is spent on legal processes and onlya small percentage of the total cost isawarded to a small percentage of claim-ants.5An adverse event or complication oftreatment is not necessarily due to negli-gence, but without some type of legal orpeer review this may not be clear to thepublic. Some type of independentreview system is necessary.Our survey showed that a majority ofobstetric opinions are given by a smallnumber of obstetricians, many of whomhave retired from active obstetrics andare not acknowledged by their peersthrough RANZCOG accreditation asqualified to give medicolegal opinion inthis area. This is of concern, as it maylead to inappropriate litigation.The problems facing the Australianobstetric workforce appear to be multi-factorial, and multifaceted solutionsmay need to be considered to avoid aserious crisis in the delivery of Aus-tralia’s most precious resource — itschildren. Some initiatives that could beconsidered are presented in Box 5.Until possible long-term solutionshave been discussed, enacted and giventime to influence recruitment to andretirement from obstetric practice, moreimmediate, radical, costly and prag-matic policies will be necessary. Thepublic sector must prepare to handle arapidly increasing number of deliveriesas private hospitals cease to offer obstet-ric services. The metropolitan sectormust expect to have to service the ruralsector with outlying clinics, and therewill be increased transfer of pregnantwomen to city hospitals. It will be nec-essary to find more obstetricians andpossibly allied staff, such as midwivesand anaesthetists, from abroad. In thenear future, a reduction in the qualityand quantity of obstetric servicesappears almost inevitable.ACKNOWLEDGEMENTS1.AcknowledgementsOur study was supported by funding from the AustralianMedical Association and the National Association of Spe-cialist Obstetricians and Gynaecologists. We thank theFellows of the Royal Australian College of Obstetriciansand Gynaecologists for their responses.COMPETING INTERESTS1.Competing interestsNone declared.REFERENCES1.References1. Campbell J. Out of the trenches II. O&G 2001; 3:199-202. (A quarterly publication by RANZCOG.)2. Bates J, Child A, Woinowski J, et al. RANZCOG/NASOG workforce 2000 survey. O&G 2001; 3: 11-25. (A quarterly publication by RANZCOG.)3. Practice intentions of new Fellows and Trainees.O&G 2001; 3: 140-142. (A quarterly publication byRANZCOG.)4. MacLennan AH. Who will deliver the next genera-tion? Med J Aust 1993; 159: 261-263.5. Ransom SB, Dombrowski MP, Shephard R, LeonardiM. The economic cost of the medical-legal tortsystem. Am J Obstet Gynecol 1996; 174: 1903-1909.6. The Right Honourable the Lord Woolf. Access tojustice. Final report to the Lord Chancellor on thecivil justice system in England and Wales. London:HMSO, July 1996. (Received 6 Mar 2002, accepted 28 Mar 2002) ❏5: Initiatives that could be considered to redress the declining numbers of obstetric practitioners■ A “no-fault” compensation system for neurologically disabled children.■ A scheme of structured awards rather than a single lump-sum payment.■ The selection of expert witnesses by the court rather than the plaintiff or the defendant.6■ Payment of indemnity premiums to practise private obstetrics in hospitals or in regions where this is required or desirable.■ Improvement in working conditions for obstetricians, with reasonable rostered hours achieved through group private practice or increased hospital staff appointments.■ Encouragement of team obstetric and midwifery practice.■ Greater public education and realistic expectations of the rates of perinatal and maternal mortality and morbidity, including birth defects.■ Better access to dispute resolution processes before civil litigation.■ The training of specialists specifically to practise only obstetrics or only gynaecology.■ Lowering of the statutory time limit in which litigation can occur after birth.

Projections of Australian obstetricians ceasing practice and the reasons

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Projections of Australian obstetricians ceasing practice and the reasons

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Projections of Australian obstetricians ceasing practice and the reasons

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