Category:Surviving complaints

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Sadly, receiving a complaint against some aspect of your medical care is increasingly a fact of life. Cultural expectations have changed and the dynamic between patient and doctor has become more like customer and provider with the attendant expectations. [1]

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Biased towards UK situation

Unfortunately, doctors, certainly in the UK, face the issue of multiple jeopardy, where a complaint from a single incident may be pursued in several settings: local Trust or Commissioner complaint, civil proceedings, criminal charges (rare) and finally GMC proceedings (Medical Practitioners Tribunal Service, formerly known as Fitness to Practice panel).

Contents

Types of Complaint

There are lots of reasons why complaints can arise. Some complaints will be justified and you may have made an error or at least suffered a lapse of concentration or judgement. Other complaints may arise from a lack of communication or a misunderstanding. Other times, patients will complain out of anger or dissatisfaction with an outcome which was outside of your control. Some complaints are purely vexatious or made out of a desire for financial compensation (often encouraged by malpractice/negligence lawyers). Some, such as those prepared on a patients behalf by organisations such as the Independent Complaints Advocacy Services (ICAS) in the UK are likely to be more serious. It seems possible that some complaints against individual doctors are encouraged by NHS Trusts who would rather see an individual doctor scapegoated than accept blame that is rightly theirs (see eg the Bawa Garba case - it has been suggested that this may have been the case here).

A question you might find useful when a patient seems to be complaining is "Are you coming to see me to put in a specific complaint about something or do you simply want me to clarify what's been going on?"[2]

The type of complaint will determine your response. There may be occasions where you will feel that a sincere apology is warranted. In other situations, after reflecting on the incident and the associated complaint, you may decide that your clinical decision and the way it was handled was reasonable (or even exemplary) and to the best of your abilities. Despite the pressure to apologise, it may be more appropriate to express regret, explain the situation, but not to indulge in needless and unwarranted self-flagellation.

Practicalities

Most complaints are best handled proactively. Prevention does work. Indeed, it is probably the major reason why some doctors have a much lower complaint rate relative to others with a similar case load. This prevention can include your approach to patient doctor interaction. Just as important as good clinical care is documentation in the medical records, as a poor record keeping can make a complaint hard to defend even if no wrong has been done.

On occasion, you may have an inkling that a particular encounter is likely to trigger an imminent or subsequent complaint. In these cases, it may be useful to clearly document circumstances while they are still fresh in your mind as this can make the complaint, when it eventually arrives, easier to defend.

Proactive management can also involve prompt, appropriate communication, even if this inconveniences you and other patients. Resolving a complaint verbally is to be recommended, if possible.

It is useful to sit down and collect your thoughts on paper. Contact your defence union early (every doctor should be a member). They will be invaluable in helping you deal with any complaint. They are there to support you and can be source of reassurance and advice in what is invariably a very difficult time.

The exact mechanism of responding to a complaint will depend on the setting in which you work (primary care vs hospital). It may also depend on the route of the complaint (formal complaint, litigation, GMC, etc.).

  • formal reply in writing
  • face to face meeting with neutral 'host' in neutral setting

Hospital Complaints

In hospitals, there is often a risk and clinical governance team who will often deal with the initial complaint. Most hospitals also have a Patient Advice and Liaison Service (PALS) or eqivilent which aims to settle complaints and disputes amicably.

As a junior doctor, a large proportion of the complaints that involve health care aspects of patients you may have cared for will be unknown to you as they do not involve you. As complaints are often lodged some time after the actual incident, you may be asked, as a junior doctor, to comment on a case that you were involved many months after it occurred. Such requests do not necessarily mean that you are the target of the complaint as the hospital may simply be gathering facts from any doctor involved in the case.

As a consultant, if the patient was under your care, you are far more likely to be involved, even if the substance of the complaint does not involve medical issues.

In the UK NHS, it will be the Chief Executive of the hospital who will be responsible for replying to a formal written complaint. If you are involved in such a formal complaint and have been asked to comment on it, you should ask to see the draft and final letter sent to the complainant. Sometimes this is a good learning experience in understanding how to express issues in plain language, sometimes you will feel motivated otherwise. A defence organisation can be useful in advising you what to do in the latter situation.

Primary Care

Complaints can be dealt with at several levels:

  • practice level
  • commissioner level
  • higher level such as GMC or health service ombudsman

Emotional Aspects

QuotationMarkLeft.png Doctors with recent/current complaints have significant risks of moderate/severe depression, anxiety and suicidal ideation. Morbidity was greatest in cases involving the GMC. Most doctors reported practising defensively, including avoidance of procedures and high-risk patients. Many felt victimised as whistleblowers or reported bullying. Suggestions to improve complaints processes included transparency and managerial competence. QuotationMarkRight.pngBourne et al.[3]


Several things will invariably go through your mind on receiving a complaint. Many complaints carry a lot of anger and hurt. Often patients or their relatives are angry at the outcome of what has happened, irrespective of whether you were responsible. Justified or not, much of this negative emotion can be directed at you. Worse still, you may be accused of being responsible for a bad outcome which you already feel bad about, but had no control over. This can be very upsetting as most complaints come without warning, often some time after the original incident.


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The patient who has the most cause to complain
Is the one who responds with a case of champagne
But the man who has had the most perfect of care

Is spiteful, litigious, rude and unfair.

Traditional, unattributed.


You may find yourself:

  • questioning your own competence
  • losing confidence in your judgement
  • replaying the scenario over and over again
  • becoming anxious or depressed

These are 'normal' responses, in the sense that even perfectly competent and conscientious doctors will feel this way.

Keep communication channels open. There may be a temptation to keep the complaint a secret (e.g. from colleagues or family) as there is still a stigma and a sense of shame associated with having an unresolved complaint. It is better to keep your family aware of what is going on. Talking to a trusted senior colleague will be helpful as they can often give advice and put a more objective perspective on the situation.

Perception

Often there will be completely different perceptions of the same objective situation. This can be very difficult to handle when for various reasons one party can not understand the other parties perceptions. Some people do have better diplomatic skills than others and it can be important to recognise situations where the fact you are right, will not make you perceived as right by a dismissive approach that might be misread as a lack of empathy by independent parties.

GMC Complaints

The GMC are obliged to investigate all complaints made to them. In the initial stages, any complaint, no matter how trivial, will trigger a standardised process. You may receive a rather startling letter to inform you that a complaint has been received against you and will be investigated. This is a standard letter and you should try not to be unduly worried!

References