ONE of my earliest career mentors advised me that “the patients that complain about you, shouldn’t, and the ones who don’t complain, probably should”; recognition by a talented and reflective practitioner that despite our best efforts, there will be poor outcomes, missed opportunities and disappointed clients.
Patient satisfaction will be determined by a range of factors, only some of which can be modified by the treating doctor. Many of our patients recognise our commitment and diligence, but some will expect more despite the best of care.
Complaint rates are low in Australia, in part a reflection of our high standards of care, but it is essential that the public has access to systems for expressing any concerns. A proper investigation process for received complaints allows an independent assessment process to determine whether the complaint is justified, and if so, what redress should be available to the complainant.
While recognising that a robust complaints reporting process can drive improvements in quality and safety, we know that doctors find the complaints and subsequent investigation processes highly stressful, regardless of the legitimacy or severity of the complaint. In a large Australian study, Nash and colleagues demonstrated that adverse mental and social health outcomes were associated with any level of complaint and investigation.
The General Medical Council (GMC) in the United Kingdom has recently published recommendations aimed at improving their approach to investigating doctors. They plan to introduce a number of changes, starting from the tone of the initial correspondence sent to doctors informing them of the complaint and investigation. The GMC seeks to strike a balance between clarity – about what’s happening and why – and sensitivity to the stress the doctor will be under.
Doctors are trained in a paradigm that mandates that effective communication should never make the patient or client feel uncomfortable. Receiving notification of a complaint in strict legal terms, with multiple appended caveats that warn of dire potential consequences for failure to comply with the investigation or for adverse findings, is a terrifying experience for doctors.
A further recommendation in the GMC report relates to speeding up the investigative process, mirroring similar calls in Australia. Slow and bureaucratically complex processes, even for minor matters, cause prolonged stress for doctors and dissipate the resources of investigatory bodies, leading to even longer delays. Similar concerns were raised in the recent review of the processes of the Australian Health Practitioner Regulation Agency, taking note of the work by Nash and colleagues, among other evidence. An important part of the GMC recommendation is that lower level concerns be dealt with expeditiously, with no justification for a lengthy and expensive investigation.
Another of the GMC recommendations was that (non-clinical) health system staff be educated about the stresses associated with clinical practice. It went so far as to say that “staff should be given the opportunity as part of their personal development plan to spend time in a clinical setting on an ongoing basis”. Having long expressed the view that anyone who works within health systems should spend time in the “real world” of clinical service delivery, the thought of the accountants and health service managers being pulled away from their offices to deal with the exigencies of limited resources, endless service demand and implacable clients appeals to me very much. However, I won’t hold my breath waiting for the adoption of this recommendation within the Australian health systems!
The GMC report recommends that doctors be trained in emotional resilience, particularly during medical school. While I agree that all doctors should have awareness and a vocabulary to understand the effects of stress, I have found that presenting information about the potential hazards associated with clinical practice has a limited impact on young doctors not yet faced with clinical responsibility.
It is much more important that we promote the availability and uptake of supportive resources to doctors at any stage of their career who may be experiencing a range of stressful circumstances, including a complaint.
To this end, the Medical Board of Australia is to be commended for recent initiatives to fund support services and resources for doctors with health problems through the Doctors’ Health Advisory Services in each state and territory. These resources will be available to colleagues experiencing the physical and emotional problems that can be associated with complaints and investigations.
I welcome this increased recognition by the regulators and peak professional bodies of the impact of complaints on clinicians. Evidence of poor outcomes for doctors has been neglected for too long, and the recent changes and recommendations are a pleasing initiative to restore some balance, with more still to be done.
Professor Simon Willcock is chair of the Avant Mutual Group.
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