MedicalResearch.com Interview with:
Professor Tom Bourne Ph.D., FRCOG, FAIUM (hon).
Adjunct Professor, Imperial College, London
Visiting Professor, KU Leuven, Belgium
Queen Charlotte’s and Chelsea Hospital
MedicalResearch.com: What is the background for this study? What are the main findings?
Response: Previous studies had suggested that complaint investigations might be associated with psychiatric morbidity – including depression and suicide. For example in the United States, malpractice litigation has been reported to be associated with burnout, depression and suicidal ideation. We had also witnessed in our daily practice both the burden that complaints investigations have on colleagues, but also that doctors were often practicing defensive medicine to “protect themselves”. Against this background we embarked on a large survey study on doctors in the UK – with almost 8000 physicians replying to the survey. This survey contained questions relating to validated psychological instruments for depression and anxiety, new metrics for defensive practice (hedging and avoidance) as well as single item questions. We published these data in 20151. We found that recent or current complaints were associated with significant levels or anxiety, depression and suicidal ideation, this was irrespective of the complaints procedure – although this was highest when it involved the main UK regulator the general medical council (GMC). Many doctors reported practising defensive medicine due to a fear of complaints – with over 80% reporting hedging and over 40% reporting avoidance. A number of recommendations were made to improve how complaints procedures might work.
In the final part of the questionnaire we asked three open questions, how the complaints procedure made the doctor feel, what was the most stressful aspects of the procedure and what could be done to improve things. It is the analysis of this qualitative data that is presented in the current paper.
MedicalResearch.com: What should readers take away from your report?
Response: This paper explores the psychological, emotional and attitudinal experiences of doctors going through complaints processes. It suggests that rather than a learning experience, these processes are perceived as almost entirely a negative experience. In general these processes leave doctors feeling emotionally distressed, feeling impotent and powerless, feeling victimised, and often feeling negatively about those who complain about them and those investigating them. A few described positive experiences, but these mainly related to support given or being relieved the outcome was not worse.
The most commonly cited reason doctors reported they were distressed was because of the procedures followed in carrying out complaints investigations. Doctors felt the time taken to carry out investigations was both unreasonable and unpredictable; communication was reported as poor as was the information provided to them. They also complained about a lack of transparency and a lack of competence in handling complaints. Doctors also reported feeling intimidated.
Doctors often reported changing their professional practice – with some leaving the profession altogether and others reporting practicing defensive medicine. Neither of these outcomes would see likely to improve patient care.
Doctors made several suggestions to improve processes:
These included having fixed timescales, greater transparency, encouraging an open dialogue and better direct communication with patients in the event of a complaint, and policies to deal with complaints when they are clearly vexatious.
We concluded that current procedures for managing complaints is not fit for purpose, as doctors perceive they are not consistent with natural justice and are associated with a culture of fear. Processes must be improved to encourage an open transparent approach to dealing with complaints that is fairer, and enables clinicians to view complaints investigations as an opportunity to learn, change practice and improve patient care. Currently the complaints culture appears to be associated with defensive medical practice including hedging and avoidance – neither of these outcomes is good for patient safety and increases healthcare costs.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Response: Doctors appear to be a vulnerable group in terms of their response to complaint investigations. Our results have shown an association between complaints and psychological morbidity. More research needs to be carried out to understand to what extent the event leading to the complaint or investigation contributes, to understand with more precision the aspects of complaints investigations that are most stressful, and gain insights into the extent doctors are vulnerable to these processes and why – with particular attention being given to the balance needed between reliance and empathy.
MedicalResearch.com: Is there anything else you would like to add?
Response: Our data suggest that how complaints are investigated contribute significantly to the association between complaints investigations and psychological morbidity amongst doctors. This is disproportionate and there seems no justification for such procedures to make doctors unwell and in extreme cases to commit suicide. We believe complaints procedures need to be reviewed to prevent this. From a policy viewpoint, of great importance is the association with defensive medical practice, as this is not in the interests of patients and adds significantly to healthcare costs (2). Most doctors did not consider complaints investigations as positive and therefore not as a learning experience. Recently medical errors were cited as the third highest cause of death in the United States3. If the impact of these is to be reduced then investigations when things go wrong must be transparent and fear must be removed from processes if a learning environment is to be created. If our data from the UK is at all generalizable to other health care environments, it would appear we are a long way from this situation.
MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.
1.Bourne T, Wynants L, Peters M, et al. The impact of complaints procedures on the welfare, health and clinical practise of 7926 doctors in the UK: a cross-sectional survey. BMJ Open 2015;5: e006687.
2. Rothberg MB, Class J, Bishop TF, Friderici J, Kleppel R, Lindenauer PK. The cost of defensive medicine on 3 hospital medicine services. JAMA Intern Med. 2014 Nov;174(11):1867-8. doi: 10.1001/jamainternmed.2014.4649.
3. Makary M. Medical error—the third leading cause of death in the US. BMJ 2016;353:i2139
Tom Bourne, Joke Vanderhaegen, Renilt Vranken, Laure Wynants, Bavo De Cock, Mike Peters, Dirk Timmerman, Ben Van Calster, Maria Jalmbrant, Chantal Van Audenhove.Doctors’ experiences and their perception of the most stressful aspects of complaints processes in the UK: an analysis of qualitative survey data. BMJ Open, 2016; 6 (7): e011711 DOI: 10.1136/bmjopen-2016-011711
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