Doctors fear being the subject of a complaint. They also get apprehensive when they read about a colleague going through a difficult medicolegal ordeal. Thoughts such as ‘will I be next’ are commonly engendered. Furthermore, the future is not reassuring, matters are likely to get worse. All bodies report that allegations against doctors continue to rise year on year. Complaints can take a number of routes- formal and informal hospital internal enquiries, medical litigation, the coroners court, and the medical council. In some cases a complaint may be channelled through more than one agency which adds further to the distress caused.
The editorials in the medical journals are increasingly expressing concern for the welfare of doctors in the face of the growth in the number of complaints. Doctors need to be better prepared and better educated in the regulatory components of their jobs. Haysom1 writing recently in the Australian journal quoted the following reflection of a GP under investigation ‘ I found that my mind was obsessing with the case 24/7, and it was too easy to let this take over. I started suffering the basic symptoms of anxiety with occasional moments of panic. I found myself waking up in the middle of the night with the case on my mind.’ This level of worry is very debilitating. It is understandable that when the complaint process is protracted, a doctor may be unable to continue practicing2.
A report by the General Medical Council3 found that a total of 28 doctors had died from suicide between 2005 and 2013. One of the points raised in the report was that several of the doctors would have been vulnerable due to health-related issues. The introduction of training on mental health issues for all GMC staff was recommended. In addition, it was urged that a senior medical officer be appointed to advise on cases where the doctor had mental health issues. The GMC does state that its core function is not to punish doctors, but to protect patients and the public.
The most illustrative study on the impact of the complaint procedure on doctors is that by Bourne et al4. Their large study included 7926 doctors. Among this cohort, 2257 doctors were facing a current complaint and 3889 doctors had been subject to a past complaint. Of the doctors involved in a current complaint, 16.9% experienced moderate/severe depression. A similar proportion suffered from significant anxiety. The level of distress was proportional to the complaint severity. In addition these doctors were at least twice as likely to report thoughts of suicide or suicide ideation. Following the complaint process over 80% of doctors changed the way that they practiced. The change was to adopt ‘defensive practice’. ‘Defensive practice’ is composed of ‘hedging’ and ‘avoidance’ activities. ‘Hedging’ is overcautious practice with an inability to make simple clinical decisions, and overprescribing, over referral, and over investigation. ‘Avoidance’ relates to not taking on complicated patients, and refusal to undertake certain procedures. A particular concern is that doctors involved in high-risk, high-intervention specialties are more likely to sued or complained to authorities. Defensive medicine is unhelpful and uncomfortable for patients. In addition, it contributes substantially to cost of healthcare
It appears that the complaint proceedings have a disproportionate effect on a doctor. It is important to point out that the vast majority of doctors referred to the GMC are subsequently found to have no case to answer. In 2012 the GMC dismissed 60% of complaints at the triage stage, and 75% of the remainder were concluded by case examiners with no action taken. Many doctors described a medicolegal complaint as the most traumatic experience of their professional life even when the ultimate outcome of the case was favourable. When doctors are asked how the complaint proceedings can be improved they emphasise that the process should be transparent, and that the assessors should be up-to-date and knowledgeable. If is a complaint is vexatious they feel that they should be entitled to financial redress. The problem, however, is how vexatious could be defined legally.
The counterbalance is that the hospital, regulatory and the courts are in place to protect patients and maintain standards. There is no disagreement about these principles. Rather, the debate centres round whether the current procedures with their high levels of associated psychological morbidity should be reviewed. Some commentators point out that instead of adhering to the specifics of the complaint the allegations may extend more widely and bring the doctor’s professionalism into question. This appears to be key in the amount of anxiety and depression generated. There is a mounting literature confirming that the formal complaint structure has a major impact on a doctor’s working, professional, and personal life. As a first step, it would be helpful if this was universally accepted. Many doctors speak about their sense of isolation and not knowing where to turn for support other than their own families. It is becoming clear that most doctors facing a significant complaint should be offered and should accept counseling. This is very important because at the end of the legal process the doctor has to face into his frontline duties again. If his confidence and self-esteem have been undermined, it is unlikely that he will be able to function optimally. Arbitration and consensual disposal should play an increased role5.
The key issues of the medicolegal and complaints process need to be kept in perspective. It is there to protect patients and provide them with an effective way of communicating concerns about their care. It provides compensation to patients when they have suffered iatrogenic injury or avoidable harm. The purpose is to learn from the process so that the mishap does not occur to other patients in the future. There is an expectation that it provide the doctor with further education/training and assistance where necessary. There are a number of unintended consequences for doctors including anxiety, depression, loss of self-esteem. The unintended consequence for patients is the increase in defensive medicine.
In summary, many commentators feel that there should be a greater emphasis on the learning elements from a complaint and a reduced concentration on the adversarial component. The benefit would more openness which is the cornerstone in the reduction of medical error.
1. Haysom G. The impact of complaints on doctors. Royal Aus. College of General Practitioners 2016;45:242-244
2. Limb M. Doctors are emotionally ‘damaged’ by complaints, analysis finds. BMJ 2016; 5 Jul.
3. Rimmer A. GMC urges national support service for doctors’ health concerns. BMJ 2014;349:g7777
4. Bourne T, Wynants L, Peters M, Van Audenhove C, Timmermann D, Van Calster B, Jalmbrant M. The impact of complaints procedures on the welfare, health and clinical practice of 7926 doctors in the UK: a cross sectional survey. BMJ Open 2015;4:e006687
5. Dyer C. GMC and vulnerable doctors: too blunt an instrument? BMJ 2013;347:f6230