Journal of the New Zealand Medical Association, 10-October-2003, Vol 116 No 1183
The characteristics of doctors receiving medical complaints: a cross-sectional survey of doctors in New Zealand
Wayne Cunningham, Raewyn Crump and Andrew Tomlin
There is little published information about the experience of medical complaints (complaints) received by doctors in New Zealand. Complaints have implications for individual doctors, for the institutions in which they work, for the medical profession and the society it purports to serve. If complaints have the potential to damage doctors and reduce the level of care provided to patients,1 then it is imperative to understand the demographics of doctors receiving complaints, and to identify particular areas of vulnerability.
In New Zealand in the year to June 2002, the Office of the Health and Disability Commissioner (HDC) received 571 complaints against medical practitioners, down from 741 in the year to June 2001, but up from 423 in the year to June 2000.2 In the year to June 2002, the Accident Compensation Corporation (ACC) received 1900 medical misadventure claims related to doctors, of which 480 were accepted, 53 being attributed to medical error (personal communication, Rosemary Matthews, Analyst Medical Misadventure Unit, ACC, 2003). Of the 35 calls from doctors received daily by the medicolegal advisors to the Medical Protection Society (MPS), approximately 40% relate to complaints. In 2002, the MPS opened 850 ‘complaint files’ for their doctor members (personal communication, Dr Denys Court, MedicoLegal Advisor, MPS, 2003).
Recognised issues confronting the complaints and malpractice process include the rising rate of complaints, the timeliness of the process, inconsistencies between the incidence of complaint and malpractice litigation both geographically and with respect to true malpractice, and differences between doctors who receive a complaint.
In the United States, malpractice payment rates vary between states from 0.7% to 3.7% per physician per year, prompting the comment that ‘such a great discrepancy seems to challenge the notion that the risk of malpractice litigation consistently promotes the quality of health care’.3 Malpractice litigation in the United States has even been described as a ‘lottery’,4 and there may be a low correlation between actual medical negligence and subsequent malpractice litigation.5
The rate of complaint to the General Medical Council in Britain rose by over 30% between 1999 and 2000, with 77% of cases having been heard and concluded within six months, with acknowledgement that ‘justice delayed is justice denied’.6
In New Zealand, the low ratio of successful claims to adverse events in a hospital-based setting under the ACC legislation suggests that cultural factors rather than a change in legal doctrine alone are important in the incidence of claim making.7
There are conflicting notions about the characteristics of doctors who receive a complaint. A study in Florida found that male, board-certified, US or Canadian medical school graduates had a 56% risk of being sued at least once, compared with a 17% risk for female physicians graduating from medical schools outside the US. Doctors who had experienced three or more malpractice suits had characteristics associated with greater knowledge.8 In contrast, a study in Michigan found that lower training credentials (medical school and residency training programme rankings) were strongly predictive of future malpractice experience.9
Some specialties may have a higher risk of complaint than others – surgeons in one study had twice the rate of complaints of non-surgeons10 – but malpractice-risk-reduction strategies (such as changing communication behaviours) are not necessarily the same in different specialty groups.11
This study aimed to characterise the distribution of complaints against New Zealand doctors, to allow comparison with other studies, and to consider the implications of the findings.
In June 2001, 1200 questionnaires were mailed to doctors on the New Zealand medical register using a stratified, systematic sampling technique. From each of the alphabetically ordered lists of (1) vocationally registered general practitioners, (2) hospital-based specialists, and (3) general registrants (junior hospital doctors, medical officers of special scale (MOSS), and general practitioners not on the indicative vocational register), every seventh name was selected until each group contained 400 potential participants. The medical discipline of each respondent was taken as that indicated on the medical register at June 2001. Hospital-based specialists were classified into ‘procedural’ and ‘non-procedural’ groups. The former group included surgical subspecialties combined with anaesthetics, emergency medicine, and obstetrics and gynaecology. All other specialties including radiology were considered ‘non-procedural’.
Each selected doctor received: (1) a mailed invitation to participate; (2) an information sheet; (3) a consent form; and (4) two sealed envelopes, one to be opened by those who had never received a complaint, and the other for those who had ever received a complaint. A complaint was not further defined, leaving participants free to decide if their experience of a particular event should be called a complaint, but participants were asked to indicate to which body a complaint had been directed (the Health and Disability Commissioner (HDC), the (former) Medical Practitioners Disciplinary Committee (MPDC), the Accident Compensation Corporation (ACC), ‘in-house’, or other).
All questionnaires requested demographic data, including age, gender, place and year of graduation, years in practice in New Zealand, and postgraduate qualification. The respondents’ views about the medical disciplinary complaint system in New Zealand were sought, along with suggestions for change.
Doctors who had ever received a complaint completed additional sections about the complaint’s short- and long-term impact on themselves and their practice of medicine. They were asked with which organisation the complaint had been laid, the time that elapsed from the event or incident that led to the complaint to actually receiving the complaint, the time to resolution of the complaint process, and whether the complaint had been upheld or dismissed. They were asked for their view of the reason for the complaint, choosing any combination of the following options:
The questions were developed from previous research by one of the authors in his study on the effect of medical disciplinary complaints on general practitioners,1 and were piloted in the Department of General Practice, Dunedin School of Medicine.
Non-respondents to the initial mailing were re-surveyed by post with a questionnaire asking only if they had ever or never received a complaint, to determine whether or not the doctors who completed the survey were representative of the wider population of New Zealand doctors. This paper does not include an analysis of suggestions for improvement to the New Zealand complaints process, nor of attitudinal and practising differences between doctors who have ever or never received a complaint.
Chi-square tests were used to test associations between doctors’ experience of complaints and the demographic variables. Because of multiple tests, the level of significance chosen for this study was p <0.01. Ethical approval was obtained from the University of Otago Ethics Committee.
Of the 1200 doctors surveyed, 598 (49.8%) completed the full questionnaire. Of these, 201 respondents (33.6%) had received a complaint at some time during their medical career and 397 (66.4%) had never received a complaint. There were 373 replies from the 602 non-respondents who were re-surveyed and, of these, 129 (34.6%) had received a complaint and 244 (65.4%) had not. The total of 971 replies represented a response from 11% of the 8715 doctors registered in New Zealand in April 2001. In total, 330 (34.0%) respondents had received a medical disciplinary complaint and 641 (66.0%) had not.
Table 1 presents the complaints received by doctor characteristic. The gender distribution of respondents was very similar to the gender distribution of the 8715 doctors on the medical register. There were 2791 registered female doctors (32.0%) and 5924 (68.0%) registered male doctors in New Zealand in April 2001. In this study, 591 respondents indicated their gender and, of these, 192 (32.5%) were female and 399 (67.5%) male. As Table 1 shows, male doctors were more likely to have received a complaint (p <0.01).
Table 1. Complaints received by general practitioner characteristic
Vocationally registered general practitioners received more complaints than either hospital-based specialists or doctors on the general register (p <0.01).
No significant difference in the rate of complaint was found between hospital-based specialists classified as ‘procedural’ or ‘non-procedural’. Classifying radiology in the procedural group did not alter the non-significant outcome.
More doctors holding higher degrees received complaints (p <0.01), but there was no significant difference between doctors who had graduated from New Zealand universities and those from overseas institutions.
In total, 81% of complaints had been resolved and 14% were still proceeding. Of the complaints that had been resolved, 136 (83.4%) were dismissed and 27 (16.6%) upheld. The results are shown in Table 2.
Table 2. Complaint outcome by body to which complaint was lodged
MPDC = Medical Practitioners Disciplinary Committee; HDC = Health and Disability Commissioner; ACC = Accident Compensation Corporation; ‘Other’ includes civil courts and the coroner
Figure 1 shows the number of complaints received per year as reported by respondents. The total for 2001 is for reported complaints up to June of that year. There appears to be a rise in the rate of complaints, which begins in the mid-1980s. The rate of complaints per doctor for the year 2000 was 5.8% (34/589) for the respondents in this study.
Figure 1. Number of complaints reported per year (to June 2001) by survey respondents
Figure 2 shows the age distribution of doctors at the time of receiving a complaint. There was no significant difference in the age distribution before and after 1997 (p <0.01). From 1995 to 1998 about 50% of doctors receiving a complaint were between 40 and 60 years old. This increased to 68% in the years 1999 and 2000.
Figure 2. Age distribution of doctors at time of receiving a complaint
Examination of the time elapsed between the incident providing the reason for the complaint and receipt of the complaint by the respondent showed that 81% of upheld complaints, 71% of dismissed complaints, and 61% of complaints that were still proceeding had been received within 12 months of the incident (Table 3). Seventy four per cent of dismissed complaints had been resolved within 12 months but only 59% of the upheld complaints.
Table 3 lists the reasons for complaint as viewed by the respondents. The majority of complaints were considered due to ‘a perceived or actual error in the practice of medicine’.
Open-text answers in the ‘other’ category included:
‘The patient had serious relationship problems with his wife...I was involved in a counselling role...the husband took exception to this.’
Vocationally registered GP
‘The patient had major psycho-social problems...mistakenly included my name in the complaint.’
‘Another doctor implying that I had not acted appropriately.’
Table 3. Reasons for complaint and time to resolution
This report documents the incidence of medical complaints made about New Zealand doctors. It raises issues about the distribution of complaints, and about the implications for individual doctors, healthcare institutions, and the medical profession and society.
This study finds a high incidence of complaint. One in three doctors in this representative sample had experienced a complaint, and in the year 2000 the complaint rate per doctor per year was 5.7% (albeit with an 85% dismissal rate). Even if the rate of complaint stabilises at this level, these findings suggest that almost one in every seventeen doctors will receive a complaint if they decide to practise medicine for another year.
Complaints were not evenly distributed throughout the medical workforce. The evidence that geographic location and procedural practice do not increase the risk of a complaint should be reassuring to those doctors who may see themselves as vulnerable for those reasons. Similarly, doctors who have trained overseas (who may be less familiar with New Zealand culture) do not seem to be at higher risk than their colleagues trained in New Zealand.
Those carrying a higher risk of complaint are general practitioners, male doctors, and those with higher postgraduate qualifications. The age and experience of the practitioner are independent risk factors. This finding is consistent before and after 1997, suggesting that it is the practitioner being of an age and experience that is important, rather than the process of ageing and practising. It is possible that it is the more experienced doctors who are carrying the burden of responsibility for patient care, and are more vulnerable to receiving a complaint as a consequence. The results challenge the notion that increasing specialisation (and expertise) is protective of receiving a complaint.
This study cannot explain why some events lead to a complaint and some do not, but it does consider doctors’ views about the reasons for complaint. In over one third of cases (if fraud is excluded), doctors considered that an actual or perceived error in the practice of medicine contributed to the complaint being made. If error (rather than doctor–patient communication, personal behaviour or other interpersonal skills) is seen as paramount in the genesis of complaints, there are implications for how doctors may behave in order to reduce their risk of future complaint.
Individual doctors may view complaints as inevitable and complaint avoidance as difficult. They may seek to practise in such a way that error is minimised and their actions can be defended. This approach risks an increase in both positive and negative defensive medicine,12 with unnecessary investigation and over-referral, or with withdrawal of services as respective examples. If important components of the Patient-Centred Clinical Method,13 such as doctor–patient communication and enhancing the doctor–patient relationship are considered less important, these aspects of patient care risk being minimised or even lost in the patient encounter.
In terms of healthcare institutions, this study finds that complaints are spread across all specialty groups, and are independent of procedural work. Healthcare institutions may be vulnerable to the impact of the rising complaint rate because the doctors targeted by complainants appear to be the senior and experienced doctors on whom the institutions rely to deliver high-quality patient care.
The time to resolution of complaints is unduly long. Not only does society need timely protection from errant doctors, but resolving complaints rapidly and providing alternative treatment may be the only opportunity a patient has to get a satisfactory outcome from poor medical care. For doctors, rapid resolution may improve their personal wellbeing, and the standard of care provided to subsequent patients.
The role of the complaints system in society needs to be debated and made explicit. If complaints are to serve to improve the quality of healthcare delivered to patients, the complaints system must function as an effective vehicle for learning by doctors and for appropriate change by both doctors and institutions. The non-uniform distribution of complaints in New Zealand suggests that either the quality of patient care is unacceptably variable, or that particular groups within the medical workforce are carrying the burden of responsibility for care and vulnerability to complaint. This situation may not be in society’s long-term best interest.
Author information: Wayne Cunningham, Senior Lecturer, Department of General Practice; Raewyn Crump, Research Assistant; Andrew Tomlin, Assistant Research Fellow, Royal New Zealand College of General Practitioners Research Unit, Department of General Practice, Dunedin School of Medicine, University of Otago, Dunedin
Acknowledgements: We thank Dr Susan Dovey (American Academy of Family Physicians) and Mr Ron Paterson (Health and Disability Commissioner) for critiques of earlier drafts of this paper.
Correspondence to: Dr Wayne Cunningham, Department of General Practice, Dunedin School of Medicine, PO Box 913, Dunedin. Fax: (03) 479 7431; email: email@example.com
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