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| Journal of the New Zealand Medical Association,
23-July-2004, Vol 117 No 1198
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 THE
NEW ZEALAND
MEDICAL JOURNAL Vol 117 No 1198 ISSN 1175 8716
The immediate and long-term impact on New Zealand doctors who
receive patient complaints
Wayne Cunningham
The rate of complaint against doctors in New Zealand has
risen dramatically in the last 20 years. Recent data suggests that one in every
17 New Zealand doctors can expect to receive a complaint each year if they
decide to continue in
practice,1
and it is reasonable to expect that there will be some impact of a
complaint on doctors and on the way that they practise medicine.
The purposes of a complaints system include:
To maintain or improve standards of professional
practice, a complaint should effect change in the behaviour of individual
doctors and the profession in a way that is of benefit to society. Put simply,
complaints should lead to improved medical practice—this assumption has
never been tested, however.
The only published data about the effect of complaints on
New Zealand doctors comes from a qualitative study of general practitioners,
which suggested that there were immediate and long-term effects on the doctor
and on the way in which the doctor practises.3
Immediate effects included an intense negative emotional response (indicating
the impact of a complaint on the person of the doctor); reduced ability to
consult with speed and confidence and to tolerate uncertainty (indicating an
impact on the doctor’s ability to practice medicine); and hostility
towards the complainant and loss of trust in other patients (indicating an
impact on the doctor-patient relationship).
In the long-term, some of that study’s respondents
held persisting emotional responses (such as depression or anger), some had an
altered perception of themselves as doctors, and some indicated an erosion of
goodwill towards patients. The implication of that study was that complaints
might reduce (rather than improve) the delivery of patient care.
American literature suggests that a complaint represents an
assault on the recipient doctor’s sense of self and personal integrity,
Canadian literature indicates that complaints can cause an increase in both
positive and negative defensive medicine, and British and European literature
suggests that complaints cause changes in doctor’s behaviours that are
predicated by concern for the doctor-patient
relationship.4–7
The vehicle for the delivery of patient care is the
doctor-patient relationship.8 If receiving a
complaint damages the person of the doctor, their contribution to the
relationship (their therapeutic effectiveness) may be diminished, and receiving
a complaint could impact negatively on patient care. The doctor’s
emotional state, their attitude towards their work and patients, and their
ability to cope with the stresses of practice may all impact on their ability to
deliver high quality care. This study seeks to document the extent of the impact
of a complaint on doctors in New Zealand, and (by implication) the possible
impact that complaints may have on patient care.
The aims of this study are to:
MethodIn 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.
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). Participants were asked to indicate to which body a complaint had
gone (the HDC, the [former] Medical Practitioners Disciplinary Committee [MPDC],
the 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 post-graduate qualification.
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. Respondents were asked to recall
their early response to having received a complaint, to consider their current
response to a series of paired statements, and to indicate their level of
disagreement or agreement on a five point Likert scale.
Chi-squared tests were used to test associations
between respondents in different vocational groups, and ‘Wilcoxon matched
pairs signed rank sum tests’ were used to examine the difference between
the immediate and long-term response data
sets.9 The level of significance chosen for
this study was p<0.01. Doctors who had
never received a complaint were asked a
limited number of matching questions about themselves and their practice to
provide a control group data set.
Non-respondents to the initial mailing were re-surveyed
by post via a questionnaire asking only if they had
ever
or never received a complaint (to
determine if the doctors who completed the survey were representative of the
wider population of New Zealand doctors).
The questions were developed from my previous research
on the effect of medical disciplinary complaints on general practitioners, and
were piloted in the Department of General Practice, Dunedin School of Medicine.
Ethical approval was obtained from the University of Otago Ethics
Committee.
ResultsThe characteristics of the
respondents to this study have been previously
reported,1 and can be summarised as follows.
Of the 1200 doctors surveyed, 34% of 971 doctors (11% of the
registered medical workforce) indicated that had
ever received a complaint, and 66% of
those 971 doctors had never received a
complaint.
598 (49.8%) doctors completed the full questionnaire. Of
these 598 doctors, 201 respondents (33.6%) had
ever, 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 received a complaint.
Of the complaints that had been resolved, 83.4% were dismissed.
Table 1 shows the responses to the statements (grouped to
indicate emotional responses, respondents’ attitudes towards themselves
and patients, and about aspects of their practice of medicine). The
‘Wilcoxon matched pairs signed rank sum test’ level of significance
indicates differences between the
immediate and
long-term responses.
There was no difference between respondents in different
vocational groups to any item, either in the
immediate or
long-term.
Immediate
response to receiving a complaint—The results indicate an impact on
the emotional state of doctors, their attitudes toward themselves and patients,
and on their practice of medicine in the first few days, and up to 6 weeks,
after receiving a complaint.
Table 1. Questionnaire results
72.5% of respondents indicated feelings of anger and 65.1%
indicated feelings of depression. 38.4% indicated that they had reduced levels
of enjoyment of the practice of medicine, and feelings of guilt and being shamed
were indicated by 32.5% and 36.4% respectively.
Respondents indicated reduction in both trust of patients
(38.2%) and sense of goodwill to patients (28.6%). Between 14% and 24% of
respondents indicated a negative impact of a complaint on their view of
themselves and their desire to keep on practising. 82.8% and 89.0% of
respondents preserved a sense of commitment and of effort into patient care,
respectively—but commitment to the complainant was
preserved in only 29.6% of cases, and
reduced in 50.3% of cases.
86% of respondents did not indicate that the complaint was a
good thing.
42.3% of respondents indicated that their ability to
tolerate uncertainty in their practice of medicine was reduced, and 29.8%
indicated reduced confidence in their clinical judgment. Only 56.6% felt that
they were able to consult well, although most respondents felt that they
continued to perform technical tasks well and continued to provide the same
range of services.
Long-term
response to receiving a complaint—The results show that the impact
of a complaint softened in the
long-term for most of the items
studied.
36.6% of respondents indicated feelings of anger—but
feelings of depression, guilt, shame, and loss of joy of practice fell to around
10%. All emotion items showed a significant difference between the
immediate and
long-term responses, and (compared with
those who had never had a complaint)
more ever had respondents indicated
that they felt depressed (p=0.009).
In the long-term,
trust and sense of goodwill toward patients returned, but 31.6% of
respondents indicated reduction of trust, and 18.1% indicated reduction of
goodwill.
Only 2.5% of respondents felt badly about themselves as a
doctor in the long-term, but this was
still significantly different from those who had
never had a complaint (p=0.007).
9.2% indicated that they did not wish to keep on practising
medicine. There was no change in the reduction of commitment to the complainant
or of the preservation of effort and commitment to other patients, although
10.6% of respondents still indicated a
long-term reduction in their sense of
commitment to other patients.
Only 27.2% of respondents indicated that the complaint was
‘a good thing’.
24.5% of respondents indicated reduction in their tolerance
of uncertainty, which was not significantly different from the respondents who
had never had a complaint (p=0.229);
and 15.1% indicated a reduction in confidence in their clinical judgment.
8.6% of respondents indicated a reduction in their ability
to consult well, but the negative impact of a complaint on the ability to
perform technical tasks fell to only 2%, and there was no change from the
immediate to the
long-term in the range of services
offered.
DiscussionThis report documents the
self-reported impact of the receipt of a complaint on a cohort of New Zealand
doctors. It raises concern about the impact of complaints on individual doctors
and the profession, and the impact of complaints systems on the delivery of
healthcare in New Zealand’s society.
This study indicates a wide range of responses to receiving
a complaint between individual doctors—but no difference appears between
vocational groups (in terms of their emotional, attitudinal, or practising
responses) . This finding is significant in terms of understanding the
similarities between doctors when considered as a group, despite practising in
different fields.
The findings of anger, depression, shame, and experiencing
‘loss of joy of practice’ in the
immediate time period, indicate that a
complaint has a significant emotional impact on the person of the doctor
receiving a complaint. These responses, by falling along a shame-rage or
shame-depression axis may indicate a shame
response.10 These are powerful emotions, and
(if present) need to be recognised by the doctor, their colleagues, and by the
work institution. For some doctors, time away from work may be necessary. The
finding that about 1 in 10 doctors have persisting negative emotional responses
after receiving a complaint suggests that (although emotions tend to return to
normal) some individuals may be deeply hurt by the experience.
This study suggests that complaints may damage trust and
goodwill toward patients. These are important components of the doctor-patient
relationship. Around 1 in 3 doctors (in receipt of a complaint) indicated
reduced trust, and around 1 in 5 doctors indicated reduced sense of goodwill
toward patients in the long-term. This
suggests that complaints have the potential to damage the doctor-patient
relationship with patients who may have played no role in the preceding
complaint.
For the medical profession, as well as individual doctors,
the findings that a complaint may adversely impact on the doctor’s ability
to practice medicine in a day-to-day setting is important. The feeling that
doctors can consult well is essential for safe and efficient practice, and for
the effective delivery of health care to society. There is no evidence from this
study that the delivery of patient care is actually improved by the receipt of a
complaint, and these results suggest that complaints against doctors have the
potential to impact negatively upon patient care.
This study confirms the findings of local and overseas
research on the impact of a complaint, and suggests that New Zealand society
should consider whether the current complaints system is actually leading to
improved medical practice.
Author information:
Wayne Cunningham, Senior Lecturer, Department of General Practice, Dunedin
School of Medicine, University of Otago, Dunedin
Correspondence: Dr
Wayne Cunningham, Department of General Practice, Dunedin School of Medicine,
University of Otago, PO Box 913, Dunedin; email: wayne.cunningham@stonebow.otago.ac.nz
References:
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