Journal of the New Zealand Medical Association, 29-July-2005, Vol 118 No 1219
The impact of complaints on medical professionalism in New Zealand
In this issue of the Journal, Bismark and Paterson explore complainants’ needs for honesty, compassion, apology, and ‘willingness to learn’ from their doctors.1 They analysed letters of complaint to the Office of the Health and Disability Commissioner, drawing attention to points of breakdown in the doctor-patient relationship. The authors rightly call for a higher standard of patient care. They call for consideration of aspects of the doctor-patient relationship in which the patient (or family) seeks understanding and explanation in order to achieve healing, particularly where there has been an adverse outcome of care.
This article will explore the links between healing and therapeutic relationships, and will consider some of the characteristics of professionalism, and the relationship between the medical profession and New Zealand society. It will question whether the way in which the complaints process impacts on doctors is actually improving the delivery of medical care, and by implication, whether the public is being protected or adequately served by the current process.
It is my contention that healing is more than a biochemical or a tissue-based process. It is related to the restoration of ‘wholeness’ and the alleviation of suffering.2,3 Understanding suffering requires the doctor to understand the many aspects that contribute to the whole of the person of the patient, beyond those of the obvious physical, emotional, and spiritual. Different components of the person include their past, their life experience, their family and other relationships, their cultural background and viewpoints, and (relevant to thinking about adverse medical events and outcomes) their perceived future.
Cassel reminds us that ‘intense unhappiness results in a loss of the future - the future of the individual person, of children, and of other loved ones.’2 To provide an opportunity for healing, the doctor must engage with the person of the patient in order to identify their points of suffering.
All healing though, happens in the context of a relationship. Relationships include the doctor-patient relationship, the relationships between spouses, between family members, between a person and God, and so on. The key point is that relationships have two sides to them and (for the doctor and their patient) that relationship is a reciprocal one.
Like patients, doctors are also people and they bring their own values and beliefs into every doctor-patient encounter. This includes those particular professional values that are essential for high quality care, and if they are not brought into each encounter, the doctor risks being ‘unprofessional.’ How then, should professionalism be considered?
The notions of profession and professionalism can be looked at from two viewpoints. In the first, the health professional is expected to ‘embody the intellectual property associated with that profession’.4 That is, the doctor should conform to the technical and ethical standards of the profession and exhibit (indeed ‘profess’) that knowledge and technical expertise in every doctor-patient interaction. Furthermore, that knowledge and skill should be used altruistically for the benefit of society.5–7 A second way of looking at professionalism is to explore the values and behaviours held by that doctor which can be ‘uniquely defined according to moral relationships.’8 That is, values and behaviours that include trustworthiness, commitment, non exploitation, and not abandoning patients.
Professionalism is also about the protection of vulnerable persons and vulnerable social values,8 and collectively these values contribute to the ‘internal morality’ of medicine.9 So, to be professional, a doctor must not only practice to the required standard of the profession, but the doctor and the profession must embody those moral values needed to care for both individual patients and meet society’s needs.
The medical profession then is defined by its work, its values, and by its interaction with society. Looked at in this way, the medical profession is in a relationship with society that may be analogous to the doctor-patient relationship. If the profession-society relationship is not functional, or if the work or values of individual doctors are damaged in the course of that relationship, there is a danger of unprofessional behaviour emerging.
Bismark and Patersons’ paper draws attention to unprofessional behaviour by doctors illustrated by lack of caring, lack of commitment, and abandonment. Such behaviour is clearly unacceptable, but if the impact on doctors of the complaints system itself is to diminish doctors’ professional values and behaviours, then should that system continue to be accepted, or called to account?
There is ample evidence from New Zealand research that receiving a medical complaint often (although not always) impacts negatively on the person of the doctor, the doctor-patient relationship, and on doctors’ ability to practice medicine.10,11
For some doctors, the impact of receiving a complaint is devastating at a personal level; some leave practice, some doctors may commit suicide, and as yet, there is little evidence of a positive outcome of a complaint in the way that doctors practice or engage in further medical education.
What is particularly worrying (from the point of view of medical professionalism) is the erosion (on receipt of a complaint) of professional values that include reduced trust of, and goodwill towards patients, which are so important in the therapeutic doctor-patient relationship. In my opinion, such an outcome from a complaints process, considered in terms of the impact on the values and behaviours of complained about doctors, could be considered unprofessional.
How might this be improved? New Zealand doctors certainly believe that there should be a complaints process, they have defined the characteristics of an acceptable complaints process, and have made suggestions for change.12 Systemic change is a sociopolitical issue, and is happening with effort from the Health and Disability Commissioner and recent changes to the Accident Compensation Corporation (ACC) Medical Misadventure legislation—and inevitably takes time.
What could be created from within the profession itself, however, is a coordinated rapid response to provide the intellectual and emotional support that is needed by doctors on receiving a complaint.
Intellectual support should come rapidly from respected and trusted colleagues practicing in the same field who can assist that doctor in assessing their practice as it relates to the complaint. Emotional support must be provided in both the immediate post-complaint period and in the long-term. It should be provided by skilled and trained counsellors with whom the doctor can form an appropriate therapeutic relationship, as it is very unlikely that the expertise for such support is to be found within that doctor’s peer group.
It is, I believe, the lack of appropriate intellectual and emotional support that contributes to doctors’ professional values being eroded on receipt of a complaint, and to the emergence of defensive medical practice.
The responsibility for addressing these issues lies with both the Medical Council of New Zealand and with the professional colleges, taking a coordinated and collegial approach. Indeed, these are the organisations that must consider the impact of the complaints process on both their colleagues and on the medical profession, and ensure that the ultimate impact of medical complaints is the enhancement of patient care.
Author information: Wayne Cunningham, Senior Lecturer, Department of General Practice, Dunedin School of Medicine, University of Otago, PO Box 913, Dunedin
Correspondence: Dr Wayne Cunningham, Department of General Practice, Dunedin School of Medicine, University of Otago, PO Box 913, Dunedin. Email: email@example.com
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