First published in The Age, January 4, 2014
Most of us trust our doctors. A 2013 Roy Morgan poll found that 88 per cent of people ranked doctors either ”very high” or ”high” for ethics and honesty – a 5 per cent increase on the previous year. Since we all rely on the health system to keep us safe and well, these results are reassuring.
However, a worrying number of patients continued to be adversely affected – physically or emotionally – through their experiences with doctors. We have known this for some time. What hasn’t been widely known is that it is actually a remarkably small number of doctors who are causing a disproportionate amount of patient distress.
A study published last year by Dr Marie Bismark and colleagues found that just 3 per cent of Australia’s medical personnel accounted for 49 per cent of all formal patient complaints. Astonishingly, just 1 per cent of the nation’s doctors received 25 per cent of the complaints.
The question on most patients’ minds, then, would undoubtedly be: what is the health system doing about this? Are there actions that health services could – and should – be taking with ”high-risk doctors” to pre-empt further harm?
The characteristics common to doctors attracting the most complaints are probably not surprising: 79 per cent are male, 80 per cent are aged over 35, with surgeons over-represented (plastic surgeons have twice the risk of GPs).
But these statistics are not the most important. A doctor’s previous complaint record is, in fact, the single most important predictor of future complaints. The Bismark study found that doctors who had received more than 10 complaints within the 10-year study period had a 97 per cent chance of receiving another complaint within the following year. Clinicians with five complaints had a 79 per cent likelihood of attracting another in the following two years.
These are unacceptable risks to patients and their families. And the risk is not just focused on clinical judgment. While more than half (61 per cent) of the complaints studied by Bismark related to clinical care, nearly a quarter (23 per cent) were about communication.
Anyone can have a bad day at the office. Misunderstandings and oversights happen in every industry. The problem is not that doctors sometimes act in ways that solicit a complaint by their patients. It is that some doctors do this regularly throughout their career. That these doctors continue to attract complaints suggests either that senior staff are unaware of, or are failing to acknowledge, this recidivism. Or that the behaviour is tackled but the complaint-prone doctors are not retrained effectively to improve the patient experience and safety.
Patient complaints alone are clearly not enough to evaluate a doctor’s performance. Other factors may influence patient satisfaction. Also, some might say it’s too harsh to judge a doctor who sees hundreds, even thousands, of patients a year on one bad encounter or case of poor judgment.
Yet it is widely accepted among health services that the number of complaints received is just the tip of the iceberg. Few people enjoy making a complaint about anything. Most will hesitate before even sending a tepid cappuccino back to the barista, much less make a formal complaint against a doctor they may need in the future. Many patients who suffer physical or emotional harm while receiving medical care don’t complain about it. They may be too traumatised or upset, don’t believe their complaint will change anything, or are nervous about negative repercussions. A 2012 report in Britain said patients were afraid to complain against their GP for fear, sometimes justified, of being removed from the GP’s list and effectively left without a family doctor.
Most health services now have a robust system for analysing and tackling patient complaints. But an internally robust system is not necessarily transparent to patients. Patients and families need to see that their complaint has resulted in lasting changes to policy or procedure. This may be especially true when it comes to grievances about an individual clinician; is it a patient’s right to know if the doctor they are seeing has chalked up a mountain of dissatisfaction? Research has shown that what matters most to patients who have complained is the knowledge that improvement and change have taken place as a result. Transparency and follow-through are essential for convincing patients that their feedback matters.
Over the past 20 years, my family has had extensive involvement with the health system, in Australia and in several other countries. The overwhelming majority of our healthcare experiences have been positive, with care provided by skilled and compassionate people. Most medical professionals are clearly doing an excellent job under often tough circumstances.
But we know that a small number of doctors are causing serious grief to patients and to the reputation of health professionals as a whole. Bismark’s results highlight a major area for improvement for health services, in ameliorating patient safety and patient experience.
For their part, patients need to use the formal complaints system. To do this, they will need to trust that the system works. Maybe the first step in this direction is for health services to ask former complainants to work together with them to improve the system – and the doctors – they rely on.
Susan Biggar is a senior manager at the Health Issues Centre and board director of the Australian Institute for Patient and Family Centred Care.