A conversation that needs to continue: what to do about the relatively small number of doctors who account for so many patient complaints

The online ecosystem, linking up journals, bloggers, mainstream media and researchers with the wider world, is bringing new opportunities for researchers to hear and learn from the responses to their findings.

The article below documents some of the wide-ranging responses to a recent study which found that a small proportion of doctors account for a large chunk of formal patient complaints filed with health service complaints commissions in Australian states and territories.

The study investigated all 18 907 formal patient complaints filed against doctors with commissions between 2000 and 2011. One-quarter of all complaints during that period related to fewer than 500 doctors. One per cent of doctors accounted for one-quarter of complaints.

The researchers concluded that their study “identifies a target population within which systematic deployment of interventions to improve performance might be manageable”, and said that intervening early with high-risk doctors “has considerable potential to reduce adverse events and patient dissatisfaction system-wide”.

Thanks to Dr Marie Bismark, a doctor, lawyer and Senior Research Fellow at the Melbourne School of Population and Global Health at the University of Melbourne, for reporting on the aftermath of the study’s publication.

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A small group of doctors accounts for half of patient complaints: What next?

Marie Bismark writes:

The largest medico-legal study ever conducted in Australia was recently published in BMJ Quality and Safety. Our research, conducted at the University of Melbourne, found that just 3% of Australian doctors account for half of all formal patient complaints against doctors made to health complaints commissioners.

Male gender, older age, and working in surgical specialties were all associated with a higher risk of repeat complaints. But the number of previous complaints a doctor had experienced was the strongest predictor. Doctors named in a third complaint had a 57% chance of being named in another one within 2 years.

The study was the culmination of three years of work, agreements with Commissioners in seven states and territories, and a review of nearly 19,000 healthcare complaints made over more than a decade.

From a research perspective, publication was the last step in a long journey. From a health policy perspective it was just the start of what we hope will be a sustained and considered conversation about how best to address the problem of “problem-doctors”.

Our findings were disseminated through the traditional channels: press releases by the University and BMJ; radio interviews with ABC, 3AW, and New Zealand National Radio; newspaper articles in The Age, the Sydney Morning Herald, the Australian Financial Review, the Canberra Times; Medical XPress;  and a television appearance on Sky News, and articles in trade journals including New Zealand Doctor and Medical Observer.

Social media and blogs also played a key role. Popular website LifeHacker offered consumer-centered advice on “How to avoid bad apple doctors”, while Dale Ann Micalizzi’s blog posted links to our research for patients and families to read.

Leading academics and policy makers shared our findings with colleagues and followers through Twitter.

Australian study found just 3% of docs accounted for 49% of major patient complaints
Atul Gawande (Professor of Surgery, author of Better, Complications, and The Checklist Manifesto)

A small number of offending doctors generate most complaints http://bit.ly/17ddrxe  Excellent piece by Ron Paterson on @mbismark study
Carl Elliott (Professor of Bioethics, author of Better than Well)

Not so random – patient complaints. http://m.qualitysafety.bmj.com/content/early/2013/02/22/bmjqs-2013-001902.full.pdf?sid=ee943405-9ced-488a-8cf7-1cba75287f54 …
Karen Luxford (Clinical Excellence Commission)

And, in fine Twitter tradition, tweets of international medical conference coverage soon followed.

@mbismark‘s Aussie doc complaints study published Thurs; today discussed at conference in Canada http://bit.ly/ZK8WNk  pic.twitter.com/ZJfW417vyi
Jennifer Yang @jyangstar (journalist, Toronto Star)

Responses to our study varied from interest to encouragement to denial.

In Australia, the Medical Board came out on the front foot, restating their commitment to patient safety and expressing an interest in the relevance of our findings to medical registration and regulation.

“The longer you leave a matter where there might be a question of risk to the public, the less you’re carrying out your primary purpose of protecting the public.”
Joanna Flynn, Chair of the Medical Board of Australia

In New Zealand, the former Health and Disability Commissioner affirmed that complaints matter – to the patients who make them, to the doctors who receive them, and to the regulators tasked with resolving them (also reported here).

“Most people don’t go through the bother of making a complaint at all, let alone a complaint to the external commissioners. So the doctors who end up being subject to multiple complaints are significant outliers – there is something going on here. These are patients who are being harmed or, if they’re not being physically harmed, they’re receiving an inappropriate standard of care or communication. We need to bring these frequent flyers to the attention of the public. The current veil of secrecy over most complaints (which avoid publicity by never reaching the stage of disciplinary proceedings) allows repeat offenders to continue unheeded’.”
Ron Paterson, former New Zealand Health and Disability Commissioner

At least one academic saw an opportunity for more effective use of scarce regulatory resources to improve the quality and safety of care.

I’m a strong believer in targeting action where the problem lies rather than across the board, wasting efforts and resources. We have to have fair ways of assessing this, with health professionals, consumers and managers of organisations being part of the assessment.
Moira Sim (Associate Professor of Medicine, Edith Cowan University)

Unsurprisingly, our findings resonated strongly with patients and consumer advocates.

100% YES!! Have been treated by a Dr who peers knew to be incompetent (found out too late; long ago)
Just Judith @justjjoke

National study: 3% Aust doctors receive half of all complaints; need to identify doctors at risk & intervene.
Health Consumers New South Wales

“I can identify very strongly with the issues identified. I can especially identify with the issue of complaints commissions, boards etc. failing to conglomerate and collectively consider multiple complaints, and complainants being isolated from knowing about each other and emerging trends. I have experience both of these problems. I very much look forward to this publication opening public discussion and awareness about this issue.”
Jen Morris (disability advocate)

However, some expressed skepticism about whether meaningful change would follow. Such concerns may be justified, given the tendency of some professional bodies to downplay the significance of patient complaints.

“We don’t know what the level of complaints are ‘cause these come from the complaints commissions and they can be quite low level and they’re often resolved and we don’t know how many of these get passed onto medical boards. So it may not be about improper practice, it may well be just personality issues or it may be interpersonal relationships or it may be excessive waiting.”
Steve Hambleton, Australian Medical Association

Importantly, our research indicates that the problem is not confined to “low level complaints”: restricting the analysis to only complaints suggestive of relatively serious concerns (namely, poor clinical care, breach of conditions, rough or painful treatment and sexual contact or relationship) produced very similar results to the main model.

Among clinical leaders, some identified the key issue as one of self-regulation and emphasised the role of peers in addressing concerns about their colleagues.

“Despite being aware of which colleagues have deficits, more often than not physicians look the other way rather than confronting the problem directly. Early complaints represent warning signs that require action from colleagues to prevent future patient problems. The critical first step is for all of us to begin speaking up when we know that a colleague is struggling in their interactions with patients and with peers.”
Tom Gallagher (Professor of Medicine, Washington) and Wendy Levinson (Professor of Medicine, Toronto)

Others saw our findings as a good news story.

“These results are not surprising. The same probably goes for any industry where a few tar the reputation of many … But the country can reassure itself that the majority of doctors aren’t flagging concerns from their patients.”
RickInOz

And, just as we found in our study, a small number of doctors accounted for a disproportionate share of concerns. One doctor – who identified himself as “Dr Phil” – offered the following comment in response to our research (abbreviated for reasons of space).

“Consider the SACRIFICE that Medico’s suffer. All in, you’re looking at someone who’s trained the better part of 8-16 yrs. Do you think we’d deserve SOME BLOODY REWARD? Consider also, this is a profession whereby day in and out, all you deal with is grumpy miserable people who complain… The sad fact is that it’s just human nature. Things that are free are taken for granted. Humans are arseholes. It’s human nature … It has turned into a situation where people act as consumers and walk in with an attitude that they are not there for diagnosis, treatment and advice, but that doctors are no better than the poor harangued cashier at McDonalds. … Guess what, just because you’ve read off Dr Goooogle that injecting day old urine and fish oil into your joints is good for arthritis, I’m not going to do it [because] I’ve been trained the better part of my adult life to take care of people, and I’m damn good at it. Yes, there’s good and bad doctors out there. But you know what, the vast majority of doctors are just like me. We want what’s best for our patients, and we’ve sacrificed a FUCKLOAD to get to where we are (Psychiatrists – high suicide rate; Surgeons average 3.5 divorces; >90% of the medical profession has some underlying chronic disease state that could be corrected by LEAVING the profession; 60% have social drug abuse issues). So you know what, BEFORE you complain, how about you think for ONE second…. Would YOU want to go through all that to be a doctor?”
“Dr Phil” (medical practitioner, Western Australia)

Looking to the future we are working closely with Commissioners to develop tools that could allow our research findings to be integrated into the Commissioner’s day-to-day complaint handling processes. Of course, identifying complaint-prone practitioners is of limited value unless appropriate interventions are available to support practitioners back into safe practice and to protect the public from harm.

Development, implementation and evaluation of such interventions is not a task that can (or should) be carried out by Commissioners or researchers alone.

Professional colleges, medical schools, medical boards, indemnity insurers and large insurers all play an important role,  and we hope that our research will provide a catalyst for action.

Open access copies of our complaint-prone doctors paper and two associated editorials are available through BMJ Quality and Safety:

• M. M. Bismark, M. J. Spittal, L. C. Gurrin, M. Ward, D. M. Studdert. Identification of doctors at risk of recurrent complaints: a national study of healthcare complaints in Australia. BMJ Quality & Safety, 2013; DOI: 10.1136/bmjqs-2012-001691
• R. Paterson. Not so random: patient complaints and ‘frequent flier’ doctors. BMJ Quality & Safety, 2013; DOI: 10.1136/bmjqs-2013-001902
• T. H. Gallagher, W. Levinson. Physicians with multiple patient complaints: ending our silence. BMJ Quality & Safety, 2013; DOI: 10.1136/bmjqs-2013-001880

• On Twitter: @mbismark