Few doctors account for the majority of patient complaints

Tagged Audit, Complications, complaints, Patient experience, RANZCOG, SurgicalPerformance; Posted 11 years ago

To many doctors, to receive a notice of a patient complaint seems random. 

Yesterday a study was published in BMJ Quality & Safety that predicts who the doctors at medico-legal risk of recurrent complaints are.  If we knew that we are at risk, individual surgeons should know it, and take appropriate action.

The authors assembled a sample of 19,000 health care complaints lodged against doctors in Australia between 2000 and 2011. Statistical analysis included multivariate models similar to predict (time-dependent) cancer recurrence. The main outcome variable was the occurrence of a complaint against a doctor. Covariates included the number of prior complaints a doctor had experienced, jurisdiction and the doctor's specialty, age, sex and principal practice location.

The study’s aim was to estimate each practitioner's risk of recurrence at specific time points.

Almost all medico-legal cases start at the level of Health Service Commission and those commissions is the typical primary avenue for a patient to lodge a complaint in Australia. Data were collected at the level of the commission and matched with data from AMPCo Direct, a subsidiary of the Australian Medical Association.  The study was approved by the Ethics Committee at the University of Melbourne.

The sample consisted of almost 19,000 complaints lodged against 11,000 doctors. The two main issues of complaints were clinical care (61%; diagnosis, treatment) and communication (23%; attitude, information, consent). The majority of complaints (79%) were made against male doctors and the majority of complaints were made against General practitioners (47%). Only 5% of complaints were directed against obstetricians and gynaecologists.

Doctors were complained against an average of 1.98 times. However, a small group of doctors accounted for the majority of complaints. Three percent of all doctors accounted for 49% of all complaints. 

Risk factors for complaints included:

• Number of prior complaints: The more complaints in an individual doctor’s history, the higher the risk of another complaint. Three prior complaints increase the risk of another complaint by the factor 3. Doctors named in a third complaint had a 38% chance of being the subject of a further complaint within a year, and a 57% probability of being complained against again within 2 years.
• Male doctors have a 36% increased risk of being complained against.
• Speciality: Compared to a GP, the specialities attracting most complaints are: Plastic surgery (twice the risk), Dermatology (56% increased risk), Obstetrics and Gynaecology (50% increased risk), General Surgery (45% increased risk) and Orthopaedic Surgery (32% increased risk).  Anaesthetists had a significantly lower risk of being complained against (35% reduced risk).
• Doctors older than 35 years of age had an increasing risk. The older, the higher the risk.
• The location of the practice (urban vs. rural) did not influence the risk of a complaint.

The report makes it obvious that the knowledge to predict who will be complained against and who will be the short-term future outliers amongst medical practitioners is available. This information is a tool to identify serial "offenders" and what follows will depend who gets a hand on the tool and what intentions those people will display. The group of authors suggest immediate steps to improve, guide or constrain the care being provided by these ‘high-risk’ practitioners as a very cost-effective way to advance quality and safety, and produce measurable benefits at the system level.

From the RANZCOG audit that we reported a few weeks ago, it is clear that obstetricians and gynaecologists are already under great stress to cope with the various forms of adverse treatment outcomes and their associated forms of stress. One of the biggest stressors mentioned by our sample was the pressure from hospital administrators and regulators. Briefly, respondents of the survey feared that these non-clinical administrators might be in powerful positions to limit or shut down their practice in case of complications.

By contrast, one could also display a rather supporting attitude: How about we identify those people who repeatedly get into trouble and offer them help. Senior colleagues could meet with those people, go through the issues, identify the problem(s) and develop strategies to fix them in a collegial way.

It is critical to note that factors that also could influence the complaint rate were not examined. The authors admit that patient factors (e.g., patients history to complain), surgical case type (benign vs. cancer surgery), doctor’s ethnicity and country of training, the practice setting, or features of the doctor-patient relationship were not examined. Restraining doctors registration or accreditation will not only destroy a career but may also leave true issues untouched.

There are opportunities to intervene and I agree that action shoudl be taken in a ratehr proactive way. Reactive action, such as currently displayed by registration bodies reminds me on a tragic opera. In a positive way, medical indemnity insurers already offer webinars and courses to assist their members. Reliably forecasting the medico-legal risk of clinicians may drive prevention, reduce adverse events and improve patient satisfaction; it may also help those doctors involved to avoid the victimisation that comes with the medico-legal processes.

However, support could still be increased and improved in various ways. Interestingly and consistent with our recent survey, medical registration bodies as well as RANZCOG or the AMA currently do not provide support.

SurgicalPerformance has always been committed to assist its users rather than policing and monitoring them. Whether a complaint has been lodged or not is curently not documented in SurgicalPerformance but it makes sense to include it in future updates. 

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