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Serious and unexpected complaint shocks you

Case history

Roberta is 48 and has a long history of abdominal pain, bloating and variable bowel habit. You have diagnosed irritable bowel syndrome and discussed her diet and tried antispasmodics. She attends with a long list of allergies to foods and mineral deficiencies that have been diagnosed at an alternative therapy exhibition. You discuss the limitations of these tests, but agree to her request to see a dietitian.

Some time later you receive a private hospital discharge letter stating Roberta has had a hysterectomy for large fibroids. Subsequently you receive a six-page complaint that you have misdiagnosed her. She says you have been dismissive of her symptoms, which have been cured by the surgery. She claims you have labelled her as 'anxious' in her medical records and prejudiced the locum who referred her. She opened the referral letter, which said 'this anxious lady'. The gynaecologist has said the fibroids were probably present for 'years'.

You check Roberta's records and find no specific reference to anxiety or gynaecological symptoms. The practice nurse took her last smear. You thought you had a good relationship with Roberta. How should you respond?

Dr Nick Imm

'It is not derogatory for the locum to describe her as ''anxious'' in a referral letter'

Fortunately, we have a well-established and logical complaints procedure at our practice. The first thing I would do is acknowledge receipt of her letter and assure her that we will review her concerns within a given time frame.

This should have the dual effect of reassuring her we take complaints seriously and preventing me from responding in haste. Then I would discuss her complaint with my colleagues and practice manager. I'd also take advice from my defence organisation.

I don't agree that I've been dismissive of her symptoms ­ I've made a diagnosis and treated her as seemed appropriate at the time. Irritable bowel still seems a possible diagnosis given her bowel problems (and lack of gynaecological symptoms). Now it seems she feels the diagnosis was incorrect and I need to be honest, upfront and sensitive to her concerns. It may be that her examination was inadequate or that further investigation would have been useful. If I've made an error, an apology is the best policy, but it's important to distinguish between fact and fiction.

'Anxious' in a referral letter is not derogatory and I feel this part of her criticism is unjust. She may have some grounds for complaint but her attitude and lengthy letter suggest she's looking to criticise her care in any way possible. I haven't referred to her as anxious in the notes and the locum's letter is not offensive.

Anxious simply means anxious and I think it's a fair description of anyone who is so concerned about her ongoing symptoms that she has resorted to alternative, unproven treatments.

Of course it's perfectly possible that she's had fibroids 'for years'. Fibroids and irritable bowel can easily co-exist. I would be interested to know exactly what the gynaecologist has said and how this has influenced her complaint. I wonder what guarantee she's had that her symptoms have now been permanently cured?

Having gone through each area of Roberta's complaint letter, I would offer to meet her with the practice manager to discuss her concerns. Often an explanation or frank discussion can defuse these situations and avoid protracted discussions. I would hope to restore our previously good relationship.

Dr Chris Hall

'How could I diagnose fibroids given a history of IBS?'

These days a complaint is something GPs are practically expected to embrace as an opportunity to reflect positively on our practice.

Roberta's complaint is irksome as it does not seem justifiable. How could I be expected to diagnose fibroids given a history of IBS and food allergy symptoms? The patient's side of the dialogue contract seems incomplete here. She has nevertheless complained, and the non-adversarial complaints procedure must swing into action, expressing sympathy for Roberta and acknowledging her feelings of anger. An added difficulty is her likely reluctance to meet in order to discuss the grievance, but the offer should be made. At the least, this will allow me to explore her health beliefs and address her concerns ­ in other words, how could her symptoms have prompted me to diagnose fibroids?

I suspect the source of her anger and of the complaint is her perception that she has not been taken seriously. Reassuring her may help defuse the situation. Should she attend, I would take care to have an impartial colleague present.

A call to my medical defence body would be prudent. I would speak to my locum colleague to clarify his comments (without implied criticism). Strictly speaking, I am to an extent responsible for the acts and omissions of my locum, but I would find it difficult to take the blame for labelling Roberta as 'anxious'. Opening a confidential letter between health professionals suggests a lack of trust, and in future it may be more prudent for colleagues to send referral letters separately.

If Roberta and I are to have any relationship in future she must be made aware of the nebulous nature of her symptoms and the many possible diagnoses, of which fibroids would not be top of the list. Ultimately it is up to the patient which way our relationship goes. If nothing positive comes of all this, at least the learning and reflective ruminations of the complaints procedure may be useful.

Dr Alison Best

'Am I taking the blame for some underlying problem?'

Given that Roberta has made a formal complaint, much of my approach would be governed by our complaints policy. The practice manager would send a letter acknowledging receipt of the complaint and advising that the matter will be looked into promptly. I would consider whether it would be more appropriate for me to respond by letter or to arrange a meeting with Roberta. I would contact my defence organisation.

I am sure I would feel upset. Having felt I had a good relationship with Roberta I would also be a little puzzled. Am I missing something? Does Roberta have some underlying problems for which I am taking the blame? Is she upset about having had a hysterectomy?

I would read the six-page complaint carefully and look back over Roberta's medical records. I would consider whether I had missed something. I am obsessional about record keeping so it is interesting that there is no specific reference to either anxiety or gynaecological symptoms in the medical records.

It appears she was referred to a gynaecologist privately by a locum and I would be keen to see the locum's notes. Perhaps her concerns about having been labelled anxious stem from her consultation with the locum.

Prior to responding to her complaint I would try to establish what she was hoping to achieve. An explanation? An apology? I would also look at the tone of her complaint.

It is a useful reminder that patients often do read both our notes and referral letters. Where possible, I talk through notes and letters with the patient face to face to avoid any misunderstandings.

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