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Complaints procedures traumatise doctors and could lead to patient harm, warn researchers

Complaints can have a devastating mental and physical effect on doctors and may lead to patients being over-investigated and given unnecessary invasive procedures, claims the largest ever study in this area.

The study of almost 8,000 doctors also found doctors who have had complaints made against them are significantly more likely to suffer from anxiety, depression, and thoughts of self harm.

It also concluded that the GMC’s inquiries into complaints ‘may do more overall harm than good in terms of patient care’, as majority of doctors who are reported to the regulator are not found to have a significant case to answer.

The profession’s leaders expressed concern about the report’s findings, calling for more support for vulnerable doctors and a speeding up of the GMC’s fitness-to-practise procedures.

It comes after a GMC-commissioned study into 28 suicides of doctors under investigation concluded that doctors should be given training in ‘emotional resilience’.

According to the report, The impact of complaints procedures on the welfare, health and clinical practise of doctors, published in the BMJ Open today, 80% of doctors who had experienced a complaint in the past claimed they had changed their clinical practice as a direct result.

The report, which included feedback from 7,926 doctors, revealed that such defensive practise following a complaint being made led to some doctors ‘acting against their professional judgement’, and deploying methods such as ‘hedging’ - overprescribing and referring more patients.

It found that of the 3,889 who had a past complaint, 79.9% changed the way they practised medicine, 82.6% displayed hedging behaviour 42.9% displayed ‘avoiding behaviour’ while 23.2% ‘suggested invasive procedures against professional judgement’.

Even the 1,780 doctors who had not suffered a complaint - but whose colleagues had - said they changed the way they practised medicine as a result of the complaint (72.7%), with 81.7% displaying hedging behaviour, 46.1%displaying avoiding behaviour and 20.2% saying they had suggested invasive procedures against their professional judgement.

The researchers said that this trend could adversely affect patients, concluding: ‘These behaviours are not in the interest of patients and may cause harm, while they may also potentially increase the cost of healthcare provision.

‘Our data also show the vast majority of doctors who took part in the study reported engaging in defensive practise. This included carrying out more tests than necessary, overreferral, overprescribing, avoiding procedures, not accepting high-risk patients and abandoning procedures early.’

The researchers also found that doctors subject to a complaint in general are at significant risk of becoming severely depressed and suicidal, with 15.6% of doctors who had received a recent formal complaint reporting they were ‘moderately to severely depressed’, compared with 12% who had received an informal complaint and 9.5% of those who received no complaint.

In addition, 9% of doctors who received a formal complaint had thoughts of self-harm, while 13.5% suffered from moderate to severe anxiety - both significantly higher than doctors who had received no complaints.

Doctors who had undergone a fitness-to-practise hearing were significantly more likely to suffer all forms of psychological distress.

The researchers admitted it was ‘possible that doctors with depression, anxiety and suicidal ideation are more likely to have complaints made against them’.

However, they added: ‘Similarly, being complained against may be the causative factor rather than the processes themselves. However, this still means the information presented is important, as if we take the former view, it means those going through complaints processes are part of a vulnerable group that needs support.’

 

The study comes after the GMC published its internal review into the suicides of 28 doctors while under investigation - and the review consequently recommended that the regulator should introduce ‘emotional resilience training’ and establishing a culture where doctors feel they are treated as ‘innocent until proven guilty.’

However, only last week, the GMC’s new chair Professor Terence Stephenson told a House of Commons health committee hearing that doctors should expect to face a GMC investigation during their career as an ‘occupational hazard’ and build up resilience to deal with it similar to soldiers in Afghanistan.

Professor Clare Gerada, the former RCGP chair, and current leader of the Practitioner Health Programme (PHP) - the support service for sick doctors - agreed that complaints against doctors can make them practise more defensively and become over cautious with patients.

Professor Gerada added: ‘Of course complaints make doctors act defensively and it persists for long time, and makes them over cautious, not just in referring and investigations but in terms of spending longer with consultations. There is a downside of complaints which can in paradox harm patients.

‘When we see someone at PHP who has been referred to the regulator we are very concerned – even if the person is not depressed at the time, we consider that a referral is a massive risk factor for depression, and we more often than not start treatment for depression with antidepressants and CBT and provide support for them during the process.

‘The GMC fitness-to-practise process has been described as akin to having a diagnosis of cancer and for doctors who are vulnerable to start with can be the tipping point for serious mental health problems.’

RCGP chair Dr Maureen Baker told Pulse that the a system that has an impact of patient care must be looked at, adding that GMC needed to speed up its fitness-to-practise process to alleviate the pressure on GPs under investigation.

‘Patient safety must be paramount in any complaints or fitness to practise process, so any system that has negative consequences for our patients needs to be reviewed.

‘It is also important that the a sense of “innocent until proven guilty” prevails throughout any investigation, and that steps are taken to ensure that any associated stress is kept to a minimum.

‘While we understand that the GMC must thoroughly investigate allegations of malpractice, lengthy investigations are not in anyone’s best interests and so we would urge the Council to speed up the fitness to practise procedures where possible,’ she told Pulse.  

BMA chair Dr Mark Porter said it was worrying that the impact a complaint can have on a doctor’s health is affecting the way they practise.

‘It is also concerning how this detrimental impact on doctors’ health and wellbeing further translates into defensive behaviour.

‘It is in the interests of both doctors and patients that, where appropriate, concerns can be raised and that these are properly investigated. But this process must be fair and offer adequate protection to ensure the system itself does not cause harm – either to doctors or indeed to patients,’ added Dr Porter.

GMC chief executive Niall Dickson added: ‘We welcome this paper which looks at the impact of complaints on doctors, including a small proportion who have been referred to the GMC. It is a valuable contribution to an important and difficult issue which we take seriously and are actively addressing. 

‘The number of complaints about doctors and other health professionals continues to rise and anyone who is subject to an investigation is bound to find it stressful, especially if the national regulator is involved. But, of course, our purpose is to protect patients and when serious allegations are made, we do need to investigate to establish if there is a case to answer.

‘At the same time, we have a duty of care to these doctors. That is why we are doing more than ever to reduce the stress of our investigations, by offering support and doing everything we can to reduce the time doctors are in our processes.’

If you have had a complaint made against you that has affected the way you practise, Pulse would like to hear from you. Please drop an email to pulsefeedback@cogora.com

 

Readers' comments (50)

  • If anyone knows the 'well dressed woman' could you ask her to post her side of the story anonymously here. It maybe the examiners were unfit to examine somebody in a fragile state/their procedure may have exacerbated the situation .........or maybe qualified security guards were incapable of handling her.

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  • Clare G In what capacity can people contact you please? What guarantees of anon if needed?

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  • 'Armed Police' - sounds like the GMC called it in as an act of terrorism.

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  • seems to me that we need insurance against a GMC investigation which could lead to loss of earnings without good reason, and the need to employ a specialised solicitor to take on the GMC if their decision making is not fair. A quick google search brings up several such law firms. Anecdotally I've heard the defence unions don't always defend doctors in fitness to practice cases. This needs looking into.

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  • I have had 2 complaints against me by patients to the Irish Medical Council in over 20 years practice. Both frivolous by serial complainants. In both cases I received a written reply to my initial response within a few weeks stating that I had no case to answer to and the case was closed. Surely nonsense complaints are dispatched as efficiently in the UK?

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  • The GMC MPTS should develope resilience from acting as stooges for NHS Egland

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  • Una Coales. Retired NHS GP.

    @William Behan sounds like our GMC could take notes from your Irish Medical Council. Many doctors would not suffer from unnecessary anxiety and stress if initial investigations were expedited in 3 weeks! Doctors here are lucky to receive a response between 4 and 6 MONTHS and this may very well exacerbate their mental wellbeing!

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  • Dear Anonymous | Salaried GP | 19 January 2015 11:16am

    “seems to me that we need insurance against a GMC investigation which could lead to loss of earnings without good reason…”

    Malicious prosecution by a private prosecutor, such as the GMC, does not happen in other countries because of legislation such as ‘que tam’

    In common law, a writ of qui tam is a writ whereby a private individual who assists a prosecution can receive all or part of any penalty imposed.

    Its name is an abbreviation of the Latin phrase 'qui tam pro domino rege quam pro se ipso in hac parte sequitur', meaning "[he] who sues in this matter for the king as [well as] for himself."

    A qui tam statute authorizes a private citizen "informer" to file suit on behalf of the Government for collection of a statutory forfeiture.

    A successful informer receives a share of the recovery. In 2008 relator share awards in the US (amount the whistleblower was awarded) was $197 million (20% of total settlement) from 375 qui tam cases.

    http://www.taf.org/FCA-stats-DoJ-2008.pdf

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  • Som further correspondence in relation to our paper for interest:

    http://bmjopen.bmj.com/content/5/1/e006687.full/reply#bmjopen_el_9064

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  • It is becoming increasingly difficulty to say know to unreasonable demands from patients sometimes. Patients can now complain to GMC directly! The last complaint I had for instance was a 54 year old who had been to a chemist and was told to see a GP about a rash on the face. When she was offered an appointment she then said she had transport issues so wanted a home visit... and i had to reply!

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