Dr Shaba Nabi on the ‘damaging’ impact of patient complaints
Ask any clinician and they will convey a similar sentiment – that there is nothing more crushing than receiving a patient complaint.
Its impact will vary based on whether it is a verbal moan or a full-blown medicolegal assault, but the same emotions are triggered. These emotions of self-doubt, anger, frustration, despair and depression play out in most of us throughout the process of addressing a complaint, yet we receive little coordinated external support in such situations.
When the effort required for the patient to submit a complaint is minimal, it’s hardly surprising that we are flooded by a litany of niggles and gripes, which are effortlessly captured by practice support staff. The lack of effort on the part of the patient is mirrored by the lack of patient responsibility for their own health.
I was recently sued by a patient* following failure to follow up on their non-attendance for a routine scan, which resulted in a delay in the diagnosis of their cancer. I received notification of this non-attendance but I didn’t chase it up as I assumed a patient with capacity would self-present if their condition was worsening. Yet medicolegally, that assumption was incorrect because the ethical principles of patient autonomy do not extend to self-responsibility and accountability for their own health.
Despite this obvious mismatch of responsibility, my indemnity organisation chose to settle out of court, and I chose to accept this. I had already exhausted my time and emotions, so this scenario can be played out repeatedly; the lack of rebuttal encouraging further complaints.
As a GP veteran, I feel adept at brushing off these emotions, picking myself back up and getting back on the hamster wheel. But for others, the consequences can be fatal. At best, an adverse incident may lead to a period of sick leave followed by the shackles of defensive practice. At worst, it can lead to burnout, early retirement or even death. This is the reason for the term ‘second victim’, which captures the immense impact these complaints and adverse incidents have on all clinicians.
But what may be even more damaging than a one-off significant event is the constant drip-feeding of patient angst we are subjected to. And this is more likely to come following considerable time, effort and care offered to the patient. There is often a degree of personality disorder associated with these interactions, but this doesn’t change the outcomes of frustration and demoralisation for all concerned. And we can’t just terminate the doctor-patient relationship whenever this happens.
What we desperately need is for the law to step up and stop treating patients like children when it comes to their own health, so we can have adult-to-adult transactions. This includes rejecting any unfounded and unreasonable complaints about things that the GP has no influence over. I have to give the same time and attention to responding to complaints about interventions not funded, or normal blood results, as I do to any errors we have made.
The entire NHS complaints system needs a radical overhaul, which should include consideration of a no-fault compensation scheme, with lessons learned from the process in New Zealand where litigation has been reduced. Otherwise, we will continue to haemorrhage a workforce who are being crushed by complaints.
*Details of the case have been changed to protect patient confidentiality
Dr Shaba Nabi is a GP trainer in Bristol. Read more of her blogs here
I’m sorry you had to go through that
Excellent article Shaba. Sorry to hear that you have also suffered. You will be aware that you are not alone, indeed nearly all clinicians who provide frontline services have endured this trauma at least once. That the process seems unjust, that many of the complaints are immoral or from the immoral, that the MDOs settle for convenience etc just increases the distress and demoralisation. Hope you recover from the assault soon.
I wonder if the patient also sued the hospital for not chasing them up? Surely the ‘buck’ had been passed to the secondary services by the referral? I rather expect the secondary service remained blissfully apart from the patient’s wrath.
What a disgusting state of affairs the litigation system is. You are not alone Shaba. I think that complaints should be addressed in clinical time rather than on a doctor’s free time. Patients who complain should be informed that their complaint has reduced the time available for doctors to attend to their patients. The stress of dealing with complaints substantially affects doctor engagement, increases referrals, investigation and prescribing, so affects service quality negatively for all patients. It also is a major cause of burn out which affects retirement, retention and deaths of doctors. The NHS has been imploding for years. No wonder. Try to put this incident behind you Shaba. Easier said than done, I know.
Unfortunately this is an example of where you can NOT get it right.
What was the alternative? To contact the patient and try to persuade them to re-book?
No- that is wrong too : The patient had made a Competent decision to NOT attend. To try to persuade them to change their mind, even exceedingly gently, like, well, just one phone call to ask if they meant to miss the appointment, casts aspersions on their Competent decision, and becomes a case of trying to ‘impose one’s own beliefs upon a patient’ which is contrary to ‘Good Medical Practice’ paragraphs.
So, either way, you cannot avoid being a ‘bad doctor’, because both available routes of action are open to a valid complaint.
What one is left with is simply reliance on our social and medical skills, and an ALMOST invariably perfect ability to discern what is the best (or least unacceptable) route to follow for any individual patient.
Shaba, you get this decision correct far more than 99 times out of 100, so you are doing pretty well, really. UK Government was given many many occasions on which to take a decision on how best to support UK through the Pandemic, and so far has gotten the vast majority completely wrong. That is why patients generally have so much faith and trust in their doctors, but not their MPs. They are brighter than we (and MPs) think.
” The patient had made a Competent decision to NOT attend.”
How do you know this ? The only way to check on the circumstances would be to contact the patient and check.
I suspect that Dr Nabi has not given us the full picture here – there is an obvious contradiction here – in that she describes the scan as routine, but the delay resulted in a delayed cancer diagnosis. Dr Nabi admits that ” she assumed …… “. Assuming things is risking un-professional conduct and can result in complaints as she has now discovered.
Good material for a tutorial with her Registrars.
Sorry to hear you had to go through this experience, Shaba. Also admire your ability to continue to work and think rationally and consider so much in this article.
As someone who was in similar situation, think your approach to dealing with this deserves nothing but admiration.
Best not to get too emotional about the fact that someone is choosing litigation over, say, life insurance. It’s probably not personal, they just need the money.
If you know the patient, nothing wrong with assuming they had same capacity moment they decided to not attend (and waste NHS time/resource) and when seen and agreed to have the investigation.
Great thoughts and wealth of experience shared in the comments. Perhaps we could use our combined experience to SEA this and safeguard clinicians from future unnecessary stress from nonsense like this.
Think on Monday my admin staff will be instructed, upon receipt of such letters informing of non attendance, to send an SMS advising patient to book a follow up appointment. Or if records show coded cognitive limitations or mental or other vulnerabilities, active safeguarding concerns-pass for attention of involved clinician.
Ian Jacobs, I disagree with your take on this and I really do wonder how far you expect doctors to chase patients to ensure they take responsibility for their health? Primary Care is literally drowning in paperwork and work being inappropriately offloaded from secondary care. I do not think it is appropriate or reasonable to expect a GP to tap you on the shoulder and ask why the patient missed their appointment or test. That is on them. I finished my training in 2015 and the RCGP very much pushed the joint decision making model with patients and with that in mind, patients need to take more responsibility for their health.
Thanks EMK. UK GP training was already moving strongly towards a patient centred approach to the Dr-Patient relationship when I started my GP training in 1979 ( eg Michael Balint ). Of course patients need to take more responsibility for their health but patients are human and many shirk this responsibility- just because they ARE human.
Dr Nabi states the claim resulted : ” following failure to follow up on their non-attendance for a routine scan, which resulted in a delay in the diagnosis of their cancer. ” So a joint decision making consultation between her and her patient may never have happened relating to this ” routine ” scan. How many patients do you have that have routine scans ? Other than USS’s in pregnancy and screening scans ( eg for AAA ) I cannot think of any
I had a complaint that was settled by my indemnity insurer that raised very similar issues for me as Dr Nabi has experienced. I failed to follow up on a letter from a hospital chiropodist/podiatrist ( not a Dr.) which suggested an urgent referral to Vascular Surgery for a difficult to treat foot ulcer that was not responding to her treatments and antibiotics. He was already well known to the Vascular Surgeons , was a smoker but had no claudication. Her letter said that he had been asked to make an appointment to see me about this . He was a frequent attender so on receipt of her letter I assumed I would be seeing him very soon and did nothing further- expecting to act when I saw him. A few weeks after the letter he developed ischaemic pain at rest and was admitted and had a below knee amputation – that was when his non-attendance to see me and my failure to refer came to light. I agreed that I had made a wrong assumption ( that he would surely come to see me )- based on me knowing him well and his recent consulting pattern. He certainly was a patient with capacity.
It was more complicated than that- in that some of my partners were also implicated as they had seen him before his ischaemic crisis and had also failed to refer him ( claiming they assumed that I had already done it )
Assuming things is potentially dangerous- check the facts and the reality – and don’t expect patients to always act rationally or in their own best interests. That’s part of what makes general practice challenging , fascinating and difficult . If it was not difficult – most GP’s would not have chosen to do it as their specialty.
Well said Dr Nabi. I had a patient with a brain tumour who attempted to sue having DNA’d his brain scan; fortunately I had reported this at the time; the litigation was abandoned.
Patients have a responsibility to behave properly, just as doctors do.
Outside of litigation, it is too easy to make compliant which remains for ever on a doctor’s appraisal record regardless of the appropriateness or otherwise of the complaint.
I recommend that the fact that patient has complained or attempted to sue should similarly remain on the patient record so that clinicians in the future can choose to exercise an abundance of caution.
@ Ian
Very interesting story.
Surely you couldn’t be held medicolegally responsible for whether or not the patient acted on the advice of a clinician outside your organisation?
Thanks. He did act on the advice but did not see me ( as I was expecting him to do ) and saw 2 or 3 of my partners before his ischaemic crisis occured. I had relied on his seeing me to act on the letter, but he ( chose?) to see my partners even though we were still trying to operate personal lists at the time . My partners missed the fact that he had not been referred and I had written on the letter ( paper letter not email ) ” await to be seen “. Naturally my partners blamed me for the non-referral but is settling the claim they were all found liable as well ( to different degrees ) This patient continued to smoke about 20/day and the Vascular surgeons had not felt it appropriate or necessary to perform by-pass surgery in the 1-2 years prior to the amputation. He was well known to the vascular surgeons . The outcome might have been different if the Chiropodist/Podiatrist had been able to refer him back to the surgeons herself- directly- rather than relying on him seeing me and me re-referring him. I don’t think the outcome was unfair on me- but my partners did think it was all my fault.
Dr Nabi- sorry if me mentioning this case has been a distraction to yours. I hope that you feel you have received some support by you ” going public ” – not an easy thing to do but I hope you find ways of living with the wounds . We can only do our best ( but there’s often a lingering feeling that we could have tried harder or done things differently ). Most Dr’s feel a huge sense of responsibility for providing the best possible care for their patients – as I am sure you do.
A simple accurx template for a text message to patient if we get notice of a DNA takes very little time.
It says I see you missed a hospital appointment on… Sometimes this is because the appointment letter was never received, or may be because the appointment was no longer needed. Please contact the hospital clinic if you still need to be seen, and if you are unable to get hold of them, let us know.
Slightly different process for children, but I do think that being able to send text messages to patients is a big help.
Hi Chin…Long time etc.
Shaba this is absolutely no reflection on your care, diligence, ability and so on. Assuming the patient competent then he – she asked your opinion, you stated a test, all part of the pathway of care and the patient DNA’s then it’s absolutely their responsibility.
Your “upset” at being held responsible actually demonstrates you are caring GP. Was listening in to a group conversation in Manchester recently of young GPs, waiting for the microwave to ping when one said “who cares if you are sued, everyone will be sued loads of times ” Now to me that’s really worrying.
Was doing a surgery in a wealthy area of a national park on Wednesday. Chap needed routine referral for some pipework. Jokingly he said ” now don’t forget to sort it, you wouldn’t want me to sue you” he joked.
I think we all have stories of similar egregious complaints and near misses .
Assumption is the mother of all cock ups, as they say.
It’s all about risk management, and unfortunately we sometimes only advance in this area through crises and not pro-active actions.
A – accept nothing
B – believe no-one
C – confirm everything
do all this, and it will minimise your chance of being successfully sued !
unfortunately, it will also eat into the time you have available to see patients,
it will also ensure you become more “zombie like”
joe public, and the politico’s, barristers journalists etc need to decide what sort of doctors they would prefer.
Slobber Dog- well said.
As even Patch Adams no doubt said, at least once:
F*** ’em.
I realise we are only hearing part of the story, but
Defence organisations make a financial decision to settle even though no negligence has occurred and the profession of ‘medical experts’ may be contributing to this
DNA scans as others have said may well be totally wrong and no appointment was sent- was the letter saying this copied to the patient ?. I would suspect no other country expects the GP to chase up adult competent peoples behaviour. An extension of this would be to be held responsible for all those who don’t get their stool FIT test done. We know a pseudo personal letter form a named GP does increase uptake but how far do you go? In cervical cytology the ‘system is pretty fool proof- should this no opt out and chase everyone be the responsibility of the imaging department for example?
Gutted for the situation.
So no responsibility on a Trust for not contacting the patient. They can send the text. That’s what the spine and summary care record is, go contact the person – tell a twiddling NHS manager at home. No, that would be silly. Most public are cc’d into letters. This spiders web they got you all in is smartly carved. Genius fear, control and monitoring. Double standards and mixed messages.
You need to be smarter.
Interact less.
Refer more.
Make them sign a contract when they register – your own charter of responsibility. I cannot still believe so many GPs delay referral or buy into A+G or referral management meetings. Move the person, they are all hot potatoes. American insurance and law is coming. Trust no one. Believe nothing. And nothing you ever did before for someone matters when cockroaches leave the woodwork.
I’m with Patrufini. The legal system will hold medics responsible for any adverse outcome. Either RLE or cover your as……