- Ashok Jain, general practitioner,
- Jane Ogden (), senior lecturer in health psychology
- Department of General Practice, Guy's, Kings and St Thomas's Medical Schools, Kings College London SE11 6SP
- Correspondence to: Dr Ogden
- Accepted 12 March 1999
Objective: To examine how general practitioners experience patients' complaints.
Setting: General practices in Lambeth, Southwark, and Lewisham health authority.
Participants: Representative sample of 30 general practitioners who had had complaints made against them under either the old or new complaints system.
Design: Qualitative study with detailed interviews.
Results: Participants described their experiences of patients' complaints in three stages: initial impact, conflict, and resolution. The first stage described being out of control, feelings of shock and panic, and a sense of indignation towards patients generally. The second stage described the many conflicts generated by the complaint: emotional conflicts such as feelings of anger, depression, and even suicide, conflicts around aspects of professional identity including doubts about clinical competence, conflicts with family and colleagues, and conflicts arising from the management of the complaint. The third stage described a sense of resolution. For many this meant practising defensively, for others it meant planning to leave general practice, and for a minority no resolution was achieved. Not all participants, however, reported such a negative experience. Some described how they had become immune to complaints, and a small minority described the complaint as a learning experience.
Conclusion: The initial impact stage and conflict stage may be necessary aspects of the experience that general practitioners endure when they have a complaint made against them. Support structures should, however, be in place to help general practitioners through these stages.
Patients' complaints against general practitioners are increasing
Negative experiences of a complaint were shock, being out of control, depression, suicide, doubts about clinical competence, conflicts with family and colleagues, defensive practice, and a decision to leave general practice
A minority of participants expressed immunity towards complaints and a small minority saw complaints as a learning experience
General practitioners find patients' complaints stressful, interfering with their working and personal lives and affecting job satisfaction.1–4 Research, however, has mainly been based on anecdotal evidence 2 3 or had been part of an investigation into doctors' stress in general. A recent study did explore general practitioners' responses to being complained about5 but analysed their responses within a sociological framework, emphasising the maintenance of professional power, rather than emotional reactions. We therefore examined how general practitioners react to receiving a complaint and how receiving a complaint affects them.
Participants and methods
Health authorities keep lists of all general practitioners who have been complained about, but these lists are confidential. To overcome this we sent out a preliminary questionnaire to all 437 general practitioners practising in Lambeth, Southwark, and Lewisham asking for their sex and ethnic group (white, black, Asian, and other) and whether they had been complained about under either the old system (12 months before the new system was initiated on 1 April 1996), or new system (12 months after onset of the new system), or both (box 1). Those who had been complained about were asked if they would participate in our study. Overall, 288 general practitioners returned completed questionnaires (response rate 66%), of whom 96 (33%) reported having been complained about: 35 (12%) under the old system, 40 (14%) under the new system, and 21 (7%) under both. Of these, 67 (70%) agreed to be interviewed; we selected 33 (49%) according to sex, ethnic group, and time of complaint, and we stratified them according to the profile of the original 96 general practitioners who reported that they had been complained about. Our sample was therefore representative of the general practitioners in Lambeth, Southwark, and Lewisham who had responded to the preliminary questionnaire and stated that they had been complained about under the old system, new system, or both. We were unable to interview three (9%) general practitioners owing to illness, being out of the country, and a change of mind. The table lists the details of the 30 participants.
Box 1 New and old complaints procedures
Before April 1996 if a patient wanted to complain about a general practitioner he or she approached the local health authority, which then investigated the general practitioner formally or informally. This system was complex and cumbersome and both patients and general practitioners were dissatisfied with it. 3 6 In 1996 after publication of the Wilson report Being Heard2 a new complaints procedure was established whereby patients were encouraged to complain directly to the practice, and the general practitioner was expected to resolve the complaint within a specified period if possible.
AJ contacted those selected and arranged an interview. We obtained ethical approval from the ethics committee of University Hospitals Lewisham. The interviews took place at the participant's home (two cases) or in a quiet room at the practice (28) and lasted between 22 and 30 minutes (box 2).
Box 2 Questions asked during interview
Preliminary question: “Can you tell me the effects of the patient's complaint on your life?” This was followed by prompts if necessary such as:
“Can you tell me about the role played by others?”
“What effect do you think it has had on you?”
“Do you think the patient had a right to complain?”
“Can you tell me what the patient complained about?”
The interviews were audio taped and transcribed. The transcripts were read several times to identify themes and categories as recommended by Miles and Huberman.7 In particular, all the transcripts were read by AJ and a subsample was read by JO. After discussion a coding frame was developed and the transcripts coded by AJ. If new codes emerged the coding frame was changed and the transcripts were reread according to the new structure. This process was used to develop categories, which were then conceptualised into broad themes after further discussion. The themes were categorised into three stages: initial impact, conflict, and resolution.
Stage 1—initial impact
The participants described the initial impact of the complaint in terms of control, their changing perception of the patient, and a sense of immunity.
Some participants felt shocked on receipt of the complaint. One participant who had not made an on-call visit to a patient who was later found to have an ectopic pregnancy said:
“It's my first complaint, so I just couldn't believe that I'd been complained against. Perhaps I was unrealistic you know … I just felt that I work hard and try to do my best.” (Participant 14: male; Asian.)
Some participants felt panicky. One participant who had asked the abusive relative of a patient to leave the waiting room said:
“When I saw the letter from her I said … ‘Oh God, not again, you know, what's going to happen now?’ … the whole process is so out of control.” (Participant 16: female; white.)
Some participants felt that the complaint was inevitable. One participant who had given the wrong dose of a drug and acknowledged his mistake described how he had expected to receive the complaint:
“I had diagnosed her thyrotoxicosis and commenced her on carbamizole, but I had pressed the wrong button on the computer, given her four times the correct dosage and she had received all sorts of side effects.” (Participant 7: male; white.)
Perception of patient
Participants also described the initial impact of the complaint in terms of how it made them feel about the patient. Some felt indignation when patients complained. One participant described receiving a complaint from a patient who she considered non-compliant and to have been influenced by her pharmacist and said:
“The patients now think that we are like a supermarket; we're like a shop. If you don't like something you complain about them, and you get this ethos with ‘entitled’ to this ‘entitled’ to that. ‘If you don't give it to me, I will complain or I will see my solicitors.’” (Participant 21: female; other.)
In contrast, others felt that patients had the right to complain. One participant who had been complained about by a patient's wife for not taking her husband's symptoms seriously enough (he subsequently died) said:
“I don't think the complaint shouldn't have happened. I think the woman had a perfect right to complain … it was a situation (that) needed clarification and I don't deny her right to complain.” (Participant 10: male; white.)
Not all participants, however, experienced the receipt of a complaint negatively. A few described the complaint as having only a minimal impact and that they had become immune to patients' complaints. One participant who had had many complaints said:
“I just grit my teeth and get on with it. I almost treat the patient's complaint just like a parking offence—don't like the ticket but pay the penalty and I get on with it.” (Participant 19: male; white.)
After the initial impact of the complaint, the participants described the conflicts resulting from the complaints. In particular emotional conflicts, and conflicts with aspects of their professional identity, their relationships, and management of the complaints process.
The participants described many emotional conflicts generated by the complaint, at times this was as anger. For example, one participant said:
“I was really incensed … I just felt very angry, very angry … I was so angry it probably took me about a week to recover from the anger. And the stupid thing is that when you have these complaints you spend the whole weekend brooding over it.” (Participant 11: female; white.)
Some participants described how they became depressed:
“The first thing that made me feel tearful was when my partner rang me up on the Saturday, the next day, and told me she'd died. I was absolutely convinced she'd had meningitis and I couldn't believe I'd missed it, right, because she was just quite well. And I did actually have—nightmares is too strong a word—but I did used to wake up for the first month or so in the middle of the night. I kept seeing her full of a bluey-mauve rash all over her face, sort of, I'd wake up like that …” (Participant 8: female; Asian.)
One participant described the negative emotional impact of the patient's complaint and mentioned suicide:
“For those two years life was difficult … I used to wake up in the early hours of the morning thinking about it, and sometimes even considered suicide in those early hours, but didn't.” (Participant 2: male; white.)
The participants also described conflicts with aspects of their identity as a professional. Some described their feelings about their clinical competence. One, who had given a patient a prescription during a home visit rather than leaving antibiotics from her bag, said:
“After many years of practising that was my first real complaint … first time that somebody had stood up and said, I think there's something wrong with your clinical judgment. I think there's something wrong with the way you practise … it did actually hit me quite badly, you know, I felt it was telling me that I was a bad doctor.” (Participant 15: female; black.)
The participants also described how the complaint had made them lose their confidence in their ability to manage patients. One participant said:
“Should I do more tests, should I do less tests, you know, should I give this information. Should I take this much more seriously. So I'm double, triple, quadruple checking and very anxious about a whole range of relatively unconnected medical management things that I'm doing. So I think it makes me question all the routine things that I do.” (Participant 7: male; white.)
The participants also described the conflicts that had arisen in their relationships. Some described the consequences for their children:
“I think because I'm feeling depressed, I'm not as reactive to the children. I want to be left alone; I get snappy because I'm worrying about something at the back of my mind all the time. When I'm at home I should be relaxed and enjoying the family.” (Participant 18: female; black.)
Some described the effect on their marriage:
“The initial complaint and its effect on my confidence and home life had an indirect bearing on the breakdown of my marriage.” (Participant 30: male; white.)
Some participants also described the effect on the practice where they worked. In some cases they felt unsupported for various reasons and let down by their work colleagues:
“I felt very isolated and I didn't know who to ask for help really because everyone seems busy with their own lives, you know, like my partners. You know they have an apparent front that they're, you know, caring normal doctors, but not for each other, I don't think.” (Participant 14: male; Asian.)
Some participants described how their relationships had improved because of the complaint. One participant described how his work colleagues had been supportive:
“The way the practice handled it, which I think is very good, is that they have a system whereby they believe that if there's a complaint made then it's made against the whole practice.” (Participant 23: female; white.)
Management of the complaints process
The participants also described conflicts arising over the management of the complaints procedure. For many participants this was described as being out of control. One participant who had asked the abusive relative of a patient to leave the waiting room said:
“When I saw each letter from her I said … ‘Oh God not again, you know, what's going to happen now?’ … the whole process is so out of your control, so you know, more of a sinking feeling when I saw the letters … you don't get told when its finished, I assume its finished, but nobody's actually said this is finished, you know. There's no line drawn under it.” (Participant 16: female; white.)
In contrast, some participants stated how they felt in control of the management process:
“Once you've met the patient and aired each other's views, then in everybody's mind so far that's been the end of the matter and its been fairly clear that there's been no further action to take, which is where the stress stops.” (Participant 25: male; other.)
The participants also described conflicts over support. For some this was experienced as support for themselves. One participant who had not provided medical care to someone who was neither his patient nor living in his practice area said:
“The FHSA [Family Health Service Authority] were quite clear in their view that it was out of my area and if it wasn't my patient then it wasn't my problem at all … curiously enough the defence organisation wasn't very supportive at all … The health authority was actually much more supportive.” (Participant 25: male; white.)
Many participants described how they felt that the patient had received more support than themselves. For many this related to the Community Health Council, which was described as trying “to stir up trouble,” “loves picking a fight with general practitioners,” “victimise the general practitioner unduly,” and “manipulates the patient to make the complaint.” One participant who had been prevented from meeting the complainant by the Community Health Council said:
“The CHC is aiding and abetting the complainant. They seem to be talking for her … I'm sure they're writing her letters because the language of the letter is not the mother's, and the way it's been done, I am sure it's not the mother who would have done it all. So it seems to be them and us.” (Participant 8: female; Asian.)
The final stage described by the participants was attempts at reaching a resolution.
Some participants managed to reflect positively on the complaint and regarded it as a learning experience:
“I think and I hope that we think … of every complaint being a treasure. That we really should try and learn from these things. These are not things that we should automatically become defensive about, and we should see them as ways of going forward. So I think on the whole it's a good safety valve and we should learn from them.” (Participant 7: male; white.)
Changing clinical practice
For many participants the resolution was not so positive. Some reported having changed their clinical practice as a result of the complaint such as offering a more limited service. One participant (the patient complained she had missed the diagnosis of paroxysmal atrial fibrillation) who had been involved in the complaints procedure for two years said:
“Sometimes I wonder why I sort of go out of the way to help all my patients. Just do a short consultation and that's the end of the matter. I just feel it's a waste of time trying to help somebody because when it comes to the complaint, whatever good you've done for the patient is all wiped out just like that.” (Participant 9: female; Asian.)
Some participants reported that they now practise by the rules. One participant who was complained about for not explaining about the possible side effects of a drug to her patient before prescribing said:
“I'm more ready to play it by the book. With hypertension before you start with anything I send them off for loads of tests, and before I start I read the Mimms, read out all the possible side effects, which in a way with some patients you don't need to because it will put them off taking it.” (Participant 21: female; other.)
Participants also reported becoming defensive, leaving no room for patients to complain:
“It has changed my kind of practice from the best I could do for my patients to becoming much more defensive and referring more things for investigation or for consultant's opinion, quite knowingly inappropriately, and the patients are now not getting the quality of care based on my knowledge, education, understanding, experience. They're not getting the quality of care as they were before this complaint was made, simply because I'm being careful to avoid possible future complaints if I can.” (Participant 2: white; male.)
Another participant who was complained about for advising over the telephone instead of visiting for a cough and cold said:
“I would visit at the drop of a hat. I wouldn't try to advise over the phone because I was just too scared of what would ensue if I advised over the phone. If there was a hint that antibiotics were a possibility I'd give them. I wouldn't try and educate the patient out of having their antibiotics.” (Participant 15: female; black.)
Leaving general practice
Some participants were so distressed by the complaint that they had decided to leave the NHS:
“I was on the point of retiring. I'm only 40 something, I wanted to give up. I was so angry. I've decided to retire ten years earlier than I would have … I love the job, but I can't be bothered with you know, always treading on eggshells with patients, and having to pamper them because you're worried that they might complain.” (Participant 21: female; white.)
Whereas most of the participants had found some resolution, whether positive or negative, some had not. One participant who had been damaged so much by the patient's complaint said:
“It's made me very angry and … but time takes the edge off, like divorce almost I suppose, or bereavement. As time goes by it becomes less important … Oh, I don't think it will ever go, no, no.” (Participant 2; male; white.)
We aimed to explore the impact of patients' complaints on general practitioners. The participants described their experiences in three stages: initial impact, conflict, and resolution. The first stage described being out of control, feelings of shock and panic, and indignation towards patients generally. The second stage described the conflicts generated by the complaint: emotional conflicts such as feelings of anger, depression, anxiety, and even suicide, and conflicts with aspects of professional identity including doubts about clinical competence and a lack of confidence in managing patients. The participants also described conflicts with their families and colleagues, and conflicts arising from the processes involved in managing the complaint. The third stage described resolution. For many this meant changing their clinical practice to become more defensive and offering a less appropriate service, whereas for others it meant planning to leave general practice or no resolution. For many participants the experience of receiving a complaint is a negative one. Both the initial impact of the complaint and the conflicts arising are distressing for the general practitioner and even the resolution stage is often unsatisfactory. Research indicates that many general practitioners experience psychological problems such as burnout, depression, and marital breakdowns, which may result in alcohol misuse and even suicide.8 Such responses are similar to those described within the literature on bereavement9 and coping with illness,10 with individuals progressing through the stages of adaptation.
A minority of our participants described how they had expected their complaint, and others described themselves as being immune. Some participants described how the complaint had improved their relationships with their colleagues, and a few described the complaint as a learning experience that had helped them to reflect upon and improve their practice.
This project was completed as part of AJ's assessment for the MSc in general practice, from the United Medical and Dental Schools..
Contributors: AJ conceived of the original idea and designed the study with JO. AJ carried out the interviews and both AJ and JO were involved in the analysis of the transcripts and writing the paper. AJ and JO will act as guarantors for the paper.
Competing interests None declared.