Intended for healthcare professionals

Observations Ethics Man

Lessons from the front line

BMJ 2017; 359 doi: (Published 06 October 2017) Cite this as: BMJ 2017;359:j4624

We need to change the culture. The current system harms doctors and leads to defensive practice that harms patients.

Mr Sokol argues that lawsuits lead to “better safer practice”. However the real issue about litigation and complaints investigations in general, is the pernicious impact they have by creating a culture of fear. As the Berwick report (1) stated “fear is toxic to both safety and improvement". Furthermore the impact on the wellbeing of many doctors is unfortunately profound. The result is that physicians inevitably practice defensively. Survey studies have obvious limitations, but they are remarkably consistent in finding that the majority of doctors admit to defensive practice with a negative impact on patient care and healthcare costs. In a survey study we found that most doctors (>80%) admitted to “hedging” (e.g. over referral, over investigating, over prescribing) and many (>40%) to avoidance (avoiding high-risk patients or abandoning procedures early). They did this either in response to experiencing a complaints procedure themselves or after witnessing a colleague do so. Neither of these behaviors is in the interests of patients and certainly does not represent improved care.(2)

More concerning is the impact of complaints on the wellbeing of doctors. We found concerning levels of moderate to severe anxiety (22%), depression (26%) and suicidal ideation (15%) amongst doctors currently experiencing a GMC investigation. Our data are but one of many studies that consistently shown the baleful impact these processes have on physicians. This is not being “miserable”, this is serious psychological illness.

One of the principal issues relating to how doctors are dealt with when things go wrong is the lack of “natural justice”. Physicians are subjected to multiple jeopardy, such that by the time a case comes to a courtroom they may well have undergone a formal investigation at their own institution, possibly a serious untoward incident investigation and/or been referred to the general medical council. Such proceedings often take months if not years to conclude. Instead of this punitive approach, the aim should be that we have a culture where mistakes are learnt from and systems constructed to make human error less likely. This should be achieved locally without any need to go near a courtroom. If the issue relates to compensation for patients, then everyone would perhaps be better served by a no-fault system.

One must question the ethics of a system that contributes to a culture where learning from mistakes is less likely, that leads to defensive practice that harms patients, and impacts disproportionally on the wellbeing of doctors.


2. The impact of complaints procedures on the welfare, health and clinical practise of 7926 doctors in the UK: a cross-sectional survey. Bourne T, Wynants L, Peters M, Van Audenhove C, Timmerman D, Van Calster B, Jalmbrant M. BMJ Open. 2015 Jan 15;5(1):e006687. doi: 10.1136/bmjopen-2014-006687. PMID: 25592686

Competing interests: No competing interests

23 October 2017
Tom Bourne
Queen Charlottes and Chelsea Hospital
Imperial College, London