Abstract
Objective To understand causes of patient dissatisfaction that result in complaints. Design Grievances received by the grievance committee between January 1, 1989, and January 1, 2000, were reviewed. Setting A 2-county area of North Carolina. Subjects Of 29 patients who filed grievances, the 9 male (31%) and 20 female (69%) patients had a mean (±SD) age of 39 (±19) years. In 18 instances, the patient consulted the physician less than 3 times (64%) before the complaint and in 8 instances more than 4 times (29%). Main outcome measures Allegations of the grievance and the committee's findings. Results Grievances fell into 5 categories: failure to fulfill expectations for examination and treatment (38%), failure to promptly diagnose (20%), rudeness (17%), producing excessive pain or practicing beyond the area of expertise (13%), and inappropriate behavior related to billings (10%). In 45% of the grievances, the committee found no breach of practice standards. In 17% of the cases, the physician resolved the grievance by apologizing, adjusting a bill, or completing insurance forms. Conclusion Most grievances were filed by younger women against newly encountered physicians and were related to inadequate communication or alleged delay in diagnosis.
INTRODUCTION
Dissatisfied patients act in various ways. Some ignore their physician's advice, others seek a new physician, and assertive patients may confront their physician. It is common for patients to discuss their displeasure with friends and relatives.1,2,3
Patients whose dissatisfaction prompts formal action have several options. These include bringing a malpractice claim and seeking redress in the courts, filing a complaint with the state medical board, complaining to the “patient relations office” of a hospital or group practice, directing a complaint to the hospital's chief of medical staff or credentials office, or submitting a grievance to the medical society. Why some dissatisfied patients do nothing and others take formal action is not known. Studying formal complaints seems a reasonable way of increasing our understanding of how patient-physician interactions go awry.
Americans are accustomed to complaining. In business, consumers are invited to file complaints or “see the manager” when they are dissatisfied. Complaints may be expressed by writing to or phoning a customer relations department, the Better Business Bureau, a governmental office of consumer affairs, attorney generals' offices, or a television station's consumer action reporter. If clients are sufficiently angered by the performance of their attorney, they might elect to take the matter up with the American Bar Association. There is, similarly, a long-standing practice of patients filing complaints with medical societies when they feel that a physician's conduct is inappropriate. Medical societies have, in turn, established policies and procedures for responding to complaints about their members.4,5,6 Part of the societal contract between the medical profession and the public is the agreement that the profession will respond to complaints and be self-policing.
We have reviewed the experience of a medical society grievance committee to gain a better understanding of the causes of patient dissatisfaction. We hope that the knowledge gained will help develop preventive strategies.
METHODS
Grievance process
Medical societies generally process complaints against physicians through a grievance committee (also called a conciliation committee) and a disciplinary committee. The grievance committee screens, reviews, and refers complaints. In addition, the committee educates physicians and their patients about the professional obligations of physicians and decides whether to pursue disciplinary proceedings. If a disciplinary proceeding is appropriate, then the matter is referred to the disciplinary committee. The independence of the 2 committees is intended to ensure that a judgment concerning discipline is rendered by an impartial decision maker.5 Although most complaints are filed by patients, they may be also filed by family or friends of the patient or colleagues of the physician. Complaints are submitted in writing. When this is not feasible because of a patient's impairment, the complaint is presented orally with a verbatim transcript taken.
When a complaint is received, the patient is asked to sign a release of medical information so that the complaint can be evaluated. The committee evaluates the medical records and interviews the complainant, the physician, and any other person who has knowledge of the facts involved. In some cases, other physicians in the defendant physician's specialty are interviewed, and the medical society records are examined for any previous complaints concerning the physician.
On completing the review, a committee may reach 1 of 5 possible conclusions. The first is that the physician did not act improperly, and no further proceedings are warranted. The second is that the matter should be referred to the disciplinary committee, state medical board, police, or another agency or institution for further proceedings. The third is that the physician acted inappropriately but not seriously enough to warrant disciplinary proceedings or proceedings by an outside agency. In some of these cases, a mutually agreed course of remediation may be undertaken. The final conclusion is that efforts will be made to resolve the matter through mediation. Grievance committees may entertain complaints about fees but cannot undertake any activity that constitutes price fixing.4,5
Population
There are 2,394 practicing physicians, not in training, in Durham and Orange counties, North Carolina. About 440 practicing physicians (18%), not including students or trainees, are members of the Durham-Orange County Medical Society, along with 129 retired physicians. The grievance committee is responsible for processing complaints concerning physicians practicing in the 2-county area.
RESULTS
From January 1, 1989, through January 1, 2000, 29 grievances were filed. The age range of the patients was 11 to 73 years (mean, 39±19 years; median, 36 years). There were 9 male (31%) and 20 female (69%) patients.
The medical specialties of the defendants in the grievance proceedings are shown in table 1. Of the 28 physician defendants, 10 (36%) were academicians and 18 (64%) in private practice. In 18 instances (64%), the patient had consulted the physician 3 times or less and, in 8 instances (29%), 4 times or more. In 2 cases, the number could not be determined.
Table 1.
Specialties of the 29 defendants in the grievance proceedings
| Specialty | Physicians, no. (%) |
|---|---|
| Internal medicine or its subspecialties | 6 (21) |
| Emergency medicine | 4 (14) |
| Dermatology | 4 (14) |
| Orthopedic surgery | 3 (10) |
| Obstetrics and gynecology | 3 (10) |
| Family practice | 2 (7) |
| Pediatrics | 2 (7) |
| Ophthalmology | 1 (3) |
| Plastic surgery | 1 (3) |
| Neurosurgery | 1 (3) |
| Neurology and urology | 1 (3)* |
| Medically related corporation | 1 (3) |
One of the complaints was against a neurologist and a urologist.
As shown in table 2, the principal grievances fell into 5 categories: failure to fulfill expectations for examination and treatment, failure to make a prompt diagnosis, discourteous behavior, unacceptable medical practice, and issues related to billing and collections.
Table 2.
Principal claims of the 29 grievances
| Complaint | No. (%) |
|---|---|
| Physician's alleged failure to fulfill the patient's expectations for examination and treatment | 11 (38) |
| Inadequate outpatient therapy—“The doctor treated me, but l'm still in pain” | 6 |
| Failure to obtain informed consent for surgery | 2 |
| Inadequate physical examination | 1 |
| Lack of prompt attention following hospitalization | 2 |
| Alleged failure to make a prompt diagnosis | 6 (20) |
| Cancer | 3 |
| Multiple sclerosis | 1 |
| Cardiovascular disease | 1 |
| Pilonidal cyst | 1 |
| Alleged rude or discourteous behavior | 5 (17) |
| Rude | 4 |
| Failure to answer mail or return phone calls | 1 |
| Alleged unacceptable practice behavior | 4 (13) |
| Producing excessive pain | 3 |
| Practicing outside area of expertise | 1 |
| Alleged inappropriate behavior related to billings and collections | 3 (10) |
| Discharge from practice for nonpayment | 1 |
| Overbilling | 1 |
| Failure of 1 physician to pay another for locum tenens work | 1 |
In 13 cases (45%), the committee found no breech of the standards of medical practice. In 5 cases (17%), the physician defendant apologized, adjusted a bill, or complied with a request to complete insurance or disability forms. One fifth of the grievances were terminated by the patient refusing to provide a written signed complaint or by a lack of jurisdiction of the committee (table 3).
Table 3.
Dispositions of 29 grievances by the grievance committee
| Disposition | Grievances, no. (%) |
|---|---|
| There was no breach of the standards of medical practice | 13 (45) |
| The committee had no jurisdiction in the case | 3 (10) |
| The plaintiff declined to provide a written, signed complaint | 3 (10) |
| The committee was unable to make a determination concerning fault | 2 (7) |
| The physician apologized to the patient | 2 (7) |
| The physician completed the disability or insurance forms as requested | 2 (7) |
| Case referred to the State Board of Medical Examiners | 1 (3) |
| The physician adjusted the bill | 1 (3) |
| The patient expressed gratitude “for being heard” and dropped the grievance | 1 (3) |
| On the recommendation of the committee, the physician enrolled in a continuing medical education course | 1 (3) |
DISCUSSION
Principal findings
Most grievances were filed by younger women against newly encountered physicians. Most grievances were related to inadequate communication or alleged delay in diagnosis.
The 29 complaints received represent, for the most part, serious allegations. Some patients clearly depart from their physician's office feeling victimized or cheated.6 Perhaps a clearer mutual understanding of the expectations for medical or surgical therapy would have avoided later dissatisfaction. Because women, on average, have more physician visits per year than men, it is not surprising that women constitute the majority of patients filing grievances.7
In some cases, the act of bringing a complaint leads to a resolution. When both parties to a dispute have to describe their roles in a disagreement to a third party, they often realize during the process of self-examination that they do not want to take the case further. Often people just want someone to listen to the cause of their unhappiness. Being given this opportunity may in itself be a satisfying outcome.6 In our study, although in about half the cases the committee found no breach of the standards of medical practice, this does not always mean that they endorsed a physician's behavior. To our knowledge, no grievance brought before the committee was ever carried forward to litigation as a malpractice claim.
Weaknesses of the study
Our data are inadequate to address the question of whether certain physician specialties are more likely to be the subject of grievances. They cannot tell us whether complaints are made more commonly against academic or private practice physicians. Our study did not determine how many complaints were taken directly by patients to their physicians rather than being brought to the grievance committee. It is unclear whether the frequency of patient use of the medical society grievance procedure varies by geographic area, whether the nature of grievances is changing over time, and how grievances evaluated by our committee compare with those being dealt with by patient relations committees, ombudsmen, or medical staff offices. Some complaints, during the process of committing them to paper, seem less dramatic to patients than they initially thought, and they are dropped. It is also possible, of course, that some patients do not submit written complaints because of literacy problems or because, in their opinion, the grievance process “just isn't worth the effort.”
Other studies
A study of complaints against Australian physicians showed that most concerned physician incompetence, practice outside the physician's capacity, the physician's use of alcohol or drugs, sexual misconduct, errors in prescribing, and insurance fraud.8 In another study, Annandale and Hunt found that the most common causes of patient disagreements with physicians were diagnosis-related—that is, failure of the physician to make a diagnosis or a patient disagreement with the physician concerning a diagnosis, disagreements about a prescription, concerns related to the doctor-patient interaction, or alleged overtreatment or undertreatment.1
In 1980, Banov summarized grievances brought to a county medical society. These fell into 5 categories: disputes over fees, physician neglect or unavailability to the patient, misunderstanding or a breakdown in communication, improper treatment, or inappropriate physician conduct.9 Banov saw more disputes over fees than our committee did. Twenty years ago, on our committee, fees were also commonly discussed. A physician in practice whose charges were thought to exceed customary community norms would be explicitly told to “lower his or her prices.” Such issues have now been excluded from the agenda of grievance committees, lest they be accused of price fixing.4,5
In a study of complaints submitted in England and Wales in 1971, the most common were alleged inadequate or incorrect treatment, failure to visit or delaying visiting a patient, and failure to refer a patient for admission to a hospital or other specialist service.3 In a study by Owen in England, the most common causes of complaints were alleged failure to diagnose or a delay in diagnosis (26%), failure to visit the patient in a timely manner (25%), and alleged error in prescribing (9%).10 Levinson and associates have identified particular types of US physician-patient disagreements related to managed care. These include disputes over the allocation of health care resources (access to specialists, diagnostic tests, or treatments), disputes over access to care (access to the primary care physician and allotment of sufficient time for office visits), and disputes over financial arrangements (fees or disclosure of physician financial incentives).11
Klein reviewed the frequency of complaints sent to the National Health Service in England and compared them with estimates of the rates of patient dissatisfaction with physicians. Not surprisingly, formal complaints represented only the tip of the iceberg. Patients far more often deal with their dissatisfaction by complaining to family and friends or switching doctors than by submitting a written complaint.3 The Harvard Medical Practice Study found that less than 2% of patients who had had adverse events caused by medical negligence filed malpractice claims. Clearly, medical malpractice claims represent only a small subset of adverse events.12
Meaning of the study
Disagreements between patients and their physician may cause patients to have diminished trust in the physician, be dissatisfied with clinical results, change their physician or health plan, file complaints, or seek litigation. For physicians, disagreements may result in frustration, anger, loss of control, and career dissatisfaction.8
Physicians should employ fundamental communication skills to avoid grievances: understand the patients' worries and concerns, express empathy, actively discuss care options, negotiate differences of opinion, and allow sufficient time for an adequate conversation.11
Physicians selected for membership of a grievance committee should command the respect of their peers. They should have a large reservoir of experience. Diplomacy, an understanding of human nature, and sound judgment are also crucial.6
Unanswered questions and future research
The challenge for physicians is to recognize patients' unfilled expectations and to engage patients in a discussion with the goal of identifying and ameliorating dissatisfaction while building a trusting therapeutic relationship.11 Future research should focus on identifying and evaluating strategies to improve communication skills and minimize patient dissatisfaction.
Competing interests: None declared
Dr Stephen Lang reviewed the manuscript and made many helpful suggestions.
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