A welcome ear

NO ONE likes negative feedback – undeserved or otherwise. But it’s an inevitable part of being a doctor, unless of course you can claim perfection and even that offers no guarantee.

The NHS defines a complaint as “an expression of dissatisfaction that requires a response.” Not only is this usefully concise it also incorporates two important elements in the overall management of complaints: dissatisfaction and response.

Patient dissatisfaction

Two questions arise once you accept the inevitability of some patient dissatisfaction:

• What can you do to minimise the dissatisfaction?

• How can you frame a response that is most likely to satisfy the patient who has complained after an adverse outcome?

But first it is important to note that an adverse outcome is one seen from the perspective of the patient and often there is no suggestion of error, negligence or threat to patient safety. Evidence from the Harvard Medical Practice Study has shown that about one third of complaints or lawsuits will arise from passages of care that were entirely straightforward.

Secondly, the two questions above are not exclusive to handling patient complaints. In the UK, the dissatisfied patient has a number of ways of escalating that dissatisfaction besides making a complaint. Some people will report the doctor to the GMC directly and for others the strictly legal route of a claim for compensation is preferred.

Doctors often grumble about ambulance-chasing lawyers and the complaints culture but these are preferable to leaving the patient with no alternative but more direct action. My chief attending surgeon in the USA was murdered by a dissatisfied patient about nine months after my overseas training period ended.

How do you minimise dissatisfaction?

The short answer is to manage patient expectations or more succinctly – under-promise and over-deliver. Think for a moment about what a patient expects from the doctor. This is probably almost the same list as you yourself would expect from your dentist or accountant or even the garage servicing your car. You expect the following:

• competence (and for airlines and doctors among others, safety)

• respect

• to be listened to

• to be kept informed and given timetables.

Let’s look briefly at these apparently simple suggestions and think about how different ways of handling them can contribute to dissatisfaction. How do people assess the competence of their clinicians?

How do you assess the competence of your garage mechanic? Do you check his qualifications and track record at fixing cars? Do you check that your GP is on the GP register? We all use surrogates for competence and in most cases, these are to do with communication style. So, in a way, competence is the least important of the four elements listed above. The patient will judge your competence based on the other three communication issues: respect, being listened to and being kept informed.

Imagine that a middle-aged woman has just come back from the dry-cleaners with an expensive blue dress that still has a visible stain on it after the cleaners have laundered it. Which of the following two scenarios is likely to generate more dissatisfaction with the cleaners when the stain is still visible after collection?

Scenario 1: “When I took the dress in last week, they did not seem at all interested; they just took it and offered me a receipt. I am not even sure that they attached the stub of the receipt to the dress or just hoped for the best when I came back in to collect it. I was not at all surprised when the stain was as bad as ever. They did not have a clue what they were doing.”

Scenario 2: “When I took the dress in, the cleaners asked to look at the stain. They asked what it was. When I could not tell them, they said: ‘It is a nasty stain which spoils a beautiful dress and we can see why you want to get it out. Because we don’t know what it is, it may be difficult even with our best efforts. Although we offer a 24-hour turnaround, this may take a bit longer if it’s a very stubborn stain so please let us have an extra day’. Well, I knew it would be difficult for them but they have obviously tried really hard and you can hardly see the stain now.”

So both cleaners tried equally and failed equally to remove the stain. In the first scenario, this was the fault of the – obviously incompetent – cleaners. In the other it was just a particularly stubborn stain.

How do you respond to dissatisfaction?

Say you find yourself dealing with a patient who has survived his emergency repair of an abdominal aortic aneurysm with his kidneys, cerebrum and myocardium still more or less intact and who is complaining bitterly about a minor stitch abscess. You are on your last of seven night shifts and it’s 4 am. The temptation is to tell the patient not to be so pathetic and he should be grateful he is still alive. While you might feel better, the patient will almost inevitably escalate his grumbles.

Only a minority of dissatisfied people are looking for compensation or retribution; the vast majority will settle for something called “empathetic validation”. This means having a good old grumble while someone mops your fevered brow, listens to your woes and agrees with you how awful it has all been.

Imagine you have come home after the train journey from hell: no seats, no air conditioning, no information, missed connections and a 45 minute walk home from the station in the rain. How do you feel if your partner greets you with: “I’m glad you are back at last. I’m just off to badminton. Oh, by the way, the cat has been sick and I’ve not had time to clear it up.”

What you wanted to hear was more along the lines of: “You poor thing! What a dreadful journey! Sit down here and I’ll bring you a drink – something long and cool with tinkling icecubes – and you can tell me all about it.”

Perhaps a Singapore Gin Sling is not necessary for the patient with the aneurysm but you do need to acknowledge the problem, which is very real to him. Empathise with the patient by showing how sorry you are that he is upset and let him tell his story while you (actively) listen. The fundamental structure is something like:

“I can see that this is a very serious issue for you Mr Smith. I am very sorry that this has not worked out as we both hoped. Please take your time and tell me what the problems are and then we can talk about how we can set them right.”

Next you should reassure the patient that his concerns have been heard and understood. Do this by active listening and feeding back short summarising sentences along the lines of: “Let me check I have understood you correctly; you are worried that the stitch abscess might be an indicator that your graft is infected. I can understand that this would be very worrying.”

A welcome ear

It’s not difficult to find people who are very good indeed at empathetic validation. They often have a sign on the door that says something like: “Have you been injured in a medical accident? Come in and talk to a solicitor today. We guarantee that all your damages will be paid to you!” The attraction of a free half-hour with a solicitor is understandable. Out comes the patient saying how competent and respectful the solicitor is having also explained how it is well worth trying to obtain some compensation. Reinforcing the view that the doctor is a complete monster is for a solicitor time well spent.

So if there is one single secret to dealing with complaints and preventing lawsuits, it is to be at least as good at empathetic validation as the lawyers and to deliver it first.

Of course, some complaints will not be resolved by empathetic validation but it’s always a good start. Remember that 80 per cent of complaints are made by 20 per cent of patients and you will always encounter people who will remain unhappy no matter how you answer their dissatisfaction.

But the “take-home” message here is that managing expectations beforehand and dealing promptly and empathetically with complaints when they happen will resolve the majority of problems before they can progress any further.

Mr Des Watson is a medico-legal adviser at MDDUS