Complaints against doctors

Clinical communication skills are at the heart of medical practice, and poor performance is an important factor in the origins of complaints and litigation.^{1 2} A recent study from Canada published in JAMA shows that poorly performing doctors can be identified early in their careers and possibly given targeted support and appropriate further training.³

Tamblyn and colleagues followed up a cohort of newly qualified doctors in Ontario and Quebec for two to 12 years.³ They found a link between both communication and quality of care scores on the clinical skills examination of the Medical Council of Canada (taken shortly after graduation) and subsequent complaints registered with the medical regulatory authorities. A decrease of two standard deviations in communication score on the examination was associated with one additional complaint per 100 years of practice. People whose scores of communication skills were in the bottom quartile had a significantly increased risk of subsequent complaints from patients (excess complaint rate 2.15 per 100 practice years compared with the three other quartiles).

Although the rate of complaints per 100 years might seem low, complaints were made against 17% of doctors at least once during the average 10 year follow-up period. Factors that were significantly associated with increased numbers of complaints were the clinician being male and working in family practice or surgery (rather than general medicine). Most of these doctors would have received training in communication skills during their medical school training, although this may have been of variable quality, and they were well aware of the content of the clinical skills examination.

Teaching communication

Considerable resources are devoted to teaching and assessing the communication skills of medical students. The Calgary Cambridge guide is well established as a generic guide to consultations and the skills needed for effective communication.⁴ Students are often tested for communication skills—for example, taking a history; exploring the patient’s perspective, concerns, and expectations; explaining diagnoses and treatment; and discussing options for treatment or care. Students also cover specific tasks such as breaking bad news.

Tamblyn and colleagues’ results indicate that doctors whose communication skills need to be improved could be identified before problems are encountered in clinical practice. Stricter thresholds for passing graduate medical examinations or postgraduate qualifications could be enforced. However, as these researchers point out, the reliability of many assessments of communication skills is low (and lower than assessments of clinical skills, for example), especially if relatively few (four or five) objective structured clinical examination stations are used.

More could be done with the data already being collected during medical training. Firstly, examinations commonly test a range of knowledge, skills, and attitudes to produce an overall mark, and poor performance in one area can often be compensated for by good performance in another. To combat this we may need to make examinations more modular and make it mandatory for students to pass the communication skills component. Secondly, more could be done with data from examinations. Students who only just pass or who fail at their first attempt and pass subsequently are at high risk of complaints in the future. Proactive efforts may be able to rectify their deficiencies and reduce the risk of subsequent poor performance or complaints.

The assessment of doctors already in practice presents greater challenges.⁵ How the doctor functions within the team is also important.⁶ Providing support to poorly performing doctors is as complex as the methods of assessment, and it is difficult to achieve improvements. A systematic review in the Cochrane Database found that only two of seven trials of interventions to enhance patient centred behaviour improved patients’ assessments of interpersonal care skills.⁷ Experienced clinicians may have developed ingrained patterns of behaviour. Lack of insight may prevent doctors from remedying their weaknesses, even when they are accurately identified.⁸ Additional training in communication skills can be provided, however, and it may benefit some groups.

Global deficits

Poor communication that triggers complaints may indicate global deficits rather than a simple lack of skill in talking to patients, and it may be an indicator of poor health, poor decision making, or other cognitive problems. Depression and burnout are common in junior doctors. They greatly affect performance and may reflect the influences of the organisation and deficiencies in service delivery as much as individual problems.⁹ A package of intervention and continuing support through remediation and reassessment is often needed. A range of services has been set up to help struggling doctors. These services often consider the individual’s health and social and personal problems.^10-12 The goals include improving clinician performance—particularly with regard to communication skills—as a way to reduce complaints and other malpractice outcomes, but more importantly to help the clinician become an effective and safe deliverer of health care. Evidence on the effectiveness of such interventions is still needed, but they are essential components of our educational programmes.

Competing interests: PK directs a university unit that generates income from teaching communication skills.

This editorial was first published in the BMJ (2008;336:841-2; doi: 10.1136/bmj.39525.658565.80).

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