7 February 2020

Dialling down the stress of patient complaints

AHPRA Medicolegal

Getting a notification from AHPRA is one of the most dreaded things that can happen in a health practitioner’s career, but it shouldn’t be, says Medical Board chair Dr Anne Tonkin.

That’s because the rate of complaints is growing so fast – by about 15% a year – that the experience is now commonplace: about 7% of all Australian doctors received a notification last year, she says.

“It’s not a rare event any more,” Dr Tonkin tells Rheumatology Republic. “I think we need somehow to dial the stress down a little bit.”

She says the growth is mostly in low-level complaints, “not the important ones”.

“It would be really nice to make the prospect of a notification not such a terrible spectre hanging over people, but just one of the costs of doing business. Because if 7% of doctors get a notification each year, which is what we’re currently running at, then over an ordinary career of 30 or 40 years, you’re likely to get at least one and possibly two just on the law of averages. So it’s not a rare event and we should be regarding it as just one of those things that happens – not pleasant but not catastrophic.”

She knows from experience that dialling down the stress is easier said than done. Some time ago Dr Tonkin, a general physician from Adelaide with a sub-speciality in clinical pharmacology, received a notification herself from the state board. While she can’t discuss the details, she says “I certainly felt pretty upset about it”.

As to why the number is rising, Dr Tonkin says “I’d love to know the answer to that”; but she knows what the answer is not.

“Certainly I don’t think the quality of medical practice in Australia is declining at all,” she says. “And I don’t think that 7% of practitioners each year are practising suboptimally.

“I think society is getting a little bit more focused on consumer rights, which is good in a way, but it does lead to people expecting perfection at all times and being willing to complain if perfection doesn’t eventuate.

“And we’ve inadvertently made a rod for our own backs by making it very easy to submit a notification. It’s an online or telephone process and it can be done very easily. I think in the old days when a letter was required, perhaps people would get to the stage of writing the letter and then feel better having written it and not send it.

“This is all speculative, but I think we’re living in times where people complain more and we’ve made it easy to do that by having an online process.”

The 7% figure is a lot higher than the 1.7% cited by AHPRA last month when it announced a new COAG policy direction, which made explicit that its primary role was to protect the public.

The rising tide of complaints has obliged AHPRA and the boards (which have slightly different roles across states) to employ more staff, implement a triage system to assess seriousness and to deal with the most trivial matters without informing the practitioner until it is over, sparing them a fretful wait.

What they can’t do is ignore a voluntary notification or dismiss it summarily, however frivolous or vexatious it may appear.

“We, under the National Law, are duty-bound to consider each complaint that’s brought to us as a notification, but some of them are very trivial. I’ve sat on a committee that had a complaint that the practitioner was eight minutes late. I’ve heard of another one where the complaint was that the practitioner examined a child’s throat and the child gagged.

“We are developing a system that will get [that sort of complaint] out of the system very, very quickly. And particularly we want to get those out of the system without bothering the practitioner until the end.”

According to AHPRA’s website, just over 70% of notifications result in “no further action taken” – in some of those cases the subject has taken some remedial action themselves; 23% result in either a caution or restrictions on practice and less than 1% end up in suspended or cancelled registration.

AHPRA says 40% of cases are closed within 90 days; the rest take longer.

“We’re working very closely with AHPRA to speed things up as much as possible,” Dr Tonkin says. “AHPRA is employing more people in the notification space to try and keep up with the ever-increasing number.

“It seems to be relentlessly going up, so we have to design systems that can cope with very large numbers while being as efficient as possible and as fair as possible to the practitioner, and keeping our primary focus always in mind, and that is protection of the public.

“It’s quite a juggling act.”

She says AHPRA may have to consider a public education campaign “to say ‘yes, we want to hear about doctors who you think pose a risk to the public, but we don’t want to know if they’re eight minutes late’.”

Currently under the triage system, she says, doctors employed by AHPRA see each new notification within 48 hours of it arriving to rate it by clinical risk – “the vast majority of them are very low clinical risk”.

The high-risk cases are rushed into a committee and into investigation.

“The very low ones, which are the vast majority, we are trying to get turned around very quickly to a committee and then a letter off to the notifier and the practitioner within a few weeks. The first thing the practitioner knows about it is the letter saying it was there and it’s gone. There isn’t that limbo time, and the stress appears to be in the limbo time.

“If you get a letter saying you’ve got a notification and then you have to wait for a few weeks or months for a resolution, that’s much more stressful than if you get a letter saying we had one, but it was baseless and it’s gone.”

If you get a notification, Dr Tonkin advises talking to colleagues, a trusted GP or Doctors Health Services, an AMA program that the board helps fund.

“I think if we could get it in perspective and destigmatise it, and have people willing to talk about it with their colleagues and health providers, that will go a long way towards making people feel less stressed.”

She agrees that besides the anxiety during the process, a doctor may suffer a loss of confidence that could damage their practice.

“There is a risk that some doctors become defensive and over-investigate and over-treat people,” she says.

“I must say when I had mine, I wasn’t yet involved in medical regulation and I didn’t react that way. I was fairly clear that the treatment that I’d given was within the current guidelines and that the notification was misconceived and didn’t threaten my sense of having done the right thing.

“I think that’s one of the reasons I want to try and turn down the level of stress and have this regarded as a more commonplace event. Because for most of them, there is no reason for people to start second-guessing their own capacity, and it’s obviously a bad outcome if they do too much of that.”

Another thing to bear in mind, she says, is that the process can be almost as stressful for the patient or family member making the complaint.

“We tend to think about what it’s like for the practitioner. But we have some research going on where both practitioners and notifiers are being interviewed and giving us feedback on the process. And it’s actually a very stressful process for notifiers as well. They don’t find it easy and very frequently they don’t think it’s fair when they get to the end and no further action is taken.

“So we have to walk a very, very fine line recognising that our processes are stressful for both the people involved.”

AHPRA last month launched a podcast series called Taking Care, including a conversation with Dr Tonkin about notifications and another devoted to vexatious notifications.