Prevalence and characteristics of complaint-prone doctors in private practice in Victoria

Medicolegal matters are not uniformly distributed across the medical workforce. Previous research has shown that malpractice lawsuits,1-8 complaints,8-11 no-fault compensation claims,12 disciplinary proceedings,8,13-15 and other referrals to oversight bodies8,16 tend to cluster among relatively small groups of doctors, who have identifiable characteristics. However, only three of these studies have centred on complaints: two were reviews of internal complaints within United States medical groups;9,10 the other was a survey of New Zealand doctors.11

Patient complaints can provide useful insights into quality of care and patient dissatisfaction.17,18 This is particularly true in Australia, where complaints to health service commissions — regulatory agencies that operate in all eight states and territories, resolving thousands of complaints each year — have become the primary avenue for medicolegal redress. Unlike lawsuits or disciplinary actions, complaints to commissions are almost entirely patient-driven, legal representation is not required, and matters are usually resolved within months.19

We analysed complaints against doctors in private practice in Victoria. We describe the distribution of these complaints and profile the subgroup of doctors involved in a disproportionately large number of them. Our goal was to inform strategies for identifying and intervening early with complaint-prone doctors.19

This study found that, in the decade to 2010, one in five of Victoria’s approximately 10 000 doctors in private practice had at least one complaint from a patient to the state Health Services Commissioner. There was a heavy concentration of these complaints among a small group of doctors. Specialty was an important marker, with surgeons and psychiatrists significantly overrepresented in the complaint-prone group. Overseas trained doctors, on the other hand, were significantly underrepresented in this group.

More generally, our findings reinforce the conclusion of previous research that it is incorrect at the population level to construe doctors’ experiences with medicolegal matters as merely the “luck of the draw”.7 Complaints clearly cluster around certain doctors — in Victoria, extrapolations from our findings indicate that less than 100 practitioners, or 1% of the medical workforce in private practice, account for nearly 20% of complaints.

It would be a feasible proposition to mount interventions in a group of this size, and this may help improve patient satisfaction, quality of care, and public confidence in the health care system. Such interventions should be tailored to the concerns identified in complaints and the degree of recidivism. At the low end of the spectrum, they may involve simple guidance (eg, information and feedback), graduating to moderately intrusive measures (eg, specific professional development modules). At the upper end of the spectrum, stronger interventions may be warranted (eg, referral for competence or health assessment), rising to practice restrictions by the appropriate agency where required. In most cases, remediation, re-skilling, or rehabilitation should be enough to help doctors return to safe practice.16

Why surgeons and psychiatrists are disproportionately at risk is not well understood. Previous complaints studies have identified the same phenomenon,9,10,18 as have studies of other medicolegal matters.1,2,5,7-10,12,13,15,16 In surgery, the inherent risks of surgical procedures and the relative visibility of poor outcomes of care are likely to play a role.21 In psychiatry, certain patients may have an increased propensity to initiate medicolegal action, although, despite speculation about this phenomenon, there is little hard evidence of it.22 Additionally, the potential for power imbalances between doctor and patient is high in both specialties.

Previous studies have found that overseas training is not a risk factor for complaints;8,11 our findings go a step further and find a “protective effect” associated with training outside of Australia. The extent to which this effect can be generalised is questionable. For example, a recent report from the United Kingdom indicated a higher rate of referral to the National Clinical Assessment Service for non-white doctors and doctors who qualified outside Europe.23

Our study has some limitations. First, we used head counts of practitioners in each descriptive category, rather than more sophisticated measures of doctors’ exposure to complaint risk, such as full-time equivalents, or volumes of patients seen and procedures conducted. Second, we selected our control group from among doctors who had experienced one isolated complaint over a decade, rather than doctors who had experienced none. A comparison of the doctors in our control group to summary statistics for all doctors in Victoria suggests that our controls closely resemble the wider pool in terms of specialty and location,20 but slightly larger proportions were male and had been in practice for more than 21 years. These differences, although minor, open up the possibility of biases toward the null in our analyses of sex and years in practice. Third, the characteristics we examined were doctor-focused. Patient characteristics,24,25 treatment outcomes,24 and the nature of the patient–doctor relationship26-29 are also likely to be important predictors. Finally, our findings are from an analysis of complaints against doctors in private practice in Victoria; the extent to which they can be generalised to practitioners in public hospital settings and in other states is unknown.

The insight that large numbers of complaints are concentrated among a small group of doctors, and that those doctors exhibit distinctive characteristics, has important policy implications. Case-by-case complaint resolution processes overlook the importance of past complaints as a predictor of future complaints, and spread regulators’ scarce resources thinly across a wide group of practitioners, most of whom are at minimal risk of future complaints. Aiming interventions at high-risk doctors has the potential to steer outliers back towards safer practice, thereby reducing risks of future harm and patient dissatisfaction. Realising that potential requires two advances: better tools for flagging complaint-prone doctors early in their complaints trajectory; and effective interventions to address problems in a timely fashion.30 Future research should address both challenges.

1 Derivation of the study population

* Complaints about them to the Health Services Commissioner of Victoria from 1 January 2000 to 31 December 2009.