Maintaining professional identity: doctors ... - Wiley Online Library

Sociology of Health & Illness Vol. 20 No.6 1998 ISSN 0141–9889, pp. 802–824

Maintaining professional identity: doctors’ responses to complaints Judith Allsop1 and Linda Mulcahy2 1

2

Department of Health and Community Studies/Politics and Management, De Montfort University, Leicester School of Law, University of North London

Abstract This paper reports on the findings of three empirical studies, conducted by the authors, of how doctors respond to complaints about medical care. We found that doctors respond to complaints with a range of negative emotions, and interpreted complaints as a ‘challenge’ to their competence and expertise as professionals, not as issues troubling the complainant or as legitimate grievances. The interview data show that the way in which doctors talked about complaints and accounted for them drew on their understandings of their work world. We suggest that this helped them maintain a sense of control, and argue that this not only sustains individual security but also reinforces professional identity and serves the interests of professional politics. However, we conclude that this reaction to complaints goes against the spirit of resolving complaints to the satisfaction of the complainant which is currently the aim of systems for quality assurance.

Keywords: doctors, profession, complaints, regulation, identity Introduction In this paper, we explore how doctors respond to complaints from patients and carers. Using data from three empirical studies, we show how they felt about receiving complaints and how they explained and accounted for them. We also present data on who doctors go to for support in dealing with complaints. Although the studies differed in a number of respects, doctors responded and accounted for complaints in similar ways. We argue that this reflects a process through which individual doctors draw on collective ways of thinking within the medical profession. These serve to protect and defend both the individual doctor and the profession as a whole against © Blackwell Publishers Ltd/Editorial Board 1998. Published by Blackwell Publishers, 108 Cowley Road, Oxford OX4 1JF, UK and 350 Main Street, Malden MA 02148, USA.

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a more general external challenge by questioning the legitimacy of this activity. The topic is of interest to sociologists of health and illness for four reasons. First, complaints are one aspect of broader consumer challenges to medicine which have brought changes to the context in which medicine is practised. There is evidence across a number of countries that complaints and medical negligence claims are increasing and this is commonly viewed in terms of a crisis (Ham et al. 1988, Fenn and Dingwall 1992, Willis 1993, Fenn et al. 1994). The reasons for the increase in complaints are diverse. Expectations of medical care, sometimes fuelled by the medical profession itself, continue to rise. Other factors include the greater availability of information and extensive media coverage of medical developments and mishaps, as well as the growth of consumer groups. In many countries, governments have encouraged consumerism. For example, in Britain the Patient’s Charter (Department of Health 1995b) provides an outline of expectations, performance targets and the means for redress which aim to facilitate user involvement. Research has been undertaken on a number of contemporary challenges to medicine – from managers (Hunter 1997); other health professions (Walby et al. 1994); through the media (Bury and Gabe 1994); from selfhelp and advocacy groups (Kelleher 1994), and legal claims (Dingwall 1994). Other research has identified how doctors react to changes in their status (Lupton 1997) and how they cope with the uncertainties of medical work (Atkinson 1981, 1984, 1995). However, there has been scant attention paid to complaints. Some authors have linked these new challenges to medics to the wider debate about professionalisation versus proletarianisation of medicine (see McKinlay and Arches 1985. Freidson 1993). Our purpose here is to focus on the more micro level of doctors’ responses to complaints and how they cope with them. However, the findings may have implications for this wider debate in that they suggest that there are strong defences against challenges to expertise. Secondly, complaints from patients and carers are of interest because of the way in which they change the usual rules of the doctor-patient relationship. Typically, doctors control interactions as they determine the flow of knowledge and the resources of time and space in the encounter. As a number of empirical studies have shown, challenges to the doctor’s authority remain relatively rare events in the total sum of doctor-patient interactions. For example, Strong’s (1979) study of paediatric encounters showed that the bureaucratic format was dominant in both UK and US settings although sometimes doctors assumed a detective or social welfare role. As Strong and Davis (1977) comment: ‘Quiet obedience was the easiest path and where patients did revolt they were soon quietened’ (1977: 793). However, a more consumerist model may be emerging. Mulcahy and Tritter (1998) found in their survey of 1637 householders that just under half were dissatisfied with an aspect of health service provision. Of those who felt dissatisfaction, around 33 per cent said they had expressed this to a © Blackwell Publishers Ltd/Editorial Board 1998

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Judith Allsop and Linda Mulcahy

health provider. They were most likely to ‘voice’ informally to the doctor. In Annandale and Hunt’s 1998 survey, about a third of the sample (307) reported a disagreement with the doctor. Less than a quarter of these took no action and 40 per cent raised their concerns verbally with the doctor. The subject of this paper is written complaints where the lay person has made allegations about inadequate health care in writing. This is a much rarer event. It barely figured in Mulcahy and Tritter’s (1998) study (see also Brennan et al. 1991). However, as mentioned above, complaints are rising, and this in Nettleton and Harding’s (1995) phrase is a form of protest. By voicing their dissatisfaction, people attempt to hold a doctor to account. We suggest this has a transformative effect on the doctor-patient relationship. A response is required from the doctor who may have to justify, or at least explain, their decision making and in so doing may well be called upon to articulate what is involved in their work and answer questions different from those posed by fellow professionals. This may be in the privacy of the consulting room or may be through a written response or a meeting with the complainant and managers. It may even require an appearance in the public arena of a tribunal or, if a claim is pursued, in a court. Thus, the doctor loses the power to define core issues and initiate further contact on their terms. The third reason why complaints are of interest is that the study of doctors’ responses allows an examination of the process of how professional work is accomplished in everyday practice, and how the boundaries are maintained or reconstituted in response to a challenge by user-led initiatives. As Macdonald suggests: Lay members of society assess the ‘traits’ of occupations sometimes in a rough and ready way, sometimes with great precision. Customers, patients and clients are continuously aware of the performance in all aspects of members of occupations: they monitor, assess and evaluate and thereby produce the climate of opinion which provides the background for ‘professional’ standing and at certain junctures may become quite crucial (1995: 7). We suggest that how doctors deal with complaints is one of these crucial junctures. Complaints procedures are at the cusp of medical and legal, clinical and managerial systems, the aims of which are not always compatible (Silbey 1981). Each case may have a radiating effect within the medical profession (Galanter 1983, Fiss 1994). Equally, responses from the profession may also have a symbolic importance, as Dingwall (1994) has commented in relation to medical negligence. From our data we show that doctors share their concerns about clinical complaints with their fellow professionals. We argue that this serves to increase professional solidarity and demonstrates how a defence of expertise is accomplished on a broader basis (see Freidson 1970 and Elston 1991 for a discussion of clinical autonomy). © Blackwell Publishers Ltd/Editorial Board 1998


A final and more practical reason why doctors’ responses to complaints are of interest is that there has been a movement towards more managed systems of health care, of which effective complaint handling is a part. In the UK, a more informal approach to resolving complaints, regulated by managers, is seen as an essential part of providing quality service delivery and helping managers to identify problems (Department of Health 1995a). This shift towards more informal resolution of disputes is being encouraged in the civil justice system more generally (Lord Chancellor’s Department 1996). The aim is to discourage recourse to formal and expensive adjudicatory fora. Effective resolution of complaints through informal means is thought to require an openness to criticism, a willingness to see things from the point of view of the health care user and a corporate approach to managing both risks and complaints (Department of Health 1995a). However, the spirit of such changes may be resisted if doctors believe that, as a consequence, they are no longer able to control the terms of their own work. This paper first describes the empirical studies undertaken. The research findings are reported more fully elsewhere (Allsop 1994, Mulcahy and Selwood 1995, Mulcahy et al. 1996, Allsop and Mulcahy 1996, Mulcahy 1996). Data are then presented on how doctors said they reacted to complaints, how they explained or accounted for them and, finally, who doctors said they had turned to for support when they received a complaint. In conclusion, the implications of the findings are discussed.

The scope and methods of the studies The data were drawn from three studies, two of general medical practitioners (GPs) and one of hospital consultants, undertaken in England in the period from the mid-1980s to the mid-1990s. Table 1 shows the detail of the studies, and the different methods of data collection and analysis are briefly described. In the first study, which we call the GP Tribunal Study, Allsop (1994) analysed letters written by doctors in response to complaints in cases which went to a tribunal hearing (a medical service committee). The tribunal is adversarial in form so that the doctors’ letters formed a defence against allegations of service failure. For the research, cases were drawn from complaint files over a 10-year period, 1976–1986. One-hundred-and-ten cases involving 122 doctors were analysed and a number of defence strategies were identified, coded and counted. The second study, undertaken in the early 1990s, is termed the Consultant Study. Its respondents were hospital-based (Mulcahy and Selwood 1995, Mulcahy 1996). The research focused on formal written clinical complaints about consultants and how they were handled internally in trusts. Data for this project were collected in two stages. First, a largely precoded questionnaire was sent out to over 800 consultants practising in an © Blackwell Publishers Ltd/Editorial Board 1998

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Table 1. Data Collection and Analysis Methods in the Three Complaint Studies Name of study

Source of data

Data collection period

Time span covered by data

Sample size and response rate

Method of analysis

GP Tribunal Study

Letters of response to formal complaints to one English FHSA.

1976–90

1976–87

All formal cases during period – 110 cases and 122 doctors.

Content analysis of accounts and defence strategies.

Consultant Study

a. Postal quesb. tionnaire to b. consultants in b. one English b. RHA. b. Exploratory b. face to face b. interviews with b. consultants.

1993–6

Experience of complaints over whole professional career of doctors involved.

a. All consultants b. in one RHA b. (848). Response b. rate 52%. b. Sample of 35 b. consultants by b. specialty, gender b. and workplace.

a. Use of SPSS to b. generate b. frequencies and b. cross tabs. b. Grounded b. analysis of key b. themes.

GP Study

a. Postal quesb. tionnaire to GPs b. in one English b. FHSA. b. Exploratory b. face to face b. interviews with b. LMC b. secretaries.

1993–5

a. Experience of b. complaints in b. last five years b. of professional b. career. b. Experience of b. complaints b. over whole b. professional b. career.

a. All GPs in one b. FHSA (363). b. Response rate b. 56%. b. All LMC b. secretaries b. in Region (4).

a. Use of SPSS to b. generate b. frequencies and b. cross tabs. b. Grounded b. analysis of key b. themes.

English health region. Fifty-four per cent responded. Second, 70 in-depth, face-to-face interviews were conducted: 35 with hospital consultants, 25 with health service managers and the remaining ten interviews with pressure groups and national organisations which supported doctors and patients. In this paper, we draw on the interviews with, and questionnaires from, consultants. The third study investigated GPs’ responses to complaints (Mulcahy et al. 1996) and was intended to replicate the Consultant Study in a primary care setting. However, the methods employed were modified to meet funding constraints. We call this the GP Study. A pre-coded postal questionnaire, which encouraged the provision of additional comments, was sent to all the GPs, over 350, working in a Family Health Service Authority in the same region as the consultant study. There was a response rate of 56 per cent. Interviews were also carried out with four secretaries of the Local Medical Committee (LMC), a parallel local branch of the British Medical Association. Each LMC has a full- or part-time doctor to support their work and one of the tasks of the secretary is to provide advice and help for doctors who have had a complaint made against them. In the Consultant © Blackwell Publishers Ltd/Editorial Board 1998


and GP Studies, interviews and ‘write ins’ provided qualitative data. Themes were identified, drawing on a range of theories. We argue here that although there were a number of important differences in the setting of the three studies, nevertheless common themes in doctors’ responses to complaints emerged. First, the doctors interviewed worked in diverse settings from general practice to a range of hospital specialties. This affected the type and content of complaints they received. Secondly, at the time the studies were undertaken, separate complaints systems operated in primary and secondary care. The apex of the GP complaints system at the local level was a tribunal, while for the hospital consultants there was a system of independent professional review set up by the regional medical officer and the BMA. Thirdly, the strength of the sanctions available differed. Fourthly, the allegations contained in complaints varied from the relatively trivial to adverse events which left lasting damage (details of the allegations contained in the complaints can be obtained from the full studies). It is our contention that none of these variations significantly affected the type of responses which doctors made to complaints. Below, we show that it was the challenge itself which caused the reaction, rather than the type of allegation, specialism or sanction. The methods used in the three studies focused on different kinds of identity work. In the GP Tribunal Study, doctors were defending themselves in a public arena. If they were found to have breached their terms of service, they could be fined, and other sanctions, such as a report to the Department of Health or the General Medical Council, could follow. In the other studies the authors used questionnaires and conducted interviews in which they asked doctors to reflect on their experiences. Despite these differences, doctors had similar understandings of complaints. From a methodological perspective, the fact that the same themes were identifiable across the three studies suggests that our findings are thus fairly robust and generalisable (see Silverman 1993 for a discussion of triangulation). This indicates that doctors tend to respond to criticism in similar ways, irrespective of their specialism. The ties that bind are greater than those which separate. We approached the data from the studies as representing an account based on doctors’ own individual experience but embedded in the discourse of the lifeworld of medical knowledge and practice (Schutz and Luckman 1974). This follows Abbott’s (1988) essentially Weberian approach that professions can best be understood as drawing on a knowledge system governed by abstractions. Members of occupational groups have a broadly similar approach to reasoning about, classifying and acting upon, problems. Within medicine, doctors elicit and infer from symptoms to diagnose and reach treatment decisions. We refer here to ‘bio-medicine’ as the body of knowledge on which doctors draw and the biomedical model as a shorthand for their general approach. This is not to deny the existence of a number of separate knowledges within medicine. © Blackwell Publishers Ltd/Editorial Board 1998

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Doctors’ initial response to complaints Within clinical medicine, formal complaints1 are not uncommon. Fifty-six per cent of the consultants said they had had a complaint during their career (which averaged 23 years). In the GP study, 34 per cent had received one written complaint which had been referred to the health authority during the five years covered by the study. Data from all three studies indicated that complaints had a powerful emotional impact on the doctors concerned. In the Consultant Study questionnaire, virtually all the doctors commented on this. Respondents were presented with a number of different responses which were pre-coded following piloting, but to which they could add categories. The options included both positive and negative emotions. The nine of the most frequently mentioned were negative: irritation (52 per cent); worry (42 per cent); concern (38 per cent); annoyance (37 per cent); anger (33 per cent); distress (32 per cent); disappointment (31 per cent); anxiety (28 per cent) and vulnerability (28 per cent).2 Thirty-eight per cent said they were ‘surprised’ by the complaint. Interview data illustrate the force of the impact. A number of LMC secretaries commented that complaints arrived unexpectedly, ‘out of the blue’. Distress and worry could follow. One consultant commented that, on receiving a complaint: ‘I had sleepless nights – I was devastated. Colleagues told me not to worry but my reputation was being questioned’ (Consultant Study). Another said: ‘Complaints are very hurtful. One gets emotionally involved because they strike at one’s perception of oneself as a doctor. That perception may be idealistic but it’s important’ (Consultant Study). In the GP Study, all four LMC secretaries also referred to anger, fear and surprise. One said: ‘Anger is the first thing, nearly always they are extremely cross’. These comments draw attention to the way in which complaints destabilise the expected order of things in the doctor-patient relationship. The doctor tends to assume that their superior technical knowledge and their moral authority is accepted by the health care user. A complaint transgresses both these norms and, perhaps for this reason, is taken in a personal way as an attack on the self. As one consultant said: I dealt with one case where a patient was seriously ill. No one would touch the case. The care had been really messed up by a plastic surgeon. An SHO (junior doctor) and I really pulled that patient out of the embers. We worked jolly hard after our normal hours. I couldn’t believe it when we received a complaint about the care. They said we had jeopardised their chances of recovery. I was so hurt. The whole team was really upset, really demoralised (Consultant Study). A complaint is interpreted as a challenge to expertise and authority which goes to the heart of doctors’ sense of identity. That doctors may experience © Blackwell Publishers Ltd/Editorial Board 1998


a series of emotions in a process of coming to terms with a complaint is summed up aptly by a clinical director who said: When doctors receive complaints they go through a series of emotions. First of all they are frightened, because it is the beginning of a process they don’t understand. Then they feel injured, because the complainant does not understand what they have done. When the complaint is unjustified, they feel irritation. Finally, they get round to asking the most important question of all – is the complaint actually about the standards of clinical care? (Consultant Study). In this context, it is interesting to note that the majority of doctors across the three studies believed that most complaints they had received were unjustified. Among hospital consultants, 88 per cent felt that these complaints were completely, or partially, unjustified, while three-quarters of GPs thought so. In the GP Tribunal Study, the vast majority of doctors (98 per cent) denied the allegations against them, although whether they thought the complaint was justified or not is not known. In the Consultant Study, emotional reactions were likely to be much more intense where doctors believed that the complaint was unjustified. The strengths of doctors’ reactions to being complained about, and their tendency to define complaints as unjustified, may be explained by the way in which their professional identity as clinicians defines their concept of themselves. Giddens (1991) has suggested that we are a bundle of identities which are brought into play through social action. Due to a variety of factors, which have been well documented in the literature on the medical profession, the clinical identity may be dominant in the conception of self among doctors. The long training, the intense socialisation process, the role of patronage in career development, the framework of self regulation, the web of promotional organisations and activities, the importance of updating expertise, the collegiate setting of much work practice and the norm of clinical autonomy create the conditions for work shelter, but also the incentives for identity maintenance and for professional politics in a wide range of institutional areas. Therefore, criticisms of doctors’ work are criticisms of them and complaints create a group as well as an individual ‘legitimation crisis’ because they call into question the doctor’s technical and moral authority over biomedical knowledge (see Habermas 1976). A complaint may represent a double challenge: to have got something wrong technically and not to have used their knowledge in the interests of the patient and thus to have broken a basic trust. Moreover, this challenge has come from a lay person who is not considered to be in a position to judge medical work. As Schutz comments: ‘ . . . the expert . . . knows very well that only a fellow expert will understand all the technicalities and implications of a problem in his field, and he will never accept a lay man or a dilettante as the competent judge of his performance’ (1964: 123). © Blackwell Publishers Ltd/Editorial Board 1998

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Doctors also face a paradox. They have been consulted as experts to act with certainty, but then that expertise has been questioned. Some doctors reflected on the requirement to exercise judgement, to be certain in the face of uncertainty and the burden that this can bring. In the Consultant Study, one doctor commented: ‘Practising medicine is about exercising judgement . . . that is why we’re so opinionated. But we are vulnerable prima donnas . . . [we] play solo with patients and have to stand alone by decisions’. Complaints may bring a powerful reaction because of the future threat that they pose. As the clinical director above said, they involve doctors in a process they do not understand. In the GP study, an LMC secretary recalled a doctor he had assisted: He [the doctor] got up in the morning of the hearing and his wife said you don’t normally put your suit on to go to the surgery and he broke down and wept and said he hadn’t told her because he was worried that he’d be struck off and they’d lose the house. This was an intelligent, highly competent doctor who had set up his own practice against the odds, a very strong character and that was how a complaint affected him (GP Study). This threat may well be increased by the fear of sanctions which exist to discipline the doctor through contracts of employment, the General Medical Council and the courts. Again, although relatively rarely used, the threat of formal sanctions may throw a shadow over all those who receive complaints. As Dingwall (1994) has commented in relation to claims for medical negligence, they trigger symbolic resistance to a challenge which goes far deeper than a few court appearances. The challenge to expertise is greater than the content of a single complaint. A complaint also may make the doctor feel they have lost autonomy and are not in control. As one consultant said: ‘The relationship is so onesided. They have done the damage as soon as they make the complaint. All we can do is to sue for defamation’. A number of respondents said they felt a sense of powerlessness, and by implication experienced a loss of autonomy, either because some issues related to aspects of care provided by others over which they had no control, or because they felt that some complainants were ‘unsatisfiable’. This led to a feeling of futility. Yet others felt disempowered because the complaint handling process was taken out of their hands and they did not have the opportunity to put their point of view forward. Some expressed the opinion that doctors also had a right to be heard: The problem is that there is no real mechanism for redress. We say we know that some complaints aren’t justified, but we can never really make our views known. There should be a mechanism to deal with frivolous complaints. Doctors want their say as well (Consultant Study). © Blackwell Publishers Ltd/Editorial Board 1998


Another said: ‘The hospital complaints system does not reject complaints. It absorbs them. We are never defended. Our actions are explained, but they are not defended’. In sum, doctors seem to interpret complaints as an attack upon their clinical judgement and their moral authority. As a consequence, complaints threaten doctors’ concept of themselves as competent practitioners. They then engage in work to reconstruct their sense of identity. We suggest below that they tend to defend the practice of their work in their own terms and have little appreciation that health care users may see things differently. This may be a way of maintaining control, but it is also a weapon which can be used in the interests of professional politics.

Understanding complaints: explanations, rationalisations and defences All three studies yielded data on how doctors explained, rationalised or defended themselves against complaints. These responses were similar across the studies, although they were framed differently depending on whether the doctor was simply reflecting on a past event or writing a defence for a tribunal hearing. The explanations fell into three main categories which all served to turn responsibility and culpability away from the doctor for the untoward events described in the complaint, and to neutralise the criticisms contained in the complaints. First, doctors drew on their knowledge of the uncertainty of the disease process, and the limitations of bio-medicine to explain events. Secondly, doctors attributed the course of events to the shortcomings of others or to the motivations or character of the complainant. Thirdly, they attributed the cause of complaints to external circumstances. Within social psychology, attribution theory has been used to explain such behaviour. At its simplest, the theory suggests that people prefer to find meaning and order in the world and usually develop explanations of why events happen and why people behave as they do. Tedeschi and Reiss (1981) have suggested that there are a number of common responses when people seek to attribute cause for untoward events which are related to awarding responsibility and blame to themselves, others or fate. Coates and Penrod (1981) and Lloyd-Bostock (1992) have applied this to disputes. However, more sociological explanations could lead to the interpretation of doctors’ defences as part of the social process of impression management (Goffman 1961, 1967), accounts which provide justifications and excuses (Scott and Lyman 1968) or of the politics of identity (Giddens 1991). The nature of clinical care: bio-medical explanations A common response to complaints was for doctors to contextualise the complaint within the arena of bio-medical, expert knowledge. Sociological studies, based on empirical work in the US undertaken in the 1950s and © Blackwell Publishers Ltd/Editorial Board 1998

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1960s, showed how doctors are socialised into the norms of the bio-medical culture which create the distance between themselves and others (Fox 1957, Becker et al. 1961, Bucher and Strauss 1961, Stelling and Bucher 1973). In particular, these studies demonstrated that doctors learned collective ways of coping with uncertainty and the inevitable failures which are part of medical practice. Fox (1957) used the term ‘vocabularies of realism’ to describe how doctors came to terms with uncertainty. The devices used included emphasis on uncertainties about the course of the disease process in individuals, the limits of clinical knowledge and the practitioner’s grasp of this knowledge. Atkinson (1981, 1984, 1995) has discussed issues of certainty and uncertainty and carried out empirical studies of medical practice focusing on bio-medical talk. Bosk (1979) found that technical errors were tolerated in their juniors and Mirzrahi (1984) found strategies for distancing and denial among medical interns in relation to mistakes. To maintain a sense of control, untoward events were redefined as non-mistakes – and just part of the risk of medical practice. In the studies reported on here, the predominant defences provided to explain complaints drew on bio-medicine to justify actions. In the GP Tribunal Study, Allsop (1994) found that 39 per cent of doctors used this form of defence. In particular cases, GPs used bio-medical explanations to account for the difficulty of diagnosis, the inevitability of the course of the disease or of death, or the speed with which the condition of the patient changed. For example, one GP commented on the limitations of his ability as a GP to diagnose: I simply fail to understand what else as a GP I could have done, as a salmonella infection is very rare in this country and difficult to diagnose . . . it was not until 48 hours after admission that the blood tests revealed a salmonella infection (GP Tribunal Study). In another case, a very young baby died of a heart defect although he had been seen by a number of doctors over a period of days. The doctor drew on the limits of medicine and wrote: As far as I can discern, in the absence of heart murmur, we had no possible means of identifying the child’s heart lesion and a careful examination by three doctors of this child failed to reveal any such lesions. Therefore our management was based on the concept that there was no cardiac deficit (GP Tribunal Study). Vocabularies of realism could take a more judgemental form. In explaining his decision to allow the disease process to take its course, a GP commented: It was best to leave him in peace and quiet and await the course of events. . . . He was 95 years old and one has to be realistic about these © Blackwell Publishers Ltd/Editorial Board 1998


things. He was obviously in a deep coma and I thought the kindest thing to do in those cases was to let an old man die in peace instead of trying to do the impossible of dragging him back to life (GP Tribunal Study). Bio-medical explanations also appeared in other guises. For example, consultants tended to see certain specialties as ‘bad’ or ‘good’ news specialties, with the former more likely to attract complaints. Bad new specialties were defined as those where clinicians were less likely to be able to effect a cure or relieve a condition. Other characteristics included the unpredictability of outcomes, whether treatment was invasive, serious consequences of error, a high degree of treatment urgency and the length and intensity of the treatment episode, which could affect the closeness of the doctor-patient relationship. Fewer complaints were seen as occurring as a result of low risk treatments and in illnesses where a close doctor-patient relationship developed. The emotional stake in success or failure was also seen as a variable, with fewer complaints in areas of care with low emotionality. Oncology, gynaecology and areas of general medicine such as terminal care were said to be at particular risk of receiving complaints, partly because of the likelihood of poor outcomes and partly because lay people did not understand the limitations of medical practice. One consultant said: We are definitely a bad news specialty. Young patients often die unexpectedly and there is a lot of guilt at the death. When it comes to it, people often do not know how to deal with it and their obvious reaction is to channel the emotions onto someone else. It’s a case of shooting the messenger. It is very difficult to do anything about those complaints because probably you couldn’t have done any better (Consultant Study). And another commented: ‘You get problems in gynaecology. In particular, there’s the problem of miscarriage which needs to be handled sensitively because people see themselves as having lost a child’ (Consultant Study). Conversely, orthodontics was described in terms of being a ‘good news’ specialty and therefore not vulnerable to complaints. One orthodontic consultant commented: There are very few down-sides to treatment. It does not involve excessive discomfort and there is an inbuilt system for explaining the treatment. . . . In addition, I only take on patients who really want to have the treatment done. We will only take on a patient if we think we can improve them significantly. In other words, we design the system so that they will be happy (Consultant Study). In sum, the incidence of complaints was explained in terms of factors associated with medical practice and thus given an objective reality beyond the actions of individual doctors. Ironically, there were some indications in © Blackwell Publishers Ltd/Editorial Board 1998

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the Consultant Study that doctors practising in bad news specialties had developed better coping strategies because of their more frequent experience of complaints. ‘Typifications’: the lay person in the complaint Another major way in which doctors accounted for complaints was to attribute them to the character of the complainant or lay person. Many complaints were explained in terms of inadequate lay knowledge, the attributes and motivations of the complainant or their incompetence as lay health workers. Implicitly, these accounts contrasted lay people’s lack of knowledge or their irrationality with the rationality, knowledge, competence of the doctor. Typifications of patients, or moral judgements about them, have been identified in a number of studies. Doctors have been shown to have models of the ‘good’ and ‘bad’ patient (Jeffrey 1979). Roth (1981) and Stein (1990) demonstrate how such moral judgements by doctors can affect diagnosis and illness careers. Over half the doctors in the GP Tribunal Study blamed lay people’s acts or omissions as contributing to the untoward events which occurred. For example, it was alleged that they had not contacted the doctor early enough, not given a proper history of the symptoms or had not followed the advice given. One doctor wrote in his defence: ‘I asked for the date of her last period but she was unable to tell me this . . . I repeated the question several times. The history was misleading and therefore the diagnosis was more difficult’ (GP Tribunal Study). Typifications of complainants were also common in the Consultant and the GP Studies. Complainants were described in negative or dismissive terms as ‘moaners’, ‘nasty’, or as ‘abusers’ and ‘malcontents’ by consultants. Patients were also said to have ‘unrealistic expectations’, either because of their social position or because they did not understand the disease process. Out of the 141 responses to the question of what type of people complain, 21 consultants (only 12 of whom were specialists in psychiatric medicine) described complainants as exhibiting signs of psychiatric illness. Twenty-eight consultants referred to the assertive, rights-conscious patient while only six made positive or empathetic comments about the people who had made a complaint. One doctor commented: ‘You could do a psychological profile of patients coming into the hospital and select those who were likely to complain before giving them any clinical care’. Doctors also saw relatives or carers as the main problem for a variety of psychological reasons. A hospital consultant said: There are very intense emotions wrapped up in the care of children. A number of relatives become attached and so there are more people to criticise us. People often feel guilty about sick children. If you feel bad, the best way to deal with it is to put the blame on somebody else (Consultant Study). © Blackwell Publishers Ltd/Editorial Board 1998


In the GP Tribunal Study, some doctors took the view that they were protecting patients from relatives. One doctor wrote: I was prompted to do this (leave the house without referring the patient to hospital) by the hostile and unreasonable attitude of the family whose main and only desire was to put Mr T into hospital so that he would be no more trouble to them (GP Tribunal Study). Sometimes, complainants were seen as vindictive and by implication to have broken their side of the trust relationship. A hospital consultant suggested: ‘There is the complaining type. . . . They shake hands with you but they are vicious. Basically, they want you to know they are in charge’ (Consultant Study). In the GP Complaint Study, a GP commented that: ‘Many complain because they find the process entertains them’. Another GP suggested that the complainant wanted: ‘Blood (mine) on the floor’. Such comments indicate that complaints can be perceived as part of a power struggle with the doctor seeing themselves as the loser. A few doctors also talked about the emergence of the ‘demanding patient’ and ‘a complaining culture’ which had been encouraged by the Government’s policies. One commented: ‘The attitude of patients, especially in the present climate of the Patient’s Charter, is that we (the doctors) should drop everything and attend to their needs’ (GP Study). In contrast to some earlier studies which found that doctors typified patients as undeserving on the basis of ethnicity or low socio-economic status, in the Consultant and GP Studies, the demanding patient could be typified as middle class and female. The external context to explain complaints In all three studies, doctors occasionally referred to external circumstances to explain complaints. In doing so, they re-attributed fault and maintained their sense of a competent professional identity. In the GP Tribunal Study, Allsop (1994) found that service failures or adverse events were attributed to the time it took to reach the patient’s home, including traffic jams, the weather, the holiday period, or occasionally to the lack of adequate resources. The later theme also occurred in the other studies. For example, one consultant anaesthetist said that the shortage of resources no longer gave him time to explain procedures and the attendant risks to patients: We used to see patients regularly before the operation. We would see them the evening before, when they were relatively calm and relaxed. That has changed now and we are rushed. . . . People often come in after the list has started. They often get cursory treatment from staff (Consultant Study). Another made reference to the shortage of resources in the following way: © Blackwell Publishers Ltd/Editorial Board 1998

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I feel what we do is unsafe. You should not really run a unit like ours unless you have adequate staff, but what do you do? Turn sick people away? I’m not just concerned that we are getting more and more complaints. I am concerned that we will get shut down (Consultant Study). Reference to resource issues contextualises complaints in the wider sociopolitical context and in so doing attributes blame to other actors and outside the delivery process. In summary, when doctors accounted for complaints, they gave biomedical explanations and presented negative images of complainants. Some also criticised the competence and concern of lay people who looked after patients. This runs counter to the idealised model of the doctor as a professional who maintains affective neutrality towards the patient as outlined in the bureaucratic role format developed by Parsons (1951) and demonstrated by Strong (1979). However, it could be argued that these accounts are the other side of the tales told by patients (Stimson and Webb 1975, Dingwall 1977). In both cases, the function of typifications and atrocity stories is an attempt to excuse and justify actions and to regain control of the interaction in terms which suit the doctor.

Professional networks for dealing with complaints Who do doctors turn to when they have complaints made against them? The data suggest that colleague networks are crucially important. Both the Consultant Study and the GP Study asked questions about who doctors talked to about the complaint and what motivated them to approach others. A large majority of doctors in both studies talked to someone else about the complaint and this was most likely to be a close medical colleague. Almost all consultants (92 per cent) approached someone else and most often this was a ‘senior’ doctor within the same organisation. They sought help for a wide range of reasons, including advice, support, information and to unburden feelings. Significantly, consultants said they approached other doctors for emotional support as often as they approached family and friends. In the GP Study, the large majority of GPs (86 per cent) talked to one or more people about the complaint.3 Contact was made with five categories of people. In descending order of frequency these were: doctors inside the practice, representatives of a defence organisation, friends and family, LMC secretaries and doctors outside the respondent’s practice. GPs within the practice were the group most often turned to, particularly for help, advice and support. Again, the data indicate the importance of close colleagues. Colleague support was also apparent in the GP Tribunal Study. In 80 per cent of cases, doctors took along other GPs to the tribunal hearing to act as a friend. In just over half these, this was the LMC secretary and in © Blackwell Publishers Ltd/Editorial Board 1998


a few, a doctor from the Medical Defence Union. The remaining cases were mainly joint complaints involving more than one doctor from the practice. Very few doctors conducted their defence alone. Overall, the data demonstrate that doctors rarely went outside medical networks to discuss a complaint and that the support of colleagues was often provided in an informal way: Doctors do want to share information and in fact they do it all the time. You are having lunch and you just start talking generally about a problem in the department or the potential for something to happen. Often you do not want guidance. You just need to get it off your chest (Consultant Study). Another said: You get support in a semi-joking way. You can be light hearted with medical colleagues in a way which wouldn’t be understood by outsiders. We share the same sense of humour and it may sound sick, but it’s a way of managing stress (Consultant Study). Doctors also felt an obligation to provide this sort of support for colleagues. One explained: A colleague of mine committed suicide last year and our first question was ‘Did a patient push him to this? Was there a complaint festering that he did not tell us about? Was he keeping something to himself that he could have shared?’ Basically we felt guilty that we were not there (Consultant Study). The findings suggest that for many, a complaint is seen not only as a challenge but as a threat – even a threat to mental stability and to livelihood. The pattern of help seeking was a form of protection, as the individual could talk to others who shared the same framework of meaning and knowledge base. Both Cohen (1994) and Weeks (1995), in their discussion of group identity, comment on the problem of maintaining common practices and the symbolic re-enactments which reaffirm both identity and difference and are thus part of professional politics. Complaints provide an opportunity for group interaction and the demonstration of solidarity as well as providing a sense of belonging through access to networks of support for the individual doctor. However, as is the case with all groups, there were also those who felt they did not belong. Doctors themselves determined who was in, or outside, their group. Managers were clearly identified by a significant number of doctors as being outsiders. In the Consultant Study, a quarter of complaints came directly to the doctor rather than through management. According to the © Blackwell Publishers Ltd/Editorial Board 1998

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regulations of the complaints system in operation at the time, it was anticipated that all complaints within a hospital should have been referred to management, at least for ‘signing off’ (see Mulcahy and Lloyd-Bostock 1994). In 60 per cent of complaints received directly, the doctor did not follow this procedure and dealt with the complaint without contacting a manager. One of the main reasons which consultants gave for not referring them was that they did not believe that managers had ‘the right’ to handle clinical complaints. In other words, they acted to protect their group autonomy. In all three studies, there was a small minority of doctors who said they did not seek help. For instance, in the Consultant Study eight per cent of respondents did not seek help. The comments made suggest the reasons for this behaviour might be explained by personality and structural factors. One consultant suggested: I am unhappy when complaints about me come out into the open. As a result, I much prefer it when they come directly to me. I feel confident that my clinical director is fairly discreet, but I do worry that others would talk. I don’t like my dirty linen to be made public (Consultant Study). However, other respondents referred to the competitiveness of medicine as a barrier. One very successful orthopaedic consultant, who had considered leaving medicine as a result of a complaint, commented: In a high profile specialty like mine, people are very competitive and it’s difficult to talk about mistakes because we all pretend we don’t make any. I felt very lonely. Eventually, it got so bad that I went to get help from occupational health and they arranged for me to have counselling (Consultant Study). Another suggested that her gender made it difficult to seek help: Basically, I am one of the only females in the region who specialises in [specialty]. I have a lot of young women who see me as their role model and a lot of men who are just waiting for me to make a mistake. No, I would not go and talk to a colleague. That’s actually the last thing I would do (Consultant Study). From the GP Study we know that the fact that some doctors did not seek help troubled all the LMC secretaries interviewed. They believed that doctors required support to deal with anxiety and needed advice on how to make the most of their case. One secretary said that he had told GP colleagues that complaints were now a fact of life and they had to share them. His concern was with the doctors who did not and he commented: © Blackwell Publishers Ltd/Editorial Board 1998


The ones you really like to get at are those who freeze and panic. Some scribble the first thing that occurs to them and you discourage that as well. I try to get them to link their response to each part of the complaint (GP Study). Data were not collected in every study on the kind of advice given by colleagues, but the LMC secretaries were asked what advice they gave. They all said that they counselled colleagues to assess the events which had given rise to the complaint and if they thought that there had been a failure of communication, their behaviour could have caused offence, their judgement had been poor or they had made a mistake, to say so and apologise. Although linked to support, such counselling is in part influenced by the need to maintain the good name of the collectivity – the profession as a whole. It can thus be seen as a form of internal, informal, social control within medicine.

Conclusion From a theoretical perspective, this paper has drawn on the concept of identity to explain doctors’ reaction to complaints. We have argued that doctors’ perception of themselves as competent doctors is maintained by the explanations, justifications and excuses which they give for complaints. These draw on their understanding of the limitations of biomedicine and the risks of particular specialties. They also typify patients and carers in particular ways and see them as not understanding the limits of medical practice, making unrealistic demands and as sometimes vindictive. A complaint can even be interpreted as being pathological and part of the complainant’s illness. Occasionally, doctors see complaints as the consequence of resource limitations. We have shown that doctors, when they receive a complaint, feel afraid, vulnerable, hurt and lonely. They interpret it as a challenge to their technical competence and may feel that the patient or carer no longer trusts them. When a complaint occurs, doctors experience a loss of control over events and are required to do identity work which is unfamiliar to them. They may well not have been trained to cope with this process and their reaction is often to protect their sense of themselves as experts by seeing the complaint as unjustified. Their narratives can be seen as constructions. They represent the ways in which doctors can separate themselves from the concerns of the complainant, and deny that something has gone wrong and their possible responsibility for it. At the same time, we have suggested that these accounts play a part in professional politics. Ways of thinking and explaining are shared by groups within medicine. It is likely that the way in which doctors turn to each other for support so readily has the dual effect of supporting the © Blackwell Publishers Ltd/Editorial Board 1998

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individual and reinforcing collective understandings about the problems of practising medicine. There is a collective advantage to be gained by the professional group in sharing constructions of medical work with colleagues. Furthermore, the defence of a position by one doctor in one setting may have a wider symbolic significance. It can be seen as an act which benefits members of the profession as a whole as it reinforces professional understanding as opposed to that of lay people and managers. However, we have shown that there are exceptions to the general rule that doctors seek support from each other to deal with complaints. These negative cases hint at the reasons why some doctors may not wish to seek help from their colleagues. How does revealing this process of identity work relate to the wider issue of the positioning of the medical profession. First, the rising number of complaints require that doctors must account for themselves more frequently. Secondly, in the UK at least, changes in complaints systems have brought these within the framework of corporate management systems and have extended the range of complaint handlers to include senior doctors, managers and lay adjudicators. Previously, clinical complaints were dealt with by systems which were hidden from view and largely under the control of the doctors themselves. Now, the detail of the doctor’s interaction with patients and other colleagues is open to scrutiny should an investigation take place. Furthermore, in responding to a complaint, the doctor must provide an explanation of the course of action they have taken. This brings changes in the relationship with others in the work arena as it allows the perspectives of lay people, other professionals and managers to emerge and increases accountability. Managers are now encouraged to improve the quality of local services by acting on complaints. This can allow a more consumerist model to develop. Whether, as a consequence, this leads to an actual loss of medical power, or simply changes the rules of engagement, is a more open question. A final point to make is that while the aim of this paper has been to demonstrate how defences are constructed, there are ‘realities’ behind them. The service provided by a doctor may be of a poor standard, mistakes may have been made. However, there may also be practical difficulties in diagnosis, and in predicting the course of an illness or the impact of a treatment. There may also be resource shortages and non-compliant patients. Neither doctors’ nor health care users’ accounts, and they also engage in identity work, can be dismissed as mere constructions. Complaint handlers have the difficult task of negotiating the claims of service users and those of professional providers and mediating between them. What our research suggests is that these negotiators should be sensitive to the framework of interpretation of both doctors and complainants – what is at stake for them and how this affects their behaviour. It is only in this way that conflicts between health service users and doctors can be resolved, fairness achieved and information from complaints used to improve practice. © Blackwell Publishers Ltd/Editorial Board 1998


Address for correspondence: Judith Allsop, Department of Health and Community Studies/Politics and Management, De Montfort University, Scraptoft Campus, Leicester LE7 9SU. e-mail: [email protected]

Acknowledgements We should like to thank David Field, David Gladstone and the editors and reviewers of this journal for their helpful comments.

Notes 1 2 3

Formal complaints are those received in writing by the doctor, trust, or health authority. These percentages do not add up to 100 percent as consultants could select a number of different emotions. The questionnaire allowed respondents to indicate who they talked to from a range of possibilities.

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