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Stress and the college complaint
An article for physicians by physicians
Originally published June 1999 / Revised April 2008
IS9906-E

Of interest to all physicians

Physicians practice in an environment that includes expectations, demands and occasionally threats.

In every doctor-patient interaction, many factors build expectations or require responses. When a patient or their family feels that a physician did not live up to their expectations, he/she may initiate a legal action or advance a complaint to the physician’s regulatory authority (College).

Colleges in Canada are required by law to consider complaints against physicians. Physicians are obliged to respond to inquiries from the College with regard to these complaints.

The Canadian Medical Protective Association provides advice and assistance to its members in these circumstances, and has become aware that College complaints create significant stress. We undertook a survey to assess the effect of the complaint process on physicians and the effectiveness of various coping strategies. With this knowledge, the CMPA can better support physicians during the complaint process, and physicians can better help themselves.

A questionnaire was sent to CMPA members immediately after the resolution of their complaint during the six months between October 1995 and April 1996. Seventy-three of 101 questionnaires were returned. The following is a summary of the survey results, which are still relevant today.

Complaints = stress, regardless of outcome

Ninety-five per cent of the respondents had experienced stress at some time during the process. The most significant stress was experienced on initial notification of the complaint (Figure 1).

Level of stress experienced (Figure 1)

Even after the complaint was resolved, only 25 per cent of the respondents felt that their stress was eliminated. In the remainder, either it was unchanged, reduced and, in a small percentage, it was increased (Figure 2).

Final outcome vs stress (Figure 2)

Life-altering symptoms

Physicians experienced a range of emotional, physical and/or behavioural symptoms. Fifty per cent of those who experienced these symptoms reported that they interfered with their personal or professional lives.

The most significant feelings experienced were:

• anxiety
• lack of trust in patients
• frustration
• anger
• sadness
• feeling of imbalance of power
• disbelief
• loss of image
• helplessness
• loss of control

The most common physical symptoms included:

• insomnia
• exhaustion
• headache
• palpitations
• gastrointestinal symptoms or generalized aches and pains

Physicians reported behavioural symptoms as well:

• sleeping problems
• the need to talk about the complaint
• internalization
• social withdrawal
• decrease in working hours

Lessons and legacies

A small percentage described the complaint process as a learning experience. Lessons included appreciation for the value of effective communication, reasonable clinical care and good documentation (Figure 3).

Effects of the complaint process (Figure 3)

Some physicians felt that although the process resulted in a loss of caring and compassion in their work, the experience made them better technically. Some made changes. More than half of the respondents changed their practice pattern to avoid the type of work that gave rise to the complaint. Many others expressed a desire to either leave their practice or even change professions. Some have moved their practices (Figure 4).

Results of the complaint process (Figure 4)

After the fact-what physicians said

Physicians who had experienced the complaint process were asked to make general comments as part of the CMPA survey. These are some of their responses:

• "I have found that the relative ease in defending myself in this case depends greatly on documentation of all patient encounters and details to help. Members of the CMPA should be reminded again and again of the necessity of detailed documentation."
• "I questioned whether I wanted to continue to practice medicine."
• "Inappropriate anger and frustration directed at [one’s own] family members and friends, with some loss of relationship quality."
• "Becoming more aware of how vulnerable the physician can be to any form of complaint from the patient when there was no wrongdoing."
• "Feeling of impotency, loss of control."
• "Although the stress is reduced the process made me change my proactive style. I no longer trust my patients."
• "The problem was not what happened but what was perceived by the patient to have happened. I learned from this. CMPA assistance was very helpful for my own understanding especially in putting the problem into perspective."

What helped

Reviewing the records, talking to trusted colleagues and the reassurance of peers were quite helpful to physicians in dealing with the stress of the complaint process. Most helpful was the ability to talk to their family, contacting CMPA and receiving the assistance of CMPA (Figure 5).

Helpful in dealing with stress (Figure 5)

Physicians also reported that general stress-reducing strategies such as developing a routine, taking care of their personal well-being, physical activity and pursuing hobbies were helpful.

It is interesting to note that the sympathetic ear of a trusted colleague was a key factor in successfully coping with stress. Perhaps we should all be prepared to recognize and welcome opportunities to help one another in this capacity.

Recognizing the significant impact a complaint can have on a physician is the first step to coping. The next step is to regain a sense of control. These strategies may help.

Pre-incident

Understand the process

1. identify the issues that may lead to complaints
2. understand the rules and regulations that govern the process

Preventive strategies

1. good patient care
2. good communication with patients and other caregivers
3. documentation (contemporaneous, dispassionate, factual) to reflect the care that was given
4. early recognition of dissatisfied patients and family members

Coping strategies

1. develop general stress management (personal care) strategies, e.g., nutrition, exercise, routine, breaks, etc.
2. develop a support network (colleague/confidant)

During incident

If involved in a complaint

1. promptly notify the CMPA
2. review the records
3. prepare a factual response that addresses the allegation
4. follow general stress management strategies
5. enlist the help of a supportive colleague/confidant