College complaints on the rise: Better communication can help

Physicians who contact the CMPA about a regulatory authority (College) complaint report experiencing significant stress. At the root of many College complaint cases is communication. To improve interactions with patients and potentially curb complaints and stress, physicians should consider their communication skills.

In the last five years, requests from members for CMPA assistance with College complaints nationally have risen 20%. In 2016, CMPA received 3,379 requests. In 2020, that number climbed to 4,045.

Physicians have told the CMPA that working through a complaint is arduous and stressful. In many complaint cases, the Association’s data shows that communication is an underlying issue. By adopting patient-centred communication skills and behaviours, physicians can improve their interactions with patients and may reduce complaints.

The stories behind the numbers

Behind many members’ requests for help with a College complaint is the story of a relationship between a patient and a physician that did not go as expected.

Patients said they were dissatisfied with the care they’d received, and some suffered harm—sometimes severe harm—from that care. Yet, the majority of the physicians involved in complaint cases are dedicated and work hard to give their patients good medical care, often in challenging conditions.

Dr. Shena Riff, a CMPA physician advisor who speaks with members who contact the Association for assistance says, “We hear from members every day that they are under enormous pressure. They have a waiting room full of patients needing their care, but rarely have enough time. They are constantly under pressure to do more.”

What is the problem?

The CMPA analyzed its College complaint cases¹ and examined the reasons patients gave for making a complaint and the critical factors identified by Colleges in their investigation of complaints. A key underlying issue in most of these cases was communication.

In the complaint cases where communication was flagged, patients reported that their physician was rude, spoke in a raised voice, used a condescending tone, or dismissed their or their families’ concerns. Colleges validate that communication was a factor in a range of clinical situations. For example, in consent discussions where patients did not receive or understand the necessary information about a treatment.

Notably, the CMPA's findings mirror previous studies in this area,² including those from other countries.^{3, 4, 5}

Tips on being a better communicator

If physicians want to improve their interactions with patients, they may wish to assess their current communication behaviours and skills, both when receiving information from patients and when providing information to patients.

When receiving information from patients:

• Do you focus on this patient at this moment?
  Do you greet the patient?⁶ Do you show respect in speech and body language? If using an electronic medical record (EMR), do you explain what you are doing and look at the person more often than at the computer or phone?^{3, 7} Do you sit down and face your patient?⁸ When appropriate, do you introduce members of the healthcare team to the patient?
• Do you listen actively?
  Do you let patients tell their story uninterrupted,⁶ recognizing that research shows most patients finish what they want to say in 30 seconds to 2 minutes?^{9, 10} Do you restate what they told you, using their words?³
• Do you try to understand the patients' perspective of their illness?
  Do you ask about their experience and how the illness is affecting them?^{3, 6}

When delivering information to patients:

• Do you express empathy?
  Do you show compassion in what you say and in your body language? Do you communicate professionally that you understand, respect, and support them?¹¹
• Do you provide information clearly and simply?
  Do you assess what patients already know, and how much information they want and need to know about their condition?³ Do you educate them on the condition without using jargon?⁶ Do you observe how the patient is responding to what you are saying, through both their body language and in what they say?
• Do you share decision-making?
  Do you involve patients in making decisions about their treatment? Do you present them with the pros and cons of different treatment options, including no treatment?⁶ Do you come to an agreement on a course of action?⁶ If a plan cannot be agreed on, do you consider whether it’s appropriate to refer the patient to another physician? Do you document your interactions with patients in their medical record including the agreed-upon plan and next steps?

Consider training

Effective communication is essential to safe medical care and physicians may be unaware of their skill level, in some instances over-estimating it.^{12, 13} An assessment of skills can clarify the level and any need for improvements and training.^{2, 13, 14}

There are resources to help physicians improve their communication skills. Some education organizations and universities offer materials, workshops, and courses. For instance, Dalhousie University in Nova Scotia offers a communications skills program for physicians.¹⁵

The bottom line

Communication is an underlying issue in many College complaint cases in which the CMPA is involved. Physicians can improve their communication with patients by focusing on patients as individuals, listening, exchanging information, expressing empathy, and sharing decision-making.

Physicians receiving a notice from their College about a complaint should contact the CMPA as soon as possible to determine their eligibility for assistance and to receive other support as required.

References

1. Based on a 10-year review of closed CMPA regulatory authority (College) cases from 2007–2016, not including cases dealing with discipline or fitness to practice.
2. Tamblyn R, Abrahamowicz M, Dauphinee D, Wenghofer E, Jacques A, Klass D, Smee S, Blackmore D, Winslade N, Girard N, Du Berger R, Bartman I, Buckeridge DL, Hanley JA. Physician scores on a national clinical skills examination as predictors of complaints to medical regulatory authorities. JAMA [Internet]. 2007 [cited 2017 Nov 30];298(9):993-1001. Available from: https://jamanetwork.com/journals/jama/fullarticle/208633 doi:10.1001/jama.298.9.993
3. Medical Defense Union (MDU). What makes a good communicator? MDU Journal [Internet]. 2011 June [cited 2017 Nov 30];27(1):9-12. Available from: https://www.themdu.com/guidance-and-advice/journals/mdu-journal-june-2011
4. Levinson W, Roter DL, Mullooly JP, Dull V, Frankel RM. Physician-patient communication: the relationship with malpractice claims among primary care physicians and surgeons. JAMA [Internet]. 1997[cited 2017 Nov 30];277(7):553-559.
5. Beckman HB, Markakis KM, Suchman AL, Frankel RM. The doctor-patient relationship and malpractice: lessons from plaintiff depositions. Arch Intern Med [Internet]. 1994;154(12):1365-1370. Available from: https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/618939 doi:10.1001/archinte.1994.00420120093010
6. King A, Hoppe RG. "Best practice" for patient-centred communication: a narrative review. J Grad Med Edu [Internet]. 2013 Sep [cited 2017 Nov 30];5(3):385-393.
7. Canadian Medical Protective Association [Internet]. Ottawa (CA):CMPA. CMPA Good Practices Guide: Communication [cited 2017 Nov 30]. Available from: https://www.cmpa-acpm.ca/serve/docs/ela/goodpracticesguide/pages/communication/Patient-centred_communication/overcoming_barriers-e.html
8. Swayden KJ, Anderson KK, Connelly LM, Moran JS, Mcmahon JK, Arnold PM. Effect of sitting vs. standing on perception of provider time at bedside: a pilot study. Patient Educ Couns [Internet]. 2012 Feb [cited 2017 Nov 30];86(2):166-171. Available from: http://www.pec-journal.com/article/S0738-3991(11)00305-3/pdf doi:10.1016/j.pec.2011.05.024
9. Wangewitz W, Denz M, Keller A, Kiss A, Rutimann S, Wossmer B. Spontaneous talking time at start of consultation in outpatient clinic: cohort study. BMJ [Internet]. 2002 [cited 2017 Nov 30];325:682. Available from: http://www.bmj.com/content/325/7366/682 doi: 10.1136/bmj.325.7366.682
10. Rabinowitz I, Luzzati R, Tamir A, Reis S. Length of patient’s monologue, rate of completion, and relation to other components of the clinical encounter: observational intervention study in primary care. BMJ [Internet]. 2003 Feb 28 [cited 2017 Nov 30] 328(7438):501-502. Available from: http://www.bmj.com/content/328/7438/501 doi: https://doi.org/10.1136/bmj.328.7438.501
11. Mazzi MA, Rimondini M, Deveugele M, Zimmermann C, Moretti F, van Vliet L, Deledda G, Fletcher I, Bensing J. What do people appreciate in physicians’ communication? An international study with focus groups using videotaped medical consultations. Health Expect [Internet]. 2015 Oct [cited 2017 Nov 30];18(5): 1215-1226. Available from: http://onlinelibrary.wiley.com/doi/10.1111/hex.12097/full doi: 10.1111/hex.12097
12. Levinson W. Patient-centred communication: a sophisticated procedure. BMJ Qual Saf [Internet]. 2011[cited 2017 Nov 30];20(10):823-825. Available from: http://qualitysafety.bmj.com/content/20/10/823 doi: 10.1136/bmjqs-2011-000323
13. Maatouk-Burmann B, Ringel N, Spang J, Weiss C, Moltner A, Riemann U, Langewitz W, Schultz JH, Junger J. Improving patient-centred communication: Results of a randomized controlled trial. Patient Educ Couns [Internet]. 2016 Jan [cited 2017 Nov 30];99(1):117-24. Available from: http://www.pec-journal.com/article/S0738-3991(15)30049-5/fulltext doi: 10.1016/j.pec.2015.08.012.
14. Boissy A, Windover AK, Bokar D, Karafa M, Neuendorf K, Frankel RM, Merlino J, Rothberg MB. Communication skills training for physicians improves patient satisfaction. J Gen Intern Med [Internet]. 2016 Jul [cited 2017 Nov 30];31(7):755-761. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4907940/ doi: 10.1007/s11606-016-3597-2
15. Dalhousie University Medicine. Halifax (CA): Dalhousie University. Communications skills for practicing physicans [cited on Dec. 11, 2017]; 1 screen. Available at: https://medicine.dal.ca/departments/core-units/DME/communication-skills/program/continuing-professional-development.html

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.