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How does a small issue escalate into a complaint to the Health and Disability Commissioner, and what happens when it does? The following case is illustrative of how a minor lapse can escalate into a major problem - reminiscent of the old proverb, "a stitch in time saves nine".
Patient history
Peter had been a patient of Dr Osler [their names are fictitious] for five years. Peter was a self-employed 33-year-old who kept good health but consulted Dr Osler two or three times a year for minor medical problems. Dr Osler was one of two partners in a busy medical centre in the city. He described Peter as "an intelligent and articulate man who took a keen interest in his health". He felt that they had a good rapport, though he found Peter "rather intense". Peter was a keen beer drinker and had suffered a bout of gout in 2002, when Dr Osler had advised Peter to decrease his beer intake and avoid certain foods.
On 27 February 2006 Peter went to see Dr Osler with what he described as "a badly inflamed right knee and sore left foot". Dr Osler took a history ("last 1/52 knees and both feet spontaneous swelling and stiffness") and on examination found "swollen R knee with large joint effusion" and "left ankle swelling medially but nil seen on right". Dr Osler recorded in his notes "Arthritis ? type and cause", prescribed anti-inflammatories, and ordered blood tests and an X-ray of both knees.
Peter promptly had blood taken by a nurse at the centre and went for his X-rays the next day. The results were reported to Dr Osler on 28 February. The radiologist's report showed no evidence of significant bony abnormality - no cancer, no fracture, no arthritis nor loose bone. Dr Osler concluded that Peter had joint inflammation and was reassured that he had been given the appropriate medication. However, the blood results did show a raised uric acid level (0.65 mmol/L), which led Dr Osler to diagnose a return of gout.
Communication breakdown
Peter's (slightly abridged) initial letter of complaint to Dr Osler continues the story:
"You told me to ring you about the blood test results on 1 March and about the X-rays on 2 March. You specifically said to talk to you directly because the results had to be read in conjunction with each other. I actually didn't ring until 6 March and when I was told you were with a patient I left a message. The message spelled out who I was, that you had specifically asked me to call, and left two numbers (both with message capacity) for you to call back.
This was the first of over a dozen identical phone calls I made over the period of the next four to five weeks. After the sixth call, I made a point of saying 'this is the seventh time I have left message' and so on. Still there was no reply or message.
You had prescribed strong anti-inflammatory tablets and also a tablet to protect my stomach. Your comment was that you didn't want me to be taking such strong anti-inflammatory tablets for any length of time while we didn't know what was going on. That now seems ironic. The prescription ran out and still I couldn't get you to return a single one of my calls.
Out of frustration, I asked to shift my medical records to [X] medical centre, where I hoped to be able to see a GP who would tell me what was wrong. About a week after I began the transfer process, on the Thursday before Easter, I was hit with a very strong pain in my right knee and left foot and considerable inflammation. I rang [X] medical centre but the records had not been transferred.
I rang [your] medical centre and eventually talked to the nurse. She said my records would be going down that afternoon. I made a further plea for you to ring me before the transfer and tell me what was wrong. The nurse said she had put my case before you several times in the previous five weeks and was surprised I was still undiagnosed.
No call came. In fact, I have still never had any response to any of my calls, from you. I spent Thursday and Easter Friday in considerable pain. On Saturday it was even worse so I went to the Urgent and Emergency Medical Centre. There the doctor looked at my X-ray, rang and got my blood results, and said it was almost certain I had a severe attack of gout. She gave me the appropriate medicines and told me to see my doctor again in a week. It took 15 minutes.
The whole ordeal seems so unnecessary. I still can not comprehend why my phones calls were never returned. I am looking for an explanation in writing. HDC has advised me [in response to a phone enquiry] that this letter is required as the first step in making a complaint."
Complaint to HDC
Seven months later, Peter made a formal complaint to HDC, explaining what had happened next:
"On the following Saturday morning I received a phone call from Dr Osler regarding my letter. His comment was that he presumed that if I could not get him to return any of my dozen or so calls, I would make a further appointment. I indicated to him that I did not consider that at all acceptable given his express instructions to call and talk to him personally. He said that he was sorry that I had spent Easter in considerable pain due to undiagnosed gout. He also said that he had no explanation for this neglect.
I asked him to put his response in writing to me. He said he was about to go on three weeks' leave. I said that I wanted a reply in writing within two weeks of his return. I stressed the importance of this reply to me. I have received no reply or call to date. I therefore wish lay a formal complaint against Dr Osler. … I have been a patient of Dr Osler for a number of years and still can not begin to understand why he has treated me like this."
One can interject at this point that Peter's insistence on a written explanation, after his doctor's very belated but fulsome oral apology, seems a little excessive. Nonetheless, Dr Osler failed to send the promised letter, thus rekindling the fire in Peter's belly. I was obliged to bring the complaint to Dr Osler's attention and seek his version of events, and did so within two weeks of receiving the complaint. Dr Osler promptly replied to HDC, explaining what had happened.
An overworked GP
The picture that Dr Osler painted was of an overworked, sincere and contrite GP. His own words pick up the story:
"What occurred in this matter is not typical of my practice and it is something that I am extremely contrite and apologetic for. I have apologised by phone to Peter and I cannot apologise enough. During my conversation with him I not only apologised for my lack of reply by telephone following his [February] consultation and subsequently, but I also discussed the long term effects of gout and the precipitating causes.
I wish to express again my sincere apologies at not having returned his calls and to extend again my profound regret that he experienced pain and disability during his Easter break to a recurrence of his gout.
I can offer no satisfactory explanation for my oversight in failing to return his calls nor my failure to compose a letter containing an explanation and a written apology on my return from my leave in May. There are however certain factors that did influence and contribute to my omission."
Dr Osler went on to explain that at the time the practice had just employed a new nurse (the previous nurse would have given the patient his results after three calls when the doctor was unavailable) and still had a manual system for messages - although the practice was "otherwise fully computerized using MedTech software", Dr Osler had not learnt to use the message alert function. Dr Osler continued:
"In 23 years in General Practice, this is the first time a formal complaint has been made against me for lack of communication with a patient. In 23 years, General Practice has changed dramatically and I have endeavoured to keep up to date and abreast of these rapid and marked changes. … Over the past 23 years I have accumulated a very large client base - currently too large - requiring me to spend up to 12 to 14 hours most days at my surgery: consulting with patients, reviewing test results, contacting patients about their results and conditions, writing letters and reports, visiting rest homes, training nurses and administrative staff, performing rostered duties at the after hours clinic and attending to the business demands of practice.
This experience has made me re-evaluate the time demands of my practice and I have advised my staff that I am no longer able to accept new patients. I have scheduled breaks during my consultation sessions when I will not see patients and allow time to review reports, with more time to ring and contact patients rather than leave it as a task to do in the evening after a full day's practice. I have recently begun training in [the MedTech] system which I am assured is an easier and safer way of recording and responding to messages."
Dr Osler summed up by saying, "This experience has been a revelation for me both in terms of thinking about my care of [Peter] and the changes I need to make to my practice and work-life balance."
Case closed
Obviously, no further action was required from HDC. I sent Peter a copy of Dr Osler's letter, noting that I could "well understand his frustration" but that I was "satisfied from the tone and contents of [the] letter that your experience has been a salutary experience for [Dr Osler]". And I wrote to Dr Osler as follows:
"I found your letter very honest and insightful. Clearly, [Peter's] experience was quite unsatisfactory. I accept your assurance that this has been the first complaint against you in 23 years. The changes you have made seem sensible and appropriate. In these circumstances, I have decided that no further action is necessary on my part and have advised [Peter] accordingly. I wish you all the best for your practice in 2007."
Ron Paterson
Health and Disability Commissioner
New Zealand Doctor, 28 March 2007