It's that time of year again when we at HDC count the complaints we've had and report on the various ways in which we've addressed them. It's been a big year, with 1289 new complaints flooding in. You'll be interested to note that, of those, 456 involved doctors.
For me, the start of the new financial year is a time of double reflection. August 1 marks the second anniversary of my shift from newshound to public watchdog, heading the Commissioner's complaints resolution team. Perhaps surprisingly, I've found that the job is not quite as different as it might seem.
In 1965 the American journalist Alistair Cooke told young doctors graduating from the Mayo School of Medicine that the media had a duty to speak on behalf of patients, to be the social link between "the expert and the layman". He said that at his or her best a journalist "reports the world not as it ought to be but as his eyes and ears tell him it is".
At HDC we call it as we see it, based on the available evidence. We also have a duty to speak on behalf of patients - to promote and protect patients' rights in a fair and impartial way.
As a journalist I saw my role as being to get to the bottom of things; to fairly and impartially inform, explain, and educate, and sometimes promote accountability. Again, there's a clear resonance. Nonetheless, there have been some surprises.
One thing that has startled me in talking to doctors' groups has been the perception by some that many complaints are vexatious or unjustified. To support this, they point to a quieter past when people seemed to complain less. But when I reflect on the year's complaints, there is little to support this. There is usually some basis for concern and more often than not it's about communication. In my view, the increased number of complaints relates more to people's greater appreciation of their rights and the higher profile of HDC than to an increased desire to create difficulties for doctors or other health care providers.
Some years ago, as a health journalist, I heard David Skegg being interviewed on National Radio about the risks involved with the third-generation contraceptive pill. Much of the discussion was around the statistical risks. What I remember most is that he reminded us that behind every number there was a woman.
In a similar vein, it's important to remember that behind every complaint there is a human story, sometimes a tragic one. No matter how difficult or time-consuming the complaint may be, it's helpful to put yourself in the shoes of the person who is making it. Even with complaints about respect or the manner in which someone has been treated, it is useful to reflect on what might have led to a perception of rudeness, or disrespect, when it was not intended - to look at it from the patient's perspective.
As a journalist, and in my current role, it has always surprised me how often the people providing care forget what it is to be a patient. We compartmentalise people into doctors and patients, at times forgetting that we are all patients.
In my former life, one of the stories that attracted the most feedback was a radio documentary where three prominent and very experienced local doctors talked of their own experiences of being a patient. One spoke of watching his leg being incorrectly set after a skiing accident and feeling unable to say anything. Another spoke of similar feelings of powerlessness when taking his daughter to a hospital emergency department. It was as if the switch in role had turned them into different people. The great thing was that these people were using their own patient experience to make them better doctors.
I am sure that upon receiving a complaint, most doctors will ask themselves what may have led to a patient leaving their practice so dissatisfied with their care. In my new role, it has been disheartening to see those who react defensively or refuse to meet requests for information in response to complaints. This does not happen often, but both reactions, while understandable, simply delay any resolution and can escalate matters.
When you remember the people behind each complaint, of course you also need to consider the providers. Much has been written about the "second victim" when something goes wrong in health care - the doctor or nurse who has made a mistake and is also suffering.
At HDC emotion plays no part in the decision-making. However, just as some complaints touch us, so too do the sincere and heartfelt responses we see from providers who are mortified by what has occurred. Like the complainants, they too need good support, particularly during a complaints process.
Back in 2001 when I was looking for a research topic during my Harkness Fellowship, my United States mentor Don Berwick suggested having a look at "the second victim". After much reflection I rejected this idea, choosing instead to look at how often errors are disclosed to patients. In my view that was the place to start because unless there was disclosure, no other learning or quality improvement could usefully occur.
Additionally, my experience as a journalist had been that most of the anger patients and their families felt about medical mistakes was related to the way events were handled afterwards, rather than the event itself. As a result, I reasoned that unless matters were handled well for the "first victim" there would be little public interest or sympathy for the suffering of providers affected by the error. That is still my view. It's one that I have come back to when faced with the other question I inevitably get confronted with now, "What about doctors' rights too?"
Patients are not bicycles
At a media training day I once heard a senior Ministry of Health official, a doctor, tell a group of health journalists that people - patients in particular - tend to think they are like bicycles. The doctor is the mechanic, able to fix whatever is broken.
I occasionally think of that now when reviewing complaints where the clinical outcome has not met the patient's expectations. In my view, the analogy is too simplistic. While it is true that occasionally people have unrealistic expectations, most complaints show that the days when patients thought doctors knew everything are fast disappearing, and most people recognise that the human body is much less predictable than a bicycle. We see some very perceptive and, under some circumstances, remarkably generous comments from patients acknowledging the complexities involved when something has gone wrong in their care.
There's a great quote from the American surgeon Atul Gawande in his first book, Complications, where he writes:
"As pervasive as medicine has become in modern life it remains mostly hidden and often misunderstood. We have taken it to be more perfect than it is, and less extraordinary than it can be."
I often use this quote in presentations to doctors' groups. To me, the fact that medicine is an inexact science and a very human endeavour is one of the strongest arguments for ensuring that patients are active partners in all aspects of their care.
On a personal level, one of the biggest changes as a result of the new job has been a move to Auckland after 27 years in Wellington. Among other things it's meant a new doctor, dentist, hairdresser and so forth.
I was thinking the other day that the best thing about my previous GP of 15 years was that he was prepared to say, "I don't know." He would give me the options, the pros and cons of those, his thoughts on the best course, and let me decide. He was great. However, there was a downside in being a journalist. He was inclined to want to discuss the affairs of the day, particularly health issues, at very inopportune moments from my point of view - such as during a cervical smear!
These days I have discovered a new occupational hazard. It is the long and difficult pause when, as the examination finishes, the brand new doctor or dentist asks, "And what do you do?"
Deputy Health and Disability Commissioner
New Zealand Doctor, 15 August 2007