The disciplined healthcare professional: a qualitative interview study on the impact of the disciplinary process and imposed measures in the Netherlands

Experiences of Physicians Investigated for Professionalism Concerns: a Narrative Review

Growing attention is being paid to physician health and behavior, including the occurrence of mental health issues and burnout in medical providers, physician impairment, and alleged disruptive behavior in physicians. In any of these areas, a physician may become the subject of an investigation. Studying the experience of investigated physicians is important to identify and mitigate any potential adverse personal and practice impacts, which in turn can hinder patient care. The purpose of this review is to (1) summarize the published scientific literature to date regarding the experiences of physicians who have been investigated, and (2) based on these findings consider strategies to mitigate any adverse effects of the investigatory process for physicians. A search of the databases PubMed and Ovid MEDLINE was conducted in June 2023 using relevant search terms. After reviewing titles, abstracts, full-length articles, and reference lists, 16 articles were identified and reviewed. Physicians in multiple countries who had been investigated commonly described short-term (feelings of anger, depression, anxiety, shame, powerlessness, isolation, being betrayed, less confidence in clinical decision-making) and long-term (increase in defensive practice, retiring early) impacts of the investigatory process. Physicians found the most difficult aspects of the investigation process to be the length of time involved, lack of transparency/communication regarding the process, feelings of isolation, and dealing with vexatious complaints. While complaints about physicians have the potential to portend constructive individual practice and systemic changes, research suggests that the investigatory process for physicians is associated with negative short- and long-term emotional and practice impacts. Strategies to mitigate the unintended adverse effects of investigatory processes are proposed. Further research is warranted to clarify the investigation experience for physicians, including physicians underrepresented in medicine, and to systematically assess the effectiveness of strategies to mitigate unhealthy or disruptive components of the investigatory process.

Alleged Malpractice in Orthopedic Surgery in The Netherlands: Lessons Learned from Medical Disciplinary Jurisprudence

BACKGROUND

Orthopedic surgery is a specialty at risk for medical malpractice claims. We aimed to assess the frequency of alleged malpractice cases related to orthopedic surgery in the Netherlands from the last 15 years.

METHODS

We systematically searched the database of the Dutch Medical Disciplinary Court for verdicts related to orthopedic surgery between January 2009 and July 2023 and extracted case data and data on allegations and outcomes.

RESULTS

We identified 158 verdicts (mean of 10.5 per year), of which 151 (96%) were filed against specialists and 7 (4%) against residents. Cases were most frequently classified as incorrect treatment/diagnosis (n = 107, 67.7%). Cases were related to the subspecialties of knee (n = 34, 21.5%), hip (n = 31, 19.6%), ankle (n = 25, 15.8%), spine (n = 22, 13.9%), and shoulder (n = 19, 12.0%). A total of 32 cases (20.3%) were judged as partially founded and 9 (6%) as founded. The Dutch Medical Disciplinary Court imposed 28 warnings, 10 reprimands, and 3 temporary suspensions. A total of 68 appeals were submitted, of which 95% were rejected for filing patients. In three instances, unfounded verdicts were changed to two warnings and a reprimand. In four appeals by an orthopedic surgeon, a warning and reprimand were dismissed, and two reprimands were changed to warnings.

CONCLUSIONS

The amount of malpractice cases against orthopedic surgeons in the Netherlands is relatively low. The cases in our study may improve our understanding of allegations against physicians and improve the quality of patient care.

Anger: an underappreciated destructive force in healthcare

Anger is an emotional state that occurs when unexpected things happen to or around oneself and is "an emotional state that varies in intensity from mild irritation to intense fury and rage." It is defined as "a strong feeling of displeasure and usually of antagonism," an emotion characterized by tension and hostility arising from frustration, real or imagined injury by another, or perceived injustice. It can manifest itself in behaviors designed to remove the object of the anger (e.g., determined action) or behaviors designed merely to express the emotion. For the Roman philosopher Seneca anger is not an uncontrollable, impulsive, or instinctive reaction. It is, rather, the cognitive assent that such initial reactions to the offending action or words are in fact unjustified. It is, rather, the cognitive assent that such initial reactions to the offending action or words are in fact unjustified. It seems that the year 2022 was a year when many Americans were plainly angry. "Why is everyone so angry?" the New York Times asked in the article "The Year We Lost It." We believe that Seneca is correct in that anger is unacceptable. Anger is a negative emotion that must be controlled, and Seneca provides us with the tools to avoid and destroy anger. Health care professionals will be more effective, content, and happier if they learn more about Seneca's writings about anger and implement his wisdom on anger from over 2000 years ago.

The silent epidemic: Death by suicide among physicians

Suicidal deaths among physicians have been on a steady rise in the past few decades, despite being a part of the healthcare system, training for early identification and easy access to treatment services. While there is no doubt that this warrants concern at individual, institutional, and community levels, physician suicide remains an under-researched topic. We examine the correlates of suicidal deaths among physicians along with risks and protective factors conferred to physicians as a population and emphasize the need for preventive and risk-reduction initiatives that are specifically tailored for physicians and the healthcare provider community.

Why Are Patients Unhappy with Their Healthcare? A Romanian Physicians’ Perspective

Background: Medical professional liability complaints are not triggered by a single factor, but rather by multiple factors, each having more or less implications, such as the characteristics of the physician, the medical system, the patients, the complexity of their pathology, and the inherent limits of medicine. Knowledge about the factors that initiate the complaint procedure is essential to identify the targeted measures to limit their prevalence and impact. The purpose of this study was to identify the reasons behind the malpractice complaints and the factors that may influence the initiation of complaints by the patients. Material and Methods: This study was conducted using an online questionnaire, addressed to Romanian doctors, with questions about the reasons for patient dissatisfaction and complaints, the factors that predispose a physician to being complained against, and the protective factors against patient complaints. Results: The study group included 1684 physicians, of whom 16.1% were themselves involved in a complaint, and 52.5% knew of a colleague who was complained against. The opinions of the participants regarding the reasons for the complaints, the predisposing factors to complaints, and the factors that contributed to the reported incident showed a strong link between professional liability complaints and the physician–patient/patient’s family relationship. The relationship between fellow physicians is additional to this. Conclusion: This study reveals that the improvement in the relational aspects of medical practice (physician–patient relationship and relationship between physicians) has the highest potential to decrease the number of malpractice complaints. Its practical relevance is related to the need for training physicians in the relational aspects of medical practice during academic years and throughout their career.

'We're gonna end up scared to do anything': A qualitative exploration of how client complaints are experienced by UK veterinary practitioners

BACKGROUND

UK veterinary practitioners are reported to be fearful of client complaints, but their experiences have not been formally captured. Understanding how complaints impact veterinary practitioners is key to mitigating detrimental consequences.

METHODS

A qualitative exploration of how UK veterinary practitioners experience and respond to adverse events was conducted. Data were collected via focus groups and interviews, which were transcribed and simultaneously analysed. Coding and theme development were inductive rather than restricted by preconceived theories.

RESULTS

Twelve focus groups and 15 individual interviews took place. One theme identified focused on the impact of client complaints. Practitioners experienced unintentional distraction and disengagement from clinical work, as well as employing defensive strategies as a direct result of complaints. The vexatious nature of some complainants was highlighted, along with concerns about practice and regulatory complaint management, lack of appropriate support, discriminatory behaviours and the influence of 'trial by media'.

CONCLUSIONS

Client complaints present a threat to practitioner mental health and workforce sustainability, as well as having implications for patient safety. Mitigating these effects is a complex and multifaceted undertaking, but fairness, transparency and timeliness of practice and regulatory complaint investigation must be prioritised, along with provision of tailored support for those facing complaints.

Socio-Demographic, Professional and Institutional Characteristics That Make Romanian Doctors More Prone to Malpractice Complaints

Background and objectives: Medical malpractice is a phenomenon that shadows current medical practice, the number of complaints following an upward trend worldwide. The background for complaints is related both to the doctor and medical practice in general, as well as to the patient. The aim of this study was to identify a profile of the Romanian doctors who are more prone to receiving complaints, by analyzing the socio-demographic, professional and institutional characteristics. Materials and Methods: We conducted a quantitative, prospective research, the data being collected using a newly developed questionnaire. Data analysis was performed with the IBM Statistical Package for Social Sciences (SPSS, version 24). We used counts, percentages, means and standard deviation, and comparative and correlational analyses. A logistic regression model was applied to select a statistically best-fit model to identify independent predictors for receiving complaints; a Hosmer–Lemeshow test was used to check the performance of the prediction model. Results: The study group consisted of 1684 doctors, of which 16.1% had been involved in a malpractice complaint. Results showed that men, senior doctors from surgical specialties who perform a greater number of on-call shifts, those who work in regional or county hospitals, those who have greater fear of receiving complaints and those whose life partner is a doctor with the same specialty are more prone to receiving complaints. Conclusions: The profile identified by the present research underlines the main characteristics that could be targeted with specific measures in order to prevent the ongoing increase of malpractice complaints in Romania.

The Personal and Professional Impact of Patients' Complaints on Doctors-A Qualitative Approach

Background: Complaints regarding medical practice represent a harsh reality of the current world. Patients have the right to receive explanations and compensation when they are injured during the medical act, but the increased potential for exposure to complaints determines personal and professional consequences for the doctors, with significant impact on their health and practice. Thus, the aim of our research was to analyze in depth the impact of complaints on the doctors involved. Materials and methods: The authors conducted a qualitative study, using a semi-structured interview, addressed to doctors who had complaints from patients. The participants in our research were identified using an adapted version of the snowball method. Results: After the analysis of the interviews using the inductive method, nine themes resulted, seven of which are addressed in this paper: injustice, personal impact, professional impact, difficulties, supportive factors, the attitude of the hospital management and the attitude of colleagues. At the personal level, the doctors were overwhelmed by insomnia, nightmares, stress and anxiety, and at the professional level by doubts about medical decisions, fear, anxiety and the tendency to avoid patients with severe diseases. Conclusions: The study revealed that physicians who had complaints from patients are deeply affected by the complaint itself and the associated investigation procedure, even if, to a lesser extent, some of the participants found motivation for a better management of the situation. The study also showed the need for changes in the legal and medical systems in order to create mechanisms to support the doctors during the investigation process.

On intimate relationships between healthcare professionals and patients: a nationwide cohort analysis of medical tribunal decisions in the Netherlands

Background

We examine the incidence of medical tribunal decisions and disciplinary actions (DAs) against healthcare professionals (HCPs). In addition, we studied whether an intimate relationship between an HCP and patient as part of the medical tribunal decision is associated with an increased likelihood of disciplinary actions.

Methods

We conducted a nationwide cohort analysis on the downloadable medical tribunal decisions from a medical disciplinary tribunal in the Netherlands from 2010 to 2017.

Results

We found that 117 (2.8%) of the 4,046 medical tribunal decisions involved an alleged intimate relationship between an HCP and patient. In these medical tribunal decisions the likelihood of a disciplinary action was significantly increased (odds ratio [OR] 12.97, 95% Confidence Interval [95% CI] 7.11–23.64). In addition, we found that nurses and psychiatrists are more frequently accused of and receive disciplinary actions due to intimate relationships than other HCP groups.

Conclusions

We found a limited number of medical tribunal decisions involving an intimate relationship. Especially given the total number of medical tribunal decisions and the number of yearly HCP-patient interactions, the number appears small. Furthermore, an alleged intimate relationship or inappropriate sexual conduct is associated with an increased likelihood of disciplinary action. Future research should obtain statistics on the number of intimate relationships that actually start between HCPs and patients.

"Incident Teaching (IT)" Lecture Series - Incorporating Education Surrounding Clinical Incidents and Complaints into Foundation Year 1 (FY1) Doctors' Induction

Patient safety incidents are any unintended or unexpected incidents which potentially could, or did, lead to harm to patients. Incident reports are crucial to improve patients’ care and to identify further actions needed to prevent harm. A common view among the FY1 doctors in our local NHS Trust involved a fearful opinion surrounding being involved in clinical incidents. Significant anxiety in those situations prompted the need for a focus on the topic of “clinical incidents” during their induction to the Trust in two consecutive years of 2018 and 2019. A near-peer lecture series was delivered to new FY1 with qualitative pre- and post-lecture series feedbacks. Results from lecture series from two consecutive years showed all FY1 doctors agreed or strongly agreed that they had a good understanding of incidents following the lecture. Compared with their pre-course feedback, there was an increase of 6-fold (2018) and 8-fold (2019) in those that strongly agreed. Post-course, more than 90% of doctors reported that they would feel comfortable sharing with colleagues their involvement in an incident. In a growing culture of blame and litigation, it is important to address the harm associated with a blame-based culture. The process of investigating an incident has the potential to expose the areas of deficiency relating to an individual. Reducing stigma associated with incidents could theoretically reduce the second victim phenomenon. An open culture to incident reporting is a fundamental part of medical education and quality improvement. Encouraging this attitude amongst medical professionals and creating a supporting environment surrounding sharing of experiences will help to form a generation of doctors that see incident reporting in a positive light. Our model of lecture series could be utilised in other UK Foundation Programmes with the aim of enriching the FY1s’ induction period.

Is the perceived impact of disciplinary procedures on medical doctors' professional practice associated with working in an open culture and feeling supported? A questionnaire among medical doctors in the Netherlands who have been disciplined

INTRODUCTION

Disciplinary procedures can have a negative impact on the professional functioning of medical doctors. In this questionnaire study, doctors' experience with open culture and support during a disciplinary procedure is studied to determine whether open culture and support are associated with perceived changes in the professional practice of doctors.

METHODS

All doctors who received a warning or a reprimand from the Dutch Medical Disciplinary Board between July 2012 and August 2016 were invited to fill in a 60-item questionnaire concerning open culture, perceived support during the disciplinary procedure and the impact of the procedure on professional functioning as reported by doctors themselves. The response rate was 43% (n=294).

RESULTS

A majority of doctors perceive their work environment as a safe environment in which to talk about and report incidents (71.2% agreed). Respondents felt supported by a lawyer or legal representative and colleagues (92.8% and 89.2%, respectively). The disciplinary procedure had effects on professional practice. Legal support and support from a professional confidant and a professional association were associated with fewer perceived changes to professional practice.

CONCLUSION

Our study shows that doctors who had been disciplined perceive their working environment as open. Doctors felt supported by lawyers and/or legal representatives and colleagues. Legal support was associated with less of a perceived impact on doctors' professional practice.

Conflict of interest in regulatory investigations on medical professionals

Medical professionals' practices may be investigated by their employers. Biased and flawed investigations impact badly on clinicians' lives and careers but also reduce the quality of patient care provided, which in turn result in serious financial costs for the National Health Service. This article considers the importance of excluding conflict of interest while organising regulatory investigations. It explores the harmful effects that a biased and badly conducted investigation may have on staff and the possible ways of ensuring that investigations are fair and unbiased, with reference to Fit and Proper Persons Test and overarching responsibility of the Trust Board of Directors.

Psychologists' experience of a malpractice complaint: Their relationship with and processes at the regulator

Background

Professional malpractice complaints in the South African health arena have increased over the last decade. There is a lack of research on how South African health practitioners experience professional malpractice complaints and complaint processes.

Aim

This article reports on one aspect of the findings in a more extensive study relating to the complaint experience of psychology practitioners, namely how a group of psychology practitioners experienced their relationship with and the processes at the regulator during a malpractice complaint. The regulator refers to the professional registration body which manages complaints against practitioners.

Setting

The study included 10 registered South African psychologists who experienced a malpractice complaint.

Methods

After sampling, semi-structured interviews were conducted, audio-recorded and transcribed. The data were managed using interpretative phenomenological analysis (IPA) to elicit the personal, subjective experience of the individual participants.

Findings

Two superordinate themes and related subthemes emerged from the analysis. First, relating to the experience of the complaint procedures and processes, participants experienced an extended timeframe for complaint management, a lack of communication during complaint management, legal challenges during some disciplinary proceedings and some complaints as unjustified and frivolous. Second, participants were unsure of their relationship with the regulator. Their responses denoted instances of vulnerability and inequality during proceedings.

Conclusions

The findings call for closer collaboration between the registration body and practitioners during complaints management, to eliminate vexatious complaints, to streamline processes and to encourage guidance of and support for the professional.

Second victim phenomenon: Is 'just culture' a reality? An integrative review

BACKGROUND

Despite rigorous and multiple attempts to establish a culture of patient safety and a goal to decrease incidence of patient deaths in the health care, estimations of preventable mortality due to medical errors varied widely from 44,000 to 250,000 in hospital settings. This magnitude of medical errors establishes patient safety as being at the forefront of public concerns, healthcare practice and research. In addition to the potential negative impact on patients and the healthcare system, medical errors evoke intense psychological responses in health care providers' responses that threaten their personal and professional selves, and their ability to deliver high quality patient care. Studies show half of all hospital providers will suffer from second victim phenomena at least once in their careers. Health care institutions have begun a paradigm shift from blame to fairness, referred to as 'just culture'. 'Just culture' better ensures that a balanced, responsible approach for both providers who err and healthcare organizations in which they practice, and shifts the focus to designing improved systems in the workplace.

OBJECTIVES

The aim of this review was to identify: how medical errors affect health care professionals, as second victims; and how health care organizations can make 'just culture' a reality.

DESIGN

An integrative review was performed using a methodical three-step search on the concept of second victims' perceptions and responses, as well as 'just culture' of health care institutions.

RESULTS

A total of 42 research studies were identified involving health care professionals: 10 qualitative studies; eight mixed-method studies; and 24 quantitative studies. Second victims' perceptions of the current 'just culture' included: 1) fear of repercussions of reporting medical errors as a barrier; 2) supportive safety leadership is central to reducing fear of error reporting; 3) improved education on adverse event reporting, developing positive feedback when adverse events are reported, and the development of non-punitive error guidelines for health care professionals are needed; and 4) the need for development of standard operating procedures for health care facility peer-support teams.

CONCLUSIONS

Second victims' perceptions of organizational and peer support are a part of 'just culture'. Enhanced support for second victims may improve the quality of health care, strengthen the emotional support of the health care professionals, and build relationships between health care institutions and staff. Although some programs are in place in health care institutions to support 'just culture' and second victims, more comprehensive programs are needed.

The NHS Long Term Plan

New guidance from NHS Improvement will help to focus minds on establishing an NHS that regards people management procedures which impact staff wellbeing with the same urgency as it regards patient safety. I outline a culture that values and promotes Fairness, Accountability, Compassion, and Excellence (‘FACE’). I also offer some advice for doctors in difficulty.  

Unprofessional behaviour of junior doctors: a retrospective analysis of outcomes by the Singapore Medical Council disciplinary tribunals

INTRODUCTION

This is a retrospective analysis of outcomes by Singapore Medical Council (SMC) disciplinary tribunals in cases involving junior doctors. We aimed to classify the types of unprofessional behaviour and consider appropriate measures for remediation and prevention.

METHODS

SMC's annual reports from 1979 to 2017 and published grounds of decision from 2008 to 2017 were examined using two screening levels to identify cases involving junior doctors. Cases were sorted into five outcome categories: (a) professional misconduct; (b) fraud and dishonesty; (c) defect in character; (d) disrepute to the profession; and (e) acquitted.

RESULTS

A total of 317 cases were identified, of which 13 (4.1%) involved junior doctors: 4 (30.8%) cases involved professional misconduct, 4 (30.8%) cases involved fraud and dishonesty, 3 (23.1%) cases saw an acquittal, and one case each involved defect in character and disrepute to the profession. The four cases of professional misconduct highlight the need to differentiate medical errors due to systems factors from those due to individual culpability, by applying analytical tools such as root cause analysis and Unsafe Act Algorithms. Disciplining the individual alone does not help prevent the recurrence of similar medical errors. We found that fraud and dishonesty was an important category of unprofessional behaviour among junior doctors.

CONCLUSION

While the frequency of unprofessional behaviour among junior doctors, as determined by the SMC disciplinary tribunal, is low (4.1%), this study highlights that complaints against medical doctors often involve systems issues and individual factors. Unprofessional behaviours related to fraud and dishonesty need special attention in medical school.

Medical disciplinary jurisprudence in alleged malpractice in radiology: 10-year Dutch experience

PURPOSE

To systematically investigate the frequency and types of allegations related to radiology practice handled by the Dutch Medical Disciplinary Court in the past 10 years.

METHODS

The Dutch Medical Disciplinary Court database was searched for verdicts concerning radiology practice between 2010 and 2019. The association between the number of verdicts and time (years) was assessed by Spearman's rho. Other data were summarized using descriptive statistics.

RESULTS

There were 48 verdicts (mean 4.8 per year). There was no significant association between the number of verdicts and time (Spearman's rho < 0.001, p = 0.99). Most allegations were in breast imaging and musculoskeletal radiology (each 18.8%), followed by interventional radiology, head and neck imaging, and abdominal imaging (each 12.5%), neuroradiology and vascular imaging (each 10.4%), and chest imaging (4.2%). There were 46 allegations against radiologists (95.8%) and 2 against residents (4.2%). The most common allegation (37.5%) was error in diagnosis. In 20.8% of verdicts, the allegation was judged (partially) founded; disciplinary measures were warnings (n = 8) and reprimands (n = 2). An appeal was submitted by the patient in 11 cases and by the radiologist in 3 cases. All appeals by patients were rejected, whereas 2 of the 3 appeals by radiologists were granted and previously imposed disciplinary measures were reversed.

CONCLUSION

Allegations against radiologists at the Dutch Medical Disciplinary Court are relatively few, their number has remained stable over the past 10 years, and a minority were judged to be (partially) founded. We can learn from the cases presented in this article, which may improve patient care.

KEY POINTS

• The frequency of allegations against radiologists at the Dutch Medical Disciplinary Court is relatively low and has not exhibited any temporal change over the past 10 years. • These allegations reflect patient dissatisfaction, but this infrequently equals malpractice. • Knowledge of the circumstances under which these allegations have arisen may improve patient care.

Multiple Vulnerabilities in Medical Settings: Invisible Suffering of Doctors

While there is a substantive amount of literature on vulnerability of different kinds of patients in different settings, medical professionals are usually considered as the ones who possess power and gain a privileged position. In this paper, we aim to demonstrate that in a certain context physicians—a social group which is usually referred to as “powerful”—consider themselves vulnerable, and this positioning may influence patients in turn. This perspective highlights the complexity of interactions within medical organizations and contributes to the studies of sensitive topics and vulnerable groups. We conceptualize vulnerability of doctors and discuss what can be problematic in powerful doctors’ position. We describe some features of the post-Soviet context of Russian healthcare system and maternity care, both of which can be conceptualized as a hybrid of legacy of Soviet paternalism and new neoliberal reforms, managerialism and marketization. Empirical research is based on the ethnographic evidence from the study of a Russian perinatal center. In this article, we explore specific “existential” and “moral” vulnerabilities of medical professionals who routinely have to cope with multiple challenges, such as complicated clinical tasks, rigid control of different state bodies and emotional responses of suffering patients. We argue that there is a bond between the vulnerability of doctors and that of patients, whose position becomes more problematic as professionals become more vulnerable. At the end, we discuss methodological and theoretical implications of our research.

Physicians' Perspectives About Burnout: a Systematic Review and Metasynthesis

BACKGROUND

Doctors' burnout is a major public health issue with important harmful effects on both the healthcare system and physicians' mental health. Qualitative studies are relevant in this context, focusing as they do on the views of the physicians of how they live and understand burnout in their own professional field.

OBJECTIVE

To explore physicians' perspectives on burnout by applying a metasynthesis approach, including a systematic literature review and analysis of the qualitative studies.

DATA SOURCES

Medline, PsycINFO, EMBASE, and SSCI from the earliest available date to June 2018 REVIEW METHODS: This metasynthesis follows thematic synthesis procedures. Four databases were systematically searched for qualitative studies reporting doctors' perspectives on burnout. Article quality was assessed with the Critical Appraisal Skills Program. Thematic analysis was used to identify key themes and synthesize them.

RESULTS

Thirty-three articles were included, covering data from more than 1589 medical doctors (68 residents and 1521 physicians). Two themes emerged from the analysis: (1) stress factors promoting burnout-ranked as organizational, then contextual and relational, and finally individual-factors and (2) protective factors, which were above all individual but also relational and organizational.

CONCLUSIONS

The individual and organizational levels are abundantly described in the literature, as risk factors and interventions. Our results show that doctors identify numerous organizational factors as originators of potential burnout, but envision protecting themselves individually. Relational factors, in a mediate position, should be addressed as an original axis of protection and intervention for battling doctors' burnout.

Prolonged mental health sequelae among doctors and nurses involved in patient safety incidents with formal complaints and lawsuits

We evaluated the presence of prolonged mental health sequelae in the aftermath of a patient safety incident and the impact of a formal complaint or lawsuit on these mental health sequelae in 19 hospitals and 2635 nurses and doctors. Of 2635 respondents, 983 (37.3%) reported a complaint and 190 (7.2%) reported a lawsuit. In both doctors and nurses prolonged mental health sequelae reflecting a stressor-related disorder were highly prevalent, each well over 20% overall. They were consistently more prevalent in case of a formal complaint or lawsuit. Lawsuits showed 2-, 3- and 4-fold increases in prevalence of mental health sequelae.

How do doctors in the Netherlands perceive the impact of disciplinary procedures and disclosure of disciplinary measures on their professional practice, health and career opportunities? A questionnaire among medical doctors who received a disciplinary measure

INTRODUCTION

Disciplinary procedures can have serious consequences for the health, personal life and professional functioning of doctors. Until recently, specific disciplinary measures (reprimands) were publicly disclosed in the Netherlands. The perceived additional impact of disclosing reprimands on the professional and personal life of doctors is unclear.

METHODS

All doctors who received a disciplinary measure from the Dutch Disciplinary Board between July 2012 and August 2016 were invited to partake in a 60-item questionnaire concerning the respondents' characteristics, the complaint, experience with the procedure and perceived impact of the procedure on health and professional functioning as reported by doctors themselves. The response rate was 43% (n=210). 21.4% received a reprimand (disclosed); the remainder received a warning (not disclosed). Differences between the two groups were calculated.

RESULTS

Respondents with a reprimand reported significantly more negative experiences and impact on health and work than respondents with a warning. 37.8% of the doctors said their health was very good. A small percentage reported moderate-to-severe depressive complaints (3.6%), moderate-to-severe anxiety disorder (2%) or indications of burnout (10.8%). The majority reported changes in their professional practices associated with 'defensive medicine', such as doing more supplementary research (41%) and complying more with patients' wishes (35%).

CONCLUSION

The Dutch disciplinary procedure has strong negative side effects, that disclosing measures seems to increase. Dutch disciplinary law aims to contribute to the quality of professional practice. A safe environment is a basic condition for quality improvement and therefore, disclosure of disciplinary measures should be carefully considered. Disclosure of disciplinary measures has always been controversial and the results of this study has rekindled this debate. Recently, a majority in the Dutch House of Representatives has voted against disclosure of reprimands, leaving disclosure of reprimands a discretion of the disciplinary board when deemed appropriate or necessary.

Complaints from patients with functional neurological disorders: a cross-sectional UK survey of why patients complain and the effect on the clinicians who look after them

OBJECTIVE

To evaluate the nature of complaints from patients with functional neurological disorders and understand the reaction of UK neurology consultants to receiving complaints from this patient group.

METHODS

A voluntary online retrospective survey was advertised to UK consultant neurologists. Questions asked about the nature of the complaint, how it was dealt with, how it affected their emotional well-being and attitude to work, and whether it influenced their clinical practice. Responses were anonymised. The frequency of responses and percentage of total responses were analysed. Respondents were also given opportunities to add personal comments.

RESULTS

Responses from 58 clinicians were received. Patient disagreement with the diagnosis was a factor in 90% of complaints received. Only 77% of complaints were resolved within 6 months and 61% of clinicians received no feedback about the outcome. 31% of clinicians reported their most problematic complaint had an adverse effect on their mood. 67% of respondents changed their practice following the complaint with 59% investigating more frequently or due to perceived pressure from patients.

CONCLUSIONS

Complaints from patients with functional neurological disorders appear to be primarily due to disagreement with the diagnosis. They are more difficult to resolve than other complaints, and clinicians who deal with them often become the 'second victim' in the process leading to potentially adverse effects on patient care. Strategies to tackle these issues are discussed.

Doctors, suicide and mental illness

This article focuses on doctors and suicide. It provides real examples to illustrate why doctors die by their own hand. These reasons are replicated in the general population, but also include a host of additional risk factors related to being a doctor. In each case, information about the doctor is in the public domain or, as in one case, consent from the next of kin has been obtained for a detail not in the public domain. The author is a doctors' doctor, heading up a confidential health service for doctors with mental illness or addiction, the National Health Service Practitioner Health Programme. Mortality data from the programme (January 2008-January 2017) will also be included. For the sake of confidentiality, data is collated and details regarding age and gender have been approximated.Declaration of interestNone.

Doctors' perception of support and the processes involved in complaints investigations and how these relate to welfare and defensive practice: a cross-sectional survey of the UK physicians

OBJECTIVE

How adverse outcomes and complaints are managed may significantly impact on physician well-being and practice. We aimed to investigate how depression, anxiety and defensive medical practice are associated with doctors actual and perceived support, behaviour of colleagues and process issues regarding how complaints investigations are carried out.

DESIGN

A survey study. Respondents were classified into three groups: no complaint, recent/current complaint (within 6 months) or past complaint. Each group completed specific surveys.

SETTING

British Medical Association (BMA) members were invited to complete an online survey.

PARTICIPANTS

95 636 members of the BMA were asked to participate. 7926 (8.3%) completed the survey, of whom 1780 (22.5%) had no complaint, 3889 (49.1%) had a past complaint and 2257 (28.5%) had a recent/current complaint. We excluded those with no complaints leaving 6144 in the final sample.

PRIMARY OUTCOMES MEASURES

We measured anxiety and depression using the Generalised Anxiety Disorder Scale 7 and Physical Health Questionnaire 9. Defensive practice was assessed using a new measure for avoidance and hedging.

RESULTS

Most felt supported by colleagues (61%), only 31% felt supported by management. Not following process (56%), protracted timescales (78%), vexatious complaints (49%), feeling bullied (39%) or victimised for whistleblowing (20%), and using complaints to undermine (31%) were reported. Perceived support by management (relative risk (RR) depression: 0.77, 95% CI 0.71 to 0.83; RR anxiety: 0.80, 95% CI 0.74 to 0.87), speaking to colleagues (RR depression: 0.64, 95% CI 0.48 to 0.84 and RR anxiety: 0.69, 95% CI 0.51 to 0.94, respectively), fair/accurate documentation (RR depression: 0.80, 95% CI 0.75 to 0.86; RR anxiety: 0.81, 95% CI 0.75 to 0.87), and being informed about rights (RR depression 0.96 (0.89 to 1.03) and anxiety 0.94 (0.87 to 1.02), correlated positively with well-being and reduced defensive practice. Doctors worried most about professional humiliation following a complaint investigation (80%).

CONCLUSION

Poor process, prolonged timescales and vexatious use of complaints systems are associated with decreased psychological welfare and increased defensive practice. In contrast, perceived support from colleagues and management is associated with a reduction in these effects.

Outcomes of notifications to health practitioner boards: a retrospective cohort study

BACKGROUND

Medical boards and other practitioner boards aim to protect the public from unsafe practice. Previous research has examined disciplinary actions against doctors, but other professions (e.g., nurses and midwives, dentists, psychologists, pharmacists) remain understudied. We sought to describe the outcomes of notifications of concern regarding the health, performance, and conduct of health practitioners from ten professions in Australia and to identify factors associated with the imposition of restrictive actions.

METHODS

We conducted a retrospective cohort study of all notifications lodged with the Australian Health Practitioner Regulation Agency over 24 months. Notifications were followed for 30-54 months. Our main outcome was restrictive actions, defined as decisions that imposed undertakings, conditions, or suspension or cancellation of registration.

RESULTS

There were 8307 notifications. The notification rate was highest among doctors (IR = 29.0 per 1000 practitioner years) and dentists (IR = 41.4) and lowest among nurses and midwives (IR = 4.1). One in ten notifications resulted in restrictive action; fewer than one in 300 notifications resulted in suspension or cancellation of registration. Compared with notifications about clinical care, the odds of restrictive action were higher for notifications relating to health impairments (drug misuse, OR = 7.0; alcohol misuse, OR = 4.6; mental illness, OR = 4.1, physical or cognitive illness, OR = 3.7), unlawful prescribing or use of medications (OR = 2.1) and violation of sexual boundaries (OR = 1.7). The odds were higher where the report was made by another health practitioner (OR = 2.9) or employer (OR = 6.9) rather than a patient or relative. Nurses and midwives (OR = 1.8), psychologists (OR = 4.5), dentists (OR = 4.7), and other health practitioners (OR = 5.3) all had greater odds of being subject to restrictive actions than doctors.

CONCLUSIONS

Restrictive actions are the strongest measures health practitioner boards can take to protect the public from harm and these actions can have profound effects on the livelihood, reputations and well-being of practitioners. In Australia, restrictive actions are rarely imposed and there is variation in their use depending on the source of the notification, the type of issue involved, and the profession of the practitioner.

Doctors' experiences and their perception of the most stressful aspects of complaints processes in the UK: an analysis of qualitative survey data

OBJECTIVES

To examine doctors' experiences of complaints, including which aspects are most stressful. We also investigated how doctors felt complaints processes could be improved.

DESIGN AND METHODS

A qualitative study based on a cross-sectional survey of members of the British Medical Association (BMA). We asked the following: (1) Try to summarise as best as you can your experience of the complaints process and how it made you feel. (2) What were the most stressful aspects of the complaint? (3) What would you improve in the complaints system?

PARTICIPANTS

We sent the survey to 95 636 doctors, and received 10 930 (11.4%) responses. Of these, 6146 had a previous, recent or current complaint and 3417 (31.3%) of these respondents answered questions 1 and 2. We randomly selected 1000 answers for analysis, and included 100 using the saturation principle. Of this cohort, 93 responses for question 3 were available.

MAIN RESULTS

Doctors frequently reported feeling powerless, emotionally distressed, and experiencing negative feelings towards both those managing complaints and the complainants themselves. Many felt unsupported, fearful of the consequences and that the complaint was unfair. The most stressful aspects were the prolonged duration and unpredictability of procedures, managerial incompetence, poor communication and perceiving that processes are biased in favour of complainants. Many reported practising defensively or considering changing career after a complaint, and few found any positive outcomes from complaints investigations. Physicians suggested procedures should be more transparent, competently managed, time limited, and that there should be an open dialogue with complainants and policies for dealing with vexatious complaints. Some felt more support for doctors was needed.

CONCLUSIONS

Complaints seriously impact on doctors' psychological wellbeing, and are associated with defensive practise. This is not beneficial to patient care. To improve procedures, doctors propose they are simplified, time limited and more transparent.