Today I’m sitting here reflecting on my practice, I’m doing so because I have my annual appraisal coming up in the next few weeks, so with the purpose of learning through reflection I’m looking again at the complaints I’ve received in the last few years years.
Given that that the number of patient contacts I have in an average day either over the phone, as a telephone consultation or in a standard face to face consultation is at least 50, then multiply this by five days a week, and then even after taking holidays into account I am looking at well over 10000 patient contacts and consultations per year.
Last year I received 2 written complaints about my practice, that’s a complaint rate of 1 in every 5000 consultations, it doesn’t seem a large amount, and neither of these were about misdiagnosis, medical error or clinical mistakes.
The general theme of these complaints, and why the people complain at all is that there’s either a breakdown of communication, that people don’t always get what they want, or that sometimes I know I can push too far.
There’s the old analogy that you can help people by pointing them in the right direction, pushing them in the right direction, or you can help people get back up after they have fallen down. In medicine we do all 3, we help people, we give direction and advice, and for some we pick them back up and get them back onto their feet after illness.
The question is how hard do you push? and when does a gentle nudge go too far, my problem is and I admit it is that I want to help people, it’s why I do my job, and it’s what I’m passionate about, however I also admit that sometimes I’m 100% guilty of pushing some people a bit too far.
About half of the complaints I’ve had in the last 10 years are from people who have pushed back, pushed back against me also have pushed themselves back into their problem state.
Let’s digress for a while, I believe that for some people to change they first need to decide within themselves that they need to change and to do this they need to cross what some therapists call a threshold.
This threshold refers to the line that needs to be crossed for change to take place, in coaching terms if a client hasn’t reached or will commit to breach their threshold they won’t follow through and they won’t take the action they need to make. A threshold can be be crossed by taking the first step, a small next step, or a real life practical step like agreeing to surgery, taking a medication, attending an AA meeting or even just making an internal mental decision so that you can let go and move on.
You may be saying why push, isn’t it down to the autonomy of the individual to make their own decisions, well yes it is but in the real world maybe waiting for someone to decide to stop smoking after they are on long term oxygen or after their diagnosis of lung cancer is almost always too late because in medicine sometimes people don’t get up after a fall.
So this is why I push, for some it’s too hard and too soon and some of the complaints I receive reflect just this, but let’s not just scratch the surface let’s look a little deeper as there are also other issues to take into consideration.
Some people have conditions that modern medicine cannot fix with tablets, because sometimes the most help a patient can get is when they first start to help themselves, for both outsiders and for the patient it’s really difficult to comprehend that the most effective help and treatment is in the patient’s own hands. The right mindset, the right habits, the right attitude, a better lifestyle, a better diet and better decisions can go a long way to prevent a high proportion of society’s ills.
In the past I’ve written on how a person has the potential to make a real change in their life, I’ve researched how people can get stuck in a problem state and more importantly what can be done to help themselves towards a life outside their problem state.
I have a responsibility to myself and to my patients to help them, and where I can I will try and do just this, when a condition exists that can be treated I will treat it, when I need to prescribe I will do so in an evidence based and safe manner. I refuse to throw medicines at patients just to get them out of the room, neither will I rotate a patient through half a dozen antidepressants when the real answer is to stay on the the one they are on, to start engaging in some form of counseling and to do something about their lifestyle.
Some people push back because life outside of their problem is more difficult, their comfort zone is to stay inside their problem state, the empathy, the primary gain, the secondary gain, their identity, their income (be it state benefits) and their relationships with others are all built on one thing, their problem. To move on and to leave their problem state, to take responsibility, to leave the sofa, the poor diet, the drugs, and to start again to create a new life in a cold world of long hours at minimum wage is far too much for some, and for some a complaint letter is their tool to fight for the recognition they need to get their problem back.
I ask myself do I take the easy route travelled by some of my more colleagues, because there’s a time when being too empathic, over medicating, over testing and needlessly referring patients is not going to get you anywhere except into a dysfunctional doctor patient relationship and a waiting room full of heart sink patients that will bleed your time and effort away from the patients that really need your help.
Lets face it criticism can be harsh at times, reflection is a great tool to help us gain self awareness and to observe our own faults, yet complaints always hurt and they hurt even more when all you have done is try and help.
My hit rate, where I have helped others far exceeds my rate of complaints, the reason I push too far is that I still believe I can help others especially those where the difference that will make the difference for that person is to take action to help themselves, but when the answer is that simple it often falls on deaf ears.
The question for me is do I roll over to avoid complaints (and the almighty monster of the complaints process), do I smile and give the patient everything they want, do I make my life easier as I lose heart and drift into early retirement, or do I wield the two edged sword of empathy more effectively and give the patient a gentle push in the right direction.
Richard Thaler recently won the Nobel Prize for the concept of the Nudge, I will continue to nudge and push too, even if it is at times a push too far.
Bibliography and References
Thaler, Richard H, and Cass R Sunstein. Improving Decisions About Health, Wealth And Happiness. London: Penguin Books Ltd, 2009. Print.