Month: April 2014

Patient complaints and the response arc



One of the painful duties that accompanies consultancy or general practice is that of responding to complaints. However good you are, or think you are, the huge numbers of patients that you see mean that complaints are inevitable. How doctors and nurses react to them is very important – both internally and externally. Their parent organisations must also respond, recognise patterns or extremes, and make changes where appropriate. But at the level of the individual, for all the important or ultimately constructive comments that these letters and emails contain, they are by their very nature critical. Criticisms will usually be directed at individuals, because care is delivered by individuals, and each must learn how to absorb the negativity and process the message such that something positive results. This is not easy, and I believe doctors or nurses who receive a complaint experience a dynamic reaction, the first phase of which involves anger and annoyance. This article describes one such arc, and interposes the thoughts of a fictional patient. The 68 year old lady, of extremely sound mind, was not informed that she was being discharged by her team, and was then left waiting for hours in a discharge lounge. Her consultant is required to respond.


Not another one

Yes, I remember the name. She didn’t look happy when I walked past her on the day she left, something to do with not being informed, or transport delays, something. But we did a pretty good job, got her better

Come on!

“Is it worth writing this? I survived didn’t I?

But it was terrible, the way they left me…”

Oh, that’s trivial…it made no difference to her outcome…

The medicine was fine…this is nothing to do with me

I mean, I come into the office, open my emails, and what do I get – this! Just because my name was over the bed, it lands in my in-box.

“Nobody arranged transport. Nobody told me anything.

They were desperate for the bed, I could tell…”

I can’t be responsible for every little thing.

“But I’m going to. They need to know. A weaker patient,

a frail little thing, could have caught their death of cold…”

Well, I’ll write a response, but I’m not going to apologise

“I can see him now, the consultant. He won’t want to take any

of the blame. But they were his nurses…”

I don’t control staffing levels on the wards, I’ve got to focus on the hard stuff, the diagnosis, the treatment

“I’d say to him – don’t you see, you represent the whole system?

You were in charge of my care, and when I was ignored on the

ward, when I was suddenly discharged and left waiting for transport

for 4 hours in a drafty discharge lounge, I thought of you…”

Do I wake up in the morning and make a decision to deliver poor care? No! I do the best that I can in a pressurised NHS, an austere system…it’s incredible that we do as well as we do. So I’m not going to take this to heart.

“But it’s not about you, as such. It’s about fixing your hospital.”

OK…got to engage with this. Got to put down something constructive. It was a pretty rough experience by the sounds of it. I had no idea. Invisible to me, all that stuff, once I leave the ward.

“…and if it was your mother?”

Strange, really, I would have no idea this sort of thing happens if she hadn’t written.

“Imagine then, how many don’t write.”

When’s the last time I complained about anything? What does it take? A lot! This lady must have been incensed, to get home, to remember, to actually make the effort. Whenever I feel like complaining about anything it wears off after a couple of weeks. Can’t be bothered.

…20 minutes later

Good. Done. Hardly a defence union issue! But I’ll go have a word with the ward manager…let them know it spoilt what was otherwise a pretty efficient and successful patient journey…what’s the point of me and my team getting all the medicine right if the patients feel abandoned when they’ve recovered? Makes the whole system looks bad.

“Well I’m pleased. It’s almost as though we’re talking!

Such a shame we didn’t talk at the time.

None of this would have been necessary, I’m sure.”

Yes…I remember her better know, she was a lively lady. Perhaps I will apologise after all. Costs nothing


The key to accessing something positive, it seems to me, is the ability to exercise empathy over paper. One only needs to imagine how reluctant most of us are to complain about poor service in other walks of life. This is combined with a natural tendency to feel less angry with each passing day, when one has ‘escaped’ the situation that was so painful. If pen is put to paper, the intensity of dissatisfaction must indeed be considerable. And just as our role in any particular patient’s poor experience is likely to represent a failure of the system rather than personal error, the letters that we receive are likely to be addressed to the system as a whole, rather than the individual named. The name may just be a representative symbol, and as such, perhaps we shouldn’t allow the criticisms within to rile us too much. Less annoyance, more understanding – easy to say, not so easy to enact.



Right to be wrong: being comfortable with uncertainty



There are occasions when having the confidence to be wrong, and to be seen to be wrong, is advantageous to the patient.

Two cases:

I once saw a patient with signs of liver failure, but there was something about her that didn’t make sense. No risk factors, no alcohol. She had too much fluid in the body (‘overloaded’), and the veins in her neck were distended, a classic sign of heart failure. So, I thought, the liver signs could be secondary to the heart, and what she really needs is a cardiac assessment. I requested that assessment, and gave my reasons…but the cardiologist wasn’t convinced it was her heart either. The story was all wrong, she had had a healthy heart scan within the last 6 months, and there were no risk factors! We talked, we went to and fro, and in order to ensure that an urgent echocardiogram was performed, I said,

‘Well I’m pretty certain it’s her heart, there is no history of liver disease, and at the moment heart failure is the most likely diagnosis…’

Thus I nailed my colours to the mast, and backed it up by writing unequivocally in the notes something along the lines of, ‘…presentation most consistent with heart failure, needs urgent investigation…’ It was a form of brinkmanship, an unsubtle distribution of responsibility, such that my colleague felt compelled to attend urgently in order to check whether this patient’s problem did indeed stem from heart failure.

The cardiologist attended an hour later, while I was still on the ward. He called me into the patient’s bed space, behind the curtains, and showed me the images. The heart was beating perfectly normally. With equal emphasis, he wrote something along the lines of, ‘…valves and chambers normal, ejection fraction 60-65%, unchanged from __ /20__.’ We discussed the details, and agreed that in fact what we were probably looking at was a case of fluid overload due to kidney failure. I went back to the notes, looked at my big, bold words on the page, and thought…’You were completely, absolutely, wrong!’ But…but…by being bold, by taking a position, I achieved what was required – an urgent heart scan and a narrowing down of the differential diagnosis.

Another example. A patient with unexplained chest pain is admitted through the ED. It isn’t a heart attack, it’s not an ulcer, it’s not a pulmonary embolism. The thought develops that it might be a thoracic aneurysm; potentially lethal, very hard to rule out. Do I really think it is? No, I’m not convinced, the pain is already settling, perhaps it is a bit of acid reflux, but I feel uncomfortable. She said it felt like a tearing sensation. She needs a scan. It’s late. I’m going to have to make a good case to the radiologist.

‘Hi, it’s Dr______. I’ve got a patient with chest pain, severe, and we’ve ruled most things out, but I’d like to exclude a dissecting thoracic aneurysm…no, the chest x-ray looks normal but I can’t rely on that…the blood pressures in both arms are equal…’

I’m not doing well. How badly do I actually want this scan? If I’m not convinced (just concerned), so why push it? But if she is dissecting, and we miss it, she’s as good as dead.

‘…I just can’t sit on her all night without ruling it out. We don’t scan every chest pain, but the way she described it…it’s the only remaining diagnosis I can think of.’ The scan is agreed to. To back up my verbal conviction I write in the notes, ‘…plan: exclude dissection.’ and I wait for the result. It is negative. Of course it is negative. Perhaps I used up a bit of credit with the radiologist, perhaps next time they won’t take my request quite so seriously, but now, this evening, I achieved what I felt I needed to achieve.

Being wrong is nothing to be proud of, obviously. But what I describe here is a willingness to make a diagnosis and push hard for the investigations that are required to prove or disprove them. The process of forming a list of differential diagnoses and eliminating all but one (the actual diagnosis) will by its very nature involve barking up several wrong trees. Being wrong is therefore a necessary corollary to discovering the right answer. However, being wrong is not something that medical students or medical trainees are very comfortable with. Our training is focussed, entirely, on retrieving facts with accuracy and providing the ‘right answer’ immediately. Then, once we enter the real world, we encounter uncertainty, a whole series of possibilities stemming from each and every clinical encounter. It is physically impossible to pick out the right explanation for each collection of symptoms and signs. To make progress we must make a stab at the problem, have a go, test a series of theories, and, one by one, eliminate those that are wrong. If the discomfort that trainees feel in the face of uncertainty results in a form of paralysis, and the ‘differential diagnosis’ section at the end of the clerking is left blank, progress cannot be made. Progress requires an acceptance that medicine is uncertainty, a willingness to bark up those trees, and the maturity to absorb any sense of embarrassment that arises when the someone shouts down from the branches, ‘Wrong one!’


Some free resources on uncertainty in medicine:
1) Clinical uncertainty- Helping our learners by Dale Guenter, Nancy Fowler and Linda Lee (Canadian Family Physician)


2) Tolerance of Uncertainty and Fears of Making Mistakes Among Fifth-year Medical Students by Maarit Nevalainen, Liisa Kuikka, Lena Sjöberg, Johan Eriksson and Kaisu Pitkälä (Family Medicine)


3) The value of medical uncertainty? By Caroline Welbery (Lancet) – On the role of art


4) Uncertainty Is Hard for Doctors by Danielle Offri (NEJM)



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Leadership – the immediacy of example

Leadership, I am sure, takes many forms, but explicit exposure to the theories and approaches that might have helped develop doctors of my generation was lacking. The leadership that I was conscious of, as a trainee, was the example set by my seniors. Thus, as a consultant myself, the most direct route to leadership that I have identified is the example I give. This may be one-dimensional, and I hope that over the years other ways will reveal themselves.

The trouble with leading by example is that we are, as fallible people, inconsistent. In medicine inconsistency is risky. After several years on the wards it is possible to recognise how the example one sets can translate, directly, into the care that is delivered. In this post I try to relate how that translation can occur with a short account. It is not a sophisticated scenario, but one that shows how healthcare, more than other profession perhaps, can excel or fail due to the behaviour and attitudes of those in charge.


A busy ward round – Monday. The consultant, Dr Blackburn, paces himself. He intends to see all the patients, but there are a handful whom he especially needs to ‘get my head round’. They are complex and potentially unstable. It will take an hour and a half to achieve that aim, and in the remaining two and half hours the spectrum of acuity and severity that he meets will be wide. Some of the patients will be medically fit, just waiting for a package of care. He tends, not unreasonably, to see them at the end of the round. But he will see them. They are his patients.

At twenty to one he looks down the list. There are still four patients to see. He has a regular meeting at one o’clock. He was late for it last time, and does not want to be late again. He asks for a précis of the patients’ problems, and they are pretty much stable. One was admitted overnight, but the word is that they failed an occupational therapy assessment at the front door, and if not for that they would have been discharged immediately. ‘Could you take a quick look?’ he asks his registrar, Emma. ‘Let me know if there are any real issues…medical issues.’ He leaves the team. In truth, he left them half an hour ago. His attention began to slip, he began to ask the same question twice. The intellectual meat of the morning had been chewed and digested hours ago. He was now using reserves of enthusiasm that only professionalism drove him to access. But the team has done well. The week should proceed safely enough, now that they have the measure of their charges.

Emma and the rest of the team need to eat. She will see the new patient later, as promised. Did she promise? Well, she was asked and did not say no. That’s the way it works. She has a clinic though, and it does not go as smoothly as she had hoped it would. At 4.50PM she bleeps the FY1, Luke, and asks him to make sure the new patient has been reviewed. He speaks his mind, does Luke, and he is just coming to terms with the requirements of the job – that is the ability to accommodate last minute requests and fit them into the sequence of the day. His job feels truly Sisyphean. Just as he is beginning to feel that he is getting on top of his list of tasks, another is added. ‘I thought you…’ he stops himself. ‘OK, but if there’s a problem, what should I hand over, the lumbar puncture or the new patient.’ Emma replies quickly, ‘Neither. But make sure the LP is done, please, that’s crucial.’

Luke circles the name of the new patient at the bottom of his list. But he concentrates on the LP. He’s done several, but cannot undertake them unsupervised. Emma would have looked on, but she remains tied up in clinic. His second option, Lucy, an experienced SHO on another firm, offered her time after lunch, but she is probably getting ready to go by now. He sees her, and sighs in relief when she makes the offer again. By 6.30PM they have done it. The samples are on their way. His day is almost over. Except for the new patient review.

A review. Just a review. But a new patient. That’s the catch. To do it properly requires a ‘from scratch’ assessment of the presenting complaint and past medical history, and a physical examination. It’s a 30 minute job, at least. He wants to do it. No, he wants to have done it. But now, at a quarter to seven, the task’s magnitude has become inflated. What if it’s complicated? What if the drug chart needs re-writing? It is unlikely. No-one has bleeped him about her during the afternoon. They must be truly stable – off legs at worst. Isn’t that what they said on the ward round? – failed OT assessment, no ‘medical’ issues. Dr Blackburn wasn’t interested. Luke recalled his far-away gaze, the evident lack of enthusiasm, ‘Let me know…’ he said, ‘if there are any real issues…’ Even consultants, with all their knowledge and experience, cannot achieve 100% of their work. Luke decides to take it on trust. The chances of that patient coming to mischief are minimal. Luke is not going to cut himself up about this one lapse. He’s done so much today.

At three in the morning the on-call FY1 is called to see the patient. She finds him confused and septic, with clear signs of pneumonia. She is surprised such basic diagnosis could have been missed, and puts the fact that his chest x-ray and his blood tests have not been scrutinised down to the circumstances – the decision to admit was made late in the evening, and they must have been arranged just before he went to the ward. But she would have thought the results of those investigations (which include grossly elevated inflammatory markers) would have been seen on the ward round that day. Strange, she was sure Dr Blackburn himself went round on Mondays.





A gift freely given: dialogue on organ donation

This week it was announced that liver transplants would be offered to ‘heavy drinkers’ in a pilot programme. Patients will be young (typically less than 40) and will have such severe liver disease that the chance of them surviving the hitherto accepted period of 4-6 months of abstinence are remote. This has raised concerns that people will be less likely to sign up to be organ donors.

Here two people discuss donation. A has been put off by the idea that active drinkers might receive his liver, while B takes a more philosophical stance, and challenges A’s hesitancy.

After the main dialogue there are extended footnotes on changes that have been made to organ donation law in Wales (‘soft opt-out’) and on the involvement of families in the decision to allow organ to be retrieved.


A “I was keen to donate my organs when I died, but I’m not so sure now. They’re going to give livers to drinkers now, without even making sure that they can stop. It’s crazy. I know they can’t help it, I know there are a million back stories and life events that lead to alcoholism, but I think it gives the wrong message – don’t worry too much, if your liver packs in there’s a chance you could be rescued. Well I’m not sure I want to be one of those who gives a liver only for it to be ruined within a year or two by their addiction. We do all have the ability, and the strength, within us, to stop drinking…if we want to.”

B “So it’s weakness. They should be allowed to die because they are weak?”

A “They have a death wish, that’s what I’m saying. Whatever the reason for them not being able to stop, and perhaps it doesn’t really matter, the fact is that if they are given a new liver what’s to say they won’t carry on drinking.”

B “But you realise, don’t you, that you can have no idea who will get your liver. It could go to a teenager who stupidly overdosed on Paracetamol, a haemophiliac who contracted hepatitis C from contaminated blood products, or a blameless sufferer of inherited disease. Or half of it could go to very young child. If you don’t give your liver, then it will be harder for those people to be treated. You can’t predict or determine who gets it.”

A “But the chances of it going to an alcoholic will be higher. And as I say, I don’t like the message it gives. There’s so much…latitude nowadays. For patients who have inflicted damage on themselves.”

B “So is it a political or social comment that you will make by not donating? An attempt to influence society in some way.”

A “I wouldn’t say that.”

B “But it’s your opinion on the subject of addiction that is being translated into your decision not to donate.”

A “Well…it is my decision, after all. It’s my body.”

B “You presume it is, but you will be dead.”

A “Are you suggesting the state takes ownership?”

B “Legal ownership is a vexed question, but the more relevant question is how the state manages your right to decide.”

A “Involuntary inclusion on the register of donors has been considered and thrown out, hasn’t it. The ‘opt out’ was debated in Wales, I don’t know what came of that [1]. But what you’re suggesting is ‘no opt out’! That’s extreme. That sounds like the Chinese prisoners [2].”

B “Imagine this. Imagine another person, a hundred miles from here, having the same conversation with a friend. And imagine he is intending to put himself on the register of donors but is equally uneasy about, say…a convicted criminal receiving his liver or kidney or whatever. He wants to add a caveat to his donor card, that his organs can go to anyone as long as they have not been convicted of a serious crime in the past. What do you think of that?”

A “I recognise the intention, and sympathise with it, but I also recognise that it’s probably not practicable. Better to just not donate if there are going to be stipulations or exclusions. Because, as you say, you can’t control who gets your organs.”

B “So this man will not donate. Another lost donor. And taking the argument further, there may be people who are uneasy about other groups receiving organs, ethnic groups, religious groups, or those with different sexual orientations. They too will have no choice but to not donate. In fact, if we accept that anyone with any concerns about their organs being used to prolong the life of another about whom they have some moral or religious or racial misgiving should probably not go on the register, then we have automatically shrunk the pool of organs by a considerable percentage. Having made a great advances in the science of transplantation, we now elevate the instinctive judgements, dare I say prejudices, of people above the opportunities that their organs might provide. Does that sound right?”

A “But hang on. You’ve gone from alcoholics to minority groups in one leap. None of those groups will be engaged in anything specific to their identity that will damage the liver. I’m not refusing to donate because I don’t want some other person to survive – what do you think I am! – but because I don’t want my liver to be wasted.”

B “That’s been considered. The trials show that the rate of liver wastage is no higher than in other groups, because the alcoholism is monitored and treated intensively. You know about Hepatitis C? Well, that always recurs in the new liver if it is not eradicated before the transplant (which it rarely is), and very large numbers of donated livers are used to replace previous transplants that have been re-infected. So many of the livers being given now are what you might call ‘wasted’, except they were not wasted because the patients benefitted hugely from receiving them. The ‘waste’ argument is a weak one. What I want to pin down is this – do donors have any right, any right at all, to have a view on the moral or character background of potential recipients?”

A “As normal, opinion-forming human beings, we are all bound to have a view. If I donated a liver and somehow knew, in the afterlife, or more to the point if my family knew, that it had gone to a previously convicted, albeit rehabilitated et cetera et cetera child-killer, I would be so angry.”

B “Your family would be angry. You’d be dead.”

A “Yes, my family would be angry. And they have a right to an opinion too.”

B “OK, so you wish to transfer your objections to your family after death.”

A “They are the natural inheritors of a potential donors wishes and concerns, aren’t they?”

B “It’s arguable.”

A “Are you now suggesting that families have no say in this?”

B “They will bring their own moral structures and pre-judgments into the argument.”

A “No, they will do their best to express what they think I felt about it. They are the best placed to do that.”

B “And you think families can do that without colouring the subject with their own opinions?”

A “I don’t know. But they have to be consulted.”

B “You’re right, families can veto organ donation, even if the patient made it clear that he or she wanted to donate. Doctors won’t take organs in the face of strong opposition, and whether that it acceptable or not has been debated at length [3]. But let’s assume your decision, taken before death, is carried through. How do you reconcile your understandable concerns about who might get your organs? This is how I feel about it. If you would receive an organ from a random person, then you should agree to donate to a random person. And if you do decide to donate, as an act of altruism to humanity, then you should accept that the range of possible recipients will include all that humanity has to offer. All sorts. And you should trust that the donation system will have in place checks to reduce as much as possible the risk of ‘wastage’, be it through drinking, or recurrent hepatitis C, or repeated overdoses…the essential decision is Am I happy to help my fellow man or woman who will die without a transplant? Am I happy to make that contribution to society, even despite the fact that there are some aspects of society that I do not like, and do not sympathise with. Have I persuaded you?”

A “Your reasoning has. But what you miss, I think, is that the decision is an emotional one. That’s the trouble you see. People are led by their hearts, not their minds.”



1] China

Executed prisoners have their organs harvested (without prior permission), although it is said that this practise will soon come to an end.

2] Wales

A ‘soft opt-out’ has now been passed into law and will come into effect in December 2015. This means that people living and dying in Wales will be assumed to have given their consent unless they have made the effort to opt-out. This checklist is from the Organ Donation Wales website.

You will be treated as though you want to be an organ donor unless:

  • you have already registered a decision to be a donor (opted in) or
  • you have already stated you do not want to be a donor (opted out) or
  • you have appointed a representative to make a decision about consent on your behalf or
  • you lack capacity to understand that your consent could be deemed or
  • a person in a relationship to you objects at the time of your death, on the basis that they knew you did not want to be a donor

In 2008 the Organ Donation Taskforce looked into what effects an opt-out system might have attitudes to donation. It took a very cautious view. It referred to experiences in Brazil and France:

There are two examples of a negative impact of presumed consent policies. Brazil adopted a ‘hard’ presumed consent law in 1997, with opt out denoted by a note on an id card or driving licence. The law had to be repealed in 1998, principally because of mistrust of government and accusations of body snatching.

In France, which has a variation of presumed consent, there was an incident in 1992 in which corneas were taken from a 19-year-old road traffic accident victim whose parents had consented to only limited organ retrieval. This resulted in a great deal of negative press coverage of the medical profession, despite the clinicians having complied with the strict letter of the law, and damaged public trust in the organ donation system for some time.

They concluded that….

[we are] not confident that the introduction of opt out legislation would increase organ donor numbers, and there is evidence that donor numbers may go down.


3] The family veto

The role of families hit the headlines in 2012, when David Shaw (a lecturer in medical ethics) wrote an article in the BMJ criticising the medical profession for acquiescing to the family veto, especially when the deceased had put their name down on the donor register. In an interview he stated that 1 in 10 families acted in this way, and a higher proportion refused donation when asked about donation and the patient was not on the register. He suggested that families often regret this decision because they have denied their relatives express wish, and also the fact that ‘their decision may have caused deaths or suffering for other patients.’

The Organ Donation Taskforce also examined the role of families. It felt that their opinion was important, and that the decision to donate should rest in their hands.

            There is an argument, advanced by some, that a system of presumed consent would relieve families of the burden of making a decision in the absence of any indication as to the deceased’s wishes. The Taskforce finds this a somewhat paternalistic view, at odds with the ethos of today’s NHS. Further, our evidence from donor families was that they stressed the importance to them of being involved in the decision to donate and of being allowed to make the decision that was right for them at the time. The Taskforce found the evidence from donor families compelling.

Additionally, the taskforce also found that recipients preferred to know that the donated organ had been given ‘freely’ and that the family was in agreement.

            Recipients of transplants reported that it was important for them to know that the family of the donor had been involved in the decision and were comfortable with it. They also stressed the importance of knowing that organs had been freely given. These families spoke movingly of the concept of organ donation as a gift, and were concerned that an opt out system might undermine the principles of organ donation as a gift.

They concluded that systems where the opinion of families was not taken into consideration

has the potential to erode the trust between clinicians and families at a distressing time. The concept of a gift freely given is an important one to both donor families and transplant recipients. The Taskforce feels that an opt out system of consent has the potential to undermine this concept.

The Christian Medical Foundation Head of public Policy, Phillipa Taylor, expressed her concerns about the exclusion of the family in this decision in a September 2012 blog post. With regard to ownership of the body in the context of an opt out system, she wrote,

            The assumption about whose body it is begins to move from personal ownership to state ownership. Unless the state wishes to suggest that the deceased now belongs to it, the family must have the right to become his/her spokesperson.

            As we have always said, CMF is supportive of organ donation in principle. However we are not supportive of presuming consent when it has not been given, nor do we support overriding the family and the important role they should play. God designed human beings in His image to be relational (Gen 1:26,27, 2:18-25) and the Bible everywhere assumes the significance of the family.

It seems the ‘soft opt-out’ system adopted in Wales has taken these views into consideration.