A survey of the complaints entering the medical council organization of tehran in three time periods: the years ending on 20 march 1992, 20 march 1997 and 20 march 2002.

One of the most important occupational tensions a physician encounters in his/her practice is the complaints lodged against him/her by the patients. The purpose of this study is examining the complaints against physicians and dentists entering the Medical Council Organization of Tehran in the years ending on 20 March 1992, 20 March 1997 and 20 March 2002 from the viewpoint of number, dispersion and inducing factors. The present study was performed as a descriptive and retrospective one with the aid of a questionnaire containing concerned data. Filling in the questionnaire or studying the file was accomplished by a trustee expert of the Medical Council Organization and the data obtained were analyzed after classification. During a 3-year period, 832 complaints were lodged against physicians and dentists. The complaints against physicians in the years ending on 20 March 1997 and 20 March 2002 were 70% more than that in the year ending on 20 March 1992. 83.1% of the physicians and dentists of Tehran that were sued had not been convicted until the date of the performance of the study, on the basis of the contents of the files, and had no malpractice from the vantage point of the Medical Council Organization. The most common causes of complaints from the viewpoint of complainers were therapeutic errors (38%), neglect (30.2%), financial affairs (25.4%) and the physicians' lack of skill (17.7%). On the basis of this study, with the increase of the doctor's practice track record and experience more than 15-20 years, the number of the complaints decreases and most of the complaints are against the middle-aged doctors/dentists with 10-20 years of experience. Most physicians and dentists of Tehran having been sued have not committed any wrong from the vantage point of the Medical Council Organization experts and a large part of the complaints are a consequence of doctor-patient inconvenient interactions. A behavior based on professional commitment of the physician/dentist vis-à-vis the patient can hinder a major part of complaints.

Introduction

The responsibility of physicians is outstanding in proportion to the respect and honour paid to them by the society. In other words, when a person proudly wears the white coat, the society sees itself bound to treat him/her with great respect and he/she, too, sees her/himself bound to observe specific dignities in the society.

One of the most important occupational tensions a doctor encounters in his/her own practice is the complaints lodged against him/her by the patient. When a doctor encounters judicial complaints made by patients, he/she sees all the beliefs and dignities shaken and his/her social prestige at shake. This induces anxiety, tension, depression, isolation and, even illness (1). This tension is not merely limited to cases wherein the doctor is wrongdoer, but, even when the patient’s complaint emanates from his/her misunderstanding or bad intention, the doctor is compelled to sustain undesired circumstances. Therefore, any complaint causes significant mental tension and negative feelings in the doctor and directly influences his/her function in addition to being time-consuming for him/her.

On the other hand, surveys have demonstrated that the increased rate of complaints in some medical specialties causes a downward trend in volunteers’ inclination to choose such professions, on one hand, and decrease of adopting measures with more risk in practice and, consequently, increased probability of complaints, on the other (1, 2). On the basis of a study, complaints filed against gynaecologists & obstetricians have escalated in recent years (3). This increase of complaints in the West has led to less inclination of doctors toward this field and increased cesarean section cases and non-acceptance of high risk patients (2).

In any way, nowadays, complaint against doctors is one of the most important tension producing factors in professional career of doctors, and, disregarding the factors causing them leads to imposition of undesirable effects on the quality of services presented by the doctors and indirectly influences the health system. Identifying the factors affecting the complaints rate and the process of complaint lodging may be applicable in prevention and education of various medical professions.

The purpose of this study is surveying the complaints filed against doctors and dentists entering the Medical Council Organization of Tehran in the years ending on 20 March 1992, 20 March 1997 and 20 March 2002 from the viewpoint of number, dispersion and inducing factors.

Materials and Methods

This study was performed as a descriptive and retrospective one. For this purpose, after preparing the questionnaire, including the desired data, by coordination with the Medical Council Organization of Tehran, all the complaint files of the years ending on 20 March 1992, 20 March 1997 and 20 March 2002 were examined. The questionnaire includes general data on patients (age, gender, illness, complications and mortality), the causes behind the complaints from the viewpoints of patients, the professional particulars of the treating doctors, and the result of expert works on the files considered. After surveying the validity of the questionnaire with regard to 20 files and influencing necessary amendments, the collection of the data commenced. Filling in the questionnaires was performed, after studying the files, by a trustee expert of the Medical Council Organization of Tehran.

In order to observe the confidentiality principles, the data were registered without mentioning the names and other particulars of the individuals; and the Medical Council Registration Numbers (MC Reg No) of the doctors, too, were registered limitedly. The data were analyzed using SPSS software.

Results

Out of a total of 1090 files examined, 832 cases were related to doctors, the distribution data of which appear in Table 1.

Table 1.

Distribution of the files examined in Medical Council Organization of Tehran

Year Number of complaints per year (%)	20 Mar 1992	20 Mar 1997	20 Mar 2002	Total
Against doctors and dentists	74 (69)	405 (79)	353 (75)	832 (76)
Against other medical professionals*	33 (31)	108 (21)	117 (25)	258 (24)
Total	**107	513	470	1090

These complaints were related to the health centres, laboratories and the like.

Lack of access to all files of the year ending on 20 Mar 1992 because of computerized registration since 1994; so 107 files out of 200 were examined.

Out of 832 complaints examined in three time periods mentioned above, 421 cases (50.6%) concerned the male patients and 403 cases (49.4%) were related to female ones. In 8 cases, the gender of the patients was unknown. The incidence frequency of the complications and the death type (based on the patients’ words) in the files examined are mentioned in Table 2.

Table 2.

The incidence frequencies of complications and death

Damage	20 Mar 1994	20 Mar 1997	20 Mar 2002	Total	P value
Complications incidence (%)	46 (62.2)	228 (56.3)	202 (57.2)	476 (57.2)	0.64
Death (%)	3 (4.1)	69 (17)	52 (14.7)	126 (14.9)	0.016
not mentioned events	25 (33.7)	108 (26.7)	99 (28.1)	232 (27.9)	---

As is seen, the rate of the complaints in this decade has not changed significantly with the incidence of complications but significant changes in mortality have been observed in the years ending on 20 March 1997 and 20 March 2002.

The causes of the complaints have been arranged in eight groups as follows on the basis of the contents of the patients’ complaints: therapeutic error, inattention (refraining from examination, non-attendance, refraining from visiting, and neglect), financial problems, doctor’s lack of skill, diagnostic errors, inconvenient approach, lack of adequate explanation to the patients with respect to the measures taken and non-observance of governmental regulations.

In Table 3, the relative frequencies of the mentioned complaints in the files examined have been specified as per the years concerned and in general.

Table 3.

Relative frequencies of the causes of complaints from the viewpoint of complainers

	Causes of complaints	20 Mar 1994	20 Mar 1997	on 20 Mar 2002	Total	P value	Chi2
1	Therapeutic errors	54.9	30.1	45.3	38	0.00	20.7
2	Inattention	21.7	30.7	31.7	30.2	0.36	2.0
3	Financial problems	24.3	23.5	27.8	25.4	0.39	1.9
4	Doctors’ lack of skill	16.2	20.2	15	17.7	0.16	1.9
5	Diagnostic errors	13.5	10.4	13.3	11.9	0.41	1.7
6	Inconvenient approach	12.2	15.6	6.5	15.6	0.00	15.3
7	Lack of adequate explanation to patient	4.1	5.2	4.2	4.7	0.88	0.4
8	Non-observance of governmental regulations	14.1	3	1.4	2.4	0.24	2.8

The only significant difference between theses time periods is related to the therapeutic errors (less incidence in the year ending on 20 Mar 1997) and inconvenient approach (less incidence in the year ending on 20 Mar 2002). In other cases, the cause pattern of lodging complaints during 1970s shows no significant difference.

Regarding the lack of full accessibility to and the limited numbers of the files relating to the year ending on 20 Mar 1992, the results of the expert examinations at the preliminary and higher committees of the Medical Council Organization in the years ending on 20 Mar 1997 and 20 Mar 2002 were analyzed. Overall, 831 files, examined in the light of the verdicts of the preliminary and higher committees, had the following particulars:

146 cases contained the verdicts of both the preliminary and higher committees.

The results of the verdicts of the files examined in the years ending on 20 Mar 1997 and 20 Mar 2002 contained the verdicts of the preliminary and higher committees have been mentioned in Table 4.

Table 4.

The verdicts issued by the preliminary or higher committee of the Medical Council Organization

Preliminary committee/higher committee	‘Acquittal’ in the preliminary committee	‘Malpractice’ in the preliminary committee	Total
‘Acquittal’ in the higher committee	55 (93.3)	23 (26.4)	78
‘Malpractice’ in the higher committee	4 (6.7)	64 (73.6)	68
Total	59 (100)	87 (100)	146

187 files contained no preliminary or higher committee verdicts.

It appears that these files are either in the examination phase at the preliminary committee or have been terminated due to mutual compromise. Of course, some of these files have been referred by the judicial system for advisory opinion and contain no verdict.

498 cases only contained the verdicts of the preliminary committee (395 acquittal cases and 103 malpractice ones). It appears that, in these cases, objection to the verdicts of the preliminary committee have not been followed with mutual agreement of the parties of the files and have not been referred to the higher committee. Less likely, the said files may still be on examination in the higher committee.

As is noted, the rate of reversal of the verdicts of the preliminary committee has been 26.4% with regard to malpractice and 6.7% with respect to acquittal. It is to be mentioned that out of 146 files containing verdicts of both preliminary and higher committees, 119 cases (81.5%) contained similar verdicts and 27 cases (18.5%) had contradictory one. Overall, out of 146 files examined at both preliminary and higher committees, 64 cases (43.8) were discerned as malpractice by both committees. In the year ending on 20 Mar 2000, the rate has been 50% in the studies performed at the Forensic Medicine Organization (4).

For examining the correlation of complaints with the medical track record of individuals, the relative frequency of the number of complaints, differentiated in 6 groups on the basis of the MC Reg No of the doctors, were surveyed, as mentioned in Table 5. Classification of doctors in these 6 groups has been performed on the basis of the approximate track records estimated based on the MC Reg No of the doctors.

Table 5.

Relative frequency of complaints in terms of the MC Reg No

MC Reg No	on 20 Mar 1992	on 20 Mar 1997	on 20 Mar 2002	P value
	Complaint rate*	Complaint rate*	Complaint rate*
Less than 10000	(>15) 38.6	(>20) 23.2	(>25) 15.9	0.028
10001 to 20000	(5–15) 46.7	(10–20) 37.5	(15–25) 26.3	0.004
20001 to 30000	(2–5) 12.6	(7–10) 15.8	(12–15) 25.2	0.00
30001 to 40000	(0–2) 2.1	(4–7) 5.4	(9–12) 8.2	0.054
40001 to 60000	-	(0–4) 5.2	(5–9) 10.2	---
60001 to 80000	-	-	(2–5) 5.7	---
MC Reg No not mentioned	-	12.9	8.5	---
Total	100	100	100	---

the approximate practice track records of each group are in parentheses.

Discussion

It appears that lodging complaints against health service providers have been done only by patients having been damaged or having objection against the services provided. This means that exclusive survey of the complaints files is not in itself indicative of the essence of all difficulties of the health service recipients. In other words, lots of difficulties are not set forth due to various reasons, including lack of tendency of the patients to file complaint, the complainers’ lack of knowledge or lack of access to legal authorities or taking consent from the complainants by the health service providers or their colleagues. Furthermore, a number of complaints have not been examined here due to having been referred to the judicial authorities. On the basis of a study by Harvard University, only 2% of patients having been damaged by care system, to any extent, legally file complaint. Therefore, the present study is only indicative of part of the existing problems of the health service providing system, although, it appears that it is, in general, a convenient indicator of the objects of the complaints filed.

The amount of the complaints in the years ending on 20 March 1997 and 20 March 2002 was 2.5 times more than that of the year ending on 20 Mar 1992, which, taking into account the increased rate of the number of complaints being much more than the increased population; and so it is indicative of the extension of the culture of lodging complaint against doctors.

From the similarity between the acquittal rate in the complaints that have led to passing verdict by the preliminary committee in the years ending on 20 March 1997 and 20 March 2002 and, the relative frequencies of the objects of complaints based on the complaints texts in the years ending on 20 March 1992, 20 March 1997 and 20 March 2002, it is inferred that the types of complaints and the results of judgments have not been significantly different in this time interval. On the other hand, taking into account the constancy of the pattern of the causes of complaints, one may conclude that no important measures have been taken in the direction of educating the doctors in order to decrease this risk.

The ratio of malpractice to complaints lodged with the preliminary committee in this study is about 30%. A study conducted by Harvard University shows that, for each malpractice confirmed in the judicial system, 7 complaints have led to acquittal (5). Regarding the findings of this study, it is not possible to analyze the data like the study in Harvard University; perhaps because of the lower level of the expectations of the society and patients of medical community. Therefore they only lodged complaints in the cases having led to more serious consequences or the more convenient interaction of the medical community with the patients, and less misunderstanding. More accurate survey of this matter entails planned studies in this arena.

On the basis of this study, most of the doctors and the dentists of Tehran who have been sued, had not committed any malpractice, from the viewpoint of the Medical Council Organization of Tehran. The following results may be obtained by examining the findings of Table 3:

Most of the complaints including therapeutic errors, diagnostic errors, lack of skill and inattention on the part of the doctor/dentist, while, it appears that the confirmed malpractice cases are not congruent with this ratio. It appears that a major part of these cases, contrary to the mentality of the patients, emanate from the natural consequences of therapeutic actions taken for them. In such cases, lodging complaints may be due to the poor relationships between patients and doctors/dentists and lack of explaining the problems by the doctors/dentists to patients (5).

A study conducted by Entman et al, assessed by a specialist committee, shows that the quality of the treatments rendered by the sued gynecologists and uncharged gynecologists is significantly different. Also other studies demonstrated that the quality of the treatment is an important factor in making complaints by the patients and their relatives (6).

Paying more attention to and spending more time for the patient by the doctor/dentist and rendering adequate information regarding the illness of the patient, the therapeutic methods and the positive and negative aspects of each method increases the knowledge of the patient with respect to the treatment provided and the circumstances for occurrence of therapeutic errors diminishes.

In this study, financial issues were the cause of only one fourth of cases. Therefore, contrary to the primary imaginations, financial issues were not the main cause of lodging complaints. The omission of the direct financial correlation between doctor and patient may be an effective way to decrease the tension between them. The above said target will be achieved through strengthening social insurance in country, providing fair and reasonable medical tariffs by the relevant authorities and efficient supervision on the observance of those tariffs. At present, when these circumstances have not been realised, explaining this relationship by the doctor/dentist to the patient can, to some extent, prevent the occurrence of dissatisfaction. Undoubtedly, the primary purpose of providing medical services is not making a profit but helping the needy patients. This must be manifested in the doctor’s behavior.

In surveying the information related to the doctors, it appears that, with the increase of practice track record and experience more than 15–20 years, the number of complaints filed decreases. This can be a consequence of their more experience or a decrease of their therapeutic activity. However, the doctors with moderate experience (between 10–20 years) have been sued more than others. This finding can be considered a as consequence of more activity of the middle-aged doctors after obtaining specialization, gaining more fame and more clients and/or a result of their more self-esteem and use of more invasive procedures. The complaints rate regarding the newly-graduated doctors follows a downward trend which may be another manifestation of the above reasoning. What appears definite anyway is that the middle-aged doctors in the culmination of their practice are more exposed to being sued and it is necessary that they pay more attention to their relations with the patients.

Conclusion

Lodging complaints, a matter of meager importance or rare for doctors in the recent past, is now an important and serious matter. On the basis of the findings of this study, many complaints are not indicative of actual errors and, thus, it may be possible to prevent them from occurring by improving the doctor-patient relationship. What appears necessary is the patients’ perception of beneficence, imposing no harm on patients (nonmalfeasance) and respecting their autonomy by the doctors. These ethical principles which manifest in the frame of professional behavior in the doctors’ interaction with patients can lead to doctors’ tranquility and a decrease of risk of complaining.