What goes up must also be going up
The State Government of Victoria announced today that a ‘code brown’ would be enacted across out hospital systems and networks. This measure has been deemed necessary to mobilise staff who may be on leave or deployed elsewhere to work shifts in hospitals coping with what is an external emergency. Unlike the thunderstorm asthma emergency in 2016, this external emergency is the number of people attending our hospitals for medical, surgical and psychiatric care, many with COVID infection. And it is likely to be in place for weeks and not days. This is also the first time that a code brown has been enacted state wide in Victoria.
While much has been spoken about the toil this had had and will continue to have on all staff working in the public hospital system right now, little has been said about another sinister stressor that lurks around the edges and impacts doctors and other health care workers, often when least expected — a complaint from a patient they have tried to help amidst the chaos.
We’d all like to presume that extraordinary times call for compassionate measures, but when it comes to the regulators, this never enters the equation. Take the process that has already commenced whereby GPs using Telehealth to see their patients during the pandemic have been investigated for over servicing. Those deemed to be using Telehealth at a rate disproportionate to their peers where soon under investigation. Rather than presuming that some GPs were adopting this technology to service their patients at a different rate to others, some GPs were deemed guilty of over-servicing, left amongst the chaos of a global pandemic to defend themselves.
Of course there are those who do the wrong thing. But our regulatory bodies have never been able to discern who these people are without applying a broad brushed approach to risk management. At most they rely on bell curves to see who they deem an ‘outlier’ when it comes to the frequency of use of an MBS item number compared to their peers. Underlying all of this too is the fundamental question — how does using a particular item number more than a peer group deem a doctor unprofessional or even unsafe?
Even more concerning is that still, after 12 years of having a national regulator, AHPRA, we still have one single door entry for all complaints against any practitioner registered with this body. Many anecdotal examples have arisen since this time of doctors being investigated for what turns out to be a vexatious complaint, or, more maliciously, a complaint from a rival colleague in a small town, or an aggrieved ex partner. Complaints are still able to be made in an anonymous fashion with no recourse if found to be vexatious or defamatory. Petty, ill founded and vexatious complaints tie up the front door process, while true concerns are left to wait for more complainants to come forward.
There has been no talk of how AHPRA and other regulatory bodies will deal with what could be a huge rise in complaints against health professionals trying to work in the most inappropriate and dangerous systems we have seen in years. This is on top of vexatious complaints by aggrieved parties exasperated and distressed by the quality of care they have seen their loved ones receive or miss out on. Medicolegal defense organisations vary in their level of expertise and pro-activity, but surely they will become awash with growing numbers of complaints against their members, many extremely capable doctors incapable of working in a safe or ideal manner.
That doesn’t even include doctors who are mere scapegoats for events, policies and bureaucratic failures over which they have no control. Consider the GP who is not given notice about changes to the frequency of administering COVID vaccinations but expected to implement the procedures post haste with no extra staff or funding. Or the resident doctor left alone on a busy ward while their registrar furloughs, keen and dedicated but unaware of basic procedures and policies. Or the nurse moved from a general surgical ward to an ICU ward, with out of date skills who just happens to be caught up in a failed resuscitation.
The moral distress is one thing; signing up for a role that requires professionalism and dedication but cannot be delivered because of events and situations way out of the individual’s control. Add moral distress to a complaint received weeks or months down the track, with little or no recollection of the event to add context.
I am in no way advocating that patients should receive anything less than the best available standard of care from all of us. But what patients expect and what we can deliver has widened, not because we want to be less unsafe, but because we are forced to be. And even if it is decided we did our best, unlike any other time, our ability to recall facts, rely on comprehensive notes or even find time to defend complaints has changed dramatically.
And it is still way to easy to complain about a doctor to an organisation who allows anonymity, no triaging and no recourse.
After working solidly across the pandemic for two years I can see a number of factors that could contribute to failures to be able to defend complaints from patients and relatives, and may even contribute to the rise in total numbers of complaints.
- Overall, there have been many more presentations to doctors and other health care professionals since the pandemic began. Because of the sheer quantity of presentations, it makes sense the number of complaints will rise too, as a percentage of cases where by it its deemed that some harm came to the the patient or relative.
- Doctors and other health care professionals know how to mitigate risk by taking breaks, pacing their work, having leave, engaging in continuing professional development and maximising work/life balance. Very few doctors have been able to follow some or even all of these measures, despite knowing this is how to remain sharp and on task.
- Doctors and nurses are working more hours than deemed acceptable by enterprise bargaining agreements, and in cases such as in general practice, covering the patient load of more than one or two other doctors as many become infected or isolate.
- Our workforce is becoming more transitory and many hospitals are relying on locum and contract staff who often don’t have access to electronic medical records and may find it difficult to access records if needed at a later stage. Often there is little or no orientation, and less of a chance to gain a sense of mastery over essential policies and procedures on the ward.
- While Telehealth has afforded many advantages, delays in diagnosis and missed diagnoses have begun to appear several years into this pandemic. Very soon, the convenience of being able to organise a prescription for an antihypertensive medication over the phone will be replaced by the anger of a missed diagnosis of uncontrolled hypertension and consequent sequelae. And continual disruption to elective surgery is leading to poorer patient outcomes — something any family member might choose to blame on the doctor treating the patient and not on why the delay happened in the first place. This is often not done in malice but from as place of ill-directed grief and sadness of losing a loved one.
- Long shifts in PPE and restrictions on numbers of people in parts of the ward interrupt work flow, and seeing patients over a screen rather than via a traditional ward round can lead to delays in documenting, and encourage very basic entries in patient files. These entries may prove to be of little substance when trying to defend a doctor’s action months down the track, even if the doctor proceeded without fault. In my case, I have been relying on Telehealth to perform psychiatric examinations on patients with severe and complex mental illness, whom I have met in a locum capacity and have no rapport with. Often they don’t have a smart phone, are paranoid and insightless. I am unable to perform a mental state examination on them in this way, yet must decide whether they should be detained on an involuntary treatment order or require a change of medication.
- Finally, patients are meant to be supported by loved ones when entering a journey through the health care system. Loved ones who can ask questions, advocate, fill in gaps and support the patient. When loved ones are shut out from the process whether it be an obstetric delivery, a surgical procedure or a medical condition that becomes complicated, understandably the confusion can lead to anger about the outcome. There is an inherent desire to know the truth, especially if having to deal with grief and loss. Increasingly, the only way many family members and loved ones will be able to find out this information will be via a complaints process.
I have worked in the doctor mental health space for many years and have been a staunch advocate for changes to the way the complaints process is handled against doctors and other health professionals. I have always said that patient safety should never come at the expense of doctor safety, but I am very concerned that given little was changed in this space prior to the COVID-19 pandemic, that urgent changes won’t appear before the wave of complaints hit our email inboxes. Pointing the finger at why doctors and nurses were forced to work in unsafe environments won’t happen in time either. And that is just not fair on anybody.
Dr Helen Schultz is a consultant psychiatrist, author, and doctors mental health advocate. She has provided clinical care, clinical supervision and advocacy/mentorship to doctors in distress. She is a fellow of the RANZCP, member of the Australian Institute of Company Directors and an accredited impairment assessor (AMA).
