Søren Birkeland

Characteristics of complaints resulting in disciplinary actions against Danish GPs

Abstract Objective. The risk of being disciplined in connection with a complaint case causes distress to most general practitioners. The present study examined the characteristics of complaint cases resulting in disciplinary action. Material and methods. The Danish Patients’ Complaints Boards decisions concerning general practice in 2007 were examined. Information on the motives for complaining, as well as patient and general practitioner characteristics, was extracted and the association with case outcome (disciplinary or no disciplinary action) was analysed. Variables included complaint motives, patient gender and age, urgency of illness, cancer diagnosis, healthcare settings (daytime or out-of-hours services), and general practitioner gender and professional seniority. Results. Cases where the complaint motives involved a wish for placement of responsibility (OR = 2.35, p = 0.01) or a wish for a review of the general practitioners competence (OR = 1.95, p = 0.02) were associated with increased odds of the general practitioner being disciplined. The odds of discipline decreased when the complaint was motivated by a feeling of being devalued (OR = 0.39, p = 0.02) or a request for an explanation (OR = 0.46, p = 0.01). With regard to patient and general practitioner characteristics, higher general practitioner professional seniority was associated with increased odds of discipline (OR = 1.97 per 20 additional years of professional seniority, p = 0.01). None of the other characteristics was statistically significantly associated with discipline in the multiple logistic regression model. Conclusion. Complaint motives and professional seniority were associated with decision outcomes. Further research is needed on the impact of professional seniority on performance.

Mental Health Nursing, Mechanical Restraint Measures and Patients’ Legal Rights

Coercive mechanical restraint (MR) in psychiatry constitutes the perhaps most extensive exception from the common health law requirement for involving patients in health care decisions and achieving their informed consent prior to treatment. Coercive measures and particularly MR seriously collide with patient autonomy principles, pose a particular challenge to psychiatric patients’ legal rights, and put intensified demands on health professional performance. Legal rights principles require rationale for coercive measure use be thoroughly considered and rigorously documented. This article presents an in-principle Danish Psychiatric Complaint Board decision concerning MR use initiated by untrained staff. The case illustrates that, judicially, weight must be put on the patient perspective on course of happenings and especially when health professional documentation is scant, patients’ rights call for taking notice of patient evaluations. Consequently, if it comes out that psychiatric staff failed to pay appropriate consideration for the patient’s mental state, perspective, and expressions, patient response deviations are to be judicially interpreted in this light potentially rendering MR use illegitimated. While specification of law criteria might possibly improve law use and promote patients’ rights, education of psychiatry professionals must address the need for, as far as possible, paying due regard to meeting patient perspectives and participation principles as well as formal law and documentation requirements.

Process-related factors associated with disciplinary board decisions

BackgroundIn most health care systems disciplinary boards have been organised in order to process patients’ complaints about health professionals. Although, the safe-guarding of the legal rights of the involved parties is a crucial concern, there is limited knowledge about what role the complaint process plays with regard to board decision outcomes. Using complaint cases towards general practitioners, the aim of this study was to identify what process factors are statistically associated with disciplinary actions as seen from the party of the complainant and the defendant general practitioner, respectively.MethodsDanish Patient Complaints Board decisions concerning general practitioners completed in 2007 were examined. Information on process factors was extracted from the case files and included complaint delay, complainant’s lawyer involvement, the number of general practitioners involved, event duration, expert witness involvement, case management duration and decision outcome (discipline or no discipline). Multiple logistic regression analyses were performed on compound case decisions eventually involving more general practitioners (as seen from the complainant’s side) and on separated decisions (as seen from the defendant general practitioner’s side).ResultsFrom the general practitioner’s side, when the number of general practitioners involved in a complaint case increased, odds of being disciplined significantly decreased (OR=0.661 per additional general practitioner involved, p<0.001). Contrarily, from the complainant’s side, no association could be detected between complaining against a plurality of general practitioners and the odds of at least one general practitioner being disciplined. From both sides, longer case management duration was associated with higher odds of discipline (OR=1.038 per additional month, p=0.010). No association could be demonstrated with regard to complaint delay, lawyer involvement, event duration, or expert witness involvement. There was lawyer involvement in 5% of cases and expert witness involvement in 92% of cases. The mean complaint delay was 3 months and 18 days and the mean case management duration was 14 months and 7 days.ConclusionsCertain complaint process factors might be statistically associated with decision outcomes. However, the impact diverges as seen from the different parties. Future studies are merited in order to uncover the judicial mechanisms lying behind.

Informed Consent Obtainment, Malpractice Litigation, and the Potential Role of Shared Decision-making Approaches

Malpractice lawsuits are a substantial concern in health systems with miscommunication, inadequate information, and unsuccessful patient involvement in decision-making seeming to be contributing factors. This paper draws attention to the explicit role of informed consent (IC) obtainment in actualized complaint cases and to what extent novel methods to exercise IC through means of shared decision-making (SDM) and supporting tools might be applicable. A national sample of cases from the Health Professionals Disciplinary Board in Denmark is reviewed and discussed together with international legal instruments and case law. It is confirmed that patients claim their right to participate in decision-making about healthcare options. In many situations SDM and accompanying tools would apply and possibly they could sometimes prevent IC duty breaches, assist documenting IC procedures, and help avert the need for litigation.

Patient Complaint Cases in Primary Health Care: What Are the Characteristics of General Practitioners Involved?

Background. Limited knowledge exists about factors increasing the risk of general practitioners becoming involved in a complaint case or getting disciplined in connection with a complaint case. Aim. The present study aimed to identify the general practitioner and practice characteristics associated with complaint cases and discipline. Methods. Information on general practitioners involved in complaint case decisions during one year (2007) was linked to Danish National register data on all general practitioners (n = 3,765). Logistic regression was used for statistical analysis. Results. With regard to complaints concerning daytime services (n = 265), the professional seniority of the general practitioner was positively associated with the odds of receiving a complaint decision (OR = 1.44 per 20 years of seniority; CI 95%, 1.04–1.98). Likewise, having more consultations per day was associated with increased odds (OR = 1.29 per 10 extra consultations per day; CI 95%, 1.07–1.54). No statistically significant association could be demonstrated between being disciplined and general practitioner or practice characteristics. Conclusion. The possible relationship between professional seniority, rate of consultations, and complaint cases merits further studies to clarify the impact of professional seniority and workload on professional performance and to furthermore consider the role of factors such as job content and communication styles.

Criminalizing doctors: response

What must we learn from Jack Adcock’s death?

Legal systems' responses to medical malpractice.

therapy are likely multiple, such as: clinician preference, patient pressure, medico legal concerns, complacency, tiredness, ignorance, indifference as well as healthcare system-related factors, such as time pressures. This, in conjunction with the tight restriction on the prescription of other antibiotic classes, is almost certainly influencing prescribing trends. Whatever the underlying reasons, a significant number of prescriptions remained unjustifiable and were not reviewed when therapy could be refined. Whilst these findings have led to targeting the prescribing of piperacillin/tazobactam through education, further analysis of prescribing behaviour along with continued active antimicrobial stewardship practice is indicated to inform future intervention and improve prescribing habits.

Threats and violence in the lead-up to psychiatric mechanical restraint: a Danish complaints audit

Abstract Coercive measures like mechanical restraint (MR) are widely used in psychiatry but may collide with bioethical autonomy principles, damage those involved, and harm patient–staff relations. Reductions in usage are desirable and addressing illegitimate MR would be an obvious starting point. As one important reason for instigating MR is dangerous patient behavior this attracts special attention. In this complaints audit the role of threats, violence, and contextual characteristics was examined in decisions concerning MR completed by the Danish Psychiatric Patient Complaint Board system from 2007 to 2014. According to case descriptions, threats and violence were common and sometimes rather serious. Mainly actualized physical violence seemed to justify MR use. However, roughly every sixth patient subject to MR episodes filed a complaint and in one in 25, usage was found unlawful. The interpretation of clinical situations vs. law elements and surrounding coercion legislation needs further investigation as does the impact of, e.g. psychiatry staffing.

Re: Prostate‐specific antigen‐based prostate cancer screening: Past and future

In continuation of the excellent review by Alberts et al. in the June issue recommending shared decision-making (SDM) when considering prostate cancer (PCa) screening, attention needs be drawn to another important aspect of PCa screening: the legal implications of sharing the “to screen or not to screen” decision. In the well-known Merenstein case from 1999, a general practice resident saw a >50-year-old male patient for a checkup. In accordance with guidelines, prostate-specific antigen (PSA) test risks and benefits were discussed, the patient declined to have it done, and the process was formally documented. Unfortunately, after a PSA test ordered by another physician without discussion, the patient was years later diagnosed with an incurable, aggressive and deadly PCa. The residency was sued for medical malpractice for not ordering a PSA test when the patient was first seen and thereby deviating from the standard of care in the State of Virginia, a position that was supported by four physician testimonials. A jury found for the patient that the residency practice was subsequently found liable for over

Communication-And-Resolution Programs

1 million. Meanwhile, in continuation of bioethical principles of respect for autonomy and right to self-determination, the obligation of clinicians to obtain the patient’s informed consent (IC) has been implemented almost worldwide as a legal imperative, and as an ethical requirement of national medical councils, disciplinary boards and professional organizations. Furthermore, the scope of, and practical requirements for, obtaining a sound IC have become increasingly well-defined, pointing towards SDM as the key to ensuring patient-centered choices. Although IC denotes the formal approval from an “informed” patient before healthcare intervention, SDM signifies an advanced, practical method of obtaining IC where the clinician and patient share information, and identify patient concerns and preferences, form a consensus, and reach an agreement about the intervention to implement. A later Danish Patient Complaint Board decision illustrates the development (case 0977004/2010). The complainant had visited his family doctor for a general health check. He had experienced no health discomfort, bodyweight was average and urination was normal. A chest auscultation, abdominal palpation, blood pressure measurement, as well as digital rectal and prostate gland examination were carried out, showing no remarkable changes, and some blood tests were taken (including PSA). The board ruled that, “Before measuring PSA the various pros and cons should be discussed with the patient [. . .]” and “When a medical doctor takes blood samples the doctor is obliged to inform about circumstances which may be considered important to the patient’s decision-making among investigations, treatment and so on.” Additionally, the decision proved that litigation risk does not necessarily hold with ordering extra procedures. Thus, the doctor was issued a written reprimand for not following up on the slightly elevated PSA, which some 2 years later was ensued by diagnosis of (operable) PCa. While in Denmark IC, but not SDM, is required by formal law, SDM is now increasingly integrated into regulations in many countries, including some state legislation (e.g. Washington, Massachusetts, Minnesota) and specialist associations’ recommendation of providing PCa screening after obtaining IC through a SDM procedure. Nevertheless, although SDM approaches probably improve patients’ knowledge and decision-making, decrease PSA test utilization and perhaps would benefit the physician during a lawsuit, the effect on patient satisfaction and complaint behavior merits further investigation.