Complaints and How to Survive Them E2: What to Do When You Make a Mistake with Drs Clare Devlin and Dr John Powell

Dr Rachel Morris: Do you live in fear of a complaint? Do you dread making mistakes or getting something wrong? No one goes to work expecting to fail, and no one ever likes to be wrong or receive a complaint. But making mistakes is normal. After all, no one has a 100% success rate, and receiving complaints from patients and clients could be seen to be an occupational hazard. We know this. So why do we find it so hard to cope when it happens? And it will. That’s why we’ve put together a series of You are Not A Frog podcasts on complaints and how to survive them.

Going through a complaint or investigation is one of the most stressful things that can happen in your career, and I’ve seen firsthand the anxiety and emotional turmoil it can cause, and I know what it’s like to berate myself when I inevitably fail. But it’s because we care that we find these aspects of our professional practice so difficult. But what if there’s a better way of handling things? What if we could learn to view the whole complaints process as just another part of our professional practice, and learn the skills we need to manage ourselves, our colleagues and our patients in an empathetic and compassionate way throughout?

In this episode, I’m talking with Dr Clare Devlin, a medico-legal adviser with Medical Protection, with a background as a paediatric doctor, and also Dr John Powell. John is an employer liaison advisor with the GMC outreach team, and he has a background as a GP partner and trainer. We talk about what you should do in that awful moment when you realise you’ve made a mistake or you receive a complaint, and you may slip into panic mode and inadvertently make things much worse. We chat about the importance of avoiding a defensive response, how to document your thoughts and take some learning from what happened, and how to get the right support and help at the right time. The good news is that many have been through this before, and we have a roadmap about how to deal with it. There are lessons learned and you can do this effectively and minimise the negative consequences and get a good outcome both for you and the patient.

So listen to this episode if you want to know how to react empathetically and professionally rather than defensively, how to avoid making things even worse by your actions after you’ve received a complaint. And listen if you want to know what the regulatory bodies are really looking for in how you deal with adverse events.

Welcome to You are Not A Frog, life hacks for doctors and other busy professionals who want to beat burnout and work happier. I’m Dr Rachel Morris. I’m a GP turned coach, speaker and specialist in teaching resilience. And I’m interested in how we can wake up and be excited about going to work no matter what.

I’ve had 20 years of experience working in the NHS and I know what it’s like to feel overwhelmed, worried about making a mistake, and one crisis away from not coping. Even before the coronavirus crisis, we were facing unprecedented levels of burnout. We have been described as frogs in a pan of slowly boiling water, working harder and longer. And the heat has been turned up so slowly that we hardly noticed the extra-long days becoming the norm, and have got used to the low-grade feelings of stress and exhaustion. Let’s face it, frogs generally only have two options: stay in the pan and be boiled alive, or jump out of the pan and leave. But you are not a frog. And that’s where this podcast comes in. You have many more options than you think you do. It is possible to be master of your destiny and to craft your work and life so that you can thrive even in the most difficult of circumstances. And if you’re happier at work, you will simply do a better job. In this podcast, I’ll be inviting you inside the minds of friends, colleagues, and experts, all who have an interesting take on this. So that together, we can take back control and thrive, not just survive in our work and our lives and love what we do again.

Did you know that for every episode of You are Not a Frog, we produce a CPD worksheet, which you can use to reflect on what you’ve learned and claim additional CPD hours. And if you’re a doctor and you want even more resources about how to thrive at work, then do join our Permission to Thrive CPD membership, giving you webinars and CPD coaching workbooks which will help transform your working life. Links are in the show notes.

Now before we dive into this episode, I’d like to share a word from our partners from this series on complaints. It’s all too easy to feel overwhelmed. And for many healthcare professionals, it’s not only feelings of burnout and stress which can be challenging. There’s also the nagging worry of making a mistake and a patient claim being made against you. It’s enough to give you restless nights and impact your day-to-day, but you don’t have to go it alone. If you’re a member of Medical Protection or Dental Protection, you can access a range of support from clinical professionals who understand what you face, who are here to help you with not just the legal stuff, but your emotional and mental well being too, from expert medical and dental legal teams to independent counselling, through to webinars and on-demand content. You can access it all as part of your membership, so you can focus on loving your job, not fretting about it. Find out more at www.medicalprotection.org and www.dentalprotection.org. And now here’s the episode.

So welcome to a very special episode of the You Are Not A Frog podcast. And this is one of the episodes in our Surviving Complaints series. And this time, we’re talking all about what to do when you make a mistake. In that moment, where you realise that something has gone wrong, what should you actually do? I’m so pleased to welcome on the podcast with me today, Dr Clare Devlin. And Clare is the medico-legal consultant at MPS. She’s an ex-paediatric trainee, so an ex-paediatric doctor. And she works with all different case types with MPS supporting doctors through. So welcome, Clare.

Dr Clare Devlin: Thank you.

Rachel: And also really delighted to have Dr John Powell. Now John is an ex-GP partner of 17 years. He’s also been a GP trainer and a portfolio GP. He currently works as the employer liaison advisor with the GMC outreach team, and is developing the GMC outreach team as part of a team during the development for that too. He’s also been a case examiner for the GMC, and he also has been an employment and a disability tribunal doctor, the tribunal service. Thank you so much for coming. So both of you, you know, you’ve got a wealth of experience for supporting doctors in this area. And first of all, I would like to talk about that, ‘Oh my goodness moment’, that moment, when you realise you have made an error, or a patient has come to significant harm, you don’t maybe don’t know if it’s an error or not, or you receive a complaint or something has gone wrong. And I can just remember what it feels like to be in that moment. Even if you’ve not made a mistake, when you hear that something awful has happened to someone, your heart skips a beat, it starts racing, you just feel terrible. And Clare, you, I’m sure see people on the front line when they just experienced these moments. What sort of reactions do you tend to see in doctors?

Clare: You’re right. First of all, it’s almost a big adrenaline rush. And you just feel shocked and maybe frightened, distressed, worried, really worried, and perhaps a bit panicky, and thinking, ‘What do I need to do now?’ First of all, you’re going to want to be sure that there isn’t, in a sense, any ongoing clinical harm or anything that you need to correct clinically with the patients, the sooner the better. If you can get in touch with your medical defence organisation, we’re able to help you take it step-by-step and almost walk through it with you and deal with things as they happen. And to help you see what you need to do straight away.

When there’s been a mistake, there’s also the duty of candour angle, and the GMC put it really very clearly. And it does make sense: the patient will need to know what’s happened, you will put it right in so far as you’re able to, you’ll apologise, and you’ll help the patient to understand any short-term or long-term consequences. Everybody makes mistakes, it’s almost not even the mistake you make. It’s what you do with it afterwards and how you handle it. So a little mistake handled badly can actually put you in a worse position professionally, than really quite a big mistake that you get the right support with and you handle well. And then you can neutralise it, you can defuse it, you can do what needs to be done for the patient. And you can put yourself in a strong position.

Rachel: Yeah, that’s such an important concept to get across. I think that if you are practising, or in any profession, you are going to make mistakes. I had someone really nicely describe it the other day, ‘If you wash up enough plates, you’re going to drop some.’ It just means that you are a normal human being and you’re practising. But like you said, a little complaint handled badly or a little mistake handled badly can be really devastating, have dreadful consequences. And I think that perhaps sometimes what’s happened is in that moment of panic, in the OMG moment, people then do things that are really, really unhelpful. What mistakes have you seen people making about making mistakes?

Clare: The worst possible thing you could do would be to perhaps try to cover up, cover up the mistake. And in a moment of panic, really, in a sense anybody can do anything. But if you can always prime yourself to think, ‘That’s the worst thing I could do.’ There’ll be an element of explaining in a clear and neutral way. There’ll be an element, a really important element of reflecting, of trying to get some insight into what happened, understanding, sort of analysing it to what happened, why it happened. And then reflecting on that. You can do that in an anonymised way, just for your own purposes so it’s not clear what case it relates to. And then it’s actually really valuable. I think people feel frightened of this, but it puts you in a strong position professionally, to go looking for learning points, and they can lead to actual concrete changes in practice. And putting together a portfolio of those different things actually puts you in a really strong position professionally. It doesn’t weaken your position.

Rachel: I think that’s what a lot of doctors worry about, that things that they do in that moment are going to weaken their position. Either apologising is going to weaken their position or admitting fault or admitting blame is going to weaken their position or if they document stuff afterwards, is that going to weaken their position? I mean John, what’s your take on that? What can doctors do in that moment? What would weaken their position and what wouldn’t?

Dr John Powell: I was thinking, initially, most important thing to do is just to stop and to breathe, and just to get your bearings. Because it’s a shocking moment for a doctor when you realise that a mistake has been made, or a bad outcome has happened which you might be involved with. And it’s difficult because you’re not a robot. You can’t just deal with it like a computer algorithm, but you’ve got to deal with it in an efficient way. And it’s a test of your professionalism. The GMC doesn’t expect people to make no mistakes. We’re all fleshy beings. You know, we make mistakes, but what is important is how we deal with it. We have to deal with the mistakes, errors, bad outcomes in a professional and useful way. So I agree, exactly, that you’ve got to make sure that the actual thing that went wrong is brought right. So if a result hasn’t been acted on, it needs acting on, or if it hasn’t been made, it needs to be made. So all those things need to happen. And if necessary, if you’re in a panic, or you just feel like you can’t do anything because your brain’s mush, then you’ll need to delegate it to someone who you can trust to do it. So you need to start putting things right straight away.

I think that’s just really important, just to get your bearings, realise that it’s gonna feel bad. And it’s gonna take some time to get through that kind of panic moment, when everything kind of closes in, and your stomach churns, and you can’t think. It will take, you will get through that, but it’ll take some time, get some help just to deal with the actual subject you’re dealing with. And then after that, you’re gonna have to start to get some advice. And that’s when you need to speak to your defence organisation, maybe to a trusted colleague as well, and just get some advice what to do next, because it is quite complex, and it will depend on the situation. And there will be the duty of candour to deal with, but to deal with it in the right way. And that’s when sometimes people make errors at that point.

The obvious error people might make is to say, change the records, which is never a good idea. And we do see cases of GMC where the initial mistake wasn’t that bad. And it was quite reasonable, someone would learn the lesson, and it would never really come to us. But someone’s altered the records. And honesty is vital to patient trust, and it’s vital to the bargain we have with patients. So that is very important. I would encourage people, you know, when I was a GP did myself when I hear something was going wrong, quickly do a brain dump of your thoughts about it as a reflective note to yourself. It may just be a bit of paper if you haven’t got anything else. But just to clarify in your head what you think. Because our notes are a small fraction of what we think. If it’s fresh in your head, just write it down to reflect. Because after a few months of correspondence and letters, you’re going to forget what came first and it all becomes a bit more difficult. So you might want to write that down. But that’s for you. And it may be later, you’ll put a clear note in the record, say, ‘This is a retrospective entry. My thoughts and recollections on this date are absolute clear from the records.’ And there’s no problem at all with that.

You can get advice about that because it’s a careful process, what you put in the records, and you’ll get advice from your medical defence organisation about what to post and how to phrase it, that sort of thing. But I think it’s that mixture of doing the right thing, controlling your emotions, and being that professional that you are, and getting through this process. And if you do it right, you will increase trust with your patients often. And you will never even go near places like the GMC and it just is just part of our career practice that these sort of things happen.

Rachel: So I’m presuming that perhaps the biggest mistakes that we make in dealing with complaints are when our emotions are high, when we’ve been triggered, when we’re in our sort of fight, flight or freeze zone, and we’re like a rabbit in the headlights. And we just don’t think clearly, do we?

John: That’s right. Yeah.

Rachel: How important is it to take a step back to give a pause, to give a break before we then take action?

John: One thing that occurred to me when I was in practice is that occasionally say, they’ve been out in the appointments list and the practice manager saying, ‘Can you see me after the surgery? Because something’s happened.’ And I can’t continue with the surgery, then I have to go see what’s happening. Because it may be just, ‘Oh, we’ve forgot to put some stamps on some letters’ sort of thing. Or it may be something disastrous. But if you work, if you make decisions, clinical decisions with patients whilst you’re under duress, or while something is in your head, that, ‘Oh, my God, what’s happened, I need to deal with this,’ you will make more errors. And the tragic thing is where someone has an error, and then in a state of panic makes a second error, which might be worse.

Acknowledge that your brain is mush for, whatever it is 10, 20 minutes, when you just take it in, have a cup of tea. I always think that a complaint from a patient that they were seeing 20 minutes late, is fairly easy to deal with. A complaint, you made a mistake, the next patient because your brain was mush, is much more hard to deal with. So acknowledge that you’re human, have a cup of tea, try and get things into context. How do you continue with your surgery or clinic, or do you need to attend to this now? Is there an action that needs to happen straight away? And so, now get some context, but don’t make that second error. Don’t compound the original problem. That’s really important.

Rachel: Yes. And I guess you can also make that second error in then, how you’re communicating with the patient who had the mistake or the complaint. And I think this, I think is what people are really, really worried about. ‘How do I communicate with the patient?’ ‘How does this duty of candour work without me completely dropping myself in it and causing problems for myself later down the line?’ What would MPS and other medical defence unions be advising in terms of that?

Clare: I think in a sense, it is actually straightforward because there is the, it’s the right thing to do. And there’s the professional imperative to be honest and open and straightforward. So in a way, I would actually, I would try to keep it simple, I would communicate in a straightforward way about what you know of what happened. I think quite often in practical terms early on, you may not really be able to, you won’t have investigated, most likely, you’ll really only be able to say what you do know. If it’s something that you’re going to look into, or your practice your colleagues are going to look into, you can explain that to give the patient a sense that they know what to expect and what sort of will be happening. You may even start off with a kind of generally worded apology, you may not really understand what happened. And you don’t have to try, you don’t try to guess basically.

There are ways of apologising that show your sincerity without pinning you down to particular points. So for example, you can say that, ‘I would really like to say how sorry I am this has happened.’ That’s sincere. You are sorry, and it will come across. You are sorry, it doesn’t sound like, I don’t know something robotic or formulaic. But at the same time, you’re not saying ‘Oh, I did this,’ or, ‘I caused that,’ things that you maybe haven’t had the chance to think about or haven’t established. So it is possible to have a meaningful and kind of sensitive discussion, but without perhaps going into some of these nuances about maybe exactly what your involvement was, sort of framing it within the limitations of your knowledge. And you know, it might be that there isn’t just one conversation. You keep the door open, you let the patient know you’re happy to discuss again, and that they can come back to you if any questions occur to them. You may even kind of arrange with them to speak at another time. Because actually, sometimes it can put, I imagine being an enormous shock for the patient as well. And they are going to want to allow things to filter down.

Rachel: John, would that be what you guys would be recommending too?

John: Yeah, because I said to trainees, I think about this kind of thing, that it is like giving bad news to a patient. Often they’ll only hear the first thing you say. You know, this has happened. And then everything else it’s just like words. So they often will just need to take in what you said and then think about it for a while, probably speak to family or friends and then come back and ask more about it. And so often, I think when you give this kind of adverse information, you’re going to give that actually what happened quickly without couching it in fancy phrases, and then an invitation to discuss it and or a callback and not an assumption that someone will then call the practice back but some sort of proactive effort. I was thinking about what an apology is. And it is a difficult thing.

What it really is just a few words down as we’re speaking is it’s kind of, it’s a sincere, empathic, professional acknowledgement that the event has happened. So it’s got some emotion because you realise it’s an emotional thing, but it’s an acknowledgement that something has happened. And that you are sorry about it. Sorry means a lot of different things. It means that you’re sad for someone else. It doesn’t mean that you would accept responsibility for everything that has happened, but you are sad that this has happened. And that most I think, most doctors with experience are good at communication, that sort of thing. It’s retaining your professional responsibility and continuity of care for something even through a difficult period. And I think it’s an important thing to get right.

I think patients will see through the ‘sorry, not sorry’ type statements. You know, ‘I’m sorry, you feel the need to complain’ type things, which isn’t, it’s not going to help. You can say, ‘I am sorry that this has happened. I’m sorry for, that we find ourselves in this situation.’ But I think getting some advice about it, writing it down, and seeing how it looks. And before you do it and thinking about it, and not the kind of hasty phone call to patient immediately after you discover something has gone wrong, just which we sometimes see where the doctor is kind of gauging whether someone realises that something has gone wrong or not, or they can get away with it sort of thing. You don’t want to, I’m just I think it’s better way of phrasing that, I think, thinking about, carefully about what you’re going to say. So it comes across correctly and not in any way, a false apology, is important.

Rachel: Yeah, and I guess that running what you’re gonna say past a trusted colleague or even your medical defence organisation is a good thing to do. Because I guess there aren’t that many things that you must do straight away unless you’ve given the wrong treatment. And you know, that stuff, don’t take that. Everything can have a little bit of time to think about it, can’t it? And it’s much better to just say, ‘What’s the tone like on this? Does it sit well with you? Does it feel like I’m justifying myself? Or does it feel sincere?’

John: I think about all the times in my GP career occasionally, say, as a mistake, but we’ve had late results come in when someone’s going away on holiday, and realise that they can’t go away, and they’re on their way to the airport. So that is a kind of urgent thing, you know, someone’s INR is completely out. And they need to stop taking something or take more of it or get more blood tests. There are urgent things. But mostly, it’s something that can wait you know, at least a few hours or overnight. So a referral needs to be made. It’s, you know, you can do some work first, you can talk to people. As much, if you can say we’ve sorted this out now, so things are now on track, it’s a lot easier for someone to accept that an error has been made. Now I think, I was thinking that our response to these questions in a lot of respects come from my experience as a GP, rather than in the GMC.

Because the GMC in the end, wants to let doctors be doctors and to make their own professional decisions. And most of what the GMC thinks about in terms of guidance, and advice and standards, comes back from what doctors are doing. I think one useful way of thinking about this is we’re all patients as well as doctors, and we’re all family, all relatives of patients. And we have to think about how would we feel if we had a letter or a phone call from a doctor saying they’d made a mistake? Or how we feel if our, if say, our elderly relative had a mistake? Would we be outraged? Would we understand? What would we want to hear? And so that’s important thing to think about when you’re thinking about what to say to someone.

Rachel: I think that’s a great practical thing you can do is think, ‘If this was me, if I was in their shoes, how would I want to hear about this?’ ‘If this was a relative of mine, how would I want them to hear about it?’ ‘What advice would I give to another doctor in exactly the same shoes as me in what I’m doing here?’ I think part of the problem is we just get so defensive, don’t we? When we think we’ve done something wrong, it’s immediately, ‘Right, let’s quickly look at the nose. Was it my fault? And if not, thank goodness, okay, it wasn’t my fault.’ But you know, what if it was your fault? And again, you’re human. And then I remember Clare, when we were talking before this podcast, you’re talking about the fact that actually getting really defensive and trying to justify stuff is pretty much one of the worst things you can do. Is that right?

Clare: I think it’s probably not the worst thing you can do. The worst thing is that we needed to try to cover up.

Rachel: Okay, covering it up, being dishonest.

Clare: But the next thing in terms of a kind of approach that won’t work, I think sometimes your care is criticised and you think, ‘Well the way to deal with this and protect myself is to show that my care was fine.’ And so people may take a legalistic approach. And it’s almost as though they’re arguing their point in a court of law. And they’re showing the patient why the patient is wrong. Maybe why the patient has misunderstood something, or misremembered something, or it’s a kind of, almost an antagonistic type of point-scoring draft response. And I understand why you would do that. It feels maybe unfair. Sometimes a patient has misunderstood things, and they think there’s been something that’s going on. In fact, it hasn’t. And you do have points that you want to make, to clarify. So I’m not saying that, in a sense, you roll over and just say yes, yes to everything that patient says. But definitely, there’s a kind of better and worse way to explain yourself.

So I think the way I would look at it is, you will approach the patient with a sort of very empathic tone, because rightly or wrongly, something’s upset them. And so empathy is the right thing. And also, I think, in all of this, the right thing is the same thing as the effective thing. So you’re not actually trying to serve two masters. So an empathic tone, taking time to understand what the patient is concerned and upset about so that you can properly kind of engage with them, and they’ll realise that you’re taking them seriously, and that you’ve given some time and some thought to this, and you will offer your explanation. You react as a human being, you have lots of emotions about a difficult case or difficult complaint. That’s normal. And that’s right. And you need to have the sort of time and space to do that.

But when you’re actually responding, that is something different, and I would always try to see it as part of your professional practice is not, sort of in a way that it’s not personal. And you’re simply looking to respond in the most professional way. So you’re offering an explanation, but it’s neutral, neutrally worded, maybe low-key, a very calm, calm, careful tone. Explaining things in a way that the patient will understand. So it’s sort of accessible and clear for a layperson. And actually, that’s the best way for you to make your points because it’s not that the patient will be sort of put off or sort of antagonised by a kind of defensive tone. So actually, you stand the best chance of being able to make your explanation if you approach it that way. And nobody will have to criticise you because of the way you said something, because you will have said it in the best possible way.

And then after that type of explanation, you make sure you really have kind of grappled with and dealt with the specific concerns that the patient has. And then from there, you’re able to re-offer reassurance, and kind of valid reassurance, because you’ll be thinking about the angle that we’ve mentioned before sort of reflecting any learning points, any action points. In a sense, the principles are simple. And if you’re able to hold on to them and know what it is that you’re trying to achieve, then it makes the whole thing in a sense, quite straightforward.

Rachel: That’s a really interesting point. What would you say people should be trying to achieve in a mistake? Because I think doctors think, ‘I want to achieve being exonerated.’ Someone said, ‘I want to achieve not being sued, being able to get my job, not losing any income.’ And people saying it was fine, it wasn’t—

John: I think one important principle around this is that just because a patient has made a complaint against you, the doctor-patient relationship is still going. And I think doctors, sometimes, in the, because the emotion as they think, ‘Oh, because of a complaint that’s destroyed the relationship, now I can go on the defensive.’ It’s not the case. I think we all know the paradox of care: that the patients that often we’ve cared for most are the ones who make most of the complaints. And the ones that, we get very forgiving patients who weren’t on our radar because we’ve got other things to look after, and they don’t complain. It’s strange how that happens. But that we should, that shouldn’t push us into a situation where we think, ‘Right. Now, this patient has pressed the combat button, and so I can now defend myself.’ You’ve got to put things right in such a way that your doctor-patient relationship continues. And the byproduct of that is it’s much more likely to continue if you have that attitude, you’re only much more likely to get through the the complaint process successfully if you considered that the person who has confronted you is still a patient and you still use the best tools to communicate effectively and to and to get a good outcome for everybody in the end.

Rachel: I think it’s about not seeing them as the enemies instead.

John: Yeah.

Rachel: Because I just thinking, when Clare’s talking about depersonalisation, so often it’s like, ‘They are attacking me as a doctor; they’re saying I’m no good.’ On the surface, they might be, but actually underneath they’re worried about their own health, they’re frightened. They want to make sure it’s never gonna happen to anybody else. They, most people aren’t vindictive, there are a few, I know that there are a few that are, aren’t there?

John: Unfortunately, especially so with grief. A grief reaction that happens often at any bad news, people don’t act in particularly logical ways, and they will lash out. And they will blame a doctor and tell you you’re a terrible person. And it does hurt when you get that sort of language get back to you. But you have to just try to be, to go, to get some reassurance and go, ‘Well, it’s just, this happened.’ And then often, that kind of language will melt away once you’ve explained what happened. Patients, often, relatives, just want an explanation for a bad outcome which they don’t understand. And once that’s supplied, and they understand that, then often, all that steam in the system will go away.

Rachel: So Clare, just coming back to when, since you know, recent complaints and things that you’ve dealt with in your role as a medico-legal advisor, were there any quite serious complaints that had a really, really good outcome? Where you thought, ‘Crumbs, that was a good outcome?’ And what was it that the doctor did that produced that good outcome, that you perhaps wish all your members would do?

Clare: Okay. I think the good outcomes that I’ve seen have been where the issue, in essence, got the time it deserved. And I think, in a way, it all came down to careful reflection and giving time for the doctor to actually almost go back and enter into what her thought processes had been at the time that she was, that the time she saw the patient. And then, looking for any learning points. And she did this individually, but she also did it in the practice. If you’re able to deal with it yourself, analyse it, reflect, neutralise it, learn what needs to be learned, change what needs to be changed, and really, you’ve done good work.

Rachel: I think what you just talked about is pretty much the opposite of a defensive response. It’s the opposite of trying to justify yourself and defend yourself.

Clare: It’s important to realise that this type of approach is not going to mean that you’re going to be, in a sense, framed for things you didn’t do, or lambed on things you didn’t do. And anybody who is, in a sense, scrutinising or looking at your care, they’ll see that.

Rachel: I think one thing, just to play devil’s advocate here, that people are really worried about now is, ‘If I reflect, if I document my learning, if we really delve deeply into how to prevent it, is that going to be held against me?’ Because there’s been some obviously fairly recent, quite high-profile cases in which the medical profession have felt that doctors’ reflections have been used against them. John, what your thoughts on that?

John: Well, the GMC doesn’t ask for reflective documents. Because the GMC, like any kind of advanced legal process, doesn’t ask people to incriminate themselves, if you like. But the reflective process is immensely important. And I think that the analysis is really important. And if a doctor has reflected early and can show that whatever concern there was, it was properly understood and properly addressed, and it hasn’t happened again, then there’s no need for any regulator to take any action with that. That’s apart of course from any sort of a court action about negligence or compensation, that sort of thing. But from a regulatory point of view, we want safe doctors with trusting patients. And if the doctor has done the work properly, then that’s fine.

Sometimes we find that in a response to a concern, a doctor will give us reflective information because it’s very relevant to their response. They’re saying, ‘I understood what the problem was. I did change these routines. I did these courses.’ We audited afterwards, they looked back. And it’s clear that we’ve solved the problem. And everything’s been sorted out, then there’s literally nothing for the GMC to do. And very commonly, even at the kind of triage where complaints come in, or concerns come into the GMC, we can see the works come in at that stage, so it doesn’t even start. It’s been dealt with.

What you don’t want to do is wait until the very final stage investigation or a GMC investigation where concerns are laid out and then go, ‘Alright, I’ll do this work now.’ Because that’s kind of leaving it a bit late. So reflection isn’t just a word. It’s an important professional attribute where we understand what we’re doing and what has happened when things go wrong. And I think about, say, a typical case that might come up, where someone acted wrongly on a result. And so they do a course, or they turn to protocols about what to do, in case of results coming in for the practice. But actually, if they reflected or done an analysis, they realised, actually, they’ve seen too many patients and had too many distractions. That was the problem. It wasn’t, they knew what to do. It’s just that they, in there, with all the noise going on, they did the wrong thing. And suddenly, that’s a minor point.

That shows what, they did the wrong process to remediate because they didn’t analyse it the right way. And the lots of people who will help you with that analysis of what might have gone wrong. And the opposite person is, say, a colleague or someone to say, your appraiser might be happy to look at what’s happened and give you some sensible advice. Obviously, the defence organisations will be happy to look through and say, ‘You’re doing this course, but actually, you should do this one instead.’ And the medical defence organisations give a very good education about dealing with concerns, whether it’s time management, whether it’s clinical issues or all the kind of human factors that we talk about. So understanding and analysing. And it’s, we don’t ask, GMC doesn’t ask this information, it isn’t wanting to incriminate themselves, but doctors do present this information as very valuable evidence that they’ve understood the issue. And it’s not a concern, the doctor is safe and fit to keep on working.

Rachel: So when mistakes happen, just constantly look for the learning in what you’re doing, make sure that’s documented, it’s discussed with peers, and don’t take it all on yourself either because nobody works in a vacuum, right? We all work in hospitals, or departments or practices, and it all influences our actions.

John: Yeah.

Rachel: Don’t take all of the blame, but don’t take none of it either.

John: Yeah, and there are plenty of sources of information to tell you what the gold standard of remediation for concern is, what you should do, how you can demonstrate it so that it’s clear to everyone that there is no issue.

Rachel: I think it’s really important just to have a roadmap really. And if you can think about this before it happens, then you’ve got it out there. I’m constantly so surprised that we are not taught more about how to do this at medical school or in our training. I don’t remember ever having a session on how to deal with complaints and what to do. But given that everyone I’m talking to is saying to me, ‘They are an occupational hazard, they are part of your professional duty,’ why aren’t we doing this more?

John: I think we’re not really taught in medical school that we’re gonna be working in, if you like, a substandard system where there aren’t enough resources, there aren’t enough people, there aren’t, there are patients with, what can you say, unrealistic expectations. We’re taught that everything’s perfect, and every test you want, when you want it, it’s just a matter of knowing what to do. But it isn’t. It’s a matter of dealing with huge amounts of over-information and obfuscation and confusion and stress and exhaustion and behavioural problems. And you know, it’s just a big mess of information. And we’re not taught about that. You could say it’s about situational awareness. But it comes as a shock I think, as a working doctor, that you never learned that as a medical student, you know, that you will get things wrong. And here’s how to get out of it.

Rachel: Yeah, just thinking, you know, rather than, you know, beating yourself up when you get a complaint, actually, we should be patting ourselves on the back saying, ‘Well done for not making more mistakes in a really stressful, imperfect system.’ We really think like that, do we?

Clare, if you were to design a program of learning for medical students. What are the things you think people really need to know when they start in medicine, about complaints and mistakes?

Clare: I don’t think you need to know a huge amount, actually. I think you just need to have a bit, like you said, a framework to have an awareness that this is something that you’re going to come across, to understand maybe the emotions that you’re likely to experience, to have some techniques for that immediate shocks, or dealing with immediate period of shock, but then to know what comes next. And I think in many ways, to keep it simple. Each case, the detailed analysis and response in each case will be case by case. So I think it’s important not to overload people, but just to let them know: this is going to be part of your professional life, and maybe even in a way that will be increasingly so with time.

Think, for example, the number of clinical negligence claims, it has increased with time. So sometimes there’s, almost, cultural factors that influence the number of complaints you get. I would quite often speak to doctors who are retiring and they say, ‘This is my first claim.’ But then there’ll be other doctors in their sort of 30s who have maybe got a couple of claims and that’s not necessarily a reflection on them. That’s a reflection on the changing culture. I think I would just feel it’s important to have a basic understanding to know that it will happen, to in a sense, be kind to yourself. But then to have an idea of the different sources of support and guidance and advice that you would want to then connect up with, and then just take it. Follow it one step at a time.

John: It’s, so there’s an interesting contrast between, say, the number of, say claims that are coming into medico-legal organisations and the number of complaints that come in, or concerns that come to the GMC. Because that hasn’t gone up exponentially, it kind of goes up and it goes down, and it changes, but it isn’t subject to the same sort of thing, because there’s a distinct difference between claims of negligence and concerns about doctors. I would say, overall concerns about doctors stay at a fairly low level because people generally are trusting of doctors. But working in the GMC, you obviously see a very biased view of it, because you only see one type of thing coming through the door. But there is a difference there.

Rachel: That’s really good to know. We’re nearly out of time. And in a minute, I’m gonna ask you for your three top tips of people on what to do when they make a complaint. But I just wanted to touch on timeline. Because both of you said interesting things to me about timeline when I’ve been chatting to you before the podcast. First thing you said, Clare, was you think sometimes people leave it too late to get in contact with the people that can really, really help them. When do you think people should be seeking support and advice in the complaints process?

Clare: Honestly, right at the beginning.

Rachel: Straightaway.

Clare: I think we prefer it that way. Then what you don’t want to be doing is to be up against a tight deadline, or maybe a deadline you’ve already extended. The complainant, the patient is losing patience with you, they feel that you’re messing them around and not taking them seriously. And then you are in a bit of a rush to finalise your complaint results. And sometimes they actually can need quite a bit of work.

First of all, maybe really, in terms of the whole tone and structure and attitude and approach. And then once that is in good shape, there can then still be, you can still need to spend time working out how to explain things as clearly as possible. So then there can be time spent finalising it. It can actually take longer than you might expect. And it’s so worthwhile to give it that, those sort of bits of extra time to prepare a really good, comprehensive, reassuring empathic response, with a clear explanation in it. And you don’t want to not have time to do that properly, really. Because how you handle the complaint at the beginning, really can be instrumental in either just settling it and neutralising it, or the alternative is that it may escalate and you could find yourself with perhaps the involvement of the Ombudsman, sometimes NHS England become involved. Worst case scenario, you could find yourself dealing with a GMC case suit. So in some senses, the stakes are high, you want to do the right thing for the patient, but also in doing the right thing for them, you’re doing the right thing for yourself as a doctor. The two go hand in hand, really.

Rachel: Yeah. And presumably, this involves, even if there hasn’t been a mistake, or there hasn’t been a complaint, if there’s a situation that’s precarious, can people contact their medical defence organisations, even before anything’s happened?

Clare: Yes, definitely. People we have, we have an advice line. And I know people contact the defence organisations just with difficult scenarios where their instincts are telling them that this could go in a sort of undesirable direction. And we’ll be happy to talk things through and quite a lot of the time, our cases are simply advice cases. Now there isn’t a complaint, there isn’t a need to write a report for somebody. That’s not the sort of formal case, but we advise them on the way to navigate some of these very difficult situations.

John: A typical instance of that would be a doctor where there’s, a patient has died. An inquest is going to happen. The doctor feels that they’re going to be criticised during the inquest. And so he can, the doctor can anticipate that they will need to self-refer, say to the GMC about that, but it may not happen. But they want to speak to their medical defence organisation beforehand. We’re gonna be very interested in helping them to navigate the inquest, and to make sure that statements are properly written, that sort of thing. It hasn’t happened yet, but it might happen.

Rachel: Yeah, and I know I’ve certainly found my medical defence organisation when there’s a phone call I need to make, and there’s a bit of a consent issue or that I’m not quite sure, and I just want to check out what the right thing is or how to approach things, and it’s been really, really helpful, just given me much more confidence.

John, I just wanted to come to you because I know that as part of your role of the GMC, you sort of helping educate the organisation of being sensitive to the vulnerable contacts you have. So doctors obviously are all vulnerable, going through complaints processes, but some may be particularly vulnerable. And one thing that you talked to me on timeline is that often this takes a lot longer than we were expecting. We wanted it shelved and dusted and sorted so we can put it to bed and forget about it. But that’s often not what happens. That is very, very difficult.

John: I think it’s, especially for a young doctor, it’s very difficult to understand. And this is something I used to say to trainees when I was a GP trainer long before I started the GMC. But if there’s a significant complaint about you or something that’s gone wrong, it will take, it’s gonna take months to years to sort this out. And so you need to build in your resilience to take that into account. And well, look at yourself when you engage with your life, your family. You can’t just kind of hold your breath until it’s over. You can’t not sleep until it’s over. Things will be happening in the background; reports will be written. What, often, you’re going to have initial correspondence, but then nothing happens for six weeks. And then you get another letter that makes your heart stop coming through, then you’ve got to get routine again, you’re gonna phone people and say this contrary, what should I do? And then again, nothing happens for a while.

It’ll take a while to get, to happen. And once you’re, if you’re a mature doctor, then you will have a few of these things going on in the background all of the time. And you have to be able to put it in the background, realise that part of your life involves this stuff happening, that you can’t get all your worries and jobs sorted and cleaned and back in the cupboards before you sleep. It’s just, it’s an inherent part of being a busy professional doing a very difficult and responsible job, where often bad outcomes happen, even if you can’t prevent it. And we’re working in a challenged, flawed, unresourced system that is trying its best to improve that. But the ideal state is always in the future. So yeah, realise, once you get over the shock, realise it’s going to take some time. It’s not just one switch you can put right, it’s going to take some time.

Rachel: I think for me, the important bit of that was recognising it is almost your job description to have this stuff going on in the background. Because I have colleagues and friends who have been, the two years that the GMC were investigating a complaint has just been the worst two years of their life. They feel that they’ve had to put everything on hold, they’ve been so stressed about it, they’ve not been sleeping, it’s been really tricky.

John: One focus of the GMC has been to alter the language it uses in its communications because in the past it has been very quasi-legal than official. We’re trying to use, if you like, more plain speaking. But I guess the problem, in the end, is that we are breaking bad news. And as a doctor, receiving a letter with that particular shade of blue, and that typeface coming through, you read the first line, and then you stop reading. If it says you’re under investigation, then that’s all you need to read, and your powers of communication and reading just finish at that point, then you fall to bits. It’s a visceral thing that happens when you get into communications. In a few minutes’ time, you’ll be able to read it and see actually, it’s not half as bad as you thought it was. But it is very difficult, I think, when you get these communications. We are trying to make it better, we are trying to, if necessary, phone people first just check it’s alright to talk to them, but make allowances for people.

Rachel: And I think you know, if you’re a doctor and you’re going through this yourself at the moment, you need to get support. You need to get support from your peers, you need to get the right medico-legal support, you may need to see a coach or someone professional, or a mentor or someone who actually can help get some perspective on it perhaps. And—

John: I think one interesting question that I would get asked by GMC stuff is, ‘Why is it so different as a doctor to get a complaint like this?’ Because everyone gets complaints, whether you’re a teacher, anybody finds it very difficult when you have a disciplinary procedure at your work. And I said, ‘Well, as a doctor is a strange thing, that when you become a doctor, when you finish your medical degree, they actually change your name. They call you doctor this, doctor that. And so a complaint that threatens your professional status, very much professional, it threatens your individual identity. And it feels very difficult.’ And the other thing is that virtually all of us, well I hope all of us, went into medicine because we want to help people. And someone’s saying that, ‘You didn’t help me, this was horrendous.’ It really gets to you. And you like to think that it can be a bit of a machine and get through the workload, but no, you care for these people. And, and the thought that you did something that didn’t do that is very distressing. And so it is different when you get this kind of concern as a doctor, I think.

Rachel: Yeah, a hundred percent. Well, all that advice is so, so helpful. In terms of generating a roadmap with people, if they were to write down three things, literally put it in their drawer for when the call comes in on their roadmap of what to do when they get, when they make a mistake or they get a complaint, Clare, what would your top three things be?

Clare: I think the first thing would be to, I said it before. But be aware. this is an occupational hazard. Is it almost, it’s not if this will happen, it’s when it will happen. And accept that. So it will be a shock. But in a sense is not a surprise, if you see what I mean. Then I think, as I mentioned before, it’s almost not the mistake you made that is the key thing, it’s how you deal with it. And that there are principles that make sense, that are right for the patient, but also put you in a strong position professionally: a kind of sensitive empathic approach, being able to give a clear account of what happened, but also responding in a really professional way. Analysing effectively, working out what the issues were here, reflecting on it so that you can draw from it any learning that can be taken and any changes, and thinking about it carefully, almost intelligently, to identify ways to address any and all of these issues that you’ve managed to pick up.

That is a strategy or kind of roadmap that will help you deal really with any type of medico-legal drama, in a sense. And be reassured that there is a good strategic way to deal with these sort of problems that is, in a way, tried and tested. And that really many, many of your colleagues will have been involved with. People don’t always talk about it, I don’t think. But you’d be, going to be surprised if you went to a colleague and said, ‘Oh, this is happening.’ And they go, ‘Oh, yes. You know, 15 years ago, I was dealing with something like that.’

Rachel: Yeah. And that is a great point. So many of us have been through it. Not many people want to talk about it. So you feel that you’re on your own when actually you’re definitely not on your own. So talk to colleagues, get support. And we are doing another episode all about how to survive, how to get that support and what to do there. John, what would your three top tips be?

John: I think, as I said before, I think the first top tip is just to pause and recognise that you are human, and you are feeling threatened. And to not act immediately, because you rarely have to act immediately. But pause, have a cup of tea. If necessary delegate tasks, deal with the thing that you need to deal with, the thing that went wrong. I think then it’s about communication. It’s about starting to deal with it by speaking to your medical defence organisation, speaking to your colleagues. And they’ll quickly give you a sense of perspective. And I think the next stage, is it a bit like getting away with grief, the stages of grief. But I think it’s about coming to terms with what’s happening, to realise that this is a long process that’s going to happen, mostly in the background. But you have to engage with your patients and your family, and yourself. You have to look after yourself, keep fit, keep well, do all the things we need to do, and get through it. And during the communication with all your colleagues, everybody, you will realise that they’ve, a lot of them have been through this before. A lot of people have been through it multiple times. Some specialities have to deal with this continuously because of the nature of what they deal with. Some specialities very rarely deal with it. But it is just, it’s inherent in the challenge of our profession. That is, we do impossible things a lot of the time.

Rachel: And those are really helpful three top tips that you’ve given. Right at the very end, what I do want to do is ask, because a lot of people who are listening to this podcast aren’t necessarily going through a complaint right now, but I’m sure that they know someone who is or they may well have someone come up to them in the future, just asking them, ‘Oh, this is just happened’. So what would you suggest for those people who want you, what should you do when one of your colleagues comes up to you and they’ve just had something happen?

John: I think that’s an interesting question. Because when they do that, it’s, you’re human as well. And that might even trigger you to think about some of the complaints you’ve dealt with. But if it’s a specific concern they’ve asked you about and you’ve got to think about, you’re being asked as a professional, ‘What’s the best thing to do?’ And you should initially obviously be concerned about the person’s welfare, who’s speaking to you, and be empathic and compassionate about that, be sympathetic. You should, as I said before, you can help in terms of remedying the thing that’s gone wrong to make sure that’s all right.

Then you’ve got to make sure that you give reasonable advice. Of course, it’s not to be, ‘Don’t worry, it’ll go away. Don’t think about it.’ It’ll be to encourage engagement with all the resources that are going to help the person get through with the medical defence organisations. You’ve got to be careful about saying, ‘Oh, just apologise. It’ll be alright.’ You know you don’t give blunt reassurance. At the same time, don’t run screaming. You can help to engage in the same way you would engage with a trainee, any other colleague, or another person who is in difficulty or in crisis. Think about it. Be responsible. Think about what you know, what you don’t know, know your own knowledge and capabilities, and be helpful. But signpost someone to the definitive resources that are going to help them through this.

Rachel: And John, just thinking, if that was me sharing that with someone else, often it might be like in a corridor where they put their head down, ‘How are you doing?’ ‘Oh, just had a complaint and—’ but what I’d really want is them to go, ‘Right, let’s stop, let’s go and get a cup of tea. just tell me about it.’ And just listen, that’s what you need. You might be a bit bravado, ‘Oh, I don’t really care’. But you just need someone to listen and an empathetic, caring ear of my colleague to start off with. Because you need to recognise it’s a really big shock for that person, even if they’re not saying that it is.

John: if you’ve got any sort of pastoral duties over any other people, you know how it is that in the heat of the moment, what’s, it might seem to you to be a very minor problem is actually really important to them. And give them space and take them out of the scene, give them a cup of tea and listen to, there will be a bit of a catharsis and there’ll be a bit, there’ll be a lot of emotion. But listen to that initially. The same way you would with a patient, let the person speak, don’t interrupt them. Let them speak to their brain. And then you can start to help and you can analyse now what is done immediately, what can be done in an hour, a day, a week’s time. Make some sense of it. Be human, and be responsible.

Rachel: And people really remember how you treat them in those circumstances. I remember talking to a colleague, he had had a really nasty complaint. And when he told his partners, they just went running for the hills. No one wanted to talk to him. And it was just, I think that was more devastating than the actual complaint actually, for him.

John: I think dealing with complaints by proxy is an important thing as well. So if say, you’ve got a complaint and realise actually, you weren’t even in the building, you’re on holiday, but it’s someone else, then how you respond to it is really important. You can still be compassionate, you can still not apologise, but acknowledge the concern on behalf of your colleague and say, he will still take responsibility for making sure that it’s dealt with. So it’s how we pass on a concern to the actual one, this is a really important thing as well.

Clare: I agree with all that. But also, sometimes if the complaint, it can take time sometimes to resolve these matters. So your colleague will probably benefit from you being sort of on hand and continuing to be supportive, maybe at certain points. So if you can help them probably through the process as well, as just at that initial moment.

Rachel: Regular check-ins. ‘How’s it going on that?’ Just because someone’s not talking about it doesn’t mean it’s not going on for them, and it’s not really important and occupying a lot of brain space. Yeah.

Thank you. Thank you both so much for being with us. We will post some links to all the resources that you talked about in the show notes. Thank you so much, both of you, that has just been really helpful. And I hope that’s given some really, clear practical points for our listeners on what they should do. So we’ll post all the links in the show notes. So thank you so much for being here and hopefully speak to you again at some point soon.

Clare: Thank you.

Rachel: Bye.

John: Thank you. Bye.

Rachel: Thanks for listening. If you’ve enjoyed this episode, then please share it with your friends and colleagues. Please subscribe to my You are Not A Frog email list and subscribe to the podcast. And if you have enjoyed it, then please leave me a rating wherever you listen to your podcasts. So keep well everyone. You’re doing a great job. You got this.