Context

Although they have no legal authority, medical organizations are frequently asked to assess physician conduct. These organizations have established a variety of procedures to review grievances brought for their consideration.

Objective

This analysis was conducted to assess the nature and the disposition of the complaints considered by the Professional Standards Committee (Committee) of an urban medical society.

Design

All cases considered by the Committee (193 complaints) during a six-year period were arbitrarily sorted into categories and the nature of how the case was resolved was tabulated.

Results

Of all the cases considered 108 (56 percent) were categorized as related to quality of care and physician/staff behavior issues. Of these, 39 (20 percent) dealt with the characteristics of the care provided, 28 (15 percent) with physician and staff behavior, 23 (12 percent) with physician and staff communications and 18 (nine percent) with ethical issues. An additional 85 cases (44 percent) were related to administrative issues and office procedures. Of these, 50 (26 percent) were related to billing, fees and charges, 23 (12 percent) concerned medical records, 10 (five percent) dealt with office practices and procedures and two (one percent) were related to worker’s compensation. Of 141 cases in which a judgment could be made, 48.2 percent were decided in the complainant’s favor and corrective recommendations were made. The grievance appeared to be inappropriate in 51.8 percent of the cases and the reason for this decision was explained to the complainant. In the remaining 22 percent of the cases irreconcilable descriptions of the circumstances made it impossible for the Committee to make a decision or recommendation about the grievance.

Conclusion

The mechanism of review by the Professional Standards Committee of a medical society does appear to offer a procedure by which there can be some resolution of these complaints. In cases in which a judgment could be made the complaint was decided in favor of the complainant as frequently as in favor of the physician.

Associations of physicians and professional organizations have no legal authority. They do not confer, nor can they withdraw a license to practice medicine. They cannot limit or obligate the form of an individual’s medical practice. Hospital staff organizations are similarly constrained. Although they can control the character of an individual practice within their own facilities, they cannot affect an individual’s practice elsewhere.

Nevertheless, these professional organizations often are called upon to assess the performance, professional activities and behavior of physicians. Assessment of quality of care, competence, administrative matters and ethics are often brought to these organizations for review. These organizations, with very little power, are asked to consider these matters, but it is not clear what kinds of issues are considered and what disposition is made of these reviews. Does this review provide any benefit to the patient, the community, the individual physician or the medical profession?

To explore some of these questions we analyzed the records of the Professional Standards Committee of the Medical Society of the District of Columbia. The study was not designed to evaluate the effectiveness, implications or consequences of this committee’s review, but rather to assess the nature of the issues that were raised and the characteristics of how the committee considered and disposed of these issues.

The records of the Professional Standards Committee of the Medical Society of the District of Columbia during a six-year period (1995–2001) were reviewed. The committee consists of 23 volunteer physicians, all members of the Medical Society, who were selected to represent a diversity of medical specialties. The committee met as a group monthly to consider all of the issues brought to its attention. All of the members served without compensation.

Prior to each meeting, detailed records and other related documents were assembled regarding the case under consideration. The complete file was sent to three members of the committee who analyzed the material and presented their findings to the entire committee. The full committee discussed and assessed the case and recommended a course of action.

The committee made a particular effort to maintain the privacy and confidentiality of all parties to the complaint. None was identified by name in the initial review. The participants were identified only in the final deliberations of the committee. All members of the committee understood, however, that a condition of the their participation is their absolute obligation to maintain confidentiality relating to all aspects of the committee’s deliberations.

The committee has a policy of accepting cases from any source. Most cases were derived from patient complaints but some were presented by hospitals, physicians or health insurance or managed care companies. Occasionally, the local government licensing board, because of its own limited resources, requested that the committee review a case on its behalf.

The committee relied substantially on documents submitted to it. It did not generally interview participants and did not take testimony in any legal sense. It did occasionally appoint a subcommittee to discuss issues in greater detail with participants.

The committee considered that its primary purpose was to assist the public and the medical community. It was considered appropriate to make recommendations to the physician about modifications of behavior or practice patterns if this was thought to be useful. In cases in which a complaint appeared unjustified, the committee tried to explain the situation and its reasoning to the complainant. In some cases it referred cases to the appropriate agency within the medical society for disciplinary action (typically, reprimand or the suspension or termination of membership) or referred the case to the government licensure or disciplinary agencies with a recommendation for further action.

During the six-year period, 193 cases were received and, after review, assigned by the committee chairmen to one of eight categories of complaint. There often was an overlap of issues in an individual complaint; the dominant issue determined which category the complaint represented. The complaints were sorted in the two general sections. One related to quality of care and physician-staff behavior. The other concerned issues of administrative office procedures. These were subdivided as shown in Table 1.

Table 1

Categories of complaints submitted

Categories of complaints submitted
Categories of complaints submitted

The number of cases per year reported to the committee appeared to have decreased during the six years of the study. In 1995 and 1996 there were 47 and 41 cases respectively reported to the committee. In 1999 and 2000 the number of cases were 25 and 23 respectively.

I.A. Quality of Care:

Most of the cases that dealt with quality of care issues focused on the patient’s concern that the physician did not meet expectations in the delivery of care. Patients characterized the doctor with phrases such as: “incompetent,” “unresponsive,” “uncaring,” or “too busy.” Patients considered by the physician to be demanding or a “difficult patient” often complained that the “doctor should have spent more time” or that they felt “rushed” or in other ways felt that their needs were not being met. Many cases were associated with billing complaints and it appeared that the unsuccessful medical encounter could have been tolerated except for the eventual presentation of an unpaid bill.

Specific issues included complaints such as delay in reporting test results, the timely return of telephone calls, proper awareness of the patient’s allergies, unnecessary testing or services and lack of appropriate supervision of a resident or medical student in the performance of an examination or procedure.

Of the 39 cases in this category the committee judged that care was appropriate in 18 (46 percent) and inappropriate or unacceptable in nine cases (23 percent). Because of the inability to corroborate conflicting descriptions of events, or because of the possibility of associated litigation, the committee was not able to make a judgment, chose not to make a judgment or provided a limited response in 12 cases (31 percent).

I.B. Physician and Staff Behavior:

Cases in this category involved the subjective description of how the physician (or how the physician’s staff) interacted directly with the patient. The physician was described with terms such as: “rude,” “offensive,” or “insulting.” Sexually based complaints included lewd comments, examinations without a chaperone, inappropriate discussions of issues of a sexual nature or “sexist” language. Some patients complained that the physician did not return calls in a timely manner, thus demonstrating “rude” behavior. Clearly, there was an overlap of categories and some of these complaints could be considered a quality of care or communication issue. Some of the complaints in this category involved confusion in the physician’s termination of the doctor-patient relationship.

Because of the inherently subjective nature of interpreting behavior and comments made by individuals, it was often difficult to make a definitive determination or recommendation. Where issues were clearly identifiable, as improper termination of a relationship or unambiguous instances of missed telephone calls, the committee recommended changes that could improve practice procedures. When seemingly irreconcilable issues, such as a mismatch in personalities occurred, the committee first established that the characteristics of the medical services were appropriate, and then suggested that an alternate physician be selected for continuing care.

Of the 28 cases in this category, the committee judged that the physician or staff behavior was appropriate in 10 (36 percent), and inappropriate or unacceptable in 11 (39 percent). The records were insufficient to make a determination in the remaining seven cases (25 percent).

I.C.Patient-physician communication:

Twenty-three of the cases considered were grouped in the category of communication; the complex problem of the difficulty that the physician and patient have of conveying information to one another. Since so large a part of the quality of medical care relates to this issue, there is considerable overlap in these cases and in those related to quality of care. Patients often said that they were not given necessary information to enable them to understand what was happening. Patients who were perceived as “difficult” or “demanding” challenged the physician’s resources and professionalism, creating problems with physician frustration, strained relationships and the allocation of time and tact. The complexity of this ineffective communication was interpreted as uncaring, uncompassionate or exhibiting a lack of interest in the patient’s problem.

Of the cases considered 12 (52 percent) were clearly related to inadequate physician communication. In five (22 percent) it appeared that the communication was related to patient issues and the physician acted reasonably with adequate physician effort to elicit patient understanding. Because the description of events was contradictory no judgment could be made in six of the cases (26 percent).

I.D. Ethics:

Many of the cases brought in the various categories could be considered violation of physician ethics. We have, nevertheless, separated a special group of complaints here which relate to the particular issues of breaches of confidentiality, conflicts of interest, misrepresentation in advertising, improper sexual conduct and abandonment.

Of 193 cases, only 18 (9 percent) specifically involved ethical issues. It was judged that there was no significant breach of ethical conduct in seven of these cases (39 percent) and that significant improper behavior occurred in five cases (28 percent). No judgment could be made in six cases (33 percent). The inability to render a specific decision was typically related to conflicting and inconsistent characterization of events occurring between two individuals, with no possibility of independent verification of assertions.

II.A. Billing:

The most frequent category of complaint was related to billing, charges, insurance reimbursement and associated administrative matters. The range of billing complaints included issues that were clearly illegal (e.g., fraudulent billing), or administratively inappropriate (e.g., withholding of records or necessary care due to an unpaid bill), to matters of judgment (e.g., the magnitude of charges), administrative concerns (e.g., timeliness of patient refunds) or issues related to the nature of reimbursement from health insurance companies.

The most common complaint was excessive billing; the contention that the bill was too high for the service rendered. This matter was particularly accentuated when the patient felt that the quality of the care was substandard. In some cases, the concern became a complaint when it became apparent that an unpaid balance existed because an insurance company had not paid an entire fee. Other billing complaints included improper collection practices, delayed refunds, staff billing errors and business office policies. This last group includes items such as pre-payment for services in an allergy practice or cosmetic surgery, fees for copying medical records and missed appointment charges.

Of the 50 complaints in this category, the committee judged that the physician (and/or the physician’s office staff) was in error in 22 cases (44 percent) and that patient’s complaint appeared not justified in 20 cases (40 percent). No clear judgment could be made in eight cases (16 percent).

II.B. Medical records:

Twenty-three cases involved problems with medical records. These included delays in the transmittal of records, fees charged or the withholding of records pending payment of an outstanding bill or a copying charge. In a number of cases it was necessary to inform the patient that charging a fee for this service was not inappropriate. On the other hand, physicians often needed to be reminded of the unacceptability of the withholding of records because of the patient’s unpaid bill and had to be cautioned to avoid what appeared to be excessive charges. In 13 cases (57 percent) it was judged that the records were sent in a timely manner with a reasonable fee. In nine cases (39 percent) these procedures were not followed. No judgment could be made in one case.

II.C. Office practice procedures and II.D. Disability and worker’s compensation:

A small group of miscellaneous cases were grouped in the category of office practice procedures (10 cases) and disability and worker’s compensation (two cases). These included a diverse group of issues including scheduling, telephone procedures, insurance eligibility or misunderstandings about the nature of disability evaluation procedures. No generalizations could be made from this small number of diverse cases.

A number of studies have considered the activities of state licensing and professional regulatory authorities and have tabulated and analyzed their experiences.15  Studies of these agencies have been directed at assessing their ability to identify health care professionals who “may be incompetent, impaired, uncaring or may have criminal intent.” The government licensing agencies and state medical boards appropriately resolve these issues.

There are relatively few studies of the process of the review of professional conduct by voluntary professional organizations that have no legal authority. To what extent, and in what format, with what authority, should any group of professionals be asked to review the work of its colleagues? The nature of the review by medical societies, specialty medical organizations or hospital staffs is variously structured, vaguely characterized and little studied. The concept of peer review may mean one thing in the assessment of material for publication, but may mean something very different for evaluating professional competence, or for the work of a governmental licensing agency and different still for review of ethical misconduct or administrative misunderstandings by a medical society. In all cases, the process appears to have been inconsistently organized and implemented.

Hickson, et al6  analyzed patient complaints presented to the patient affairs office of a large medical group. They focused on the relationship of these complaints to the risk of malpractice litigation. Wofford et al7  analyzed the unsolicited complaints collected at a large academic medical center. They established seven categories of complaints related to physician behavior and explored their epidemiology: disrespect (36 percent), disagreements about expectations of care (23 percent), inadequate information (20 percent), distrust (18 percent), perceived unavailability (15 percent), interdisciplinary miscommunication (four percent) and misinformation (four percent), with overlapping categories in 19 percent of the cases. A descriptive summary report of the activities of one medical society was published in 1952.8 

The AMA Council on Judicial and Ethical Affairs has no data on the patterns of patient complaints.9  In a report analyzing the experience of the Saskatchewan Medical Society10 , “rudeness” accounted for the greatest number of complaints against a physician. The lack of proper role modeling in physicians’ training was cited as a cause for creating arrogant physicians. The report speculated that contributing factors included physicians’ intolerance of a more knowledgeable patient-consumer and an unwillingness to spend necessary time discussing care with the perceived obligation to cope with burdensome time constraints and increased administrative responsibilities.

An 11-year study of the complaints submitted to the Grievance Committee of the medical society of a two county area of North Carolina11  analyzed 29 complaints that were sorted into five categories: failure to fulfill expectations for examination and treatment (38 percent), failure to properly diagnose (20 percent), rudeness (17 percent), producing excessive pain or practicing beyond the area of expertise (13 percent) and inappropriate behavior related to billing (10 percent). This Grievance Committee judged that there was no breach of professional standards in 45 percent of their cases. In an accompanying editorial12  Localio estimated the number of medical encounters in this community and calculated a grievance rate of 0.6 per million patient encounters. He reflected on the “... remarkable decade of amicable human interaction.”

Such reassurance can be misleading. The spectrum of patients’ reaction to medical care extends from enthusiastic praise to mere satisfaction, and then to dissatisfaction or the perception of it being inappropriate or, in the extreme, to unacceptable. Even then, it is likely that relatively few cases are thought to be so unacceptable as to justify the time and effort involved in the submission of a complaint. While not all complaints appear justified and many do not involve a breach of standards or conduct, it should be assumed that only a small fraction of perceived grievances actually result in the submission of a complaint to any grievance committee through any mechanism.

Several issues emerge from reviewing these cases. It is apparent that many of these grievances could have been avoided by the use of some simple preventive and educational procedures.

  1. Fees. The most common complaints were related to billing and financial matters. In large part, this appears to relate to patient and physician confusion and uncertainty about what services are reimbursed by various health insurance and managed care programs. The issue is confounded by the administrative complexity of adjusting bills and collecting fees. The reasonableness of a fee is a matter of judgment and, similarly, what an insurance company will pay for that service is uniquely determined by that insurance company. Because many grievances derive from these issues, it seems obvious many of these complaints could be avoided if fees were published or discussed in advance of the provision of services.

  2. Medical records. Physicians should be cautioned of their obligation to make medical records promptly available regardless of outstanding patient balances. Patients should be informed that a fee can be charged for the preparation of these records.

  3. Termination of physician-patient relationship. Physicians should be informed of their options in the termination of the care of a patient and should understand the proper legal and ethical standards with which this can be implemented, including the timing of this termination, the arrangements for alternate care and the availability of medical records.

  4. Chaperones. Physicians should avoid any situation that might create an appearance of impropriety. They should use chaperones for patient comfort, in patient-sensitive and unstable-patient situations, or in any case in which their judgment suggests the use of a chaperone would be helpful.

  5. Communications. Physicians should make a particular effort to review administrative policies and procedures and staff behavior to ensure that inappropriate administrative practices are not adversely affecting the provision of professional care. Physicians should make a particular effort to try to understand the variability of patient behavior and expectations, and should be prepared to adapt their behavior to accommodate this variability and to avoid untoward results. They should make a particular effort to provide information, including the prompt return of telephone calls and the reports of studies in a format that is comfortable for their patients.

The experience of this Professional Standards Committee suggests that this function can assist the community in the resolution of some physician-patient conflict. Although the committee has no legal authority, very few physicians ignored the requests by the committee for information, comments and records and very few were unresponsive. Physicians were respectful of this obligation to their colleagues. Although about half of the cases involved physicians who were not members of this medical society, the non-members were as responsive to the committee’s inquiry as were the members.

Professional committees are always at the risk of appearing to dismiss complaints and to favor their colleagues. There is, of course, an element of sympathy for the often-difficult position of a colleague, but the committee made a particular effort to avoid this professional bias — perhaps with some success. Of the 141 cases in which it was thought possible to make a judgment 51.8 percent were decided in the physician’s favor and 48.2 percent were decided in the patient’s favor; not clearly a whitewash or a universal condemnation of behavior This fraction is comparable to the North Carolina experience11 .

It seemed striking that relatively few cases clearly involved misconduct or ethical behavior. Although one could argue that any case judged in the patient’s favor involved some element of inappropriate behavior, the ethical issues thought by the committee to involve breaches of confidentiality, conflicts of interest, misrepresentation in advertising, improper sexual conduct and abandonment were relatively few; only 9.3 percent of the total cases.

It is not possible to accurately estimate the prevalence of complaints in this community. The population base is undefined since many suburban patients obtained care in the urban center (and vice versa). Similarly, the number of physicians in the community is difficult to measure since many had both urban and suburban offices. There is no simple way of estimating the number of patient encounters. Nevertheless, a crude calculation can be made. There are about 3000 practicing physicians in the community. If one assumes that they each have 10 patient encounters on each working day, and about 225 working days in each year, there would have been about 40.5 million patient encounters in the six years of the study. The 193 complaints represent a frequency of about 4.8 complaints per million professional encounters. This is slightly higher than the results in the North Carolina study11 ; a difference that may be related to the rural/urban differences in the two studies. It is of concern that there are so many complaints, but similarly, it is remarkable that there are so few. It is, of course, not possible from this study to assess how many grievances are unreported.

It also is reassuring that patients can feel comfortable that this mechanism can offer an outlet for their grievance. There are no data in this study about patient satisfaction with the process or its outcome, but in at least 48.2 percent of the cases in which a judgment could be made (and 37.6 percent of the total cases) a decision favorable to the patient was made and some satisfaction was provided. No judgment was made in this study whether deliberations and considerations of the committee actually affected physician practice patterns or subsequent behavior.

Finally, it does appear that one can make a reasonable case that volunteer physicians, working under the aegis of a medical society, can review these cases, can reach a decision, can do it with confidentiality and can, in doing so, provide a service to the complainant and to the community, the medical profession and to the affected physician.

The authors are grateful to the members of the staff of the Medical Society of the District of Columbia and the members of the Professional Standards Committee for their assistance in the collection of these data and the preparation of this manuscript.

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Author notes

Dr. Frank: The Medical Society of the District of Columbia, Washington, D.C, .and the Department of Medicine, The George Washington University School of Medicine, Washington, D.C. Dr. Hoffman: The Medical Society of the District of Columbia, Washington, D.C. Dr. Stolar: The Medical Society of the District of Columbia, Washington, D.C.