Results of the analysis of the 14 interviews are first reported here by means of the “heuristic narrative” to show how themes – i.e., what matters for physicians when they make sense of their experience of patients/relatives’ complaints – tend to be connected for the participants as a whole. This heuristic narrative is an interpretative synthesis of the analytic work. A detailed description of the emerging themes is then provided, with excerpts from the interviews.
Physicians’ sense-making of their experience: An overview narrative
Physicians showed a need for reconsidering and elaborating on the reason(s) leading to the complaint, and on the expectations patients/relatives may have had towards medicine and health care professionals [theme: What happened?: attributed causes]. This may be interpreted as an attempt to assign their meaning, and even “truth”, to what they had to face; such meaning having the potential to ease the distress associated with the experience of a complaint. Their decision to disclose or not to disclose this experience to their colleagues and/or superiors reveals the importance attributed to being subjected to a complaint and to its clinical relevance [theme: To share or not to share]. In this respect, the fact that communication-related complaints seemed to be considered problems unrelated to clinical decision-making and management is especially interesting [theme: To change or not to change].
Secondly described is the complaint experience with regard to the relationship physicians usually have with their patients, resulting in a seeming definition of what they perceive to be a good relationship [theme: What is a good patient relationship]. Their perception, in turn, influenced if the complaint was considered as comprehensible or not and the associated feelings (e.g., relief about the mediation when the relationship was viewed as tense or sadness when the therapeutic alliance was considered as having been strong) [theme: How it affected me]. When complaining patients/relatives were experienced as unpredictable, the meaning physicians were able to derive from the experience was hampered; the complaint was related to a specific type of person rather than a situation [theme: The complainant]. Finally, the mediators were difficult to apprehend by the physicians because of a lack of knowledge of their role (particularly their neutral stance) and of the aim of mediation [theme: The mediation].
Physicians contextualized their experience by referring to the role and missions of the EPP, and to the practice of medicine nowadays. With respect to the EPP, physicians considered its role to achieve an overview on the patient’s trajectory, to allow patients/relatives to express themselves, to reduce tensions outside the clinical setting, to provide responses patients did not receive from health care professionals, and to serve as a supportive third party which – particularly in difficult situations – assisted them in a non-judgmental way: “I told myself, well there is an arbitrator who will tell us how to communicate” (3 = number of the interview). Some physicians also felt that the EPP contributes to the improvement of the quality of medical services by reporting on the managed cases: “It is important that information from the EPP is fed back to the medical services, otherwise one has no opportunity to improve, to reflect.” (14). Others, however, considered that the EPP took over the health professionals’ duty to manage problematic situations (particularly owing to lack of time or objectivity), possibly judged the physicians’ behaviors: “A little bit like pointing the finger or something like that?” (6), or wasted the physician’s time: “Because it comes to discussing and not to punishment [of the guilty ones, whoever they are]” (11), generating more work for health care professionals and even encouraging patients against whom health care professionals already have to defend themselves: “We have to defend ourselves against people who are never satisfied, because they pay too much insurance and have the impression they also have more rights and so on” (11). Finally, the EPP was sometimes considered as “promoting a culture of complaints” and tarnishing the hospital’s image: “When one goes to a very good restaurant, if there is a vomitorium just next door, […] I think it gives a bad impression.” (11)
The broader context of medical practice was also addressed, such as medicine being omnipotent: “Medicine wants to solve everything. With this type of medicine, error is not possible” (7), or the power of litigating patients who take their frustration out on physicians: “The philosophy now in our hospital is essentially that every time a patient behaves in an unbearable manner, one writes a letter saying that we are sorry that everything didn’t turn out as well as we would have liked to, instead of saying ‘Listen Mister, you behaved in an absolutely inappropriate manner […] so you can stick your letter you know where’” (11). Similarly, some physicians felt that the hospital sacrificed physicians in fear that patients may turn to the media, and that university hospitals are “trash cans” (11) obliged to treat all patients, including those with a reputation of being difficult and litigious.
Emergent patterns of meaning
What happened?: Attributed causes
Physicians considered that most complaints originated from communicational or relational difficulties (1, 2, 3, 4, 5, 6, 7, 8, 10, 12, 13), such as questions that remained unanswered (3, 5, 13), a lack of mutual understanding (3,6), or an unbalanced relationship (2). But they also conveyed that complaints issued from malpractices and neglect (1, 7, 8, 9, 10, 12, 13, 14), such as a missed diagnosis (10), the non-respect of medical confidentiality (7), an unsuccessful operation (1), the lack of a care plan or of advance directives(6). Physicians also considered that the complaint was related to characteristics of themselves, like being incompetent (3) or lacking pro-activity (6): “What was hardest to endure [for the patient] was me” (12).
They furthermore explained the patient’s/relatives’ decision to turn to the EPP as a consequence of their tendency to perceive physicians as seemingly inaccessible to hear a complaint; as if they were on a pedestal (4, 14). The involvement of the EPP was also interpreted as a mean of patients to have an effect (e.g., to destabilize physicians by taking them out of the clinical setting (2), to fight against fragmentation of care by bringing together all health care professionals involved in their care (7)), and as an expression of a deception about medicine. Complaints were thus considered to emerge from situations in which medicine was unable to solve the problem of the complainant (1, 3, 6, 9, 13, 14). Here, physicians particularly referred to complaints related to non-acceptance of a chronic disease (14), the rapid evolution of a life-threatening illness (1), the progression of a problem (e.g., senile dementia) considered as reversible by relatives – “The patient had to be helped to eat […] she [his wife] came and said: ‘Listen, my husband is getting worse, there is a problem, as physicians you must solve this problem, I have to get my husband back, as before’” (3) – or the impression that the medical staff had not done everything possible (6), and that a medical intervention (e.g., in vitro fertilization) had failed (13).
To share or not to share
Physicians informed their hierarchy or colleagues about the complaint (2, 3, 4, 6, 8, 9, 10, 12, 13, 14), either because they wanted to convey their perception of the situation (2) or because the complaint was considered as being “just” related to a “communication problem”(4) and thus – unlike an error in clinical judgment – of little importance. Other physicians decided to not inform their hierarchy for the very same reason: because they attributed the complaint to communication issues and thus without further consequence (4, 12). These attitudes may indicate that physicians conceived communication problems and associated complaints as minor issues without a clinical impact.
To change or not to change
The estimated impact of the complaint process on practice seems to validate the last interpretation; indeed, physicians felt that its main effect was on communication (2, 3, 4, 6, 8, 10, 12): for example, increased repetition of information (6, 8), verifying that information is understood (6, 8), or acknowledging that a lack of communication is bad communication (3). Physicians also reported changes in how they started to explore patients/relatives experience of the situation, and to listen carefully, particularly if they were passive, anxious, or suffering: “Maybe I should have listened more to the fact she was really anxious about her [medical] history” (10).
What is a good patient relationship
Physicians made sense of the complaint experience in light of what they defined as a good relationship and good communication with patients/relatives, such as referring patients when there were communication problems (1, 5, 11, 13), or addressing the issues of death and the limits of medicine (3). This can be interpreted as an attempt to demonstrate and defend their way of encountering patients/relatives and practicing medicine. They emphasized for instance the importance of being transparent by explaining treatment protocols and their benefits (3, 5, 6, 7, 8), by initiating immediate discussions with the family when a complication or “a silly thing” (5) occurs, and by “taking responsibility for all the shit” (11) and fixing resulting problems. Physicians also stressed the importance of responding to patient/relative complaints, for example, by not avoiding the situation, accepting mediation, and dealing with threats from patients who wanted to write to the hospital management (1, 5, 11, 13), and they mentioned their willingness to encounter the patient as a person: “I always try to ask myself… what is the person like?” (3). Finally, physicians endorsed the need for reflexivity (3, 4, 11), particularly by constantly questioning oneself and by learning to accept criticism: “A resident or a chief resident who can’t bear to be criticized misses his vocation” (11). Good medical care was also evoked, characterized by the ability to recognize, as a physician, the limits of medicine, which may involve ceasing rather than increasing investigations or providing detailed information to prevent unrealistic expectations (3, 14).
How it affected me
The emotional experience associated with the complaint process was influenced by how physicians perceived themselves as “carers” and how they conceived their relationship with the complainant(s).
Physicians expressed sadness (1, 2, 4, 10, 12, 13): “[…] I was also depressed because they did not recognize all I have done for them” (13) or surprise (2, 3, 4, 6, 9, 10, 12, 13, 14) that patients had contacted the EPP or that a stranger (the mediator) had informed them of the problem: “To me, it was like out of the blue, to hear this, not from my usual staff” (3). They were also surprised that patients/relatives had turned their tragedy into a complaint (9), or considered the provided care as a bad experience (12). Some reported a certain satisfaction(1, 2,) that they gained through this experience a capacity to understand that hospital users undergo subjective experiences, that their reproach is legitimate, and that they benefited from the procedure initiated by the EPP. Relief (2, 4, 7, 8, 10, 11, 12, 13) was experienced due to the ending of the relationship with the complainant or to the involvement of the EPP as a neutral third party. Fear and apprehension (2, 4, 6, 7, 9, 13) were felt regarding conflict evolution: “It begins like this but I don’t know how far it could go” (2), having made a mistake, or the perception of a threatening attitude of the complainants.
Feelings of discomfort (2, 3, 4, 9, 12, 14) were mostly associated with a tendency to take the complainant’s criticism personally or to blur the professional and personal spheres: “As physicians, as caregivers, it is extremely difficult to retain a distinction between one’s caregiver position and one’s own self” (3). Self-criticism (2, 3, 8, 12, 13) was caused by doubts about one’s capacities: “Did I make mistakes with everybody or only with her?” (2) Physicians also related feelings of “being a punching ball” (2), feelings that they had to shoulder all the blame, and that they lack support from mediators and the hospital: “Mediators do not have to support physicians even if physicians would sometimes like to be supported (4).”
The complainant
The sense conveyed here is that the complaint was related to the profile of the patients/relatives rather than the clinical situation, which implies that physicians were unable to act on the situation that led to the complaint. Complainants were thus characterized in terms of their attitude (1, 2, 3, 4, 6, 7, 8, 9, 11, 12, 13, 14), their way of being in the world (2, 3, 4, 7, 8, 11, 14), their emotional state (1, 3, 4, 7, 8, 9, 12, 13, 14), and their individual characteristics (1, 2, 3, 4, 7, 8, 9, 11, 12, 13, 14), including their origins, rather than in relation to what they reported of having experienced. They were described as anti-physician: “The son in particular felt an animosity towards the medical community ‘Anyhow, you protect each other’” (4), malicious: “When she saw I was affected and crying, it was as if it provided her with a kind of satisfaction” (12), judgmental (3), and unable to accept apologies and listen to explanations (12,14). Regarding their way of being in the world (i.e., their relationships with themselves, others, and the world), complainants were viewed as difficult to please (3, 7, 14), self-centered (14) or persecuted and persecuting (7), and their emotional states was described as “vengeful”(9), “desperate”(13), “depressed” (13), or “in need of reassurance” (8). Finally, physicians described complainants by means of personality traits linked to origins (African (12), not French-speaking (13)), cultural and socio-demographic background (Moroccan’s emotionalism (13), advanced age (13), modest income (13)), psychic fragility (paranoid, psychotic, drug-dependent) or biography (history of abuse) (3, 4, 13).
The mediation
Physicians did not have a shared perception of the mediators and their role. Some physicians evoked their neutrality and acknowledged that mediators who are not involved in the situation can be more objective (1, 3, 4, 10, 12, 13), gain perspective (1, 3, 6, 10), and “smooth things”: “It was a good thing to have a mediator who was framing the discussion […] There was such an emotion, such a revolt, such a rage, we needed somebody” (1). For others, neutrality was interpreted as passivity: “He did say he would do something for us, if we wanted, but I got the impression it would be only a little bit [he was just like] an observer” (3). While some physicians felt that the mediators supported them and served health care professionals (e.g., because they marshaled complaints) (1, 3, 4, 6, 7, 9, 10, 12, 13, 14), others considered mediators to be the complainants’ defenders(4) or to lack lucidity regarding the complainant’s personality or the subject of the complaint (12).
Mediation as such was considered as allowing the recognition of the experience of the complainants (1), the improvement of the relationship with them, and mutual concession, or as generating frustration: “Difficult patients stay difficult” (11).