HOW TO RESPOND TO A FORMAL PATIENT COMPLAINT

Dr. Noble sorts her mail while munching a quick lunchbetween patients. There is the usual junk, some jour-nals, and a letter from a consultant. But one letter islike a punch in the gut. Her eyes widen as she reads.

Only 8 months into practice, Dr. Noble is happywith her working environment. After completing herresidency she joined Community Primary Care As-sociates, one of several group practice options avail-able to her, which is located 15 minutes from herhome. She is pleased with the reimbursement pack-age she arranged, a combination of salary and annu-al bonus, and she likes her coworkers. The director ofthe group has told her she is fitting in well, the teamappreciates her clinical skills, and the businessheadaches are someone else’s, although she feels theadministration has listened to the few concerns shehas expressed so far. Best of all, after a few months ofadjustment she is attracting patients who appreciateher warm bedside manner.

But today her stomach churns as she discovers thata patient has filed a formal complaint against her. Theletter is from Major Metropolitan Health Plan, a man-aged care organization (MCO) that accounts for morethan half the patients seen by the physicians in hergroup. It is signed by a person she does not know,who is identified as a “Quality Improvement Advisor.”The opening lines sound accusatory: “We are chargedwith maintaining the quality of care for our mem-bers… .” Dr. Noble’s mind races with questions. Howcould this have happened? What should she do?

Criticism and allegations are hardly welcomefeedback from patients. But the reality of clin-ical practice is that patients may find reasons to

complain, despite one’s best efforts to provide goodcare. When suddenly faced with a patient complaint, aphysician should be prepared to offer a constructive

response and to consider the possibility that the com-plaint, even if not valid, may reveal an opportunity forimprovement. Patient satisfaction plays an importantrole in today’s consumer-oriented practice environ-ment [1–3]. Thus, it is worthwhile to take appropriatesteps to address problems that may undermine the suc-cess of individual patient encounters as well as the over-all health of one’s practice.

An angry or unhappy patient occasionally will ap-proach a physician or office staff member directly and exp-ress dissatisfaction. It is important to be open-mindedwhen a patient voices a concern and to consider that shemay indeed be right. Furthermore, she may have some-thing useful to offer, such as insight into how to commu-nicate more effectively. Addressing the patient’s concernappropriately usually does not require great effort and willlikely ensure that the patient leaves happy and thereforewill return.

Less commonly, a physician may receive a formal,written patient complaint through an official third party,such as an MCO that the physician or group practice hasa contract with or the medical licensing board of the statewhere the physician practices. Estimating from the vol-ume of formal complaints received in the author’s officeand anecdotes from practicing physicians, a typical physi-cian might receive one of these complaints every fewyears. A formal patient complaint by nature is unnervingfor the physician who receives it and may easily inciteanger, fear, and a defensive response. To put such com-plaints to rest and get on with one’s work, a physicianmust be able to respond quickly and effectively.

This article focuses on the process typically followedwhen MCOs handle formal written complaints againstindividual physicians in ambulatory practice and offersadvice about writing an effective response without un-due time and effort. The medical literature offers fewresearch findings regarding formal patient complaintsabout physicians. This article, thus, draws heavily fromthe author’s experience as a managed care medicaldirector, whose office receives many patient complaintsabout physicians each week and whose work has takenhim inside many MCOs nationwide. Having read hun-dreds of physicians’ letters, the author shares the ele-ments of a good response that is most likely to resolvethe matter. Although confidentiality constraints pro-hibit reprinting the text of actual patient or physician

Vol. 4, No. 2 June 2001 SEMINARS IN MEDICAL PRACTICE 17

PRACTICE BASICS

HOW TO RESPOND TO A FORMAL PATIENT COMPLAINT

Spencer H. McCleave, MD, MBA

Spencer H. McCleave, MD, MBA, Medical Director, PatientManagement Department, Aetna U.S. Healthcare, Middletown,CT. Dr. McCleave is a family physician. One of his duties atAetna U.S. Healthcare is reviewing and resolving health planmember complaints about physicians. As a former surveyor for theNational Committee for Quality Assurance, Dr. McCleave hasobserved how the formal complaint process works in many orga-nizations across the United States.

letters, the fictitious scenarios and examples offered aretypical of what the author has seen in actual practice.

The Formal Patient Complaint

As Dr. Noble reads the letter (Figure 1), she notes thatshe is asked to respond in 10 days. Attached to the let-ter is a photocopy of the patient’s brief, hand-writtencomplaint, which reads as follows:

Dear Sir or Madam:

I’d like to let you know about a bad experienceI had with Dr. Noble, one of the doctors in yournetwork, because I don’t think she should beallowed to treat people the way she treated me.I saw her twice, and the first time I went to herI thought she was going to help me. The sec-ond time, I had the feeling she just wouldn’t lis-ten to me. I had to talk her into doing an x-ray.How was she supposed to know what waswrong with me without it? What if I had can-cer? I hope you look into this and take this doc-tor off your approved list.

Thank you,

Hubert Baxter

Why Patients File Formal ComplaintsBased on the author’s experience, several factors maymotivate a patient to file a formal complaint against aphysician (Table 1). Most patients raise a legitimateissue from the health care consumer’s point of view.Some may be well-meaning citizens who sincerelyhope to save someone else from suffering at the handsof a “bad doctor.” For example, a mother who believesher baby’s ear infection was misdiagnosed might com-plain, thinking that the proper authorities can educateor discipline the physician and prevent another baby’sunnecessary suffering. Other patients may want todraw attention to something that could be improved,such as a chilly examination room, just as one mightnotify a hotel about a dripping faucet. Occasionally, apatient may be trying to retaliate, perhaps for a doc-tor’s rudeness or failure to listen.

Little research has been done on the subject of whypatients file formal complaints, although some indirectconclusions might be drawn from the literature on pa-tient satisfaction. Several studies have sought to revealreasons for poor patient satisfaction [4–12]. It shouldbe noted, however, that the findings from these studiesare quite variable and may not be generalizable to rea-sons for filing formal complaints. Some of the factorsthat have been linked to patient dissatisfaction include

service problems (eg, difficult encounters or poor com-munication with the provider, rudeness of the officestaff, long wait times) [6,7], unmet patient expecta-tions (eg, tests not done, medications not prescribed,specialty referrals refused, information not provided)[8,11], and patient perception of provider interperson-al behavior [9].

Outpatient service problems are common reasons forformal complaints in the author’s experience. In partic-ular, patients often complain about long waits to beseen or alleged rudeness of a provider or office staffmember. The author also has seen many complaint let-ters suggesting the occurrence of a misunderstanding, amiscommunication, or a failure of a physician to listencarefully enough to understand a patient’s true desires.

Clearly one cannot hope to eliminate complaints bysimply doing whatever patients want. However, strivingfor effective communication is a worthwhile goal for im-proving overall patient satisfaction [13,14] and for avoid-ing the risk of communication breakdown that is sosevere that an angry patient files a malpractice claim [15].

Agencies that Handle Formal ComplaintsIn this article, a formal complaint is distinguished froman informal one by the fact that it comes indirectlyfrom the patient to the physician, in writing, throughan official third party acting on behalf of the patient.Some patients may prefer going through a third partyto avoid directly confronting the physician with a com-plaint, or because a third party may have more cloutthan the patient acting alone.

In the author’s experience, individuals with gripesabout physicians usually send written complaints toorganizations and officials perceived as having somelegitimacy or authority. Some complaints go to officialswith little direct connection to health care administra-tion, such as the Better Business Bureau, local mayors,congressional or state legislators, nationally prominentpoliticians, and the press. Many of these officials haveno direct authority to investigate and act upon patientcomplaints about physicians, but will follow up as acourtesy to the complainant or because the agency seesits mission as helping to resolve disputes. When sentsomewhere inappropriate, a patient complaint often isredirected to an agency better able to deal with theindividual’s immediate concerns.

Several agencies familiar to physicians have authorityto investigate and act on formal complaints, includingMCOs, the administrative offices of physician organ-izations, state licensing boards, and Medicare. A thirdparty’s authority depends on what stake it has in the dis-pute, what right or obligation it has to become involved,

FORMAL PATIENT COMPLAINTS

18 SEMINARS IN MEDICAL PRACTICE Vol. 4, No. 2 June 2001

and what relationship it has with the patient and thephysician. The major agencies that routinely handle pa-tient complaints have an obligation to convey the prob-lem to the physician, to get a response, and to assist inresolving the immediate issue.

MCOs. All MCOs are licensed by the state gov-ernmental department that regulates insurance, andalmost half are accredited by the National Committeefor Quality Assurance (NCQA) [16]. Most statesrequire MCOs to respond to their members’ com-plaints, and most state insurance regulators can getinvolved if the complaint is not handled properly.Typically, the goal of such state oversight of MCOs isto prevent abuse of the consumer by the MCO, withimproved clinical care as a secondary consideration.NCQA requires MCOs that seek its accreditation toaccept complaints from MCO members, to investigatethem, and to seek to resolve them [17]. In addition,NCQA accreditation encourages MCOs to review

complaints it receives to find systematic problems thatcan be improved. For example, if MCO members in acertain geographic area complain often about how dif-ficult it is to find an obstetrician, the MCO might tryto find more obstetricians to serve its members in thatarea. MCOs are required by their state regulators—and if accredited, by NCQA—to respond to and inves-tigate complaints within specified time frames. For aphysician, the most severe adverse consequences thatcould result from a complaint to an MCO include ter-mination of the physician’s contract, which couldimpact revenue, and reporting of certain serious prob-lems to the National Practitioner Data Bank [18] andto state licensing authorities.

Physician organizations vary from small group prac-tices, to independent practice associations with hundredsof employed physicians, to contracted arrangementsbetween hospitals and local practices. The diverse natureof these organizations does not permit a meaningful dis-cussion of how they handle formal complaints. Generallyspeaking, the authority to act on formal complaints mayvary, depending on the organization’s legal relationshipwith the physician. This authority might derive from anorganization being a physician’s employer or may bestated in a contract that a physician signs to become apartner or member of the organization.

State medical boards have defined areas of jurisdic-tion and specific legislative mandates. For example, theTexas State Board of Medical Examiners has a responsi-bility to review patient complaints looking for violationsof the Texas Occupations Code, which is a specific set ofstate regulations governing the licensing and activities of



Beatrice Noble, MDCommunity Primary Care Associates212 Fourth Street, Suite A-1Roseland, NY

Re: Hubert Baxter, MMHP member number 982375001

Dear Dr. Noble:

We are charged with maintaining the quality of care for our members and as such must investigate any concerns they haveabout the physicians in our network. Please review the attachedcopy of a letter we received from one of our members, andrespond. Your response will be confidential and will not be sharedwith the member, although it may be used in quality improve-ment efforts and referred to our Physicians’ Clinical PracticeCommittee. You may include any pertinent medical records thatrelate directly to the member’s concerns. We must have your written response within 10 days, in order to ensure that we meetimportant deadlines.

Sincerely,

Jane ClarkQuality Improvement Advisor

Figure 1. Sample letter from a managed care organizationrequesting that a physician respond to a patient complaint.

HealthPlanMMMajor Metropolitan Health Plan 400 Market Street Bedford Hills, NY

Table 1. Possible Factors Motivating a Formal PatientComplaint

To improve health care and service

To exercise one’s civic duty to protect others from “baddoctors”

To correct an error, such as an incorrect bill

To express frustration, outrage, or anger at a physician

To gain leverage on a specific issue by using the offices of amore powerful agent

To avoid confronting a physician directly about some issue

To punish a physician for some wrong suffered (real or perceived)

To influence others to achieve an end (eg, to obtain insur-ance coverage for a medical procedure)

To distract attention from one’s own bad behavior (eg, anoutburst of loud swearing in the waiting room)

health care professionals. This code requires the TexasState Board of Medical Examiners to investigate when aphysician may be impaired (eg, due to substance abuse,a cognitive disorder, or some other problem); however,it does not investigate complaints that do not directlyaffect the physician’s ability to provide good medical care[19]. Therefore, a patient who complains that her doc-tor was drunk will get the Board’s attention, whereas apatient who complains that the office has no convenientparking likely will not. State boards tend to investigateallegations of significant clinical care problems (eg, mis-diagnosis of a myocardial infarction), substance abuse,sexual misconduct, and fraud (eg, lying to obtain a med-ical license). Physician impairment deserves and receivesattention from state medical boards, and a physician whois found to have seriously violated state statutes couldlose his license or even face criminal prosecution.

Medicare has defined authority over Medicare-participating physicians and takes complaints abouthealth care fraud from consumers, inviting patients tocompare their Medicare statements with the servicesreceived from their providers [20]. For example, if a pa-tient saw on his statement that Medicare was billed for acolonoscopy that he did not have, he could contactMedicare and report it as possible billing fraud. Medicarecannot revoke a physician’s state license, but it can pros-ecute for various offenses and can restrict a physician’sability to be paid for seeing Medicare patients.

Complaint Handling Within an MCOA few words about the jargon of complaint handlingare in order. The correspondence a physician receivesfrom a third party may contain terms that have specif-ic meaning, but perhaps only to that agency. For exam-ple one third party may call a patient’s written com-plaint a concern, yet refer to oral comments coming inby telephone as complaints. An appeal generally refersto a request for an MCO to change a coverage decisionit made, but not every complaint is an appeal. Al-though the jargon can be confusing, one does not needto know the jargon to respond.

In Dr. Noble’s case, the patient complained to anMCO. MCOs typically route written complaints aboutphysicians in their provider networks to a specific personor office within the MCO for investigation. A largeMCO may have a department dedicated to handlingformal complaints and a database or system for keepingtrack of the correspondence involved in the complaint-handling process. Patients’ letters are scrutinized forsigns that a clinical care problem occurred. An examplewould be a complaint from a patient who came to herphysician’s office while having a severe asthma attack

and then waited 2 hours before being told the physi-cian had been called out on an emergency.

Many physicians express concern that a patient com-plaint may lead to termination from an MCO’s providernetwork [21]. In actuality, typical MCO proceduresinclude safeguards against frivolous termination of aprovider contract. Formal complaints are reviewed by amedical director within the MCO, who has experiencein patient care and who therefore understands that notevery complaint is an indication of substandard care.Then, even if a clinical care problem is uncovered (eg, apatient on prolonged digoxin therapy with no monitor-ing of drug levels), the MCO medical director will like-ly refer the matter to a peer review committee inside theMCO. In an NCQA-accredited plan, this committeeincludes MCO-appointed practicing physicians of var-ied specialties, who are in the MCO’s network but notemployed by the MCO. This helps ensure that thephysician’s interests, not just those of the patient andthe MCO, are protected. When an MCO peer reviewcommittee examines a case of a possible clinical mishapor substandard care, the MCO usually gathers any avail-able information about other complaints against thephysician. It is unlikely that such a committee will cen-sure a physician for one or two complaints about incon-venience in the waiting room or alleged rudeness.However, if a serious problem is identified (eg, sub-stance abuse affecting clinical care, grave errors in treat-ment), the peer review committee is obligated to takesome action, not simply because of its relationship tothe MCO but because of its ethical duty to protectpatients and the legal requirement to report seriousproblems to state licensing authorities.

It is important to appreciate that many MCOs viewpatient complaints as a means to gather informationwith which to improve care processes in the long termand to effect change. For example, an MCO may cate-gorize all the complaints it receives from members andfind that at the end of a year, out of hundreds of com-plaints about physicians, 60% were about alleged rude-ness. As a result, the MCO might seek to improve thecommunication skills of its network providers, perhapsby offering courses about techniques for handling dif-ficult patients and situations or for improving commu-nication approaches and increasing awareness ofpatients’ individual desires and preferences [22].

The Physician’s Response: Constructive First Steps

As the letter sinks in, Dr. Noble begins to feel angryand confused. Who is this patient? What is it that hethinks she did? Did she miss a cancer diagnosis? Is she



going to be sued? She begins to worry. The nursewho assists on outpatient visits also does not recall thepatient. Dr. Noble sends her running after the medicalrecord.

The patient who filed the complaint is Mr. Baxter, aman in his 40s. The thin record documents only threeoutpatient visits. The first was for gonorrhea, treated 2 years ago by a physician who has since retired. Thatvisit does not seem relevant. On the second visit, about4 months ago, Dr. Noble saw Mr. Baxter for acute backpain he said began while he was working under his car.The examination was unremarkable, and the treatmentplan was the standard symptomatic advice Dr. Noblehas given to many other patients, who seem to acceptit well. She also prescribed a small quantity of narcoticanalgesics. Mr. Baxter returned a few days later to visitDr. Noble a second time, complaining that he had notimproved. The examination was the same. Dr. Nobleordered a lumbosacral radiograph, which was not herusual practice for a routine back strain. She recalls thatMr. Baxter had pressured her for the study and asked fornarcotics. Instead, on the return visit she prescribed anonnarcotic, nonsteroidal anti-inflammatory drug. Shesees that the medical record indicates that a colleaguehad called in a narcotic prescription the following day.Try as she might, she cannot remember anything said atthe time that might have let her know the patient wasunhappy.

Dr. Noble worries that Mr. Baxter’s complaintcould damage her reputation. She has no control overwhom the patient talks to, but she avoids mentioningthe matter to people who have no business to know.Frustrated, she speaks to another doctor in the prac-tice, describing the scenario in general but not identi-fying the patient. She asks if he sees any problem withthe care she had given, and he does not. He adds thathe might have ordered physical therapy and wondersif the man was drug seeking. Although Dr. Noble isafraid that the MCO may leak the complaint, her col-league reassures her that the health plan is subject tothe same type of patient confidentiality restrictionsthat they are. He says he too has had complaints likethis one over the years and always finds them upset-ting. He says it seems quite natural to react emotion-ally to the letter, but reassures her that since therewere no problems with her care, the complaint isunlikely to lead to any serious consequences.

At home, she vents to her husband, again withoutbeing specific about who the patient is. Her husbandurges her to concentrate on the many patients andcolleagues who have said good things about her atthe office. Dr. Noble sees that the letter from the MCO

asks for a response in 10 days. Swamped with paper-work, she decides to try to forget about the letter fora few days.

Cool Off and Calm DownMost physicians respond defensively to a complaint atfirst. One study found that practitioners experiencetheir reactions to patient complaints in three stages: ini-tial impact, conflict, and resolution; during the firststage, they feel shocked, panicked, out of control, andindignant toward patients [23]. Dr. Noble avoided im-mediately drafting a response while she was experienc-ing her initial emotional reaction. Like most physiciansin such a position, she was committed to providingquality patient care and felt deeply hurt that someonewould think that she had done anything other than herbest. A defensive reaction is natural and probably un-avoidable in these situations.

Because an effective response requires some thoughtand calm planning, it is best to wait until the initialshock has lessened before attempting to respond. Re-viewing the complaint with someone not directly in-volved can lessen its emotional impact and bring someobjectivity to the matter, as long as patient confiden-tiality is not violated and one does not create new legalrisks. Realizing that a single complaint is unlikely tomake or break a career helps to keep the matter in per-spective. In the author’s experience the vast majority ofcomplaints do not lead to dire consequences for thetypical competent physician who receives only one ortwo formal complaints every few years and who doesnot establish a pattern.

Accept that a Response is NecessaryThere are a few good reasons to respond to a formal com-plaint. For one, simple courtesy dictates that a response isessential. But even if a physician is not feeling particularlyaffable, she may have legal and contractual obligations torespond to a patient complaint. The obligation to a statelicensing board is obvious to the physician who wants tomaintain a medical license, but many physicians also haveobligations to MCOs because of language routinely in-cluded in contracts, which requires participating physi-cians to cooperate with utilization and quality man-agement programs. For an MCO, managing patientcomplaints properly can help identify problems that pa-tients are having with its network of physicians. Suchproblems are legitimate arenas for improving the quality ofthe MCO. If the contract states that participating physi-cians should cooperate with efforts to improve quality,physicians are obligated at the very least to respond and toexplain what happened when a patient complains.



For perspective, it is important to note that MCOsreceive complaints not only about their physicians butabout all aspects of their business activities, such as theircoverage limits, formularies, marketing materials, tele-phone service, and claims paying processes, to name justa few examples. They also receive complaints fromphysicians. An MCO that is responsive to its customerstakes note of all complaints it receives and deals withthem effectively.

Recognize the Value of a Good ResponseAn inappropriate or clumsy response can, at the least,prolong the matter’s resolution and consume more ofthe physician’s time later on, when the MCO needsmore information or writes to remind the physician thatthe initial letter went unheeded. One option Dr. Noblehad was to ignore the MCO’s letter altogether, perhapshoping the problem would go away. This passiveapproach will not work, however, because of theMCO’s obligation to follow up when a physician fails torespond. In some cases, the physician’s lack of a re-sponse becomes a separate issue worthy of investiga-tion, aside from the initial complaint, only creatingmore paperwork and trouble for the physician.

A good response can be crafted in a short time. Aclinical practice is like a business in many ways; han-dling complaints well does much to keep a businessfunctioning and growing. One has a reputation to pro-tect; but beyond that, a well-handled complaint canhelp keep patients in the practice—including the onewho complained, as well as with any relatives, friends,or coworkers of the patient who may also be, or will be,regular patients. A disgruntled patient usually sharesher problem with someone and may be conspicuouslyvocal about how a dispute with a doctor was handled.In rare cases, it may be best to dismiss a patient from apractice, if the physician-patient relationship cannot bemaintained because of persisting irreconcilable issuessuch as hostility or serious behavior problems (eg, vio-lence) [24]. Formal procedures for dismissing a patientexist and are usually defined by the state medical board.

The Physician’s Response: Taking Action andResponding Effectively Things to ConsiderIt is important to note that two responses may be nec-essary: a written response to the agency handling the for-mal complaint and some action to restore the patient’sconfidence and meet legitimate needs. For example, if apatient complained that a physician failed to mail in aform for her daughter’s summer camp physical exami-nation, it would not be enough to write a deft reply to

the MCO handling the complaint. The physician shouldfind the form and mail or fax it in as soon as possible.

What is the deadline for responding? Most officialcorrespondence will mention a deadline for the physi-cian, because the agency has a deadline of its own, some-times imposed by state law. This can mean that the agen-cy may choose to complete its investigation without thephysician’s response, rather than miss a deadline. It isbetter to be sure one’s own side of the story is reviewedand on file.

Is patient confidentiality at risk? Patient confiden-tiality is widely recognized as a fundamental element ofthe physician-patient relationship [25]. Before respond-ing to a complaint, a physician must be certain that theresponse will not violate patient confidentiality. When apatient complains to a third party and asks for assistance,it is implied that the patient is consenting to the MCO’sinvestigation and the disclosure of information pertinentto the investigation by the physician. The consent ismade more explicit in some cases if the patient signs ageneral release of liability or consents to have recordstransferred to others as needed in the course of medicalcare, as is typical when a patient is admitted to a hospitalor joins an MCO. The safest procedure is to check withthe MCO to see whether the patient has signed such aform and if not, the physician should ask for and receivesigned consent from the patient before responding.When responding to the complaint, only the minimuminformation needed for the purpose at hand should bedisclosed.

New national standards for the privacy of medicalrecords, gradually going into effect over the next 2 years, will influence how much and what kind ofinformation can be disclosed as part of quality assuranceactivities such as dealing with formal patient complaints[26]. Federal regulations derived from the HealthInsurance Portability and Accountability Act of 1996(HIPAA) require that patients’ medical records (in anyform, including written hard copies or electronic data)be used only for health purposes, such as health caretreatment, payment, and operations [26]. Health careoperations in this context refers to the administrativerunning of health care facilities and activities; thus, thedisclosure of medical records for a legitimate qualityimprovement purpose is permitted, provided that vari-ous restrictions that HIPAA specifies are followed. Itappears that, after the full implementation of theHIPAA privacy rules, a physician will still be able torespond to requests from agencies related to patientcomplaints and to include pertinent medical records.

Is a lawsuit impending? Infrequently, a complaint isthe first indication of an oncoming malpractice lawsuit,



the warning signs for which include a significant loss,injury, or damage sustained by a patient; a very angrypatient; or correspondence from an attorney indicating adirect threat of a lawsuit. In the author’s experience,most complaints have no realistic potential for develop-ing into a lawsuit, because most incidents described inpatient complaints do not have the prerequisite charac-teristics. First, although any patient can sue—at least the-oretically—about anything, before the lawsuit can mate-rialize a lawyer must be found to take the case. To bepursued, there must be an injury or loss, such as a severedrug reaction with permanent sequelae or blindnessfrom failure to diagnose herpetic keratitis. The loss orinjury does not need to be severe, but one cannot estab-lish malpractice without some adverse consequences suf-fered by the plaintiff. Next, the injury or loss must berelated to a negligent act or omission on the part of thephysician, such as misdiagnosis or failure to treat. How-ever, a claim of medical malpractice will wither on thevine if the harm or loss cannot be linked somehow to thephysician’s conduct or treatment of the patient.

If a patient alleges to an agency that some damageoccurred and a physician is implicated, that physicianshould discuss the matter with his insurer or legal advi-sor without delay. He may still be obligated to respondto the complaint, but the insurer may give advice aboutwhat to say and what actions to avoid.

Are there practice implications? Patient complaintsabout fees and billing can lead to practice managementdilemmas. Simple billing mistakes should be corrected.However, if a patient asks for a refund because the treat-ment did not work or because of an alleged misdiagno-sis, it is more difficult to choose the right course ofaction. Businesses in other industries sometimes refundunhappy customers even when no error was made, in aneffort to preserve the relationship. In certain clinicalpractice situations, offering a refund may be helpful,such as when the office makes a scheduling error thatseriously inconveniences a long-term, loyal patient onewishes to retain. However, one should consider the risksbefore refunding a fee. If good medical service was pro-vided and the result was not what the patient had hopedfor, a refund may imply that one agrees that the servicewas substandard. If a lawsuit is a realistic possibility, oneshould seek authoritative advice before promising torefund or reimburse a patient.

Was physical harm threatened? Rarely, a patientcomplaint will contain a threat of violence or harm. Avaguely worded threat that says, “I’m going to get backat you for this,” can be hard to interpret. However, if apatient is specific about what harm is threatened towhom, a physician should seek competent advice about

how to manage the security risk and take practical pre-cautions without delay.

Gather the FactsThe first step in preparing a response, after the coolingoff period, is to gather the bare facts and list them inlogical, if not chronological, order. In the author’s ex-perience, many physicians load their letters with argu-mentative statements that help to express their feelingsbut do not help bring the matter to resolution. Care-fully laying out the facts first makes it far easier to crafta calm and orderly description of events.

List the needs of the agency. In addition to speci-fying a date by which the physician should respond, theagency may ask for answers to specific questions spelledout in the letter. Surprisingly, many physicians fail torespond to direct questions, thus forcing the agent towrite back for a second response. For example, anagent might write, asking, “Did you refer Mr. Scarletto a dermatologist?” If such a specific question is notanswered with a “yes” or a “no,” it is hard for the agentto let the matter rest.

List the patient’s issues. The specific complaintsand requests of the patient also should be itemized,even if they seem irrational or unfair. By closely analyz-ing the patient’s complaint, a physician may discoverneeds that are implicit but not stated. For example, apatient who complains that her physician did not sendmedical records to another physician may still need tohave those records sent, even if that need is not explic-itly stated in the patient’s letter. The intention here isnot necessarily to satisfy all needs and requests but sim-ply to understand what they are. With an understand-ing of the facts, the needs of the agent, and the pa-tient’s issues, one can draft an appropriate response.

Draft the ResponseA physician’s response to a formal complaint will be kepton file by one or more of the involved parties. The tonetherefore should be businesslike and calm and the factscorrect. When responding to complaints, physicians canbenefit from the practical advice offered by quality ex-perts in other industries. John Groocock, former VicePresident for Quality at the international technology andmanufacturing firm TRW, Inc., recommends a com-monsense approach that is courteous and professional[27]. Mistakes should be corrected, apologies should beoffered, and questions should be answered straightfor-wardly [27]. One should assume that the quality com-plaint is justified, because even if it is not, offering a pro-fessional response is a good will gesture that may lead tothe same results in either case—a satisfied patient who is



more likely to return. Of course, if the physician in factagrees that the complaint is justified and correct, anapology for lapses of courtesy or bedside manner, officeinefficiencies, or service goofs are very appropriate andalso likely to restore the patient’s confidence.

The letter should describe any incidents or eventschronologically, unless another sequence is clearer.Often it is appropriate and helpful to include medicalrecords that pertain directly to the matter at hand. Peerreview allows the inclusion of medical records, as domost managed care contracts. One way that managedcare has influenced common office practice is that out-patient medical records are more likely to be read byothers outside the physician’s office. This is becausemore physicians belong to MCO networks, which havestandards for outpatient medical record keeping [17],and medical records are often included in MCO quali-ty improvement efforts.

Some things should not be included in the letter, suchas a direct response to a rhetorical question posed by anangry patient. For example, if the patient wrote, “Whatveterinary school did this quack go to?” it might not beconstructive to list one’s educational qualifications. Like-wise, it is not useful to try to convince the agent howwrong the patient is. Sometimes these attempts onlycloud the facts, fill the letter with irrelevancies, and makethe physician appear self-serving. For example, if a pa-tient with a known penicillin allergy claimed that a physi-cian prescribed a penicillin-related drug in error, the fol-lowing explanation would not be helpful:

“I resent the implication that I made a prescribingerror. In 20 years of practice I have never been sued,and I am well known in the community. As you know,I am department chief and I would not be in that posi-

tion if I did not have the respect of my fellow physi-cians. My enclosed resume speaks for itself.”

Having examined some of the mechanics of how aformal complaint is handled (Table 2) and an appropri-ate response is prepared, let’s see how Dr. Noble pro-ceeded.

Dr. Noble’s unhappy patient wrote in vague terms butprovided enough for her to begin to craft a response.After a few days pass and her anger subsides, she jotsdown the following:

The MCO asked for:• a response• that she meet a deadline (10 days from

receipt of the complaint)

The patient: • had the feeling she wouldn’t listen• had to talk her into doing an x-ray

She makes a first draft, trying to stick to the facts.She does not mention Mr. Baxter’s visit for gonorrhea.She starts out with an opening salvo:

“This man was drug seeking and clearly had hisown agenda. I don’t know why I ordered theradiograph, but it was not necessary and I thinkthe only reason he came to see me was to see ifhe could get narcotics. Since neither I nor mycolleagues here prescribe these drugs freely, hemust have gone elsewhere.”

Although she feels momentary satisfaction writingthis paragraph, she decides to delete it. When shereread it, she saw that it was full of speculation on herpart and did not help her meet her goal of resolvingthe issue. She tries again, this time confidently writinga factual account that will be helpful to the MCO andthat relies upon the good care she provided to speakfor itself (Figure 2).

The MCO’s quality improvement advisor takes theletters from Dr. Noble and Mr. Baxter to the plan med-ical director. Having been in practice himself, he toohas received complaints from a few disgruntled pa-tients over the years. He scans Mr. Baxter’s complaintand Dr. Noble’s letter and cannot conclude that Dr. Noble committed any clinical error or failed to pro-vide good medical care. The matter does not requirereferral to the plan’s peer review committee. The MCOsends Mr. Baxter a letter thanking him for expressinghis concerns. Because peer review laws in Dr. Noble’sstate forbid disclosure of the results of the MCO’sinvestigation, Mr. Baxter cannot be told what action



Table 2. Recommended Steps to Resolving a FormalComplaint

Cool off emotionally

Gather the facts

Seek professional advice if there is a risk of a lawsuit or ifphysical threats have been made

Follow confidentiality rules

Understand what specific things the patient and the agentare asking for

Write a draft, using the facts and addressing the specifics

Remove irrelevancies and unnecessary defensiveness

Recognize that complaints have value, and use them to improve

the MCO takes or what conclusion it reaches about thecare he received. The MCO’s database now recordsone complaint against Dr. Noble. Because the healthplan finds no violation of law, evidence of impairment,or other serious problem, it does not report the infor-mation to any governmental agency. Dr. Noble’srecord of one complaint does not distinguish her inany meaningful way from the other physicians in theplan’s network.

Dr. Noble, rather than dismissing the complaint asthat of a manipulative drug seeker, considers whethersomething in her attitude or demeanor gave Mr. Baxtera legitimate reason to think that she was not listening.There is no way to tell, now, what she could have donebetter—if anything—but she makes a mental note that,perhaps, her listening skills are not as good as shethought. She resolves to take the issue of patient com-munication more seriously and decides that, should shereceive other feedback suggesting a weakness in hercommunication approach, she will seek training toimprove her skills.

As this scenario illustrates, physicians should be ableto resolve the matter of a formal patient complaint withminimal agonizing. The key is to take a systematic andcareful approach so that one can prepare a carefullyworded letter that meets the deadline, includes a factu-al account of what happened, does not speculate, andaddresses, as well as possible, the patient’s specific com-plaints. Dr. Noble did not promise to do anything dif-ferent in the future—there was no need for her to doso in this case. Had a patient complained that her officedid not have wheelchair access or something similarlyspecific, that would have been worth addressing, per-haps with mention of a remediation plan.

Complaints Have Value In keeping with contemporary medicine’s drive towardimproved quality of care, patient satisfaction has be-come an important measurement for judging the suc-cess of medical services. The implications of patientcomplaints fit naturally into this scheme, providingfeedback on patient care that can be addressed at sev-eral levels.

Individual Physician ImprovementsPhysicians who find clinical work frustrating because ofpatient complaints may provide less than the best serviceand care to patients. It is a better strategy to considercomplaints as a guide to improving practice [28]. Phys-icians who have received common complaints such as“My doctor was rude to me” or “My doctor did notanswer all of my questions,” might benefit from training

to develop skills in effective physician-patient communi-cation. With effective skills in communication, a physi-cian may come to see responding to a complaint as ameaningful and satisfying method of resolving a conflict.

Several organizations such as the American Academyon Physician and Patient offer training programs toboost communication skills [22]. Minor adjustments incommunication style can help physicians encourage



Ms. Jane ClarkQuality Improvement AdvisorMajor Metropolitan Health Plan400 Market StreetBedford Hills, NY

Re: Complaint filed by Mr. Hubert Baxter

Dear Ms. Clark:

I am responding to Mr. Baxter’s complaint and to your letter ofMarch 14. I saw Mr. Baxter on November 12 for an acute backstrain. He said this occurred while working under his car at home.I enclose my office notes. The examination was not abnormal,except that I recorded tenderness in the lumbar paravertebralmuscles. I recommended that he apply warm moist heat and restas needed, as well as other symptomatic measures. I prescribednarcotic analgesic tablets to last 2 days if taken every 4 hours. He was advised to contact me if the pain worsened, especially ifthere was pain or numbness in his legs.

I saw Mr. Baxter again on November 16, when he returned to say he had not improved. The examination was the same. I ordered a lumbosacral radiograph, which was performed thatday in a radiology office in my building. I told him, in layperson’sterms, that it showed only mild degenerative changes consistentwith his age. At this visit I wrote a prescription for a nonnarcotic,nonsteroidal anti-inflammatory drug. On November 17, my colleague Dr. Foanitin called in a prescription for a narcotic. Our office has not heard from Mr. Baxter since then.

Mr. Baxter stated that he felt I wouldn’t listen, and that he had to talk me into doing the radiograph. It is true that I wouldn’tnormally order a radiograph of the spine under these clinical circumstances, but, after we discussed it, I did do so. I don’trecall anything unusual about that discussion, or anything during the visit that might have led me to think he was unhappy with his care.

Please contact me if I can be of further help.

Sincerely,

Beatrice Noble, MD

Figure 2. Sample letter from a physician to a managed careorganization in response to a patient complaint.

CA

P

C Community Primary Care Associates212 Fourth Street, Suite A-1, Roseland, NY

patients to take an active role in their health care, orconvince noncompliant patients to alter their behavior.Such programs also aim to renew a physician’s enthusi-asm for improving skills [29] that can help maintainpatients’ trust [30] and loyalty [31]. More informationis available than ever before about the art of communi-cating with patients [32,33], and its importance is notin doubt [34]. It should be noted that, although re-search is limited on the subject, at least one study sug-gests that low-intensity communication training pro-grams are not effective in improving general patientsatisfaction [35]. The authors speculate that longer,more intensive training across a broad range of skills,with ongoing performance feedback, may be needed toachieve overall patient satisfaction with office visits.

Organizational ImprovementsWith the advent of managed care, the profession ofmedicine has become more consumer oriented[36–38] and can therefore look to management pro-cedures in other industries as a model. Like businessesin other industries, physician practice organizationsshould create a systematic procedure for handling pa-tient complaints [39]. That procedure should involveinvestigating the complaint, having someone—eitherthe physician or another designated person—get backto the patient (verbally or in writing, whichever is moreeffective), and responding as necessary to an MCO ora state licensing board. The practice should keep trackof all complaints, categorize them, and seek to addressthe most common ones systematically. For example, ifmost patient complaints are related to telephone inter-actions with staff, improving telephone service shouldbecome a priority for the practice, which could usereadily available staff training materials [40]. (For moreinformation about complaint handling, readers aredirected to the Council of Better Business BureausWeb site at www.bbb.org.)

Because most patients, like customers of any busi-ness, never express their dissatisfaction to physicians,feedback should be actively encouraged to find outwhat patients think needs improvement [41]. To besure the practice hears from those who are too timid tospeak to their physicians directly or too busy to write aletter, the author recommends that office staff betrained to ask all patients if they are satisfied at the endof their visit or invite patients to write comments on acard. The more active the method, the more informa-tion will be gathered. Patient surveys are another wayof gathering feedback [42–45].

Whatever insights are gained from considering pa-tient complaints should be shared with everyone with-

in the organization. The organization, large or small,could then plan changes in problematic procedures andprocesses, then after implementing them, check andmeasure progress. The process can be adjusted furtherand the results checked again, until the problem isresolved to everyone’s satisfaction. This systematic ap-proach to improving the quality of work is often called“Plan, Do, Check, Act” [46], or continuous qualityimprovement (CQI). This powerful method of find-ing and implementing improvements was originallydescribed by Walter A. Shewhart in the 1930s [48],then adopted by many leading businesses, especially inmanufacturing. Donald Berwick, of the Institute forHealthcare Improvement in Boston, is an inspiringleader in the medical profession who is helping to bringsuch effective quality improvement methods to healthcare [48–50].

CQI in health care is driven by the need to containcosts while improving or maintaining the quality of carethat is delivered and responds to the new trend towardconsumerism. CQI embraces efforts to improve clinicaloutcomes, clinical efficiency, access, and service. Ber-wick and others [2] have argued that service to patientsis a major issue that deserves much more attention fromhealth care providers, and patient complaints in partic-ular can serve as a measure of the quality of service.Patient satisfaction has become a major concern ofhealth plans because of NCQA’s Health Plan EmployerData and Information Set (HEDIS), a method it usesto measure the quality of MCOs, and because of thenewly acquired ability to measure patient satisfactionthrough surveys [3,45]. These efforts necessarily filterdown to the individual doctor, where care and serviceare administered. CQI can be applied in any organiza-tion, regardless of size. Thus, many medical practicesare following the example of other types of businessesand are learning how improvement in service to pa-tients, not just clinical care, can pay off [51,52].

References

1. Ford RC, Bach SA, Fottler MD. Methods of measuringpatient satisfaction in health care organizations. HealthCare Manag Rev 1997;22:74–89.

2. Kenagy JW, Berwick DM, Shore MF. Service quality inhealth care. JAMA 1999;281:661–5.

3. Weiss BD, Senf JH. Patient satisfaction survey instru-ment for use in health maintenance organizations. MedCare 1990;28:434–45.

4. Brody DS, Miller SM, Lerman CE, et al. The relation-ship between patients’ satisfaction with their physiciansand perceptions about interventions they desired andreceived. Med Care 1989;27:1027–35.



5. Cleary PD, McNeil BJ. Patient satisfaction as an indica-tor of quality care. Inquiry 1988;25:25–36.

6. Harpole LH, Orav EJ, Hickey M, et al. Patient satisfac-tion in the ambulatory setting. Influence of data collec-tion methods and sociodemographic factors. J Gen InternMed 1996;11:431–4.

7. Rondeau KV. Managing the clinic wait: an important qual-ity of care challenge. J Nurs Care Qual 1998;13:11–20.

8. Kravitz RL, Callahan EJ, Azari R, et al. Assessing patients’expectations in ambulatory medical practice. Does themeasurement approach make a difference? J Gen InternMed 1997;12:67–72.

9. Froehlich GW, Welch HG. Meeting walk-in patients’expectations for testing. Effects on satisfaction. J GenIntern Med 1996;11:470–4.

10. Hall JA, Dornan MC. What patients like about their med-ical care and how often they are asked: a meta-analysis ofthe satisfaction literature. Soc Sci Med 1988;27:935–9.

11. Joos SK, Hickam DH, Borders LM. Patients’ desires andsatisfaction in general medicine clinics. Public HealthRep 1993;108:751–9.

12. Markham FW, Diamond JJ, Hermansen CL. The use ofconjoint analysis to study patient satisfaction. Eval HealthProf 1999;22:371–8.

13. Hall JA, Dornan MC. Meta-analysis of satisfaction withmedical care: description of research design and analy-sis of overall satisfaction levels. Soc Sci Med 1988;27:637–44.

14. Kaplan SH, Greenfield S, Ware JE. Assessing the effectsof physician-patient interactions on the outcomes ofchronic disease. Med Care 1989;27:S110–27.

15. Levinson W, Roter DL, Mullooly JP, et al. Physician-patient communication: the relationship with malprac-tice claims among primary care physicians and surgeons.JAMA 1997;277:553–9.

16. National Committee for Quality Assurance. NCQA’sstate of managed care quality report. Washington (DC):The Committee; 2000.

17. National Committee for Quality Assurance. 2001 stan-dards for the accreditation of managed care organizations(MCOs). Washington (DC): The Committee; 2000.

18. National Practitioner Data Bank. Available at http://www.npdb.com. Accessed 9 May 2001.

19. Disciplinary actions and procedures. Texas occupationscode. Section 164.052. Available at http://www.capitol.state.tx.us/statutes/oc/oc016400.html#oc013.164.052.Accessed 9 May 2001.

20. Health Care Financing Administration. Medicare fraudand abuse. 2000. Publication number 10111. Availableat http://www.medicare.gov/Publications/Pubs/pdf/fraud.pdf. Accessed 5 May 2001.

21. O’Hare PK. Terminating physicians from managed careorganizations. Healthc Financ Manage 1998;52:37, 39.

22. Kelly CK. Making patients the center of the medicalinterview. ACP-ASIM Obs 1999. Available at http://www.acponline.org/journals/news/feb99/center.htm.Accessed 3 May 2001.

23. Jain A, Ogden J. General practitioner’s experiences ofpatients’ complaints: qualitative study. BMJ 1999;318:1596–9.

24. Crane M. How to cut loose from a troublesome patient.Med Econ 2000;77:54, 59, 63–6 passim.

25. Confidentiality. In: Code of ethics: current opinions ofthe council on ethical and judicial affairs. Chicago (IL):The American Medical Association; 1994: E-5.05.

26. U.S. Department of Health and Human Services. Protectingthe privacy of patients’ health information. HHS Fact Sheet.Available at http://aspe.hhs.gov/admnsimp/final/pvcfact2.htm. Accessed 3 May 2001.

27. Groocock JM. The chain of quality: market dominancethrough product superiority. New York: Wiley; 1986.

28. Barlow J, Møller C. A complaint is a gift: using cus-tomer feedback as a strategic tool. 1st ed. San Francisco:Berrett-Koehler Publishers; 1996.

29. Reifsteck SW. Difficult physician-patient relationships.Med Group Manage J 1998;45:46–50, 54.

30. Murphy J, Chang H, Montgomery JE, et al. The quali-ty of physician-patient relationships. J Fam Pract 2001;50:123–9.

31. Safran DG, Montgomery JE, Chang H, et al. Switchingdoctors: predictors of voluntary disenrollment from a pri-mary physician’s practice. J Fam Pract 2001;50:130–6.

32. Makoul G. Essential elements of communication in med-ical encounters: the Kalamazoo consensus statement.Acad Med 2001;76:390–3.

33. Kurtz SM, Laidlaw T, Makoul G, Schnabl G. Medicaleducation initiatives in communication skills. CancerPrev Control 1999;3:37–45

34. Meryn S. Improving doctor-patient communication.Not an option, but a necessity [editorial]. BMJ 1998;316:1922.

35. Brown JB, Boles M, Mullooly JP, Levinson W. Effect ofclinician communication skills training on patient satis-faction. Ann Intern Med 1999;131:822–9.

36. Mayer T, Cates RJ. Service excellence in health care.JAMA 1999;282:1281–3.

37. Thomas AM. Patient satisfaction: measuring the art ofmedicine. JAMA 1998;280:2127.

38. Bolus R, Pitts J. Patient satisfaction: the indispensableoutcome. Manag Care 1999;8:24–8.

39. Better Business Bureau. Effective customer relations andcomplaint handling. A Better Business Bureau BusinessAdvisory Service Publication. Available at http://www.bbb.org/library/ba%2Dcust.asp. Accessed 9 May 2001.

40. Finch LC. Telephone courtesy & customer service. 3rded. Menlo Park (CA): Crisp Publications; 2000.

41. Tasa K, Baker GR, Murray M. Using patient feedbackfor quality improvement. Qual Manag Health Care1996;4:55–67.

42. Cleary PD. The increasing importance of patient surveys[editorial]. Qual Health Care 1999;8:212.

43. Cleary PD. The increasing importance of patient sur-veys. BMJ 1999;319:720–1.

44. Ford RC, Bach SA, Fottler MD. Methods of measuring



patient satisfaction in health care organizations. HealthCare Manage Rev 1997;22:74–89.

45. Gaynor S. Patient surveys. J Child Fam Nurs 1999;2:153–4.

46. Langley G, Nolan K, Nolan T, et al. The improvementguide: a practical approach to enhancing organizationalperformance. 1st ed. San Francisco: Jossey-Bass Pub-lishers; 1996.

47. Deming WE. Out of the crisis. Cambridge (MA):Massachusetts Institute of Technology, Center for Ad-vanced Engineering Study; 1982.

48. Berwick DM. Controlling variation in health care: a con-

sultation from Walter Shewhart. Med Care 1991;29:1212–25.

49. Kilo CM, Kabcenell A, Berwick DM. Beyond survival:toward continuous improvement in medical care. NewHoriz 1998;6:3–11.

50. Berwick DM, Leape LL. Reducing errors in medicine[editorial]. BMJ 1999;319:136–7.

51. Kilo CM, Horrigan D, Godfrey M, Wasson J. Makingquality and service pay: Part 1, the internal environ-ment. Family Pract Manag 2000;7;48–57.

52. Mertz MG. What does Walt Disney know about patientsatisfaction? Fam Pract Manag 1999;6:33–5.



Copyright 2001 by Turner White Communications Inc., Wayne, PA. All rights reserved.

Documents

HOW TO RESPOND TO A FORMAL PATIENT COMPLAINT