How we view complainants; an ethical dilemma?

Dentistry can be a rewarding career. Sometimes it can seem thankless and it is all too easy to become disillusioned when we do not feel appreciated. This may result from conflict with colleagues within a practice or hospital environment, or from a breakdown of the professional relationship we have with patients. It could be argued that, as a dental professional, it is important to concentrate on the positives and work on the Rousseauian1 premise that patients (and people in general) are intrinsically ethical and moral beings with a focus on values such as compassion and empathy. Accordingly, when dental professionals don't act with compassion and empathy, patients are more likely to find them cold and have reason to find fault.2 As a result, this coldness is often the progenitor of complaints being brought against a practitioner. It is well documented that the empathy scores of dental students decline as they progress through dental school.3 Somewhere along the training pathway it is not being properly emphasized that empathy is one of the key ways dentists and dental care professionals can promote equality and trust in their relationships with patients.

Complaints about hospital and community healthcare (including dentistry services) have increased dramatically in recent years. The total number of complaints rose by 1.3% between 2011 and 2012,4 and by 1.9% in 2012–2013 for organizations providing data in both years.5 This suggests that the current culture of increased complaints about dental treatment is unlikely to change dramatically any time soon. This increase in incidence of complaints requires dental professionals to engage actively with the complaints process at all levels. It is important to ensure that grievances are dealt with effectively, without the patient feeling the need for escalation.

When an objective view of the issue of a complaint is taken, a view of both perspectives must be considered; that of the clinician and the view of the patient. When the view of the dental professional is analysed, it is not unusual to find feelings of shame or embarrassment upon receiving a complaint. Why is this so? The perception that dentists can utilize a wide knowledge and skill base to ‘know’ the best way to treat their patients leads to a great inequality between dentist and patient.6 This approach portrays the dentist as being ‘all-knowing’. This is wrong as it is impossible for a dentist to be so omniscient. Not only is this incorrect factually, it is also ethically incorrect. By fostering this belief that they are ‘all-knowing’, all attempts at the equalization of power between dentist and patient are destroyed and there is a complete failure to build trust. This way of thinking leads to a paternalistic approach to patient care which is no longer acceptable in modern dentistry. It is not particularly surprising to find that dentists who subscribe to the ‘all-knowing’ belief system are devastated by complaints made against them. Even confident practitioners who are experienced in treating patients report feelings of shame and inadequacy when they receive complaints.7 It is interesting to speculate that if the current system of complaints causes such a dent in dentists’ confidence and trust in their skills, then there must be an issue either with the complaint system itself, the way professionals are reacting to it or both.8 There are many instances of dentists recalling how long-standing patients, who the professional believed they had a good relationship with, have complained. The reaction to this instance tends to be one of feeling let down. It is curious that practitioners tend to take personal offence at this occurrence and react intensely negatively, instead of using the patient's complaint to look at whether any improvement can be made to their practice as a result of understanding the reason for the grievance. This ‘all-knowing’ philosophy leads to a concentration of blame on the patient for his/her complaint, instead of rebuilding trust and remedying the situation. It has been documented that practitioners, having received a complaint, would be more likely to practise defensively and not in the best interests of patients.7

The General Dental Council (GDC) state in its nine principles of practice in dentistry that registrants must, ‘Have a clear and effective complaints procedure.’9 It is therefore well within the remit for the GDC to initiate disciplinary measures against referred dental professionals who have been shown to have failed in managing patient complaints properly. This highlights the importance the GDC places on the effective management of complaints in protecting the dignity of patients. Many dental professionals have concerns that, in the receiving of a complaint, the issue must be dealt with before escalation to a disciplinary hearing occurs. As a result, complaints may be dealt with defensively. This is unfortunate as disciplinary action due to complaints in general practice is rare. It is well documented that, in the majority of complaints, the purpose is to gain an explanation of events and fair compensation, if the patient is entitled to it.10 This action serves to redress the power mismatch that exists between the professional and patient. Despite this, many dentists are fearful that the GDC will use perceived disproportionate sanctions if they are complained about; this has the effect of creating defensive feelings when a dental professional is challenged by a patient on his/her actions.

It is possible to change perceptions of complaints so that, instead of the morale-lowering effect they instil, it is possible to look upon them in a positive light. It is unlikely that complaints will ever decrease below a certain level so as to be rare, however, if the current approach to their management is not working to create a truly positive outcome for both patient and practitioner, then an alternative perspective needs to be found. One such measure that could be suggested would be to increase training in dental schools that teaches students that dental professionals are not ethically or legally obliged to appear as ‘all-knowing’. The relentless drive to appear confident and competent in front of patients is not productive either in shaping expectations in patients or professional attitudes in students.

When patients complain, dental professionals are always given the advice to apologize by indemnity organizations. If a professional is to seem contrite, an apology must be perceived by the patient on the receiving end to be sincere and empathetic. It is not the intention of this article to discuss what an effective apology should entail, but the majority of patients would feel that an apology is not about blaming or retribution, more an acknowledgment that an unfortunate incident has occurred and that the professional has the ability to understand why the patient is upset. An important aspect of this sincerity is giving any apology in a timely fashion.

The paradigm, that often seems so appropriate in healthcare situations, ‘To err is human, to forgive divine,’11 should always be borne in mind when dealing with patients' complaints. So often, the complaining patient is not dealt with as a concerned human being, but as an awkward character who becomes the butt of jokes within the practice or clinic. It is less difficult to empathize if the reader thinks back to the last time they felt as if they had been poorly treated. When patients raise concerns, their comments and criticisms should be taken seriously and reflected upon once resolved. If we as dental professionals fail to do this, surely we are negating our raison d’être as a profession to serve those we treat. Some practitioners might look upon complaints as actions that break trust, that once a complaint has been made, the professional relationship has been irrevocably damaged. In the light of this, complaints may be better used to build trust by opening a dialogue that makes way for a more honest and sincere relationship. In doing this, complaints can be made into a more positive experience, with practitioners welcoming feedback and patients appreciating sincere attempts at redress.

There are some practitioners who, due to innate character flaws, will always be able to rationalize poor conduct.12 Thankfully, these types of practitioner are in the small minority and dental professionals are generally noble and honourable in their intentions. Dentistry is seen by many patients as a trusted profession and a failure to deal with complaints is an insult to this trust. It is an important duty of every dental professional to ensure that the dignity of patients is respected. It is important to maintain this respect when complaints arise. An effective and simple way of achieving this is by properly addressing complaints and by rebuilding lost trust in a humble and considerate way, rather than allowing false perceptions to cloud reason.