3.2.4. Inappropriate Behavior

"Inappropriate behavior" as a reason for complaint was associated with the residence area (rural or urban): χ2(1) = 4.296, *p* = 0.038; Phi coefficient = 0.172, *p* = 0.038, indicating a small effect size. In cases where patients lived in rural areas, inappropriate behavior was more likely to be a reason for complaint (16.7%) compared to those who lived in urban areas (5.8%).

#### **4. Discussion**

This study allowed the analysis of data gathered during 14 years of activity of the Commissions on monitoring and professional competence for cases of malpractice in the Moldova region of Romania. Our results showed several findings that could be the starting point for formulating prevention methods designed to the reduction in the number of malpractice claims.

Our study showed that the ground for complaints are both reasons related to technical aspects of the medical activity and reasons related to the relationship between patients and medical staff, these results are consistent with literature data [14]. The analysis of these reasons is important so as to improve the medical practice by identifying various prevention methods that target both the medical practice and the doctor–patient relationship, to improve medical services provided to patients, and to protect the medical staff from complaints [2].

In our study we found that over half of the complaints were registered in two counties (Iasi and Galati). The large number of cases in these two counties (compared to the other counties included in the research) is due, most likely, to the fact that Iasi and Galati are university centers, with clinical hospitals, which can provide a higher level of medical services and can treat more severe cases, and where many patients from other counties in Moldova are referred from smaller hospitals. Likewise, many patients request on their own initiative a referral by the general practitioners to specialists working in university centers, sometimes contrary to their recommendation [15].

Literature data show that there are no medical specialties spared by malpractice complaints, but some specialties have a higher risk compared to others [16].

In our study, the most frequently reported medical specialties are obstetrics and gynecology, emergency medicine, general surgery, and orthopedics and traumatology. These results are partly consistent with those of other studies. Obstetrics and gynecology, general surgery, and orthopedics and traumatology also occupy the first places in studies conducted in other countries, such as the United Kingdom, China or the United States of America [4,7,17].

The increased risk of certain medical specialties for malpractice claims is mainly due to the particularities of the medical services provided and the patients treated. Physicians in obstetrics and gynecology, for example, treat not only one patient, but often at least two (mother and child) or even three, if we take into account the concerns of the future father, while by taking care of the reproductive system of the woman, it also deals with potential future patients, the reproduction of the human species, thus becoming a specialty of the entire family [4]. Patients accessing obstetrics and gynecology services often expect for more than what a doctor can actually do, asking for flawless results of the medical interventions, such as safe labor when the child is to be given birth [18]. Becoming a parent can be an overwhelming issue, and the perinatal period is characterized by plenty of emotions related to the health status of the newborn. As such, this emotional burden on the parents may become a trigger for complaints against professionals in this field when the newborn is not healthy [19].

Physicians in orthopedics and traumatology are at high risk because they have to take care of patients' work capacity [4], which may have significant social and professional implications.

The increased risk for complaints of malpractice in surgical specialties is underlined by Jena et al. (2011), who showed that allegations of medical malpractice occur quite frequently in this specialty. Those authors found that 88% of physicians in at-risk surgical specialties (neurosurgery, thoracic and cardiovascular surgery, general surgery) had one complaint against them until the age of 45, and the number increased to 99% by the age of 65 [7]. Patients who need surgery usually suffer from severe diseases for which they expect doctors to work miracles. As the medical procedures are more complex, the associated risks increase in a directly proportional manner [4].

A peculiar result of our study was the fact that emergency medicine was the second most claimed specialty in terms of the number of complaints, and the third most claimed specialty in terms of the number of doctors involved, which is in contradiction with other studies that found a small number of complaints against the medical personnel who work in emergency medicine units, patients and the general public taking into account that physicians in this specialty work in critical

conditions [20]. However, a similar result was reported in the study conducted by Hwang et al. (2018) in Taiwan, where this specialty occupied the third place, with 8.5% of complaints, after obstetrics and orthopedics [18]. Furthermore, unlike various studies published in the literature in which there is an increased number of complaints against general practitioners [21–23], in our study family medicine (which in Romania is equivalent to general practice) was involved in only one complaint against doctors from several specialties.

Our finding that the ratio between the number of complaints in Emergency Medicine and that in family medicine was reversed compared to other studies finds its explanation in the fact that Romanian patients use emergency medicine unit services excessively, to the detriment of primary health care services [15,24]. Patients often shunt the family doctors, abusively calling emergency medical services, even in non-life-threatening situations. This overuse of emergency medicine to the detriment of family medicine (which is underused) is also demonstrated by the fact that many ambulance requests, especially during regular working hours, are resolved at the patients' homes, representing situations that could have been solved by the family doctor [15]. An essential reason for patients requesting excessive consultations from emergency services is the possibility to be seen by a doctor without a referral from the family medicine physician or in case they do not have health insurance. Although health insurance is mandatory for all Romanian citizens, European Commission reports show that in 2017, 11% of the population did not have it [25]. There are certain diseases (e.g., genetic diseases, diabetes, tuberculosis, myasthenia gravis, increased obstetrical risk in pregnant women, peptic ulcer, mental illnesses) [15,26] which can be assessed or followed up by a specialist physician directly in the outpatient department, without a referral from the family doctor [24], which could further explain the lower number of complaints to the latter, by the lower addressability. Moreover, the primary health care system in Romania is not accessible to everyone, about 2.5% of the population do not have access to a family doctor [27].

In our study, 9.2% of the patients complained about the doctors' inappropriate language, 9.2% complained about their inappropriate behavior, and 15.7% complained about the lack of information or the deficiency in offering information. These issues raise an alarm about how doctors approach and relate to their patients and the fact that deficiencies in the doctor–patient relationship can lead to a malpractice complaint.

Our study highlights that individuals from rural areas were more likely to report inappropriate behavior compared to those from urban areas. In rural areas, the relationship between the doctors and their patients is much closer [28,29]. This closer relationship might result in the patient preferring to wait a long time (sometimes even a few hours) to be examined by their own doctor when the latter is very busy, or even to postpone a consultation if their doctor is not available, instead of contacting another physician [28]. Interpersonal relationships are generally closer in rural areas, where communities are small, people communicate more with each other (for example, they usually all greet even if they do not know each other), they live in communion. The rural environment is characterized by greater social integration, with friendly and neighborly support and involvement by the community, compared to the urban environment [30]. The rural patient, accustomed to close interpersonal relationships in their area of residence, both with the community and with the physician, is disturbed when urban physicians, with less time allocated to patients, interact less with the patient, behave more distantly and sometimes arrogantly, as some patients in our study pointed out. These issues become more relevant when the outcome of the medical intervention is not in line with the patient's expectations.

Data from the literature show that in addition to the actual harm caused to the patient, as an independent reason, an important role in formulating the complaint has a series of triggers, especially related to the relationship between doctor and patient [31], to how the patient is approached by the doctor [5], and to the fact that the doctor often leaves the patient without explanations as to the reasons for the failure of the medical act [32]. At the same time, there are studies showing that despite the occurrence of harm to the patient, the proper way in which physicians have related to their patients contributed to the patients' decision to not complain about the medical act [33].

The ability of inter-human relationships, in the form of communication and the attitude of the doctor towards the patient [5], strongly influences the medical practice. Communication failure often predisposes the occurrence of adverse events [34]. Moreover, patients are more likely to complain about the doctor after the occurrence of an adverse event if the doctor–patient relationship is dysfunctional [3]. Thus, the study conducted by Veerman et al. (2019) showed that at least 10% of patients were disappointed in how their doctors behaved and communicated with them, in the sense that their problems were not given due consideration and that their doctors were too busy to discuss with them [5].

A study conducted in the United States of America that analyzed the malpractice complaints in general surgery showed that 34% of complaints were related to poor communication [35].

Doctor–patient communication triggers complaints of malpractice also from the perspective of obtaining the medical history. Failure to obtain an accurate medical history predisposes to misdiagnosis and treatment errors, which generates patient dissatisfaction and subsequent malpractice complaint [36]. On the other hand, a good communication may prevent the patient from making a malpractice complaint even if the result of the medical act is not as expected, because the level of communication between doctor and patient allows the latter to understand the situation and accept the result [37]. Regarding the starting point of conflicts, both family members and physicians recognize the implications of poor communication [38]. Doctors who disregard their patients' feelings and concerns, who provide little information, who do not have the patience to listen to or are not open with their patients are more likely to be reported, compared to their colleagues who communicate more efficiently with patients [3].

Our study showed that the lack or deficiency in communication was more likely to be reported by the family than by the patient, rather when the patient had died and when the patient was a newborn. These elements suggest the need of the family to be informed in difficult moments, such as the unexpected death of a family member or the health condition of their children. Moreover, when death occurs in a child, the need for the parents to receive information and explanations is even higher, given that usually a child is not supposed to die from natural causes [20]. Communicating bad news can be a difficult task for doctors, with a great emotional load on both sides. To provide it in an appropriate way, the doctors need specific training and protocols [39]. In general, the perinatal period is associated with a strong emotional load [19], and as the reality of a newborn's health problem adds significant a degree of vulnerability [40], it can strongly upset the new parents, some of them perhaps experiencing parenthood for the first time. Therefore, the need for realistic, accurate information about the medical situation becomes essential [38,40]. Moreover, it is necessary that the doctor–parent interaction be grounded on clear, prompt, and compassionate communication by doctors [38,40].

In our study, inadequate informed consent or lack thereof was reported in 6.5% of cases. This result is closely related to the results of other studies, such as one conducted in Australia, which showed that 5% of negligence claims and conciliated complaints were related to the process of obtaining the informed consent [32]. Obtaining the informed consent is an important part of the process of communicating with the patient. Agarwal et al. (2018) identified aspects related to professionalism and inadequate informed consent as factors favoring the initiation of malpractice complaints in cases involving spine surgery [41].

Our results showed a higher probability of complaining about the lack of consent in cases where patients were newborns. This result was related to another result of our study indicating that the lack or deficiency of communication was a more common reason for complaint by the patient's family (when the patient died, or the patient was a newborn or incompetent). Data from the literature indicate the need for a family-centered approach in the medical settings for the care of newborns, requiring the adequate approach of the parents [40,42,43]. In a family-centered approach, the parents and the doctor form a partnership in which the parents are offered the opportunity to actively participate in the care of their child [42,43]. Sarin and Maria (2019) reported that parents often show distress, frustration, and alienation when they are not involved in caring for their own child [42], thus creating the premises for complaints when the evolution of the case is not favorable.

Patients who complain about their doctors for the damage they suffered as a result of a misdiagnosis or treatment error [2] may want to obtain compensation, to find out what happened [3], to get an explanation, or they may want the doctor to admit their mistake [3,31] and express their regret [31]. Patients may also want to prevent the occurrence of similar incidents in the future or for justice to be done, i.e., those responsible for the mistake to be held accountable [3,44].

Our results showed that in 59 (38.5%) cases the reason for complaints was the occurrence of a complication of the medical act, the complaints being directed towards 75 (36.58%) physicians. The most frequently claimed specialties for this reason were obstetrics and gynecology (15 complaints, 19 doctors), general surgery (6 complaints, 10 doctors) and orthopedics and traumatology (7 complaints, 9 doctors), all of them major surgical specialties, which, by their nature, involve an intrinsic risk of the occurrence of additional harm during surgical interventions which are often complex [4]. Some of the complications are related to the complexity of the disease, but others are related to errors that could have been prevented [45]. Our results show that women were more likely to claim complications than men and for the complaint to be made by the patients rather than their relatives, probably because the patient is the one who endures the physical suffering associated with the occurrence of a complication and the subsequent necessary treatments. The complaint for the occurrence of a complication of the medical act was associated with a greater number of hospitalization days and with multiple hospitalizations because the occurrence of a complication requires additional medical or surgical treatment.

The diagnostic error was a reason for complaint identified in 19 (12.4%) cases, involving a number of 28 (13.65%) individual physicians, the three most involved specializations for this reason being pediatrics (4 complaints, 6 doctors), obstetrics and gynecology (2 complaints, 3 doctors), and orthopedics and traumatology (2 complaints, 5 doctors). This was a more likely reason for complaint for patients with multiple hospitalizations. The lack of diagnosis was a reason for complaint in 8 (5.22%) cases, involving 11 (5.36%) doctors, the most involved specialty for this reason being general surgery (2 complaints, 4 physicians). Although the literature data most often refer to diagnosis errors in general (lack of diagnosis, misdiagnosis, and delay in diagnosis), the results of our study showed a lower percentage compared to those reported in other studies. For example, 32.1% complaints related to diagnosis were reported by Gupta et al. (2018), 38.8% of them concerning hospitalized patients [46]. Gupta et al. (2018) observed a decrease in this percentage during the 13 years of the study period (January 1, 1999-December 31, 2011), an aspect that can be explained by the increasing accessibility of the diagnosis techniques, especially in the medical imaging field [46]. The diagnostic errors in outpatients were estimated at 5.1% of the cases [46]. Schaffer et al. (2017) showed that diagnostic errors were the most reported reason in cases of paid claims, being found in 31.8% of these cases [47]. Diagnostic errors were the most common cause of complaint in the study performed by Saber Tehrani et al. (2013), which showed that diagnostic errors were accompanied by the highest costs and the highest degree of danger for patients [48].

Misdiagnosis is often associated with mistreatment and may require multiple re-admissions in the hospital, increasing morbidity and the associated costs [46]. Agarwal et al. (2018) found 31.6% claims for delayed diagnosis and 32.7% claims for failure to provide appropriate treatment, which may underline that acute patients need prompt and appropriate care [41].

In our study the lack of diagnosis was reported by men rather than women, a similar result being obtained by Gupta et al. (2018) [46]. According to the empathizing-systemizing theory, proposed by Baron-Cohen and cited by Zaidi (2010), men tend to systematize, seek solutions, understand, and build different systems, going to the root of the problems, so that everything becomes clear to them. Therefore, male patients are dissatisfied by the lack of a clear explanation for their health problems and start their own search for solutions or answers [49].

The consequences of diagnosis errors have been analyzed by several studies. For example, Zwaan et al. (2010) identified a 6.5% death rate in a hospital due to adverse events [50]. Gupta et al. (2018) showed that diagnosis errors result in 47.4% of deaths and 33.9% of disabilities [46]. In our

study, diagnosis errors were not significantly associated with the patient's death, this being reported only in 10.6% (*n* = 7) of the deceased patients. A reason for complaint strongly associated with the patient's death in our study was the delay of the medical act. The most involved specialties for claiming delay in the medical act were general surgery (4 complaints, 5 physicians) and emergency medicine (4 complaints, 4 physicians). Delay as a reason for medical malpractice claim in emergency medicine is again associated with the overutilization of the emergency services where the waiting time to receive medical care is inversely proportional to the severity of the emergency.

In cases when the patient is deceased or incompetent (i.e., by age, by physical or psychical disability), the complaint is submitted by a family member. In our study, this occurred in more than half of the cases (i.e., 58.8%). This aspect has multiple facets. Except for the already mentioned reason regarding the stress and emotions surrounding the perinatal period, the parents of an injured child might be preoccupied by the future of their offspring in case of disability [19]. Likewise, the death of a loved one may cause a great deal of distress, with material or moral prejudice, the family thus being entitled to ask for explanation and compensation in case of the physician's malpractice leading to the misfortunate event [1]
