A 10-year retrospective descriptive study of internists’ complaints referred to Fars Legal Medicine Center

Today, physician’s malpractice in Iran has been increased due to economic slump and financial problems and reduced people’s general incomes. Therefore, many people want to compensate these property damages and lack of finance with complaints from physicians. One of the most important occupational challenges of physicians is patients’ discontent and complaints (Zengin et al., 2014) which are referred to a forensic medicine center and also its sequences in patients’ lives which may take place everywhere in the health care systems (Velsor et al., 2018; Obama, 2016). Health care systems are defined through dependence on human operators who work with uncertainty, complicated cumulative technology, and different kinds of facilities (Mossialos et al., 2016). Errors and legal issues are inevitable and may have serious effects on patients’ lives (Popescu, 2015). These sequences not only waste the physician’s time and energy (Oshel & Levitt, 2016) but also are a stressing situation that any physician with any academic degree and expertise may face during her/his professional life (Castro et al., 2018).

Medical malpractice includes diagnosis, misdiagnosis, and treatment of diseases. Namely, malpractice can occur in the first referral of a patient to a doctor or it can occur during management and treatment of a patient’s problem or disease (Gaither & Copp, 2016). In other words, malpractice is a failure and lack of competence and knowledge of physicians in the diagnosis and treatment in a standard level (Jimenez-Corona et al., 2006). Medical malpractice includes different types as lack of skill, lack of respect to the governmental system, imprudence, and inconsiderateness. Lack of skill can result from being amateur and inexperienced, or insufficient boon from medical knowledge and updated medical sciences (Traina, 2009). Lack of respect to the governmental system means disregarding of established rules by the ministry of health and/or health deputy which can occur due to negligence or incompetence (King & Crewe, 2014). Imprudence is defined as giving up an action due to negligence, delinquency, and forgetfulness (Hamilton, 2016). In fact, it means that a person has done something that should not be done (Arhan et al., 2009). Inconsiderateness means lack of awareness of a physician of an obligation which he/she did not perform (Nakanishi, 2014). In the case of an error, patients tend to learn about a medical error if it happens or they want to know the cause of complication, and acquire ways to prevent its recurrence (Madea & Preuß, 2009).

Nowadays, the rate of dissatisfaction and complaints of the patients is increasing despite physicians and therapeutic staff’s efforts and use of available facilities (Friele et al., 2015). According to the statistics of the USA, in 1970, 3 to 4% complaints were recorded against physicians. In 1980, this rate increased to 20%, and in the year 1990, it reached to 25% (Dyrbye & Shanafelt, 2016; Kermode-Scott, 2005). Also, 11 states of the USA show that the data of medical malpractices since 1993 to 2002 increased by 18%. In Italy, the hospitals were against claims of medical malpractice beside physicians in offices. Yet, the number of confirmed cases has been declared about mistreatments of physicians in private offices more than those working in hospitals specially for esthetic medicine (Dyrbye & Shanafelt, 2016). In most cases, autopsy proves that medical malpractice has not taken place and also there is no real scientific connection between the suspect misuse and the patient death (Casali et al., 2014).

Malpractice in Iran has increased as economic condition has worsened and economic and financial sanctions have been imposed against the government by other countries. On the other hand, in Iran there are not widespread studies in the case of internal medical malpractice field, so this study aimed to estimate the magnitude of the internal malpractice field and its five related subspecialties and also other fields’ specialists that receive complaints simultaneously.

Based on the plaintiffs’ sexuality in the investigated cases, the frequency of male plaintiffs was 147 cases (53.4%) and female plaintiffs was 127 cases (46.1%); in 1 case (0.3%), sex was not recorded. Maximum age range of the patients with complaints by sex in males was 30–39 and 50–59 years (n = 23, 11.25%) and in females it was 30–39 years (11.45%) (Fig. 1).

Among the 275 cases of the complaints against internists and aforementioned subspecialists, minimum cases and commissions belonged to the year 2007 (n = 5, 1.8%) and maximum commissions of complaints belonged to the year 2014 (n = 114, 41.5%) (Fig. 2). Also, the maximum age range of complaints in male was more than 90 years which was one person (0.7%) and there was no similar case in females (Fig. 2). The frequency of the plaintiffs’ education was as follows: 29 cases (11%) illiterate, 73 cases (27%) elementary school, 55 cases (20%) middle school, 44 cases (16%) diploma, 23 cases (8%) associate degree, 27 cases (10%) bachelor, 4 cases (1%) master’s degree, 9 cases (3%) doctorate, and in 11 cases, the plaintiffs’ education was not recorded. Among these 275 cases, 64 cases (23%) were single and 210 cases (76%) were married, and in 1 case, the marital status was not recorded.

Among the 275 investigated cases, the situation of the plaintiff which occurred after malpractice (according to their first referral for their compliant) included the following: 189 cases (68.7%) death, 39 (14.2%) malformation, 42 (15.3%) recovering, and 4 cases (1.8%) recovered.

The high rate of medical errors, malpractice payments, legal issues, and complaints from physicians leads to waste of the physician’s time and energy as well as high costs for related individuals and organizations. With respect to sex among males (53.4%) and females (46.6%), there were no significant differences in the number of the complaints. The most common level of the plaintiffs’ education was elementary (27%) and the least common level belonged to master’s degree (1%); based on statistical tests, it can be concluded that there was a significant relationship between education and the number of complaints, in such a way that education affects reduction in the number of complaints and we did not find any study with a similar education level. The most frequent complaints were in the year 2014 (41.5%) and the least frequent ones happened in the year 2007 (1.8%). This result is very similar to other studies conducted in Asia such as those of Li et al. and Buken et al. in China and Turkey, and interestingly in Iran, the ascending trend of complaints against physicians is visible (Li et al., 2017; Büken et al., 2004).

In this study and based on the investigations, educational and public medical centers were at the top in the rate of complaints and this can be due to the old educational curriculum and also lack of medical equipment and facilities. The reason of hospitalization made a significant difference in the number of complaints as the emergency medicine service section dominated 90% of complaints and the most malpractice by physician occurred due to inconsiderateness and negligence (59%), similar to the results of Beigi et al. in Isfahan (Beigi et al., 2015).

Annual malpractice from the beginning of 2006 to the end of 2016 varied between 0 and 5% generally, while the rate of the annual complaints in the same period varied between 0 and 45%, in which in contrast to the results of Studdert et al.’s study in USA (Studdert et al., 2006). This rate indicates that the complaints of patients against physicians and therapeutic staff are ascending annually, but the percentage of physician accusations and also paid malpractice payment amount have not significantly increased (Schaffer et al., 2017) (Fig. 3). This result indicates that the most common reason of complaints against physicians during this period is the increasing rate of economic slump and financial problems in Iran which put people under pressure, so finally, people need to meet their needs in other ways such as these complaints.

According to the high ratio of cesarean section (CS) to normal vaginal delivery (NVD) and the high tendency to have children in Iran, “while the government has been working hard to control it but, it has not yet reached the desired result,” and also, according to the dangers and complications of CS section, maximum malpractice payment belongs to gynecology for as much as 50,358,000 Rials which equaled to US$11,990 and general surgery field sustained the minimum amount of malpractice payment which involved malpractice and complaint simultaneously with internists. Among subspecialty fields, the maximum amount of malpractices belonged to gastroenterology for as much as 38,808,000 Rials which equaled to US$9240, and the most important reason of which is diagnostic treatments as colonoscopy, endoscopy, and endoscopic retrograde cholangiopancreatography (ERCP).

Annual malpractice which reached a final decision from the beginning of 2006 to the end of 2016 varied from 0 to 5% generally, while the rate of the annual complaints which was registered in the forensic medicine organization in the same period varied between 0 and 45%. Maximum malpractice payment belonged to gynecology for as much as 50,358,000 Rials which equals to US$11,990 that involved malpractice and complaint simultaneously with internists.

The most prevalent cause of death in complaints was colonoscopy, endoscopy, and ERCP, followed by misdiagnosis. Also, the most prevalent cause of side effects in complaint cases was sepsis and infection after hospital admission in general (Table 2).