Talking of patient satisfaction, why exactly are the writers of this report so obsessed with it. It is at such a high level that we are likely to make very little improvement. There will always be a hardcore of career malcontents, determined to find fault no matter what we do and we are not going to make any difference to them either. I have certainly known one patient who was such a prolific writer of unjustified complaints that the trust eventually just refused to acknowledge them any more. And even when patients are justifiably aggrieved they still tend to be very British about it. Although I am told violence against medical staff is on the increase I personally have never seen an instance in my entire career, and even verbal abuse or threats I have seen very rarely. The worst most of us have to deal with is the odd written complaint. When it comes to the actions of dissatisfied patients or relatives our American colleagues have far more serious possibilities to worry about.