Communication skills diminish malpractice risk

February 19, 1997

A new study suggests that the most important reason a patient with a bad outcome decides to sue his or her doctor for malpractice is not a lapse in the quality of care or medical negligence, but how the doctor talks with the patient.

Previous studies have dispelled the presumed link between malpractice suits and clinical errors, which can be difficult for a patient to detect.

Now a massive study of how physicians communicate with patients during office visits, published in the February 19, 1997 issue of JAMA, has documented specific conversational behaviors that differed between primary care physicians who were never sued and those had a history of malpractice claims.

"Effective communication enhances patient satisfaction and health outcomes," said Wendy Levinson, MD, professor of medicine and section chief of general internal medicine at the University of Chicago Medical Center and first author of the study. "On the other hand," she added, "poor communication often leads to patient dissatisfaction."

The combination of a bad outcome and patient dissatisfaction, note the authors, "is a recipe for litigation."

This study found that the process and tone of how physicians talk with patients may be even more important than what they say. Although the researchers found no association between malpractice claims and the content of the doctor-patient conversation, they did find a strong link between law suits and shortcomings in how that content was presented.

Simple things like orienting the patient about what to expect during a clinic visit or checking to be certain patients understood any information or instructions made the difference. Primary care physicians who frequently used humor were less likely to have been sued.

Physicians who had not been sued also spent slightly longer with patients (18.3 vs 15 minutes). They used more "facilitation," cues designed to get patients to talk about their concerns and express their opinions. Their patients provided more information about therapy.

"By practicing a few simple communication techniques, many physicians could significantly reduce their risk for malpractice claims," said Dr. Levinson. "More important, by learning to communicate better with patients, they could also increase patient satisfaction, improve compliance rates and thus have better biologic outcomes."

The researchers performed close analysis of 1,265 audiotapes of ten routine visits to each of 59 primary care physicians (general internists or family practitioners) and 65 general and orthopedic surgeons in Colorado and Oregon. The physicians were stratified by years in practice as either mid-career (13 to 20 years in practice) or late career (more than 20 years). They were divided into two groups: those who had no malpractice claims against them and those who had two or more.

Each statement from the 350 hours of audiotape was classified and given one of 38 codes for either content, process or emotional affect. Content included all medical information; process involved orientation about the flow of the visit; and emotion encompassed support or approval, empathy or concern, humor or criticism of third parties (eg, "It's pretty stupid for the insurance company to do that").

Despite the correlation between facilitation, orientation and humor and avoidance of malpractice claims among primary care physicians, the researchers found no such link among surgeons. One possible explanation: patients may not expect the same levels of compassion or personal relationships from surgeons. This study is the first truly empirical research on the relationship between physician communication and malpractice, Levinson said. In all the excitement over technological progress, she added, "not enough research has been devoted to the human side of healing."

The doctor-patient interview, she emphasized, remains the most common and important procedure in medicine. The average primary care doctor conducts 25 interviews a day, 110 a week, 5,400 a year or 162,000 interviews over a 30-year career.

"So we have lots of room to improve outcomes by making simple, inexpensive changes in the way we connect with patients," she said. "Competence doesn't stop with the technical."

The other authors were Debra Roter, Dr. P.H., Johns Hopkins University; John Mullooly, PhD, Kaiser Foundation Hospitals Center for Health Research, Portland, Oregon; Valerie Dull, PhD, Portland State University; and Richard Frankel, PhD, University of Rochester.

Summary:
A JAMA study suggests that the most important reason patients with bad outcomes sue their doctors is not medical negligence but how their doctors talk to them. The study documented specific conversational behaviors that differed between physicians who were never sued and those who had a history of malpractice claims.