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The Tonal Qualities of Providers' Voice Predictive of History
Abstract & Commentary
By John Shufeldt, MD, JD, MBA, FACEP, Chief Executive Officer, NextCare, Inc.; Attending Physician/Vice Chair, Department of Emergency Medicine, St. Joseph's Hospital and Medical Center, Mesa, AZ, is Editor for Urgent Care Alert.
Dr. Shufeldt reports no financial relationships with companies having ties to this field of study.
Synopsis: Surgeons' tone of voice in routine visits is associated with malpractice claims history.
Source: Ambady N, et al. Surgeons' tone of voice: A clue to malpractice history. Surgery. 2002;132:5-9.
Medical malpractice history is not only associated with medical negligence but is also associated with a provider's interpersonal skills — the nature and quality of communication with a patient. The quality of the care is not the only reason patients initiate a law suit. Rather, the decision to sue is based upon a number of factors, including the relationship the patient has with their provider.
This study is the first to evaluate the tone of voice of surgeons, as opposed to the content of the conversation, as a predictor for malpractice claims. The tone or manner in which a physician communicates may be as important as what was actually said to the patient. If the patient believes, based on the provider's tone, that they were harsh or negative, the patient may be much more likely to initiate a suit if the outcome is not what was expected.
This study recorded 114 conversations between 65 surgeons and patients during their pre-op visit. Half of the surgeons had 2 or more malpractice claims; the other half did not have any malpractice history. Two 10-second clips were extracted from each surgeon from the first and last minute of their conversation, with 2 different patients. The tapes were content-filtered to remove the content of the message, leaving only the tonal qualities of the conversation. These tapes were "judged" by Harvard undergraduate students and ranked on a 7-point scale for the following voice characteristics: warm, anxious/concerned, interested, hostile, sympathetic, professional, competent, dominant, satisfied, and genuine.
Using the 4 10-second clips from each surgeon, the judges were able to determine which of the surgeons had previous malpractice history and which surgeons did not. Controlling for content, ratings of higher dominance and lower concern/anxiety in their voices tones significantly identified surgeons with previous claims compared with those who had no claims. For dominance: Odds ration 2.74, 95% CI 1.16 to 6.43. For concern/anxiety odds ratio: 0.46, 955 CI 0.21 TO 1.01. Dominance was described as deep voice tone, which was loud, moderately fast, unaccented, and clearly articulated. According to Ambady and colleagues, this may communicate a lack of empathy and understanding for the patients, in contrast to the tonal qualities of concern/anxiety, which were felt to be positively related to feelings of concern and empathy.
This suggests that how something is communicated may be just as important as what is communicated. This study adds another piece to the already compelling data, which suggest that outcomes, such as patient dissatisfaction, provider shopping, poor adherence to medical directions, and medical malpractice claims are related not only to medical negligence but also to the content and tone of the communication with the provider.
I first came upon this study while reading the book Blink by Malcolm Gladwell. Although surgeons were the subject of Ambady et al's study, the findings are particularly relevant to urgent care practitioners. Given the nature of our patient encounters, urgent care providers need to be aware of any possible breaches in care or service which may lead to a malpractice complaint. We do not have the luxury of a long standing provider-patient relationship to help smooth out areas where we, or our staff, fell below the patient's expectations. Therefore, as urgent care providers we should be utilizing every tool we have to lower our medical malpractice risk. We can train ourselves and our colleagues to appreciate that both their verbal (content and tone) and non-verbal (posture and presence) communication will influence a provider's malpractice exposure.
Other ways an urgent care group can improve the malpractice exposure are to: Hire providers without previous malpractice history; identify patients with high risk complaints; identify patients who demonstrate by their actions that they may have unrealistic expectations; identify providers who engage in high-risk activities (yelling at staff, swearing in the clinic, dating patients, etc.).
Urgent care medicine ranks up with other high risk medical specialties and anything we can collectively and individually do to lower our malpractice exposure will benefit the entire specialty.