Physician bedside manner linked to malpractice suit

Laugh, listen to patients to reduce risk

The leading indicator of a malpractice suit is a physician’s communication style rather than a lapse in medical judgment or a lack of quality care, according to a study in the Feb. 19 issue of the Journal of the American Medical Association.

Based on these results, the journal suggests that primary care physicians who spend time with their patients, talking with them, listening to them and laughing with them may reduce the risk of being sued.

"We were floored at how predictive communication variables are," says research team member, Debra Roter, DrPh, a social scientist and professor in the department of health policy and management at Johns Hopkins school of hygiene and public health in Baltimore. "The bottom line is that it is important for physicians to pay attention to individual relationships. They should enhance patients’ abilities to participate in their own care." She cites other studies that show outcomes improve when patients are involved in their own care.

The study was funded by the Agency for Health Care Policy and Research (AHCPR) and was led by Wendy Levinson, MD, formerly of Oregon Health Sciences University and Legacy Good Samaritan Hospital and Medical Center in Portland, OR, and current chief of the section of Internal Medicine at the University of Chicago.

Roter says researchers specifically wanted to know whether malpractice suits stem from "critical incidents" in which something went terribly wrong with the care, or from routine "stylistic elements," such as the way in which a doctor practices medicine. Roter says this is quite a departure from the critical-incident thinking that the industry has always studied.

The researchers also looked at whether they could find an enduring pattern with the physicians’ interaction skills that could be measured and improved upon.

"Malpractice is overwhelmingly under-researched," Roter says. "It is a tremendous problem with financial and psychological implications for caregivers, but the occurrence is rare.

"We were intrigued by people’s motivation for filing a malpractice suit," she continues. "Only 1% of patients with bad outcomes caused by negligence will sue. Of course there are tons of frivolous suits, but we don’t count them. The hypothesis was whether the risk for physicians to be sued is predictable."

Researchers each audiotaped at least 10 routine patient visits with 59 primary care physicians, and 65 general and orthopedic surgeons in Colorado and Oregon. Subjects were randomly selected and were divided into two groups, depending on their malpractice claims history. The 1,265 audiotapes were analyzed by coders who did not know whether the physicians fit into the "claims" or "no claims" group.

Roter’s team went beyond traditional surveys to eliminate objective measurement. "We didn’t ask the patient how they thought a visit went," Roter says. "We audiotaped and did our own analysis on physician-patient encounters."

The researchers developed a code scheme that characterized statements as they were made.

The study found significant differences in communication styles between primary care physicians who received claims and those who had not.

Primary care physicians in the no claims group spent more time with patients during a routine office visit than those in the claims group, an average of 18.3 minutes to 15 minutes. In addition to length of the visit, researchers found several other differences in the interaction between physicians and patients. Primary care physicians in the no claims group were more likely to tell patients what was going to happen during the office visit by using phrases like, "First I’m going to examine you and then we will talk the problem over." These physicians also asked patients for their opinions and elicited questions and were more likely to use humor and laugh during an office visit.

In a related finding, the study shows that the communication style of surgeons did not appear to make a difference in malpractice claims. The researchers theorize that patients may see surgeons more as technical specialists and thus expect a more businesslike approach.

The researchers conclude that to decrease the risk of a lawsuit, hospitals should focus more on improving a physician’s communication skills. Roter points out that typically, hospitals focus on preventing malpractice suits through risk reduction programs that address the technical aspects of care. "They tell doctors what documents to keep in order to ‘cover’ themselves. But rarely do you see classes focus on relationship-building," she notes.

The researchers conclude, that "physicians can incorporate these behaviors into routine practice to improve their communication skills and decrease their malpractice risks."