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When your patient's opinion of you goes from "Well, my doctor says ..." to "I'm going to sue that S.O.B.!" what could account for such a reversal? Two recent research studies may shed some light on this metamorphosis. One concludes that permanent harm, more than physician fault, decides lawsuits. The other concludes that effective physician-patient communication, not the quality of the care or documentation, is key to avoiding malpractice lawsuits.

Thank goodness, the vast majority of patients are not litigious (i.e., prone or inclined to litigate). Study after study confirms that patients are normally reluctant to sue their physician for malpractice, even where obvious misconduct has caused serious harm. Only a tiny fraction of negligently-harmed patients will actually file malpractice claims. (However, the incidence of frivolous lawsuits may be 4 to 5 times as high!)

Of course, low frequency is small comfort for the physician who, nonetheless, is named a defendant in a malpractice lawsuit. To make matters worse, it now appears that the type of harm, not blameworthiness, is a better predictor of the injured patient's success. A study appearing late last year in the New England Journal of Medicine1 concluded that permanent disability, not malpractice, is key to the success of a malpractice lawsuit.

The bottom line: Medical errors will only rarely land physicians in court; but if they are sued, having done everything right will not necessarily save physicians from a malpractice award! Clearly, physicians are far better off avoiding malpractice lawsuits in the first place. Doctors and courtrooms are not a good mix, even when the physician is present solely to testify as an uninvolved expert. Thanks to capitation and managed care, courtrooms pose more threats for physicians that ever before.

It is no secret that angry patients are more likely to sue. But what really motivates an unhappy, dissatisfied patient or family to decide to file a malpractice claim? A recent study in the Journal of the American Medical Association2 concludes that bad outcomes, combined with poor physician-patient communication, are the necessary ingredients for litigation. In 1993, Wendy Levinson, M.D., and her colleagues studied routine office visits at 124 physician offices in Oregon and Colorado. The group examined the relationship between physician-patient communication and malpractice claims, for primary care physicians and surgeons. Unlike previous studies, this research attempted to identify specific communication behaviors associated with malpractice history. Thanks to the JAMA article, we now have spotlighted some specific factors that may improve physician-patient communications.

1. Length of Primary Care Office Visit:
At a time when payers are pressuring primary care physicians to squeeze more patients into each day, this study demonstrates a strong correlation between extra time spent with patients and lower frequency of malpractice claims. Since patients dislike feeling rushed or ignored, physicians who are "too busy" to sit down, listen attentively, and respond to a patient's questions may set the stage for problems down the road.

2. Ability to Establish a Dialogue:
In addition to allocating sufficient time for a relaxed, friendly encounter, the physician should encourage two-way communication. The study identified orientation ("First, I will examine you, and then we will talk the problem over.") and facilitation questions ("What do you think it is? Go on, tell me more."), including humor and laughter, and utterances designed for emotional effect ("You look worried!" or "Good, I'm happy to hear you are feeling better."), as good techniques to encourage patient feedback.

Also, since patients seek a relationship with their primary care physicians, how a physician says something may be as important as what is said. In addition to questions about medical condition ("What can you tell me about the pain?") and therapeutic regimen ("How have you responded to the medication?"), the physician should inquire into psychosocial and lifestyle issues ("What's happening with your son?"), as well as give information ("The medication may make you drowsy.") and advice ("Call me if you're not feeling better by next week.").

Proper orientation counteracts the patient's nervousness and fear of the unknown ("I will leave time for your questions."). Facilitative questions encourage the patient to talk ("What do you think about taking these pills?") while the physician listens. Use of humor and laughter express warmth, friendliness and empathy ("That must make it tough for you.") and build a bond between physician and patient. Imparting information and advice in a manner that demonstrates the physician's genuine caring ("I'm concerned that this may happen again in the future") tends to diffuse patient anger and resentment. Physicians who have been sued for malpractice often cite "unrealistic expectations" on the part of their patients. Encouraging two-way communication helps the patient develop appropriate expectations about a medical visit, and prompts the sharing of critical information.

Breakdowns in communication between physician and patient fuel distrust and pent up anger. No one wants to feel that their concerns are ignored, nor that their problems have been minimized or disregarded. Add in a bad outcome, and we have achieved the "critical mass" for a lawsuit. On the other hand, effective physician-patient dialogue tends to enhance patient satisfaction and encourage healthy outcomes.

1 Brennan, T, Relation between negligent adverse events and the outcomes of medical-malpractice litigation. New Eng. J. Med. 335(26):1963-67, December 26, 1996.

2 Levinson, W, Physician-patient communication: the relationship with malpractice claims among primary care physicians and surgeons. JAMA. 277(7):553-59, February 19, 1997.