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The Relationship With Malpractice Claims Among Primary Care Physicians and Surgeons

Wendy Levinson, MD; Debra L. Roter, DrPH; John P. Mullooly, PhD; Valerie T. Dull, PhD; Richard M. Frankel, PhD

JAMA. 1997;277(7):553-559.

Abstract
Objective.
—To identify specific communication behaviors associated with malpractice history in primary care physicians and surgeons.

Design.
—Comparison of communication behaviors of "claims" vs "no-claims" physicians using audiotapes of 10 routine office visits per physician.

Settings.
—One hundred twenty-four physician offices in Oregon and Colorado.

Participants.
—Fifty-nine primary care physicians (general internists and family practitioners) and 65 general and orthopedic surgeons and their patients. Physicians were classified into no-claims or claims (2 lifetime claims) groups based on insurance company records and were stratified by years in practice and specialty.

Main Outcome Measures.
—Audiotape analysis using the Roter Interaction Analysis System.

Results.
—Significant differences in communication behaviors of no-claims and claims physicians were identified in primary care physicians but not in surgeons. Compared with claims primary care physicians, no-claims primary care physicians used more statements of orientation (educating patients about what to expect and the flow of a visit), laughed and used humor more, and tended to use more facilitation (soliciting patients' opinions, checking understanding, and encouraging patients to talk). No-claims primary care physicians spent longer in routine visits than claims primary care physicians (mean, 18.3 vs 15.0 minutes), and the length of the visit had an independent effect in predicting claims status. The multivariable model for primary care improved the prediction of claims status by 57% above chance (90% confidence interval, 33%-73%). Multivariable models did not significantly improve prediction of claims status for surgeons.

Conclusions.
—Routine physician-patient communication differs in primary care physicians with vs without prior malpractice claims. In contrast, the study did not find communication behaviors to distinguish between claims vs no-claims surgeons. The study identifies specific and teachable communication behaviors associated with fewer malpractice claims for primary care physicians. Physicians can use these findings as they seek to improve communication and decrease malpractice risk. Malpractice insurers can use this information to guide malpractice risk prevention and education for primary care physicians but should not assume that it is appropriate to teach similar behaviors to other specialty groups.

Author Affiliations
From the Departments of Medicine, Oregon Health Sciences University and Legacy Good Samaritan Hospital and Medical Center, Portland, Ore (Dr Levinson); School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Md (Dr Roter); Kaiser Foundation Hospitals Center for Health Research, Portland, Ore (Dr Mullooly); Department of Psychology, Portland State University, Portland, Ore (Dr Dull); and Department of

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