What leads patients and families to sue their doctor? What can physicians do to decrease their risk of experiencing a malpractice suit? The answers to these questions are critical to doctors, hospital systems, and malpractice insurance companies seeking to provide the highest quality care and minimize liability risk. Some physicians may believe that if they provide high-quality care, following established standard practices in their specialties, they will not be sued. While providing high-quality care is important to malpractice prevention, good communication with patients and families is also critical. This article reviews the data supporting the relationship between doctor-patient communication and medical malpractice, and describes specific communication behaviors physicians can use to enhance quality of care and relationships with patients, focusing on the kinds of communication required for pediatricians working with children and families. Specific situations that present communication challenges to pediatricians also are discussed, including breaking bad news and communicating with adolescents. Finally, the article addresses how physicians can improve their communication skills and the resources available to achieve this goal.
THE RELATIONSHIP BETWEEN DOCTORPATIENT COMMUNICATION AND MEDICAL MALPRACTICE
Studies have explored the relationship between physicians' claims experience and the quality of care they provide.1,2 Surprisingly, the differences between sued and never-sued doctors are not fully explained by the quality of their care nor their chart documenta' tion. Entman and colleagues1 showed that the quality of treatment, as judged by peer review, was not different in frequently sued versus never-sued obstetriciangynecologists. This finding is consistent with other data indicating that the quality of care is apparently not the major determinant in a patient's decision to initiate a malpractice claim. In a 1984 study of hospitalization in New York state, 1% of hospitalized patients suffered a significant injury due to negligence,3 but only a small percentage of injured patients initiate a malpractice claim. Even when patients suffer severe morbidity or mortality, few patients or families sue the physician or hospital. Based on these studies, it appears that the quality of care, true medical negligence, and chart documentation are not the only factors that determine malpractice risk.
If quality of care measures do not fully explain malpractice risk, what other factors are important? Patient dissatisfaction is critical.4 The combination of a bad medical outcome and patient dissatisfaction is a recipe for litigation. When faced with a bad outcome, patients and families are likely to reflect on whether the physician was caring and compassion' ate, and whether he or she invested the needed time and attention in the patient's management.5'7 If patients and families feel the physician was not caring and compassionate, they are likely to be more dissatisfied, experience anger when a bad outcome occurs, and possibly turn to the litigation system. Conversely, if patients and families have a close, trusting relationship with their physician, they are more likely be satisfied with their care and may even forgive a physician for a mistake leading to a bad outcome.
Several studies have explored what kinds of breakdowns in communication contribute to malpractice claims. A study by Beckman and colleagues6 examined malpractice depositions and identified communication problems between physicians and patients in 70% of the cases they reviewed. The communication problems they identified were of four types:
* deserting the patient,
* devaluing patients' views,
* delivering information poorly, and
* failing to understand patients' or families' perspectives.
Other studies of malpractice also conclude that providing adequate explanations about diagnosis and treatment, and developing a trusting, respectful relationship with patients are of utmost importance to malpractice prevention.7 For example, Hickson and olleagues5 explored patients' satisfaction with their obstetrician-gynecologists and compared the perceptions of patients whose physicians had prior malpractice claims with those of patients whose physicians had no prior claims. Patients of the "high-frequency claims" physicians reported feeling rushed and ignored and receiving inadequate explanations or advice from their doctors. In comparison to patients of physicians who had not been sued in the past, they also reported that their physicians spent less time with them during routine medical visits. Overall, the patients of the "high-frequency claims" physicians had twice as many complaints about their care as the patients of the "no-claims" physicians. Taken together, these studies support the conclusion that the quality of the relationship between doctors and their patients and families and the nature of doctor-patient communication are critical to malpractice.
In what situations do communication breakdowns really matter? Perhaps it is only in times of critical health events, such as delivering the bad news of a diagnosis of acute leukemia in a child, that physicians need to prevent poor communication. Conversely, it may be that routine daily communication in the office setting is associated with malpractice risk. A study by Levinson and colleagues examined routine office communication using audiotapes of visits to primary care general internists and family practitioners. This study demonstrated that the routine office communication of primary care physicians with prior malpractice claims was different than physicians with no prior claims (unpublished data). This study, which is ongoing, is attempting to identify specific communication behaviors that distinguish the "claims" from the "no-claims" primary care doctors to make recommendations about what types of communication physicians might incorporate into their routine practice to enhance quality of care and reduce malpractice risk.
WHAT IS "GOOD COMMUNICATION?"
All practicing physicians spend a significant amount of each day talking with patients and families. In fact, the medical interview is a practicing doctor's most common procedure. Many physicians conduct a hundred medical interviews in a week and more than 150,000 interviews during their careers. Studies have demonstrated that specific skills in communication can optimize the quality of the medical interview, enhancing patient satisfaction and improving actual biologic outcomes. Thus, using specific communication skills in the medical interview can both enhance quality of care and reduce malpractice risk.
The pediatrie interview is more complicated than the traditional adult-patient medical interview since it usually is conducted with at least two people, the patient and the parent. This situation poses a challenge for the pediatrician to decide how much of the questioning and discussion to direct to the child versus how much to the parent. In general, as the age of the child increases, it is critical to have the interview conducted largely with the child and to involve the child directly in decision-making. Studies of chronically ill children demonstrate that children's active involvement in their own health care improves both parent and child satisfaction with the medical interview, increases children's knowledge of how their medication should be taken, and improves the functional status of children.8 In general, a "patient-centered style of interviewing," characterized by active involvement of patients in setting the agenda for the visit, expressing their opinions about diagnosis and treatment, and helping to choose among treatment options, is associated with positive outcomes, including patient satisfaction, improved biologic outcomes, and patient decisions to continue care with their physicians.9,0 Hence, it is important for the pediatrician to tailor the medical interview to involve the child maximally as is appropriate for his or her age and developmental stage. One of the challenges for pediatricians is that in addition to developing a relationship with the child and addressing the child's questions, the pediatrician must similarly attend to the needs of the parent or other family members.
The medical interview can be defined as having three broad functions: data collection, developing relationships and dealing with patients' emotions, and educating and motivating patients. Specific communication skills in each of these areas can improve both the quality and outcome of the interview. Conversely, problems in any of these areas may increase malpractice risk. The information presented below is based primarily on studies and literature from adult primary care but the concepts are applicable to the pediatrie setting. Where specific pediatrie studies are available, they are included.
Physicians begin to gather data as soon as they enter the examination room. Both verbal and nonverbal observations collected in the opening seconds of the medical encounter can provide useful information. For example, when the physician walks in the door, one child may be clinging to the mother and looking apprehensive, while another child may be exploring the furniture and equipment in the room. These observations may be helpful clues in understanding the child and his or her relationship with the parent.
Early in the medical interview, physicians elicit the concerns of the patient. Typically, this is accomplished most effectively by asking open-ended questions about the reason for the visit, such as "What concerns have led to your visit today?" or "What is the problem that brings you here today?" Studies demonstrate the importance of letting patients complete the opening statement about their concerns uninterrupted. Interrupting patients prematurely, before they have told the physician their reasons for the visit, may demonstrate a lack of interest or time and deter patients from expressing their real worries, which may emerge late in the visit or not at all.
Patients seeing a primary care doctor have an average of three concerns. It is most efficient to find out all of the patient's concerns early in the visit so the physician and patient can decide how best to use the time available. After the patient has completed his or her opening statement, it is often helpful to ask, "What else?" or "Are there any other things you would like to make sure we cover today?" Occasionally, this strategy leads the patient to reveal more problems than the physician believes can be adequately covered in the time available. In this case, the physician and patient can negotiate about what will be addressed in the present visit and what will be deferred to a subsequent visit. In general, patients are more satisfied if all of their concerns are elicited during the interview, even if each one cannot be fully addressed on that date.
In pediatrics, parents often have psychosocial concerns that may be embarrassing or difficult to discuss. For example, a child may be hitting or biting other children and the parent may be conflicted about whether to raise this topic with the doctor. Studies demonstrate that up to 25% of parents may leave the pediatrician's office without having shared their greatest concerns, particularly when those worries are about the child's behavior.11·12 Asking open-ended questions and allowing parents to talk openly can help in soliciting information on these more sensitive topics. In addition, physicians can ask nonjudgmental questions, such as: "Sometimes children and parents have questions about bedwetting or temper problems that can be difficult or embarrassing to discuss. I'd like to do whatever makes you comfortable to discuss any of the concerns you have with me." An open, nonjudgmental tone can reassure the parent and the child that the physician is interested and willing to discuss these topics.
Allowing Patients To Tell Their Stories in Their Own Words
Allowing patients to tell the story of their illness in their own words is the most efficient and comfortable way to begin to assess a problem. This strategy permits the patient to share what he or she perceives as relevant and reveals his or her personal views of cause and effect in relation to the problem. Moreover, the patient may mention details and facts a physician would not think to ask. Inviting the patient to tell the story of the illness reveals the context of the illness, such as the nature of the patient's daily life and relationships among siblings in the home. This understanding is needed in planning approaches to care. Depending on the age of the child, it can be helpful to begin by asking the child to tell his or her story. After the child has had an opportunity to express his or her perceptions, the parent can similarly describe his or her own views and elaborate on details.
It is important to ask children directly about the effect of a chronic illness on their well-being. A recent study showed that children, not their parents, were best at judging the actual functional and psychological limitations caused by the illness. In general, parents tended to overestimate the psychological consequences and underestimate the functional impairment of their children's chronic illness (unpublished data).
Eliciting the Patient's Beliefs About the Problem
Prior to seeing their doctor, patients often have discussed their problem with a trusted friend or family member. Parents and children typically have beliefs about what their illness is due to, and children may have fears about the cause of their problem. For example, a child may believe that a symptom comes on or is made worse when he or she is "bad." Understanding patients' beliefs or worries about the cause of their problem allows physicians to correct misperceptions or tailor their explanations to incorporate patients' beliefs. These example physician statements may be useful to this inquiry: "Many patients have ideas about what has been causing their problem. Sometimes patients have talked to friends about this. What do you think may be causing your problem?" or "Have any kids at school had problems like yours? What was their problem caused by?"
The use of medical jargon is difficult to avoid, and physicians inadvertently use language that can be confusing to patients, particularly children. Children's unfamiliarity with medical words can lead to confusion. Physicians should be attentive to using language that is as simple as possible and should welcome patients to point out if they have not understood something that was said. For example, a physician might say: "Sometimes I use words that can be confusing to children without even knowing I am doing that. I would really like it if you could tell me if 1 use a word that you don't know so I can explain it better." In pediatrics, physicians can enhance a child's sense of control in the interview by developing a system for the patient to stop the conversation when he or she is confused.
BUILDING RELATIONSHIPS AND ADDRESSING PATIENTS' FEELINGS
Simultaneously with collecting data, the physician is building a relationship with both the child and the parent. Building a relationship in which the patient feels respected, supported, and trusting is critical to patient satisfaction and malpractice risk reduction. Particularly in a first visit with a child, establishing a trusting relationship is important both for that visit and for the future contacts between the physician and the child. Specific communication skills can help to build this positive relationship. For example, communicating directly with the child demonstrates that the physician is interested in the child's opinion and welcomes the child to be an active participant in his or her care. Physicians also can demonstrate interest in a personal aspect of the child's life by asking a question about school, pets, friends, or other topics relevant to the child's life. Sometimes it is useful for physicians to make a chart notation about an important event occurring in a child's life so they can ask about it at subsequent visits, ie, "How did that soccer tournament go a month ago?" In addition, nonverbal communication can enhance the relationship with the child. For example, physicians can position themselves so that they are looking directly at the child at eye level rather than standing and towering over the child.
Dealing With Emotions
Children and parents frequently come to visits with feelings of anxiety, worry, or other powerful emotions. For example, a child may worry for days about an upcoming pediatrie visit, knowing or fearing that he or she is going to have to have an injection. Parents may be worried about whether symptoms, such as a headache, may be due to a brain tumor or another serious disease. Sometimes, families are stressed because of a life crisis, such as the death of a grandparent. These patients may arrive at the visit experiencing strong feelings that may be unrelated to the immediate reason for the visit. The critical communication task for physicians is to deal with the patient's emotions directly. Talking directly with patients about their emotional experiences demonstrates caring and compassion, and is a powerful communication strategy to enhance relationships with patients.
Physicians may feel that dealing with patients' emotions is opening a "Pandora's box" that will lead to longer visits and, possibly, feelings of frustration for the physician. Physicians may feel that if a patient expresses a negative feeling, they are responsible for helping to fix it, a task that often cannot be accomplished in brief visits or at all. But in fact, dealing with patients' emotions directly actually may make medical visits more efficient and, even though problems may not be correctable, talking about feelings can be therapeutic for patients.
How can physicians address patients' feelings directly and efficiently? This can be accomplished by first commenting directly on the feelings and then making a statement that indicates understanding of the patient's experience. Physicians can help to normalize patients' emotions by explaining that other patients have the same feelings. For example:
Physician: You seem pretty sad about this problem
Child: Yeah, I really wanted to play baseball and I can't.
Physician: I can understand feeling disappointed about missing the baseball game. I know baseball is really important to you.
Such brief comments that recognize the patient's emotional experience can have a powerful positive effect on the doctor-patient relationship.
It can be particularly difficult to deal directly with emotions such as anger since physicians may feel that the anger will be directed at them personally or believe that addressing the anger may escalate it. Especially in these situations, it is important to address the feeling directly. When physicians can hear and understand a patient's feeling of anger without being defensive, it indicates to the patient that it is safe to talk about anything, including negative emotions, with the doctor. Dealing with anger effectively may be particularly important to malpractice prevention.
Dealing directly with patients' emotions can be demonstrated by the example of a child anticipating an injection. The physician may be aware that most children are fearful of this situation or notice that the child looks anxious as soon as he or she comes into the room. A sample dialogue illustrates how to deal with these emotions directly:
Physician: Hi, John. How are you today?
Physician: You look a little bit nervous. Sometimes kids are nervous if they need to have a shot here.
Child: Yeah, I guess so.
Physician: Feeling nervous is pretty natural. Sometimes kids like to have the shot first and get it over with, and other kids like to wait until the end. What would you like?
In this way, the physician addresses the child's worst fear right at the beginning of the visit and gives the child some control over how to minimize his or her sense of anxiety.
EDUCATION AND MOTIVATION
Patients often are dissatisfied with the amount of information they receive about their diagnosis and treatment. Physicians may underestimate patients' desires to be educated, may inadvertently use medical jargon that confuses patients, or may allow too little time in the interview for the important task of patient education. Particularly for patients with chronic illness, it is important that they are well-educated about their therapeutic management. Patients who are active partners in developing and maintaining their treatment plan are more likely to be satisfied, adhere to the plan, and have better therapeutic outcomes. In addition, adequate patient education is important before patients undergo invasive procedures, such as surgery. When there is a bad outcome and patients feel that they have been ill-informed about the potential adverse outcomes of procedures, they are more likely to sue their physician. Specific communication strategies described below may help physicians provide tailored educational information.
Asking What the Patient Believes About the Treatment
Patients may have ideas about appropriate or inappropriate treatments based on conversations with friends and family members, or based on lay health material. Eliciting patients' beliefs about effective therapy helps physicians tailor the treatment regimen or correct misunderstandings. It is particularly important to ask children about their experience with therapies so that children's worries can be addressed directly. For example, a child with asthma may have seen a student at school use inhalers. The child may assume that use of this treatment means that children cannot participate in sports activities and, hence, believe that this treatment would limit his or her active life. Useful questions might include: "Do any of the kids you know at school have asthma? Do any of them use inhalers or other treatments for it?" Physicians also can assess and respond to parents' beliefs about treatment options.
Allowing Questions and Planning for Problems
Before a visit is over, it is critical to allow patients time to ask unanswered questions and to anticipate difficulties that may arise during the treatment course. Patients may not be comfortable telling their physician directly that they are unlikely to follow the instructions. Physicians can elicit this information in a nonjudgmental way by asking patients to anticipate the difficult parts of the treatment regimen: "I know it's hard to take pills three times a day. Lots of kids fot' get to take pills or just don't want to take them. What will be the hardest part of taking these pills for you?" When patients identify what might be the difficult part of the treatment regimen, the physician can ask patients how they might handle that problem. This strategy allows patients to problem-solve before leaving the visit.
Obviously, the involvement of the child in discussing the treatment regimen depends on the age of the child. In general, the more children understand and participate in treatment decisions tailored to their lifestyle, the more likely they are to follow the plan. Particularly for chronic illness, the involvement of team members in educating children is critical. Multidisciplinary team approaches to educating children about diabetes and asthma are particularly effective. In addition, use of written materials, pictures, and doll demonstrations help children understand treatments. These approaches can augment and enhance instructions provided by the physician but cannot replace adequate time provided by physicians.
SPECIFIC COMMUNICATION CHALLENGES IN PEDIATRICS
Breaking Bad News
Delivering sad or bad news about a child's welfare can be difficult for both patients and physicians. Often, physicians have not had training in specific communication skills that make the delivery of bad news most supportive for the patient.13 It is critical for patients to feel cared for and supported, despite the difficulties they will face in the future. Good communication during these critical discussions can have a long-lasting effect on patient satisfaction and emotional well-being. For example, in a study pertaining to delivering news about Down syndrome, psychologists trained pediatricians to inform patients in an unhurried, honest, and empathie manner.14 Parents who were given the news by physicians using these techniques reported significantly higher satisfaction than parents given the news by untrained physicians.
In nonurgent situations, thoughtful planning about the conversation is important. Physicians can request that the patient be accompanied by a trusted friend or relative who can provide support as well as listen to some of the explanation by the physician. Whenever possible, it is useful to prepare the patient for the possibility of a bad outcome, such as a diagnosis of a cancer, so that the patient can mull this over before the visit.
During conversations when physicians must deliver bad or sad news, keeping medical information simple and to a minimum is critical. When patients are feeling intense emotions, such as shock, grief, or sadness, they are not able to attend to the cognitive process of understanding information about the diagnosis and treatment options. It is often best to delay detailed discussion of treatment options until a subsequent conversation. Even in the most difficult of situations, such as the death of a child, physicians can offer compassion and willingness to be supportive for the family in the future. Other communication issues to be considered when breaking bad news are listed in the Table.
Communicating With Adolescents
Often, adolescent patients present barriers to effective communication because they are embarrassed or ashamed, they do not trust that the conversation is confidential, or they anticipate that physicians will act in an authoritarian manner that does not respect their opinions. Whatever the barrier an adolescent may present, physicians need to recognize it and be flexible enough to deal with these potential challenges. Almost all important adolescent issues are sensitive, such as sexuality, family discord, and the use of drugs or other highrisk behaviors. Without frank discussion of confidentiality, adolescent patients are unlikely to discuss these issues honestly with physicians. Physicians should be explicit that confidentiality will be maintained, unless there are grave threats to the health of the patient. Physicians can tell adolescent patients that they might encourage patients to discuss sensitive issues with their parents and that, in these cases, they can help teenagers plan how to do so. For example, the physician might say:
Points To Be Considered When Breaking Bad News
Sometimes there may be situations where I think you should discuss something with your parent. In those situations, 1 would help you think about the advantages and disadvantages of honesty with your parent, and consider how you might discuss the issue. Ultimately, the choice would be yours, but perhaps I can help be your advisor.
This strategy allows adolescents to have control over the flow of information and develop a trusting relationship with the physician.
HOW CAN PHYSICIANS IMPROVE THEIR COMMUNICATION SKILLS?
Most physicians have had relatively little formal education during medical school, residency, or continuing medical education programs that is designed to enhance communication skills. However, studies demonstrate that physicians can improve their communication skills by participation in formal educational programs.15 Physicians participating in welldesigned programs can change their routine style of communication to a more patient-centered, collaborative style. Programs also can help physicians develop skills to handle difficult situations such as breaking bad news or discussing advance directives. Effective programs allow opportunities for physicians to practice skills and receive feedback through the use of audiotape or videotape review or direct observation by colleagues. Like training in other technical procedural skills, it is essential to practice, modify, and practice again. Most effective programs require some ongoing reinforcement over time.
Educational programs focusing on physicianpatient communication are offered by several organizations, including the Northwest Center for Physician-Patient Communication, the Bayer Institute for Health Care Communication, and the American Academy on Physician and Patient. In addition, many malpractice insurance companies have incorporated seminars on communication into their malpractice prevention programs and some offer malpractice premium reductions for physicians attending.
Effective communication is critical to building relationships with patients and providing the highest quality of care. Not only does effective communication lead to patient satisfaction and positive health outcomes, but it also has a positive effect for physicians by enhancing their professional satisfaction through developing meaningful relationships with patients. Furthermore, these same communication skills help to prevent patient anger and possible malpractice litigation. While the factors leading to patients launching a malpractice suit are complex and multifactorial, a good doctor-patient relationship may help prevent litigation when adverse events occur in the course of care.
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Points To Be Considered When Breaking Bad News