Physician Gender and Claims: Is There a Link?

By Laura J. King, MD
Dr. King serves on OMIC's Board of Directors and is a member of OMIC's Finance Committee and the Academy/OMIC Insurance & Marketing Committee. She practices ophthalmology in Atlanta, GA.

[Digest, Summer, 1999]

We all know by now that men and women are from different planets, so it comes as no surprise that researchers have found significant differences in the way they communicate. By understanding the role that gender plays in communication styles, research data suggests that we can improve our interpersonal relationships. But what about our professional relationships? Are the different communication styles of women and men carried over into medical practice, and is one style more positively correlated with patient satisfaction than another? Are there any differences in the medical malpractice claims experience of men and women ophthalmologists?

Much has been written about the importance of communication in avoiding medical malpractice suits. Communication and rapport are at the heart of the physician-patient relationship, and patient dissatisfaction with either the physician-patient relationship or the medical outcome is associated with medical malpractice suits.

Recently, OMIC began studying gender differences in the claims experience of ophthalmologists. A review of more than 1,000 OMIC claims over 11 years found 40 in which a woman ophthalmologist was the sole OMIC defendant. Men ophthalmologists were more than twice as likely to have been sued than women ophthalmologists. Additionally, once sued, men ophthalmologists were nearly twice as likely to close the suit with an indemnity payment either through settlement or jury award. (Assumes the distribution of OMIC women insureds by state, claims-made maturity, and severity classification are the same as the total OMIC population, and that the current year's proportion of OMIC insureds who are women is the same for all prior years.) In OMIC's experience, women ophthalmologists appear to have fewer suits in which they are the sole OMIC defendant, and the suits they have are more likely to be closed without an indemnity payment.

Better Communication or Better Medicine?

How can the better malpractice outcomes of women ophthalmologists be explained? Why do patients seem less likely to sue a woman ophthalmologist? Is there a difference in clinical outcomes between women and men ophthalmologists? Are women ophthalmologists "better" doctors? A survey of literature suggests the difference in claims experience may be due to differences in communication style between women and men.

The correlation between patient dissatisfaction with the doctor-patient relationship and medical malpractice claims is well established, although it has been studied independent of physician gender.

After reviewing 700 medical malpractice claims in ophthalmology, Jerome Bettman, MD, concluded that "lack of rapport" was critically important in the instigation of claims.¹ Marvin Kraushar, MD, who reviewed 40 medical malpractice claims involving cataract surgery, found that a breakdown in the doctor-patient relationship was the most important factor for a patient deciding to initiate a medical malpractice suit.^2,3 Howard Beckman, MD, et al., identified "problematic relationship issues" in 70 percent of plaintiff's depositions from settled malpractice suits.⁴ These issues included the patient's perception of desertion by the physician, devaluing the patient's views, delivering information poorly, and failing to understand the patient's perspective. Clearly, the doctor-patient relationship went awry, at least in the opinion of these patients.

Perception of a relationship can be subjective. However, communication is an observable, measurable aspect of the doctor-patient relationship that can be objectively studied, described, and categorized by third party observers. Recent studies of communication patterns of physicians have provided insights into what specific types of communication enhance the doctor-patient relationship, thereby improving patient satisfaction and reducing medical malpractice risk.

Wendy Levinson, MD, et al., used the Roter Interaction Analysis System to study the link between specified physician-patient communication styles and medical malpractice claims.⁵ These investigators analyzed audiotapes of 1,270 physician-patient encounters of primary care and orthopedic surgery physicians, 53 physicians with no medical malpractice claims history, and 64 physicians with two or more prior medical malpractice claims. Among primary care physicians, the authors found that those with no claims history tended to practice certain specific communication behaviors: orienting statements facilitative comments, humor, laughter, patient providing information, and physician providing counsel. Among surgeons, these behaviors were less important in predicting no-claims status; however, physician empathy was strongly predictive of no-claims status for all physicians.

Rapport Associated with Patient Satisfaction

Other investigators have found that communication styles that establish rapport are associated with patient satisfaction. Mary Klein Buller and David Buller used a modified 36-item version of Norton's Communicator Style Measure in phone surveys of 219 patients of 19 physicians in eight surgical and non-surgical specialties.⁶ They found that patients who were more satisfied with their physician's communication style were more satisfied with their health care. Affiliative styles were evaluated more favorably, while dominant/ active styles resulted in less favorable evaluations. Communication style was somewhat less important to severely ill patients but more important in patients' evaluations of younger physicians than of older physicians and to patients who see physicians less frequently. Interestingly, taking more time with a patient did not translate into more favorable evaluations, suggesting that the style of communicating, not its absolute quantity, is the more important determinant of patient satisfaction. Affiliative communication styles that develop rapport and demonstrate genuine concern for the patient were positively correlated with patients' satisfaction with their physician and their health care.

Are women physicians more likely to communicate in a style that fosters patient satisfaction? Physician and patient gender were not addressed in either Levinson's or Buller's studies; however, Debra Roter, Dr PH, et al., focused on physician and patient gender in a study of communication patterns during physician-patient encounters.⁷ Analyzing audiotapes of 537 primary care office visits involving 127 physicians (101 men and 26 women), these investigators found differences between men and women physicians in duration and content of conversations with patients. Women physicians talked more, especially during the history segment of the visit, and their communication included more positive talk, partnership building, question asking, and information giving. Women physicians' communication strategies were more patient-centered and generally more positive in content. Patients of both genders engaged in more positive talk, partnership building, question asking, and information giving in both biomedical and psychosocial areas when they were with women physicians. Most of the difference in talk during the visit was found to correlate with the physician's gender rather than the patient's gender.

In clinical practice, women physicians do, in fact, communicate with patients differently from men physicians. The communication patterns of women physicians strongly resemble the patterns identified by Buller as correlating positively with patient satisfaction and those identified by Levinson as correlating inversely with medical malpractice claims.

Bedside Manner Still Counts

Based on these studies of communication patterns, risk management strategies can be developed that deliberately target adoption of certain types of communication with patients in everyday practice. Of course, each doctor-patient relationship may be impacted by many factors - multiple treating physicians, language differences, severity of illness, frequency of interaction, insurance plan requirements, and cultural attitudes including gender assumptions. However, an individual physician, regardless of gender, can choose to adopt certain patterns of communication that have been shown to foster patient satisfaction (see Communication as a Risk Management Strategy). Office staff and comanaging care providers should be encouraged to adopt these communication patterns as well.

In the remote history of medicine, the only "medicine" a doctor had was essentially the doctor-patient relationship. Bedside manner - the laying on of hands, the developing of rapport and affiliation, and community between physician and patient - contributed more than any other intervention to final outcome. What is striking is that communication with the patient has been found still to be a major determinant of patient satisfaction with a medical outcome, even in this technologically driven age.

Clearly, physicians should use all available techniques, pharmaceuticals, and treatments shown to be clinically effective and cost efficient. But technologically based medicine certainly does not reduce the importance of effective physician communication patterns, whether the objective is quality care in the eyes of both physician and patient, avoidance of a malpractice suit, or both. Lessons learned in the 1990s from observing women physicians' communication styles can help all physicians keep an eye on the best of the age-old doctor-patient relationship.

Notes:

1. Jerome W. Bettman, MD, "Seven Hundred Medicolegal Cases in Ophthalmology," Ophthalmology, October 1990, v. 97 (10), 1379-1384.
2. Marvin F. Kraushar, MD, and Margaret F. Turner, MA, "Medical Malpractice Litigation in Cataract Surgery," Archives of Ophthalmology, October 1987, v. 105, 1339-1343.
3. Marvin F. Kraushar, MD, "Recognizing and Managing te Litigious Patient," Survey of Ophthalmology, July-August 1992, v. 37 (1), 54-56.
4. Howard B. Beckman, MD, Kathryn M. Markakis, MD, Anthony L. Suchman, MD, and Richard M. Frankel, PhD, "The Doctor-Patient Relationship and Malpractice - Lessons from Plaintiff Depositions," Archives of Internal Medicine, June 27, 1994, v. 154, 1365-1370.
5. Wendy Levinson, MD, Debra L. Roter, DrPH, John P. Mullooly, PhD, Valerie T. Dull, PhD, and Richard M. Frankel, PhD, "The Relationship With Malpractice Claims Among Primary Care Physicians and Surgeons," JAMA, February 19, 1997, v. 277 (7), 553-559.
6. Mary Klein Buller and David B. Buller, "Physicians' Communication Style and Patient Satisfaction," Journal of Health and Social Behavior, December 1987, v. 28, 375-388.
7. Debra Roter, DrPH, Mack Lipkin, Jr., MD, and Audrey Korsgaard, "Sex Differences in Patients' and Physicians' Communication During Primary Care Medical Visits," Medical Care, November 1991, v. 29 (11), 1083-1093.