Is Patient Satisfaction a Factor in Lawsuits?

A study of patients who stayed with the same doctor over a 3-year period found they were less satisfied with the relationship at the end of that period. When asked about the quality of communication, interpersonal treatment, doctor's knowledge of the patient, patient trust, financial access, organization access, visit-based continuity and integration of care, there was a significant decline in three of four indicators of relationships. Personal interactions declined by 15% followed by communication and trust. Murphy, J: The Quality of Physician-Patient Relationships. J Fam Practice, Feb. 2001.

In a study of doctors in high-volume practices, researchers found that visits were 30% shorter, one-third fewer patients were scheduled for well-care visits, and the doctors were more likely to be males who owned their own practices. Patients of high-volume doctors had lower up-to-date rates of preventive services and lower scores on satisfaction and doctor-patient relationships. Zyanski, S. et al.: Trade-offs in High-volume Primary Care Practice. J Fam Practice, Vol. 46 n5 p397, May 1998.

Americans have a low opinion of the health-care system in general. In a 2001 Kaiser/Harvard poll, only oil companies rated worse in terms of how various industries served their customers. Fifty-two percent said oil companies did a bad job, versus 46% who said the same of HMOs and managed-health-care plans. And this was before the corporate scandals. “The Bottom Line,” American Demographics, July/August 2002.

The Facts on Patient Visits

Doctors in the United States schedule more time with their patients than doctors in Europe. Indeed, some countries schedule visits as short as 5 minutes. Deveygekem, M et al.: Consultation Length in General Practice: Cross Sectional Study in Six European Countries. Br Med Journal 2002; 325:472, Aug. 31, 2002.

Despite what doctors may think, between 1989 and 1998, the average length of an office visit increased from 16.3 minutes to 18 minutes. Mechanic, D et al.: Are Patients' Office Visits with Physicians Getting Shorter? N Engl J Med 2001: 344: 198-204, Jan. 18, 2001. Similarly, the actual number of patient visits per week decreased from 120.9 in 1990 to 119.6 in 1997. The average time spent with patients in initial visits where longer appointments would be expected increased from 24.4 minutes in 1990 to 26.4 minutes in 1997. The number of hours doctors worked per week decreased from 58.8 to 57.9 over the same 7-year period. Gabriel, Id.

A 2001 study in an academic primary care clinic found that patients were more satisfied with their visits to the doctor when they perceived that the amount of time the doctor spent with them was greater than what they had anticipated before the visit. Furthermore, a majority of patients (58%) and physicians (52%) underestimated the actual time spent together. Lin, C, et al.: Is Patients' Perception of Time Spent with the Physician a Determinant of Ambulatory Patient Satisfaction? Arch Intern Med Vol. 161 ill p 1437, June 11, 2001. In this same study, researchers found that even when doctors felt rushed, patient satisfaction was identical when enough time was spent with them. While doctors felt rushed 10% of the time, patients perceived it only 3% of the time.

Patient Satisfaction and Lawsuits

A 1994 study found 53% of calls to plaintiffs' law firms were precipitated by poor relationships with providers before the injury complained of. Huycke, L: Characteristics of Potential Plaintiffs in Malpractice Litigation. Ann Intern Med, Vol. 120, No. 9, May 1, 1994. Plaintiffs have reported that physicians will not talk with them or answer their questions, will not listen, mislead them, and do not warn them of possible poor outcomes. Hickson, G: Factors That Prompted Families to File Medical Malpractice Claims Following Perinatal Injuries. JAMA, Vol., 267, No. 10, 1992. In addition, a review of plaintiff depositions has identified problematic relationship issues were evident in 71% of those depositions. Beckman, H.: The Doctor-Patient Relationship and Malpractice: Lessons from Plaintiff Depositions. Arch Intern Med, Vol, 154, June 72, 1994.

A study in the British journal The Lancet found that lack of clear, sympathetic explanations pointed to deficiencies in communication and a failure to appreciate the emotional needs of the patient. The authors concluded that communication assumes a special importance when things have gone wrong. Vincent, C: Why Do People Sue Doctors? A Study of Patients and Relatives Taking Legal Action. Lancet, Vol. 343, June 25, 1994.

A study of Colorado and Oregon primary care physicians and surgeons determined that process and tone of how physicians talk with patients may be even more important than what they say. Although the researchers found no association between malpractice claims and the content of the doctor-patient conversation, they did find a strong link between lawsuits and shortcomings in how that content was presented. Levinson, W et al.: Study of Patient Clues and Physician Responses in Primary Care and Surgical Settings. JAMA, Aug 25, 2000.

Patients seeing Florida obstetricians who were sued most often were significantly more likely to complain that they felt rushed, never received explanations for tests, and were ignored. In response to the open-ended question, “What part of your care were you least satisfied with?” women seeing physicians in the high frequency malpractice risk group offered twice as many complaints about physician/ patient communication as those seeing physicians who had never been sued. This was true even when none of the study patients had actually filed a lawsuit. Hickson, GB, et al.: Obstetricians' Prior Malpractice Experience and Patients' Satisfaction with Care. JAMA, Vol. 272, Nov. 23, 1994.

What Makes the Difference to Patients?

Several factors influence the way patients perceive their visits with health care professionals and whether they subsequently have good or bad feelings about the care they received. Because patient perceptions impact on their responses to bad outcomes, care should be taken to prevent any bad feelings that could lead to the filing of more lawsuits.

Time spent with the patient is one crucial predictor of patient satisfaction. There is, however, conflicting opinion on how much time is “enough time.” What we do know is that 15 minutes is not enough. In a study of malpractice claims, doctors who had not been sued spent more time (18.3 minutes) with their patients as opposed to those who had been sued (15 minutes). Levinson, W et al.: Physician-Patient Communication: The Relationship with Malpractice Claims Among Primary Care Physicians and Surgeons. JAMA, February 1997. Some research shows that there is a measurable difference in patient satisfaction beyond 20 minutes. Napoli, M: How to Get the Most Out of an 18-minute Doctor Visit. HealthFacts, February 2001. Patients routinely equate adequate time with a more satisfying visit. Gross, D et al.: Patient Satisfaction with Time Spent with Their Physician. J Fam Practice, Vol. 47, n2 p133, August 1998.

The quality of human contact is as important as the quantity. In a study conducted with medical interns, patients were more satisfied with care when humanistic qualities were higher. The amount of time the interns spent with patients and their families was not a factor in whether patients and their families were satisfied with their care, but the quality of the human contact was. Lindsay, H: Quality of Visit Matters More than Quantity of Time. Int Med News Group, Jan. 1, 2000.

Taking an interest in the patient, even beyond the interaction necessary to make a proper diagnosis and prescribe a treatment, is also important to patients. Researchers have found that satisfaction with time spent was strongly correlated with longer visits and, when length was controlled for, satisfaction was correlated with several factors beyond the physician's control: greater patient age, Caucasian race and better perceived health status, for instance. But satisfaction was also correlated with at least one factor very much within the physician's power to influence: Even a brief amount of “chatting,” defined as nonmedical talk, was associated with greater patient satisfaction with the time spent with the physician. “Physicians may improve patients' sense that the doctor has given them adequate time by simply talking about the weather, telling a joke, or invoking conversation about something other than the health of the patient,” claims an article in The Journal of Family Practice. “The patient may find comfort in being communicated with as a person rather than as a patient.” Gross, D et al.: Patient Satisfaction with Time Spent with Their Physician. J Fam Practice, Vol. 47, n2, p133, Aug. 1998.

Doctors who takes the time to listen to their patients do themselves a favor. The average patient visiting a doctor gets 22 seconds to make his or her initial statement. Doctors often fear that if a patient is given all the time he or she needs to state his or her concerns, the visit will be too long. In actuality, when given just that opportunity, researchers have found that the mean spontaneous talking time is 92 seconds, and 78% of patients in the study finished their statements within 2 minutes. Langewitz, W et al.: Spontaneous Talking Time At Start of Consultation in Outpatient Clinic: Cohort Study. Br Med Journal, Vol.3 25, i7366, Sept. 28, 2002. As the researchers noted after that study, “Doctors do not risk being swamped by their patients' complaints if they listen until a patient indicates that his or her list of complaints is complete. Even in a busy practice driven by time constraints and financial pressure, 2 minutes of listening should be possible and will be sufficient for nearly 80% of patients.”

Finally, doctors should address psychosocial issues that their patients may be experiencing because 30% to 40% of patients screen positive for significant levels of emotional distress. When doctors spent just 8 hours in a training program designed to help them communicate more effectively in addressing patients' emotional distress, patients of those doctors reported a reduction in emotional distress for as long as 6 months. Roter, D et al.: Improving Physicians' Interviewing Skills and Reducing Patients' Emotional Distress: A Randomized Clinical Trial. Arch Intern Med, Vol. 155, Sept. 25, 1995. Not only were the visits not longer, patients did not feel the need to schedule more visits over the 6-month period. As the researchers said, “Despite many physicians' fears that opening a Pandora's Box of psychosocial concerns will lead to … interminable visits, our experience suggests otherwise.”

Conclusion

So what is the bottom line? Although physicians in the United States actually spend more time with their patients than in many parts of the world, it doesn't necessarily mean that patients are more satisfied with the quality of the office visit. Those who represent medical providers need to encourage them to do the types of things that actually will help to prevent medical malpractice lawsuits — specifically making the office visit quality time for the patient, not just quantity time.

Doctors feel hurried these days, and they resent it. They believe that the demands of their days have caused them to spend less time with patients. They also believe that their patients resent it. Let's look at what has really happened to the office visit — and then let's see if better patient satisfaction levels correlate with fewer lawsuits.

'Times Have Changed'

Several studies have been done in recent years showing that modern patient visit models are negatively impacting both physician and patient satisfaction. In a 1999 survey of doctors and nurses, 83% said managed care had decreased the amount of time doctors spend with patients, 72% believed the quality of health care was worse under managed care and 58% of doctors reported that spending more time on administration rather than with patients was a “great concern.” Gabriel, B: The Doctor Will See You Now: Are Physician Office Visits Getting Shorter … or Longer. Reporter, Vol. 10, No. 7, April 2001.

A study of patients who stayed with the same doctor over a 3-year period found they were less satisfied with the relationship at the end of that period. When asked about the quality of communication, interpersonal treatment, doctor's knowledge of the patient, patient trust, financial access, organization access, visit-based continuity and integration of care, there was a significant decline in three of four indicators of relationships. Personal interactions declined by 15% followed by communication and trust. Murphy, J: The Quality of Physician-Patient Relationships. J Fam Practice, Feb. 2001.

In a study of doctors in high-volume practices, researchers found that visits were 30% shorter, one-third fewer patients were scheduled for well-care visits, and the doctors were more likely to be males who owned their own practices. Patients of high-volume doctors had lower up-to-date rates of preventive services and lower scores on satisfaction and doctor-patient relationships. Zyanski, S. et al.: Trade-offs in High-volume Primary Care Practice. J Fam Practice, Vol. 46 n5 p397, May 1998.

Americans have a low opinion of the health-care system in general. In a 2001 Kaiser/Harvard poll, only oil companies rated worse in terms of how various industries served their customers. Fifty-two percent said oil companies did a bad job, versus 46% who said the same of HMOs and managed-health-care plans. And this was before the corporate scandals. “The Bottom Line,” American Demographics, July/August 2002.

The Facts on Patient Visits

Doctors in the United States schedule more time with their patients than doctors in Europe. Indeed, some countries schedule visits as short as 5 minutes. Deveygekem, M et al.: Consultation Length in General Practice: Cross Sectional Study in Six European Countries. Br Med Journal 2002; 325:472, Aug. 31, 2002.

Despite what doctors may think, between 1989 and 1998, the average length of an office visit increased from 16.3 minutes to 18 minutes. Mechanic, D et al.: Are Patients' Office Visits with Physicians Getting Shorter? N Engl J Med 2001: 344: 198-204, Jan. 18, 2001. Similarly, the actual number of patient visits per week decreased from 120.9 in 1990 to 119.6 in 1997. The average time spent with patients in initial visits where longer appointments would be expected increased from 24.4 minutes in 1990 to 26.4 minutes in 1997. The number of hours doctors worked per week decreased from 58.8 to 57.9 over the same 7-year period. Gabriel, Id.

A 2001 study in an academic primary care clinic found that patients were more satisfied with their visits to the doctor when they perceived that the amount of time the doctor spent with them was greater than what they had anticipated before the visit. Furthermore, a majority of patients (58%) and physicians (52%) underestimated the actual time spent together. Lin, C, et al.: Is Patients' Perception of Time Spent with the Physician a Determinant of Ambulatory Patient Satisfaction? Arch Intern Med Vol. 161 ill p 1437, June 11, 2001. In this same study, researchers found that even when doctors felt rushed, patient satisfaction was identical when enough time was spent with them. While doctors felt rushed 10% of the time, patients perceived it only 3% of the time.

Patient Satisfaction and Lawsuits

A 1994 study found 53% of calls to plaintiffs' law firms were precipitated by poor relationships with providers before the injury complained of. Huycke, L: Characteristics of Potential Plaintiffs in Malpractice Litigation. Ann Intern Med, Vol. 120, No. 9, May 1, 1994. Plaintiffs have reported that physicians will not talk with them or answer their questions, will not listen, mislead them, and do not warn them of possible poor outcomes. Hickson, G: Factors That Prompted Families to File Medical Malpractice Claims Following Perinatal Injuries. JAMA, Vol., 267, No. 10, 1992. In addition, a review of plaintiff depositions has identified problematic relationship issues were evident in 71% of those depositions. Beckman, H.: The Doctor-Patient Relationship and Malpractice: Lessons from Plaintiff Depositions. Arch Intern Med, Vol, 154, June 72, 1994.

A study in the British journal The Lancet found that lack of clear, sympathetic explanations pointed to deficiencies in communication and a failure to appreciate the emotional needs of the patient. The authors concluded that communication assumes a special importance when things have gone wrong. Vincent, C: Why Do People Sue Doctors? A Study of Patients and Relatives Taking Legal Action. Lancet, Vol. 343, June 25, 1994.

A study of Colorado and Oregon primary care physicians and surgeons determined that process and tone of how physicians talk with patients may be even more important than what they say. Although the researchers found no association between malpractice claims and the content of the doctor-patient conversation, they did find a strong link between lawsuits and shortcomings in how that content was presented. Levinson, W et al.: Study of Patient Clues and Physician Responses in Primary Care and Surgical Settings. JAMA, Aug 25, 2000.

Patients seeing Florida obstetricians who were sued most often were significantly more likely to complain that they felt rushed, never received explanations for tests, and were ignored. In response to the open-ended question, “What part of your care were you least satisfied with?” women seeing physicians in the high frequency malpractice risk group offered twice as many complaints about physician/ patient communication as those seeing physicians who had never been sued. This was true even when none of the study patients had actually filed a lawsuit. Hickson, GB, et al.: Obstetricians' Prior Malpractice Experience and Patients' Satisfaction with Care. JAMA, Vol. 272, Nov. 23, 1994.

What Makes the Difference to Patients?

Several factors influence the way patients perceive their visits with health care professionals and whether they subsequently have good or bad feelings about the care they received. Because patient perceptions impact on their responses to bad outcomes, care should be taken to prevent any bad feelings that could lead to the filing of more lawsuits.

Time spent with the patient is one crucial predictor of patient satisfaction. There is, however, conflicting opinion on how much time is “enough time.” What we do know is that 15 minutes is not enough. In a study of malpractice claims, doctors who had not been sued spent more time (18.3 minutes) with their patients as opposed to those who had been sued (15 minutes). Levinson, W et al.: Physician-Patient Communication: The Relationship with Malpractice Claims Among Primary Care Physicians and Surgeons. JAMA, February 1997. Some research shows that there is a measurable difference in patient satisfaction beyond 20 minutes. Napoli, M: How to Get the Most Out of an 18-minute Doctor Visit. HealthFacts, February 2001. Patients routinely equate adequate time with a more satisfying visit. Gross, D et al.: Patient Satisfaction with Time Spent with Their Physician. J Fam Practice, Vol. 47, n2 p133, August 1998.

The quality of human contact is as important as the quantity. In a study conducted with medical interns, patients were more satisfied with care when humanistic qualities were higher. The amount of time the interns spent with patients and their families was not a factor in whether patients and their families were satisfied with their care, but the quality of the human contact was. Lindsay, H: Quality of Visit Matters More than Quantity of Time. Int Med News Group, Jan. 1, 2000.

Taking an interest in the patient, even beyond the interaction necessary to make a proper diagnosis and prescribe a treatment, is also important to patients. Researchers have found that satisfaction with time spent was strongly correlated with longer visits and, when length was controlled for, satisfaction was correlated with several factors beyond the physician's control: greater patient age, Caucasian race and better perceived health status, for instance. But satisfaction was also correlated with at least one factor very much within the physician's power to influence: Even a brief amount of “chatting,” defined as nonmedical talk, was associated with greater patient satisfaction with the time spent with the physician. “Physicians may improve patients' sense that the doctor has given them adequate time by simply talking about the weather, telling a joke, or invoking conversation about something other than the health of the patient,” claims an article in The Journal of Family Practice. “The patient may find comfort in being communicated with as a person rather than as a patient.” Gross, D et al.: Patient Satisfaction with Time Spent with Their Physician. J Fam Practice, Vol. 47, n2, p133, Aug. 1998.

Doctors who takes the time to listen to their patients do themselves a favor. The average patient visiting a doctor gets 22 seconds to make his or her initial statement. Doctors often fear that if a patient is given all the time he or she needs to state his or her concerns, the visit will be too long. In actuality, when given just that opportunity, researchers have found that the mean spontaneous talking time is 92 seconds, and 78% of patients in the study finished their statements within 2 minutes. Langewitz, W et al.: Spontaneous Talking Time At Start of Consultation in Outpatient Clinic: Cohort Study. Br Med Journal, Vol.3 25, i7366, Sept. 28, 2002. As the researchers noted after that study, “Doctors do not risk being swamped by their patients' complaints if they listen until a patient indicates that his or her list of complaints is complete. Even in a busy practice driven by time constraints and financial pressure, 2 minutes of listening should be possible and will be sufficient for nearly 80% of patients.”

Finally, doctors should address psychosocial issues that their patients may be experiencing because 30% to 40% of patients screen positive for significant levels of emotional distress. When doctors spent just 8 hours in a training program designed to help them communicate more effectively in addressing patients' emotional distress, patients of those doctors reported a reduction in emotional distress for as long as 6 months. Roter, D et al.: Improving Physicians' Interviewing Skills and Reducing Patients' Emotional Distress: A Randomized Clinical Trial. Arch Intern Med, Vol. 155, Sept. 25, 1995. Not only were the visits not longer, patients did not feel the need to schedule more visits over the 6-month period. As the researchers said, “Despite many physicians' fears that opening a Pandora's Box of psychosocial concerns will lead to … interminable visits, our experience suggests otherwise.”

Conclusion

So what is the bottom line? Although physicians in the United States actually spend more time with their patients than in many parts of the world, it doesn't necessarily mean that patients are more satisfied with the quality of the office visit. Those who represent medical providers need to encourage them to do the types of things that actually will help to prevent medical malpractice lawsuits — specifically making the office visit quality time for the patient, not just quantity time.