Hickson GB, Federspiel CF, Pichert JW, Miller CS, Gauld-Jaeger J, Bost P. Patient Complaints and Malpractice Risk. JAMA. 2002;287(22):2951-2957. doi:10.1001/jama.287.22.2951
Author Affiliations: Departments of Pediatrics (Drs Hickson and Bost), Preventive Medicine (Dr Federspiel), Medicine (Dr Pichert), and Social Work (Ms Miller), and Office of Patient Affairs (Ms Gauld-Jaeger), Vanderbilt University School of Medicine, Nashville, Tenn.
Context A small number of physicians experience a disproportionate share of
malpractice claims and expenses. If malpractice risk is related in large measure
to factors such as patient dissatisfaction with interpersonal behaviors, care
and treatment, and access, it might be possible to monitor physicians' risk
of being sued.
Objective To examine the association between physicians' patient complaint records
and their risk management experiences.
Design, Setting, and Participants Retrospective longitudinal cohort study of 645 general and specialist
physicians in a large US medical group between January 1992 and March 1998,
accounting for 2546 physician-years of care.
Main Outcome Measures Computerized records of all unsolicited patient complaints were recorded
by the medical center's patient affairs office, coded to characterize the
nature of the problem and alleged offender, and compared with each physician's
risk management records for the same period.
Results Both patient complaints and risk management events were higher for surgeons
than nonsurgeons. Specifically, 137 (32%) of the 426 nonsurgeons had at least
1 risk management file compared with nearly two thirds (137 [63%] of 219)
of all surgeons (χ21= 54.7, P<.001). Both complaint and risk management data were positively
correlated with physicians' volume of clinical activity. Logistic regression
revealed that risk management file openings, file openings with expenditures,
and lawsuits were significantly related to total numbers of patient complaints,
even when data were adjusted for clinical activity. Predictive concordance
of specialty group, complaint count, clinical activity, and sex for risk management
file openings was 84%; file openings with expenditures, 83%; lawsuits, 81%;
and multiple lawsuits, 87%.
Conclusions Unsolicited patient complaints captured and recorded by a medical group
are positively associated with physicians' risk management experiences.
Conventional wisdom holds that a physician's malpractice experience
is determined by factors associated with the physician, caseload, and unpredictable
circumstances. One risk factor for lawsuits is area of specialty, a belief
confirmed actuarially in the setting of malpractice rates.1,2
Even within a given discipline, however, some physicians are sued more often
than others. Sloan et al3 observed disproportionate
malpractice activity among internists, obstetricians, and surgeons, with 2%
to 8% of these specialists accounting for 75% to 85% of their group's award
and settlement costs.
Factors associated with physicians' experience with claims appear stable.
Bovberg and Petronis4 found that a physician's
malpractice risk did not fluctuate appreciably over time. Their finding is
not surprising given that insurers typically handle claims one at a time,
seeking to resolve individual claims, not necessarily to provide prevention-oriented
feedback. Because suits are relatively infrequent even for physicians with
high claims rates, physicians with the highest risk may not be aware that
they generate more suits than their colleagues. Furthermore, physicians at
high risk may dismiss individual claims simply as a cost of practicing a high-risk
discipline, an especially litigious population, or even bad luck.
Research has forced reconsideration of these traditional explanations
of claims experience. Risk seems not to be predicted by patient characteristics,
illness complexity, or even physicians' technical skills.5,6
Instead, risk appears related to patients' dissatisfaction with their physicians'
ability to establish rapport, provide access, administer care and treatment
consistent with expectations, and communicate effectively.7- 11
If claims experience is related to patient dissatisfaction, it might
be possible to create a monitoring or surveillance system that could be used
to alert physicians to their risk of being sued. Such a system would require
a proxy for a malpractice claim, something that could be counted and related
to the reasons patients file claims, but that occurs more frequently than
lawsuits. A previous study12 of one medical
group showed that 10% of its physicians were associated with more than half
of all unsolicited patient complaints, recalling the finding that malpractice
suits were similarly disproportionate.3,4
That study did not evaluate whether complaints and risk management activity
were related. Nor did it account for physicians' area of specialty, volume
of service, years in practice, sex, or other variables that might affect complaint
generation, risk management–related activity, or any association among
them. The research hypothesis tested herein is that unsolicited patient complaints
will differentiate physicians at high and low risk of malpractice even after
accounting for such variables. If evidence is found to support this hypothesis,
patient complaints might then provide a foundation for a monitoring system.
The specific issues under investigation include (1) the distribution of unsolicited
patient complaints in a large multispecialty group of physicians with varied
risk management activity and (2) the extent to which a physician's risk management
activities might be predicted from knowing her/his numbers of patient complaints,
specialty area, volume of service, and other potential predictors.
Examining the relationship between complaints and risk management activity
requires longitudinal data from a well-defined physician cohort. Cohort members
were employed in a medical center with (1) a complaint system capable of capturing
patient dissatisfactions with inpatient and outpatient services and identifying
physicians mentioned in the complaints, (2) an insurance and risk management
program for assessing the potential for legal actions, and (3) a reliable
means for identifying practice specialty and volume of service. Data from
3 sources were integrated into a research database that covered a 75-month
period from January 1992 through March 1998. This study was approved by the
Vanderbilt University Committee for the Protection of Human Subjects and Executive
Leadership. The research team was constituted under the aegis of risk management
and quality assurance.
The cohort was defined using files that identified individual physicians,
dates of service, specialty, sex, year, country of medical school graduation,
and numbers of relative value units (RVUs)13
provided each service year. The medical group included 645 eligible physicians.
Pathologists and radiologists were excluded because they rarely have patient
contact as well as anesthesiologists, emergency medicine physicians (who could
rarely be identified from patient complaints), resident physicians, and those
in administrative and research positions with fewer than 100 RVUs of care.
The cohort was divided into surgical and nonsurgical practice types
for some analyses.1 The surgical subgroup included
general, vascular, cardiothoracic, plastic, and orthopedic surgery, otolaryngology,
obstetrics and gynecology, neurosurgery, and ophthalmology. The nonsurgical
subgroup included medicine (generalists and all specialties), pediatrics,
psychiatry, and neurology.
Clinical activity was measured using a log transformation of the number
of RVUs expressed as a percentage of the group average. The transformation
was used to normalize the clinical activity variable within the cohort, yielding
an overall mean (SD) of 100 (10).
Complaint data came from the files of the medical center's Patient Advocates
Office (PAO). The PAO staff entered each patient or family member complaint
into a database that included the names of staff and locations associated
with the incident(s) and a narrative describing the problem(s). Narratives
were coded for specific complaint(s) using a standardized set of codes. This
coding system and interrater and test-retest reliabilities have been previously
reported.12,14 Complaint codes
include 6 general categories: communication, humaneness, care and treatment,
access and availability, environment, and billing. All complaints about cohort
members were included in the database.
The database included risk management activities associated with each
physician. The study's 3 risk management outcomes included risk management
files (RMFs), RMFs with expenses, and lawsuits.
The medical group and medical center are self-insured. An Office of
Insurance and Risk Management solicits incident reports whenever staff are
concerned about adverse events, errors, threats to file a lawsuit, and attorneys'
requests for medical records. If risk management staff determine that an incident
could lead to legal action, an RMF is opened. Each RMF contains a description
of the incident, a list of possible defendants, activity associated with the
case, and expenses incurred. Expenses include the cost of documentation, legal
fees, expert witnesses, and settlements and awards. However, actual dollar
values are not reported. Considerations of confidentiality and extreme variation
in expenses precluded using financial data directly. The RMFs are closed after
settlement, court action, or passing of a statute of limitation. The incident
data files included all RMFs (open and closed) during the study period in
which any cohort physician was listed as a defendant or potential defendant.
Lawsuits alone are too limited a variable for assessing risk management
activity. Several studies15,16
suggest only a fraction of patients with valid claims file a lawsuit. Families
may never question care received, or may just decide not to sue even if they
have a claim.17 Consequently, we also included
RMFs both with and without expenses because they represent the universe of
all risk management activity. No attempt was made to determine whether the
RMFs represented valid claims. The validity of most lawsuits is difficult
to determine because there are no universally accepted standards for assessment.18,19
Mean numbers of complaints and 95% confidence intervals were used to
evaluate the medical group cohort's distribution of complaints. For each risk
management–related variable, specific comparisons involved practice
type (surgeons vs nonsurgeons), sex (female vs male), time since medical school
graduation, and country of medical training (United States vs other). The
complaint data were highly skewed (consistent with previous research,12 many physicians had few or none; few had many), so
log transformations of the numbers of complaints were used to achieve normality,
producing geometric means used for inferential statistical analysis. Means
of raw complaint numbers are reported throughout the article for ease of interpretation.
To test for independence of numbers of complaints and RMFs, χ2 analyses were used. Logistic regression analyses were conducted to
evaluate associations between numbers of complaints and risk management outcome
variables, adjusting for physician specialty (surgery vs nonsurgery), clinical
activity (normalized RVUs), and selected physician demographics. To reflect
the appropriateness of these logistic models, we tabulated the predictive
concordance, which is the probability that the model correctly classified
the observed data. Wald χ2 values for the explanatory variables
also were computed to show the relative importance of complaints, specialty,
clinical activity, and sex for each logistic regression fitted. Finally, a
second set of logistic regressions was conducted for those physicians who
had any complaints to assess whether any category(ies) had greater association
with risk management outcome variables. All statistical analyses were performed
using SAS statistical software (Version 6.09, SAS Institute Inc, Cary, NC).
The level of significance was set at .05.
During the 75-month period, the 645 physicians provided 2546 years of
care. Two hundred nineteen (33.9%) were surgeons; 426 (66.1%) were in medicine,
pediatrics, or neurology. Most were male (79.1%) and US medical graduates
(89.3%). Almost one fifth (18.7%) completed training before 1970; 11.4% graduated
after 1989. Length of cohort members' service in the medical group during
the target period averaged 4 years (surgeons, 4.0 years; nonsurgeons, 3.9
The PAO staff documented 18 851 complaints in 7977 separate reports
during the study period. Complaints originated almost equally between inpatient
and outpatient sites. Of the total number of complaints, 5108 (27%) identified
a physician by name, 2856 (56%) identified a surgeon, and 2252 (44%) a nonsurgeon. Figure 1 depicts the cumulative percentage
of complaints by the percentage of physicians in the group. Of 645 physicians,
239 (37%) received no complaints during the study period (30% of surgeons
and 41% of nonsurgeons). The dotted lines in Figure 1 highlight the points in the curve that show that 9% of
the cohort generated more than 50% of all complaints and 5% accounted for
nearly one third of all complaints. The mean number of complaints for all
group members was 7.9 (5.3 for nonsurgeons and 13.0 for surgeons; P<.001).
During the study period, 847 RMFs were opened and 504 (59.5%) involved
cohort members. The 343 RMFs not involving a physician included slips and
falls, missing belongings, intravenous infiltrations, medication errors not
involving physicians' orders, and miscellaneous injuries involving environmental
hazards. Of the RMFs involving cohort members, 254 (50%) involved expenditures.
In 135 cases (27%), either a lawsuit was filed (111 cases) or settlements
were made before initiation of formal legal proceedings (24 cases). These
135 cases are referred to as lawsuits.
Most RMFs named only 1 physician (77%), with a smaller percentage naming
2 (16%), whereas 7% involved 3 or more. Similar findings were obtained when
the RMFs were restricted to the 254 cases with expenses. Among the 135 lawsuits,
a single physician was named in 99 (73%). Two physicians were named in 23
(17%) and 3 or more in 13 (10%) cases.
Because the unit of observation was the physician, not a risk management
event, data for all 645 physicians were summarized (Table 1). Fewer than half (n = 274 [42%]) were named in any RMF,
and 139 (22% of the total) were subjects of at least 1 lawsuit. Forty-three
physicians (7%) were involved in 2 or more lawsuits during the study interval.
When examined according to practice type, nonsurgeons had less risk management
activity. Specifically, 137 (32%) of the 426 nonsurgeons had at least 1 RMF
compared with nearly two thirds (137 [63%] of 219) of all surgeons (χ21= 54.7; P<.001). Only 19% of
nonsurgeons had RMFs involving expenditures compared with more than half (51%)
of the surgeons (χ21= 71.2; P<.001). Thirteen percent of nonsurgeons vs 37% of surgeons had been
named in at least 1 lawsuit (χ21= 49.5; P<.001), and only 2% of nonsurgeons compared with 16% of surgeons
were named in 2 or more suits (χ21= 46.2; P<.001).
Table 2 reveals the numbers
of study cohort physicians with selected combinations of RMF openings and
unsolicited patient complaints. Two hundred twenty-three cohort members (35%)
had zero or 1 complaint and zero RMFs during the study period. By contrast,
36 study physicians (6%) were associated with 25 or more complaints and 3
or more RMFs. For the data in Table 2,
which are not adjusted for demographic variables or service volumes, the association
of complaints and RMFs per physician was significant (χ212= 274; P<.001). Alternative groupings
of complaints and RMFs per physician yielded similar results. Complaint activity
also was associated with the number of RMFs with expenses (χ212= 205; P<.001) and lawsuits per physician
(χ212= 165; P<.001).
Surgeons named in a single lawsuit generated significantly more complaints
than surgeons with no lawsuits (mean complaints = 16.7 vs 6.1; P<.001). The same pattern of results was true of nonsurgeons (9.2
vs 4.7; P = .004). Surgeons with 2 or more lawsuits
had significantly more complaints than their colleagues with 1 lawsuit (35.1
vs 16.7; P = .001) or zero lawsuits (35.1 vs 6.1; P<.001). The results were similar for RMFs and RMFs
with expenses. Physicians of both types who had no suits generated few patient
complaints (6.1 for surgeons vs 4.7 for nonsurgeons, P
Other physician characteristics that might affect complaint counts or
RMF generation were examined. These included clinical activity, sex, year
of graduation (as a proxy for age), and country of medical school training.
Neither year of graduation nor country of medical training were related to
complaint generation or any of the risk management outcomes. Complaints did
vary by sex (means, 5.0 for female physicians and 8.8 for male physicians; P<.001). Female physicians also were less likely than
male physicians to be involved with RMFs, RMFs with expenses, or lawsuits.
Specifically, for RMFs, 31% of female physicians had file openings vs 46%
for male physicians. Similarly, the counterpart RMF openings with expenses
and lawsuits were 19% and 13%, respectively, for female physicians and 33%
and 24%, respectively, for male physicians.
Logistic regression analyses were performed to assess the adjusted relationships
between risk management variables and physicians' complaints, specialty type,
clinical activity, and sex (Table 3).
High complaint generation, surgical specialty, and higher levels of clinical
activity were all significantly associated with each measure of risk management
activity: an RMF, an RMF with expenses, and involvement in a single or multiple
lawsuits. Male sex, however, was significantly associated only with having
an RMF or an RMF with expenses. Goodness of fit was measured for the logistic
regression models (Table 3) using
predictive concordance. For the models involving all physicians, predictive
concordance ranged from 81% to 87%.
Relationships among complaints, risk management activity, clinical activity,
and sex were also examined separately for surgeons and nonsurgeons
(Table 3). For each group, high complaint
generation and high clinical activity were significantly associated with having
an RMF. For surgeons, high complaint generation, clinical activity, and male
sex were associated with having an RMF; only high complaint generation and
clinical activity were associated with having an RMF with expenses. Similarly,
both complaints and clinical activity were significant explanatory variables
for surgeons named in a lawsuit. Only total complaint count, however, was
associated with surgeons named in 2 or more lawsuits.
Next, using data only from the 406 physicians who generated at least
1 complaint, we examined the distributions and influences of particular complaint
categories. As with the entire cohort, surgeons in this group attracted significantly
more complaints than nonsurgeons (mean, 18.6 vs 8.9; P<.001).
Within complaint categories, surgeons more frequently than nonsurgeons were
associated with complaints related to care and treatment (mean, 5.9 vs 2.9; P<.001), billing (mean, 4.9 vs 2.4; P<.001), communication (mean, 4.0 vs 1.7; P<.001),
access and availability (mean, 2.1 vs 0.9; P<.001),
and humaneness (mean, 1.6 vs 1.0; P = .06). Finally, Table 4 shows the relationships, adjusted
for clinical activity, between these 406 physicians' risk management variables
and numbers of complaints within each category. Table 4 reveals that clinical activity accounted for most of the
concordance in logistic regressions that used complaint types to predict risk
management outcomes. No category of complaint was more predictive of risk
management activity than others.
Unsolicited complaints recorded by a medical group's PAO can be used
to differentiate physicians by their malpractice risk. A relatively small
number of physicians generated a disproportionate share of complaints. Furthermore,
physicians' complaint generation was positively associated with risk management
outcomes, ranging from file openings to multiple lawsuits. Relationships between
overall complaint generation and risk management activity remained even when
clinical activity was controlled, suggesting that patient complaints may serve
as an important indicator for a risk management monitoring system.
Results are consistent with previously published research on relationships
between patients' dissatisfaction with care and malpractice claims.7- 11
Patients who saw physicians with the highest numbers of lawsuits were more
likely to complain that their physicians would not listen or return telephone
calls, were rude, and did not show respect.8,9
Such complaints are similar to those documented in interviews with families
who sued their physicians.7,10,11
In the present study, the total number of patient complaints, not any particular
type, predicted risk management outcomes. Subsidiary logistic regression analyses
showed that numbers of each complaint type were significantly associated with
risk management outcomes (data not shown). However, as shown in Table 4, when clinical activity was added to the model, the relationships
largely disappeared. Only complaints about care and treatment added a modest
contribution to predictive concordance with RMF openings and RMF openings
with expenses. Perhaps that is because complaints about care and treatment
are more likely to come to the attention of risk managers who, in turn, may
be more likely to investigate them (ie, open RMFs and pursue more extensive
and costly reviews) than complaints about interpersonal issues of communication
and concern. Possible reasons that type of complaint was not predictive include:
patient thresholds for registering dissatisfaction and pursuing claims are
idiosyncratic and variable, patient and family complaints stated in terms
of one thing (eg, billing or access issues) may really have been about others
(eg, care and treatment), and/or the system for coding complaints is not accurate.
However, both the coding system and patients' narrative complaints have substantial
face validity.12 Although one category of complaint
is not more predictive of malpractice activity than another, typing the complaints
may suggest both the cause(s) of a particular physician's risk and directions
for quality improvement.
Other findings include the association of risk management activity with
sex, practice type, and volume of clinical activities. Female physicians attracted
fewer unsolicited complaints and were less likely to be involved in RMFs compared
with their male colleagues. Perhaps the female physicians in this cohort were
more clinically and/or interpersonally competent. Or perhaps patients were
less likely to complain about and/or risk managers were less likely to open
files in cases involving female physicians. Until replicated, this result
should be interpreted with caution.
The fact that surgeons attracted more lawsuits than nonsurgeons is not
surprising.1,2 The association
between lawsuits and clinical activity has been reported by Baldwin et al.20 Their study, however, focused only on physicians
providing obstetric care and relied on self-reported numbers of deliveries,
not a standardized measure of productivity. Although data from the present
study do not provide a causal link between volumes of service and lawsuits,
it is plausible that high numbers of RVUs mean less time per patient and less
attention to interpersonal and/or technical aspects of care. Perhaps one implication
is that practice managers should consider discounting RVUs above some threshold
as counterproductive for group reputation and liability experience. A larger
data set than the one used will be required for reliably estimating such a
Although positive relationships were identified among unsolicited patient
complaints, clinical activity, and risk management outcomes, the results may
not be generalizable. The study reflects only 75 months of data from a single
group. Claims experience varies regionally. Patient willingness and opportunity
to complain may vary as well. The analysis also is limited in that unsolicited
complaints undoubtedly represent only the "tip of the iceberg"21
and may not be as representative as data from a standardized survey. On the
other hand, unsolicited complaints have face validity and are readily available
as a part of "customer service" activities,14,22
and they may more adequately describe respondents' experiences, expectations,
and priorities.23- 25
Another concern is that PAO personnel may have recorded only the big
complaints, such as those from families complaining about adverse outcomes,
recorded physicians' names only in big complaints, or recorded complaints
only about physicians they know have problems. All are possible, but unlikely.
During the study period, more than 18 000 complaints were lodged, including
thousands about parking, food services, and the physical environment. Furthermore,
nearly two thirds of all physicians were identified in at least 1 complaint.
The PAO policy is to record all complaints, and staff are expected to forward
"write-ups" to all professionals involved to encourage resolution of patient
dissatisfaction.14 Selective reporting would
defeat the goal of identifying and helping to resolve patient complaints.
Both PAO and risk management personnel were aware that their reports
were being read "for research purposes" only during the last third of the
75-month target period. They were not, however, aware of the specific research
questions being addressed. We could find no quantitative evidence in numbers
of files created that either group increased overall reporting or changed
its reporting practices during the study period, but we cannot rule out the
possibility. Anecdotally, after PAO staff became aware that their writings
were being read by the researchers, their reports, although not more numerous,
did seem to include somewhat more narrative detail, although no more specific
Notwithstanding the possibility of reporting biases, our study did identify
a relatively small number of physicians in a medical group who had both dissatisfied
patients and relatively high malpractice activity. Using 3 variables (unsolicited
complaints, relative RVU production, and specialty), we identified 52 physicians
(8% of the cohort) with the highest risk scores who were involved in 48% of
all suits experienced by the physicians in this study. A subsequent study
will evaluate the effectiveness of a complaint-based intervention on high
No attempt was made to examine whether patient complaints or lawsuits
occurred first. If a physician named in a lawsuit is widely known in a community,
such awareness might encourage other patients to complain. The physician also
may act angry and defensive with subsequent patients, in turn generating more
complaints. In such circumstances, complaints would be a product of being
sued, not a reflection of practice behaviors that created dissatisfaction
and set the stage for litigation in the face of an adverse outcome. Such a
scenario is possible but not likely. In our view, few patients are aware of
the lawsuit status of their physicians. Furthermore, since risk status appears
stable over time,4 the practical implication
is the same regardless of temporal order. That is, whether complaints beget
suits or vice versa, the cycle needs to be disrupted, perhaps as suggested
herein by aggregating complaints as a risk management monitoring and intervention
tool. This is not to suggest that the question of the temporal relationship
between complaints and suits is unimportant. This study, however, was designed
simply to examine the association between complaints and risk management variables
for purposes of evaluating the utility of the former for monitoring risk of
The ability to identify lawsuit-prone physicians by means other than
counting lawsuits offers opportunities for intervention. Levinson et al10 found that physicians without malpractice claims
offered patients more orienting and facilitating comments, as well as used
more humor than colleagues with malpractice claims. Others have reported that
physicians with low claims experience were more likely than their colleagues
with high claims experience to be perceived as concerned and willing to answer
questions.10 Both technical and interpersonal
skills can be learned,26,27 and
it is likely that some physicians could acquire and use needed skills if they
both recognized that they were at high litigation risk and understood the
environmental and behavioral factors that contributed to their risk. Studies28,29 have shown that physicians' practice
patterns and behaviors can change when data show them to differ substantially
from their peers, especially if the messenger and method of disclosure are
appropriate, strategies for practice changes are available, and the administrative
environment is supportive.
The process of capturing, coding, aggregating, and reporting patient
complaints carries risk.19,30
A PAO provides a means of confidential complaint resolution. Release of information,
whether intentional or inadvertent, might reduce the incentive for patients
or employees to alert medical center representatives of potential problems.
Reduced reporting would obviously hinder the PAO's mission, to say nothing
of the potential of unwarranted damage to reputations, disruption of relationships,
and lawsuits. Research and quality improvement efforts that make use of complaint
data must be performed in an atmosphere of confidentiality. Every research
team member involved in the present study received counseling regarding the
sensitive nature of the data and signed a confidentiality agreement before
Finally, efforts to improve institutional quality by identifying and
intervening with high complaint-generating physicians will require protection
from legal discovery.30 In an environment characterized
by high rates of legally invalid lawsuits, medical centers and their patients
can benefit by identifying the origins of invalid claims in hopes of preventing
others. Justifying protection from discovery, however, requires that such
confidential information actually be used for quality improvement purposes.
The identification of an association between complaint data and risk management
activity offers an excellent opportunity for addressing sources of patient
dissatisfaction that can lead inappropriately toward the courtroom.