MDs with Poor Communication Skills Prime Targets for Patient Complaints

MONTREAL, Sept. 4 -- Doctors who scored poorly on the patient-physician communications portion of a clinical skills examination were significantly more likely to be the targets of patient complaints to medical authorities than fair or good communicators.

Every two standard-deviation decrease in communication score was associated with 1.17 additional retained complaints per 100 physicians per year, translating into a relative risk of 1.38 (95% confidence interval, 1.18 to 1.61), reported Robyn Tamblyn, Ph.D., of McGill University, and colleagues in the Sept. 5 issue of the Journal of the American Medical Association.

"The clinical skills examination communication score, when added to a model that included a traditional written examination clinical decision-making score, significantly improved the prediction of overall retained complaints and communication complaints, but not complaints about quality of care," the authors said.

The Medical Council of Canada, Educational Commission for Foreign Medical Graduates, and United States Medical Licensing Examination all include a clinical skills examination as a requirement for licensure, the authors noted, and medical schools have added communications and clinical skills to their curricula to help prepare students for a career in patient care.

To see whether scores on the clinical skills portion of licensure exams could be predictive of future complaints, they conducted a cohort study of all 3,424 physicians who took the Medical Council of Canada clinical skills examination between 1993 and 1996 and who were licensed to practice in the provinces of Ontario and Quebec. The participants were followed until 2005, including their first two to 12 years of practice.

The primary outcome measure was patient complaints against study physicians that were filed with medical regulatory authorities in Ontario or Quebec and retained (not dismissed) after investigation.

The authors used multivariate Poisson regression modeling to estimate the relationship between complaint rates and scores on the clinical skills examination and the traditional written exam. The scores were based on a standardized mean of 500 + 100.

There were 1,116 complaints lodged against the physicians, and that 696 of these were deemed to have at least some merit. In all, the researchers noted, 17.1% of the physicians had at least one complaint, and 81.9% of the complaints were about communication problems or quality-of-care issues.

Communications scores for the cohort ranged from a low of 31 to a high of 723, mean 510.9 + 91.1. The authors found that every two standard-deviation decrease in communication scores was associated with 1.17 additional retained complaints per 100 physicians per year, translating into a relative risk of 1.38 (95% confidence interval, 1.18 to 1.61).

In addition, each two-standard deviation decrease was associated with 1.20 more communication complaints per 100 practice years, which translated into a relative risk of 1.43 (95% CI, 1.15 to 1.77).

After adjusting for the written clinical decision-making score, they found that the physicians in the bottom quartile of communications scores accounted for an additional 9.2% (95% CI, 4.7% to 13.1%) of retained complaints and 11.2% (95% CI, 5.8% to 16.9%) of communication complaints.

"This is not a huge difference, but it takes on added weight when combined with the finding that communication scores in the bottom quartile were clearly associated with patient complaints," wrote Gregory Makoul, Ph.D., and Raymond H. Curry, M.D., of the Center for Communication and Medicine at Northwestern University in Chicago, in an accompanying editorial.

They added that examiners who observe poor communication skills during clinical skills exams -- making condescending remarks, for example, or judgmental behaviors, or failure to listen to patients -- may wish to discuss these problems with the test takers on the spot.

It's likely that if such issues crop up in a test where the examinees are supposed to be on their best behavior, the problem is likely to be more deeply rooted, they suggested.

"This observation underscores the importance of addressing professional skills and perspectives early and often during medical education," the editorialists wrote.

"In terms of communication," they said, "initiatives could include more systematically assessing interpersonal skills during the admissions process, better connecting clerkship and residency experiences to earlier training in communication skills, and ensuring that clinical skills assessments include a communication component."