Doctors with lax manners tend to get sued most, Vanderbilt studies show.

Obstetricians who want to reduce their risk of medical negligence should brush up on their etiquette, not necessarily their medical expertise, according to two university studies that examined Florida doctors and their patients.

Both studies were published in the Journal of the American Medical Association. One attempts to show that the National Practitioner Data Bank (NPDB)--which was set up to identify potentially dangerous physicians--is a system whose fundamental premise is based on flawed reasoning. (Stephen Entman et al., The Relationship Between Malpractice Claims History and Subsequent Obstetric Care, 272 JAMA 1588 (1994). The NPDB, operated by the U.S. Department of Health and Human Services since its 1986 inception, lists malpractice payments and disciplinary actions against health care practitioners.

The second study suggests that communication problems are at the heart of many negligence suits. (Gerald Hickson et al., Obstetricians' Prior Malpractice Experience and Patients satisfaction with Care, 272 JAMA 1583 (1994).)

"There they go again," said Jack Olender, a Washington, D.C., lawyer whose practice focuses on medical negligence. "The doctors are trying to put the blame on anyone but themselves. They've been doing that for the past 10 years."

In the first study, Dr. Stephen Entman and researchers at Vanderbilt University Medical Center in Nashville, Tennessee, found no relationship between the frequency of suits filed against a physician and the technical quality of care that was delivered.

The researchers concluded that "if the frequently sued physician does not practice substandard medicine, but has, for example, poor interpersonal skills that promote claims, then the deterrent effect of the tort system may be targeting physicians because of their personalities and not the technical care they provide."

The researchers warned: "A physician who is deeply concerned about a patient may nonetheless be at greater risk of being sued if that patient sees her physician as brusque and unavailable."

Entman contended that "significant objective errors [in medicine] are uncommon, and it is difficult to relate them directly to outcome in a setting [such as the NPDB, which is] stripped of the inherent bias of the adversarial process of litigation.

"Although the goals of the NPDB may be in the public interest, this study suggests its data may not reliably identify physicians likely to make errors," Entman said.

Olender disagreed. "I think it is correct that some patients come to lawyers for the wrong reason: They don't like their doctor's bedside manner," he said. "But many have bona fide cases. To say the National Practitioner Data Bank has invalid information is illogical because the information that goes into it is based on the payments made and the jury verdict. It doesn't matter how the patients are driven to the lawyer's office."

The second study was conducted by Vanderbilt's Dr. Gerald Hickson and his colleagues, including Entman.

This report showed that more than 85 percent of payments by Florida malpractice insurers stemmed from lawsuits against only 6 percent of the obstetricians whose records were examined.

"Although most physicians ... are threatened with malpractice claims or have claims filed against them, some physicians attract a disproportionate share of malpractice suits and losses," Feckson said. "[Filing suits] does not appear to be random. Rather, many physicians who are sued frequently have problems communicating and establishing rapport with their patients.

"Physicians who have been sued frequently are more often the objects of complaints about the interpersonal care they provide--even by their patients who do not sue."

Hickson concluded that the medical profession must "identify and rectify, poor communication skills among doctors, preferably before these deficiencies lead to litigation.... Medicine needs to reaffirm its commitment to the truth that care involves more than technical expertise. Increasing patients' satisfaction with the care they receive should be a central goal of all efforts to improve health care."

Dr. Wendy Levinson of Portland, Oregon, wrote an accompanying JAMA editorial. Negligence attorneys, when asked to cite the primary reason a patient pursued a negligence suit, report that more than 80 percent are due to communication issues.

"Breakdowns in communication between patients and physicians and patient dissatisfaction are critical factors leading to malpractice litigation," Levinson said. While preventing malpractice claims is important, providing high-quality humanistic care is the best reason to communicate effectively.